AGENDA - Poole Hospital 1 May 2014 Website... · 2014-04-24 · Top Poole Hospital NHS Foundation Trust Council of Governors Council of Governors May 2014 01 May 2014 - 16:30 Board

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Poole�Hospital�NHS�Foundation�Trust

Council�of�Governors

Council�of�Governors�May�2014

01�May�2014�-�16:30

Board�Room,�Poole�Hospital,�BH15�2JB

AGENDA

1 Apologies�for�Absence

2 Declaration�of�Interests

3 Draft�Minutes�of�Meeting�held�on��16�January�2014CoG�May�14�A�Minutes�Jan�14�Part�1�Draft 8

4 Matters�Arising/Action�ListCoG�May�14�B�Actions 16

5 Chairman’s�Comments

6 FOR�APPROVAL

7 Outline�Proposed�Changes�to�the�ConstitutionOwner:�Co�Sec

CoG�May�14�C1�Proposed�Changes�to�Constitution�cov 17CoG�May�14�C2�Part�1�-�Outline�Proposed�Changes�to 18

8 Governors�Meeting�Schedule�for�2015Owner:�Chairman

CoG�May�14�D1�Governors�2015�Meeting�Schedule�cove 21CoG�May�14�D2�CoG�Meeting�Schedule�2015 22

http://www.eshareuk.com

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9 Reappointment�of�ChairmanOwner:�Senior�Independent�Director

CoG�May�14�E1�Part�1�-�Chairman's�A�Reappointment� 25CoG�May�14�E2�Part�1�-�Chairman's�B�Reappointment� 26CoG�May�14�E3�Part�1�-�Chairman's�C�Annex�1�JD��PS 28CoG�May�14�E4�Part�1�-�Chairman's�D�Annex�2�New�Ap 34

10 Reappointment�of�Non-Executive�DirectorOwner:�Chairman

CoG�May�14�F1�Part�1�-�NED�(NZ)�A�Reappointment�Co 35CoG�May�14�F2�Part�1�-�NED�(NZ)�B�Reappointment�Re 36CoG�May�14�F3�Part�1�-�NED�(NZ)�C�Annex�1��JD��PS 38CoG�May�14�F4�Part�1�-�NED�(NZ)�D�Annex�2�New�Appo 43

11 TO�RECEIVE

12 Revised�Governors�Meeting�Schedule�for�2014Owner:�Chairman

CoG�May�14�G1�Revised�Governors�2014�Meeting�Sched 44CoG�May�14�G2�CoG�Revised�2014�Meeting�Schedule 45

13 Disputes�ProcedureOwner:�Co�Sec

CoG�May�14�H1�Board�and�Council�Disputes�Procedure 48CoG�May�14�H2�Part1�BoD�and�CoG�Dispute�Resolution 49

14 Report�from�NREC�Meeting�1�May�2014Owner:�Chairman

15 Annual�Report/statement�on�the�work�of�the�Nominations,�Remunerationand�Evaluations�CommitteeOwner:�Chairman

CoG�May�14�I1�NREC�2013-14�Annual�Report�cover�she 51CoG�May�14�I2�NREC�2013-14�Annual�Report 52

16 FOR�INFORMATION/�SCRUTINY

17 Planned�Non�Executive�ReviewOwner:�Chairman

CoG�May�14�J1�Part�1�-�Planned�NED�Refresh�Cover�S 54CoG�May�14�J2�Part�1�-�Planned�NED�Refresh�Report 55


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18 Update�on�Trust�Position�re�Francis�ReportOwner:�Director�of�Nursing�&�Patient�Services

19 Trust�Performance�Report�Month�12Owner:�Chief�Executive

CoG�May�14�K�1�2�IPR�March�2014�FINAL�14th�April 58

20 Monitor�Quarter�3�Monitoring�FeedbackOwner:�Chief�Executive

CoG�May�14�L1�Q3�Monitor�feedback�cover�sheet 94CoG�May�14�L2�POOLE�1314�Q3�feedback�letter 95CoG�May�14�L3�POOLE�1314�Q3�executive�summary 97

21 Disclosure�and�Debarring�Service�(DBS)�Checks�(ex�CRB)Owner:�Co�Sec

22 FOR�REVIEW

23 Reports�from�Reference�Groups:

23.1 Membership�Engagement�and�RecruitmentOwner:�Mrs�Yeoman

23.2 Future�Plans�&�PrioritiesOwner:�Mr�Purnell

23.3 Governor�Training�and�DevelopmentOwner:�TBC

24 Reports�from�Other�Groups

24.1 SWGENOwner:�Attendees

24.2 Staff�GovernorsOwner:�TBC

25 Future�Agenda�ItemsOwner:�Chairman

SWASFT�Presentation�TBA�CB


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26 Motions�on�NoticeOwner:�Chairman

27 Urgent�Motions�or�QuestionsOwner:�Chairman

28 Date�of�next�meeting:�31�July�2014Owner:�Chairman

29 A�glossary�of�abbreviations�that�may�be�used�in�these�papers�will�be�foundat�the�back�of�this�document

Governance�Cycle�Apr�14 98Glossary�of�abbreviations�Feb�13 101

30 AGENDA�PART�2

31 Presentation:�PWC�Initial�Report�–�Mark�Friedman

32 Draft�Part�2�Minutes�of�the�Meeting�held�on�16�January�2014

33 Matters�Arising/Action�List

34 Draft�Minutes�from�Nominations,�Remuneration�and�Evaluations�Committeeheld�on�16�January

35 FOR�DECISION

36 Request�from�Dismissed�GovernorOwner:�Chairman

37 FOR�INFORMATION�/SCRUTINY

38 Matter�of�Concern�Raised�with�a�GovernorOwner:�Lynn�Cherrett

39 Strategic�Risk�ReportOwner:�Director�of�Nursing�&�Patient�Services

40 Quarter�4�Submission�to�MonitorOwner:�Chief�Executive


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41 Close�of�MeetingOwner:�Chairman

42 A�glossary�of�abbreviations�that�may�be�used�in�these�papers�will�be�foundat�the�back�of�this�document

Attendees


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IndexCoG�May�14�A�Minutes�Jan�14�Part�1�Draft.doc.......................................................................8

CoG�May�14�B�Actions.docx...................................................................................................16

CoG�May�14�C1�Proposed�Changes�to�Constitution�cover�sheet.d........................................17

CoG�May�14�C2�Part�1�-�Outline�Proposed�Changes�to�the�Const.........................................18

CoG�May�14�D1�Governors�2015�Meeting�Schedule�cover�sheet.do.....................................21

CoG�May�14�D2�CoG�Meeting�Schedule�2015.docx.............................................................. 22

CoG�May�14�E1�Part�1�-�Chairman's�A�Reappointment�Cover�Shee......................................25

CoG�May�14�E2�Part�1�-�Chairman's�B�Reappointment�Report.doc....................................... 26

CoG�May�14�E3�Part�1�-�Chairman's�C�Annex�1�JD��PS.docx................................................28

CoG�May�14�E4�Part�1�-�Chairman's�D�Annex�2�New�Appointment�...................................... 34

CoG�May�14�F1�Part�1�-�NED�(NZ)�A�Reappointment�Cover�Sheet....................................... 35

CoG�May�14�F2�Part�1�-�NED�(NZ)�B�Reappointment�Report.docx........................................36

CoG�May�14�F3�Part�1�-�NED�(NZ)�C�Annex�1��JD��PS.doc.................................................. 38

CoG�May�14�F4�Part�1�-�NED�(NZ)�D�Annex�2�New�Appointment�Ou....................................43

CoG�May�14�G1�Revised�Governors�2014�Meeting�Schedule�cover�.....................................44

CoG�May�14�G2�CoG�Revised�2014�Meeting�Schedule.docx................................................ 45

CoG�May�14�H1�Board�and�Council�Disputes�Procedure�cover�she...................................... 48

CoG�May�14�H2�Part1�BoD�and�CoG�Dispute�Resolution�Procedure.................................... 49

CoG�May�14�I1�NREC�2013-14�Annual�Report�cover�sheet.doc............................................51

CoG�May�14�I2�NREC�2013-14�Annual�Report.docx..............................................................52

CoG�May�14�J1�Part�1�-�Planned�NED�Refresh�Cover�Sheet.doc..........................................54

CoG�May�14�J2�Part�1�-�Planned�NED�Refresh�Report.docx................................................. 55

CoG�May�14�K�1�2�IPR�March�2014�FINAL�14th�April.doc..................................................... 58

CoG�May�14�L1�Q3�Monitor�feedback�cover�sheet.doc..........................................................94

CoG�May�14�L2�POOLE�1314�Q3�feedback�letter.pdf............................................................95

CoG�May�14�L3�POOLE�1314�Q3�executive�summary.pdf.....................................................97

Governance�Cycle�Apr�14.doc................................................................................................98


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Glossary�of�abbreviations�Feb�13.docx.................................................................................101


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COUNCIL OF GOVERNORS

The minutes of the meeting of the Council of Governors of Poole Hospital NHS Foundation Trust held on 16 January 2014 at 4.30 pm in the Board Room, Poole Hospital.

Present: Mrs A Schofield Chairman Mrs L Cherrett Clinical Staff Ms C Cherry Bournemouth University Mrs V Duckenfield Poole Mrs B Hooper Purbeck, East Dorset and Christchurch

Cllr. D Jones Dorset County Council Miss K Knudsen Clinical Staff

Dr C McCall Dorset Clinical Commissioning Group Mrs I McLellan North Dorset, West Dorset, Weymouth

and Portland Mr B Newman Bournemouth Mrs L Nother Poole Mrs E Purcell Poole Mr T Purnell Bournemouth

Mr G Whittaker Non Clinical Staff Mrs S Yeoman Poole

In attendance: Mr M Beswick Company Secretary

Mr C Bown Chief Executive Mrs D Fleming Chief Executive Elect Dame Yvonne Moores Trust Vice Chairman Miss J Retigan Minute Taker Mr M Smits Director of Nursing & Patient Services

Mr G Spencer Senior Independent Director Mr P Turner Director of Finance

CoG 001/14 Apologies for Absence

Apologies for absence were received from AVM G Carleton; Purbeck, East Dorset & Christchurch, Mr A Creamer; Poole, Mrs R Gould; Purbeck, East Dorset and Christchurch, Mrs S Lowrey; Clinical Staff, Mr J Pride; Poole and Cllr. A Stribley; Borough of Poole.

CoG 002/14 Declarations of Interest

The Chairman, Dame Yvonne Moores and Mr Spencer declared their interest in item 8.

The members on the Nomination, Remuneration & Evaluation Committee

declared their interest in items 9 and 10. No other declarations of interest were noted.

CoG�May�14�A�Minutes�Jan�14�Pa

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Overall�Page�8�of�104Page�1�of�8


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CoG 003/14 Minutes of the Meeting held on the 26 September 2013 (Paper A)

It was noted that the part 2 minutes would be amended to record the apologies of Mr Jones. The minutes were agreed as an accurate record of the meeting.

CoG 004/14 Matters Arising (Paper B)

107/13 – Mr Smits reported that a meeting with Governors regarding the setting of the Quality Accounts for 2014/15 would take place before the end of February.

It was noted that all actions, unless subject to this agenda, had been executed.

CoG 005/14 Chairman’s Comments

The Chairman reported that Cllr. Adams had resigned as the nominated governor for Bournemouth Borough Council, effective from 9 January 2014, and a replacement nomination would be sought. The Chairman noted that Mr Bown, Mr Smits and Mr Turner were attending their last Council of Governors meeting. On behalf of the Council she thanked them for their tremendous achievements and contribution to the Trust. The Chairman reported that Mrs Debbie Fleming would take up the post of Chief Executive from 1 April 2014 and Mr Mark Friedman had been appointed on a contract basis as Transformation Director. It was noted that interviews for the remaining executive director vacancies would commence on 20 January 2014. The Chairman and Mr Bown had met with Staff Governors at their regular quarterly meeting on 9 January and the main business had been a discussion on how staff were managing during this very busy period. Mr Bown detailed national and local pressures on trusts and the ongoing close work with partners. It was noted that the A&E target had not been met for the previous three weeks and focused work to achieve the target for the quarter was underway. The Chairman reported that Monitor had issued their new Code of Governance and a link to the document would be issued through the Governors Newsletter. ACTION: MB The programme for the election of two new public Governors for Poole had been set with the details previously circulated to Governors. At the private Council of Governors meeting on 26 September 2013 the Council had approved the reappointment of three Non-Executive Directors: Dame Yvonne Moores (to 31 October 2014), Mrs Jean Lang (to 30 November 2014), both for 12 months, and Mr Michael Mitchell for three years (to 31 October 2016). At a Special Council of Governors meeting in November Mr Faith was removed as a Governor.


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Following a request from NREC the Chairman issued a reminder to Governors, that should they not attend two consecutive meetings, the reasons for non-attendance would be scrutinised by NREC due to this being a requirement of tenure. Mr Beswick noted that one Governor, Mr Hermsen, had been disqualified from remaining as a Governor of the trust and his tenure as a Governor had been terminated on 23 October 2013. Another Governor, Mr Faith, had been removed as a Governor of the trust and his tenure as a Governor had been terminated on 19 November 2013. The report was NOTED.

CoG 006/14 Council’s Draft 2014/15 Governance Cycle (Paper C) Mr Beswick presented the report which set out the work plan for the Council

for 2014/15. He noted that the document could be amended if required. It was also noted that references within the report would be updated to reflect the changes to the Code of Governance.

The report was APPROVED. CoG 007/14 Chairman’s and Non-Executive Directors Appraisal Process – 2013/14

and Onwards (Paper D)

Mr Beswick presented the report which detailed proposed changes to the process for the Chairman’s and Non-Executive Directors appraisals. It was noted that the main changes were to amend the Chairman’s appraisal from a scoring pro forma to a performance narrative, to increase the recipients of the Chairman’s questionnaire from five Governors to the whole Council and correct the inaccuracy on Chairman’s Appraisal Processes (page 1, step 3) from Lead Governor to Deputy Chairman of the Council of Governors. Mr Beswick also noted that step three in the Chairman’s appraisal process says the SID also canvasses the views and comments of Non-Executive Directors. To comply with Monitor’s new code of governance (A.4.2) it should read; Led by the SID, the non-executive directors will meet without the Chairman present to appraise the Chairman’s performance. It was noted that the report had been considered by NREC and they recommended that the Council approve the process for 2013/14 onwards. The report was APPROVED.

CoG 008/14 Revised NREC Terms of Reference (Paper E)

The Chairman presented the report which would introduce new governance arrangements for NREC specifically they included a change to the process for the selection for NREC membership.

Mr Beswick detailed the main changes which would be that Governors would become a member of NREC for a maximum of two, three year terms by constituency nomination. It was noted that a ballot would take place where there was more than one nomination.


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The report had been considered by NREC who recommended that the Council approve the revised NREC Terms of Reference.

The report was APPROVED.

CoG 009/14 NREC Transitional Arrangements for Tenure of Members (Paper F)

The Chairman presented the report which set out a programme for the review of NREC membership following the approval of the revised NREC Terms of Reference.

Mr Beswick detailed the transitional arrangements. He noted that NREC had scrutinised the report and recommended that the Council approve the report.

The report was APPROVED. The Chairman noted the excellent work carried out by the current members of

NREC. It was highlighted that the demands on this subcommittee of the Council had been onerous over the previous few years and the Trust were greatly appreciative of the work and support provided.

CoG 010/14 Council of Governors Development Governor Statutory Duties (Monitor Reference Guide) Mr Beswick reported that this guide had been issued to Governors. Output from Development Session on 19 December 2013 The Chairman reported that an excellent joint Council of Governors and Board

of Directors development session had taken place on 19 December. It was noted that the event had been very useful for all and Giles Peel of DAC Beachcroft had provided excellent facilitation.

Draft Governor Development Plan (Paper G) The Chairman presented the report which had been updated to include the

output from the Development Session on 19 December. Mr Beswick detailed the contents of the report. He noted that the available

resourcing would require management alongside the three proposals put forward in the report for approval. These were that the Council would continue to enjoy the same access to development as previously; the Council would form a small Development and Training Reference Group to monitor the Governor Development Programme and the Council would approve its own development plan for 2014 onwards with a formal year-end report on performance.

The Chairman noted that the lunchtime sessions on clinical services had

ceased and she proposed that on Council of Governor meeting days a clinical presentation would take place, with members invited to attend twice a year. She noted that attendance would be voluntary and it was agreed this was a good idea. The Chairman reported that the Emergency Services Clinical


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Directorate would be keen to give a presentation prior to the next meeting at 2pm on 1 May 2014.

Following discussion it was agreed that Mr Smits would provide the

programme of hospital walkabouts for inclusion in the next Governor Newsletter. ACTION: MSm

Mr Purnell reported that the Membership and Engagement Reference Group

would like to hold recruitment meetings and he was working to see if sponsorship could be obtained from the Rotary Club.

The report was discussed and the three recommendations APPROVED. CoG 011/14 Revised Membership Strategy (Paper H) The Chairman noted that for the previous 18 months the membership strategy

had been based on the likelihood of merger and now required review. Mr Beswick introduced the report which had been agreed by the Membership

and Engagement Reference Group (MERG). The report was discussed and it was noted that a concerted effort to increase the membership of the Trust was now required as in recent time the focus had been given to membership of the proposed new organisation. It was agreed a report would be submitted to the next MERG meeting. ACTION: MB

The report was RECEIVED. CoG 012/14 Outcome of Deputy Chairman and Lead Governor Ballot The Chairman thanked Governors who had put their names forward for the

roles of Deputy Chairman and Lead Governor. The Chairman reported that Mrs Duckenfield would become Lead Governor

and the remit of the role was to act as the contact between the Council and Monitor.

Mr Carleton would take on the role of Deputy Chairman, who is the person the

Chairman would contact to seek the view or advice of the Council and who Governors would contact should they have any issues or communication difficulties with the Council.

The Chairman thanked Mr Pride who had fulfilled this role for the previous

three years and had been helpful and supportive. The report was NOTED. CoG 013/14 Report from NREC Meeting on 14 January 2014 The Chairman reported that everything discussed at the NREC meeting would

be discussed as part of the part 1 or part 2 agenda of this meeting. The report was NOTED.


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CoG 014/14 Revised Governors Meeting Schedule for 2014 (Paper I) Mr Beswick presented the report and it was noted that a further revision would

be required with the introduction of Governor Clinical Presentation, which would affect meetings of NREC. A revised schedule would be presented to the next meeting. ACTION: MB

The report was NOTED. CoG 015/14 Update on Trust Position re Francis Report Mr Smits presented his report and detailed the work undertaken at the Trust

following the publication of the Francis Report. He reported that a Francis Action Plan had been introduced and he detailed the key focus areas, which included clinical staffing, governance and a refresh of the Poole Approach.

Mr Smits reported that on 19 November 2013 the Government had published

its response in a report named Hard Truths. Mr Smits noted that this report was long and commended the easy read document which provided an excellent overview and was available online. The new recommendations were detailed by Mr Smits. It was noted that the Quality, Safety & Performance Committee and the Board of Directors would be following up on the contents of the Hard Truths Report and the Francis Action Plan.

The Chairman asked if Governors could support the Trust with this work and Mr Smits reported that a mock inspection would take place later in the year and it would be valuable to have Governors included as part of the group. It was agreed that invitations would be issued when the detail was known.

ACTION: MSm The report was discussed; particularly the requirement to publicise staffing

level by ward. The report was NOTED. CoG 016/14 Integrated Trust Performance Report Month 5 (Paper J) The Chief Executive presented the report which detailed the position on key

performance targets until the end of November 2013. He noted that, as predicted, the Trust was now operating at a small financial deficit which was being managed by non-recurring funds. It was also noted that the cash position was now projected to be approximately £8 million at the end of the year. Mr Bown reported that work with the Clinical Commissioning Group and the 2014/15 contract was ongoing.

Clinical performance remained good and the quarter three Emergency Department targets had been met. Mr Bown noted that exceptional pressures at the start of 2014 would be a challenge for the next quarter. The Trust remained on track to deliver the Clostridium Difficile and MRSA targets. The report was discussed with a particular focus on how busy the hospital had been and the issues and challenges across the health community relating to delayed discharges.

The report was NOTED.


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CoG 017/14 Register of Interests (Annual Review) (Paper K) Mr Beswick presented the report and noted that any corrections or changes

should be notified to the Company Secretary Office. It was also noted that the register would be updated to remove Cllr. Adams.

The report was NOTED. CoG 018/14 Reports from Reference Groups Membership Engagement and Recruitment Mrs Yeoman reported that MERG continued its focus on recruiting junior

members with Karen Hollocks, Head of Communication. She detailed the ongoing work and plans to increase the general membership.

The report was NOTED.

Future Plans & Priorities

Mr Purnell reported a meeting had been held on 30 October with Governors and Mr Turner following the decision of the Competition Commission to prohibit the merger. A further meeting had been arranged for 30 January and all were welcome to attend. Mr Spencer noted he would be attending the meeting and it was noted that all Non-Executive Directors had been issued an invitation by Mr Purnell to attend. The report was NOTED.

CoG 019/14 Future Agenda Items

The Chairman reported that the SWAST presentation would be arranged as appropriate and it was agreed that the Council of Governors should keep their focus on the issues currently facing the Trust.

CoG 020/14 Notices of Motion

No notices of motion were received.

CoG 021/14 Urgent Notices of Motion

No urgent notices of motion were received. Mrs Duckenfield reported that she had been a member of the Patient

Information Steering Group for the last five years and would like to stand down. It was agreed that a replacement would be sought and further information made available in the Governor Newsletter.

CoG 022/14 Date of Next Meeting

1 May 2014 at 4.30 in the Board Room, Poole Hospital.


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CoG 023/14 Withdrawal of Press and Public

The Chairman asked any members of the public and representatives of the press to withdraw from the meeting.


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B POOLE HOSPITAL NHS FOUNDATION TRUST

COUNCIL OF GOVERNORS ACTION LIST

1 May 2014

Minute No Meeting Date

Agenda Action Deadline Lead

050/13 25/04/2013 Part 1 Presentation from the Ambulance Service to be a future agenda

item

As

appropriate

Richard King / Chief

Executive

005/14 16/01/2014 Part 1 Link to Monitor's new Code of Governance ato be issued

through the Governors Newsletter

As

appropriate

Company Secretary

010/14 16/01/2014 Part 1 Programme of hospital walkabouts to be included in the next

Governor Newsletter

As

appropriate

Director of Nursing &

Patient Services

011/14 16/01/2014 Part 1 Revised Membership Strategy - report to next meeting of MERG Next MERG Company Secretary

014/14 16/01/2014 Part 1 Revised governors meeting schedule for 2014 to next meeting May Company Secretary

015/14 16/01/2014 Part 1 Invitations for Mock QCQ Inspection to be issued when details

are known

As

appropriate

Director of Nursing &

Patient Services

CoG�May�14�B�Actions.docx

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Meeting Date: 1 May 2014

Agenda Item: 7 Paper No: C

Title:

Outline Proposed Changes to the Constitution

Purpose:

The Council is asked to consider if it wishes to incorporate amendments, as outlined in the attached paper, to the Trust’s Constitution.

Summary:

The changes are presented under the following headings

Removal of a Governor

Disqualification Periods

Miscellaneous

Recommendation:

Council are asked to support the progressing of the outline proposals

Prepared by:

MICHAEL BESWICK Company Secretary

Presented by:


CoG�May�14�C1�Proposed�Changes

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C Poole Hospital NHS Foundation Trust

Council of Governors

Meeting Thursday 1 May 2014

PROPOSED AMENDMENTS TO THE CONSTITUTION

& GOVERNORS CODE OF CONDUCT

Introduction The Council is asked to consider if it wishes to incorporate amendments, as outlined below, to the Trust’s Constitution. These amendments were considered by the Board at its 24 April 2014 meeting. Proposed amendments will come formally to the June 2014 Board meeting and the July 2014 Council of Governors ‘meeting for approval together with any amendments to the Governors’ Code of Conduct Proposed amendments Removal of a Governor The January 2014 Monitor’s Code of Governance provision B.6.6 (slightly amended from previous version D.2.3) says; Where there is any disagreement as to whether the proposal for removal is justified,

an independent assessor agreeable to both parties should be requested to consider

the evidence and determine whether the proposed removal is reasonable or

otherwise.

The Trust does not comply with this part of the code and as required will note such in its Annual Report. The provision raises questions;

In relation to a recent case of a governor ceasing to hold office, there was no proposal to remove as he became disqualified however Monitor are not aware of any distinction in either the Code of Governance or the legislation between removal of a governor from office on the grounds that he/she meets the Trust’s criteria for disqualification and removal from office for any other reason. At what point would it be determined that a Council is considering a proposal for the removal of a governor? What is the nature of ‘any disagreement’? Can a third party process be initiated by another governor/third party? Who would commission and pay for a third party review?

CoG�May�14�C2�Part�1�-�Outline

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C Does any amendment to incorporate this provision need the approval of the membership?

These questions and the process requirements arising from this provision will be considered in more detail by Council in July 2014 Disqualification Periods The constitution refers to differing disqualification periods the column on the right hand side suggests a more consistent approach;

Current Disqualification

Period

Reason Proposed Disqualification

Period

3 years Absent from meetings 6 years

Lifetime Refuses to undertake training 6 years

3 years Resigns from office 6 years

Lifetime Expelled as a governor from another NHS foundation Trust

9 years

3 years

Removed as governor of PHFT 9 years

Whilst such a determination is in place

Vexatious complainant/persistent litigant of the Trust

9 years (from lifting of any such determination)

Lifetime Written warning for verbal/physical abuse to staff

Lifetime

Lifetime CRB (DBS) check revelation Lifetime

Miscellaneous

Re; page 64 2.1 xi) the disqualification in relation to verbal/physical abuse of staff; Add ‘patients, relatives or visitors’ (for reasonableness)

Re; Page 10 add to clause 12.1 (re disqualification) new paragraph 12.1.4. ‘A

person who is subject to an unexpired disqualification order made under the

Company Directors’ Disqualification Act 1986’. (Re Monitor’s Fit and Proper

Persons Test)

Re; Page 105 5.3.3 Executive committee structure to be updated

Re; Page 77 3.1 Notice of public meetings will also be published on the Foundation Trust’s website, in a local newspaper or newspapers circulating in the area served by the Trust and in the Members’ newsletter.The cost of


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C placing adverts results in very few (if any) members of the public attending meetings therefore it is proposed that ’…. in a local newspaper or newspapers circulating in the area served by the Trust…’ be deleted

Proposal It is proposed that the constitution be updated to account for these proposals noting that the bulk of the changes relating to the removal of a governor will probably be presented in an updated Governors’ Code of Conduct. These two amended documents will be presented for approval to the Board and Council in June 2014 and July 2014 respectively.


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Agenda Item: 8 Paper No: D

Title:

Governors Meeting Schedule for 2015

Purpose:

To approve the 2015 Governors meeting schedule

Summary:

The attached schedule for approval sets out the meetings for Council for 2015

Recommendation:

Council approve the 2015 meeting schedule

Prepared by:

DEAN BURGIS Administrator

Presented by:

ANGELA SCOFIELD Chairman

CoG�May�14�D1�Governors�2015�M

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COUNCIL OF GOVERNORS MEETING SCHEDULE 2015

NREC Clinical

Presentation Pre Meeting

Briefing CoG

BoD/CoG Development

Session

BoD Governor Briefing

CoG Development

AMM

January 14/01/15 1.00pm

14/01/15 2.00pm

Lecture Theatre*

14/01/15 3.15pm

14/01/15 4.30pm

--- 28/01/15 5.00pm

--- ---

February --- --- --- --- --- 26/02/15 5.00pm

--- ---

March --- --- --- --- 11/03/15 4.00pm

26/03/15 5.00pm

--- ---

April 30/04/15 1.00pm

30/04/15 2.00pm

Board Room

30/04/15 3.15pm

30/04/15 4.30pm

--- --- --- ---

May --- --- --- --- --- 28/05/15 5.00pm

TBC ---

June --- --- --- --- 10/06/15 4.00pm

25/06/15 5.00pm

--- ---

July 30/07/15 1.00pm

30/07/15 2.00pm

Lecture Theatre*

30/07/15 3.15pm

30/07/15 4.30pm

--- --- --- ---

August --- --- --- --- --- 27/08/15 5.00pm

--- ---

September --- --- --- --- 09/09/15 4.00pm

1/09/15 5.00pm

TBC TBC

October 29/10/15 1.00pm

29/10/15 2.00pm

Board Room

29/10/15 3.15pm

29/10/15 4.30pm

--- --- --- ---

November --- --- --- --- --- 26/11/15 5.00pm

--- ---

December --- --- --- --- 16/12/15 10.00am

With lunch --- --- ---

Red Text- TBC All meetings in Board Rooms unless stated otherwise *Members to Attend

CoG�May�14�D2�CoG�Meeting�Sche

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CHAIRMANS MEETING SCHEDULE WITH COUNCIL 2015 TBC

Chair/CE meeting Staff Governors

Chair meeting with DC & LG

January

February

March

April

May

June

July

August

September

October

November

December

Red Text- TBC


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COUNCIL OF GOVERNORS REFERENCE GROUP MEETING SCHEDULE WITH COUNCIL 2015 TBC

Governor Training &

Development Reference Group

Membership Engagement &

Recruitment Group

Future Plans and Priorities

Reference Group

January

February

March

April

May

June

July

August

September

October

November

December


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Agenda Item: 9 Paper No: E

Title:

Reappointment of the Chairman of the Trust

Purpose:

To recommend the reappointment of the Chairman of the Trust

Summary:

Mrs Angela Schofield’s term of office as Chairman of the Trust is due to expire on 15 May 2014

The attached paper asks that the Nominations Remuneration and Evaluation Committee (NREC) recommend to the Council of Governors that it approves the reappointments of Mrs Angela Schofield for a further period of three years until 15 May 2017:

As the meeting of NREC is on the 1 May 2014 the recommendation from NREC will be made orally to Council.

Recommendation:

To approve the recommendation from NREC on the reappointment of Mrs Angela Schofield.

Prepared by:


Presented by:

GUY SPENCER Senior Independent Director

CoG�May�14�E1�Part�1�-�Chairma

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E

Poole Hospital NHS Foundation Trust

1 May 2014 Meetings of the

Nominations Remuneration and Evaluation Committee (NREC)

And The Council of Governors

Joint Report on the Reappointment of the Chairman

Background The Chairman’s current tenure ceases on 15 May 2014. Mrs Angela Schofield is willing to be reappointed for a further three year term of office. Monitor’s Code of Governance The following are extracts from Monitor’s Code of Governance in relation to the reappointment of chairman/non-executive directors B.2.13 The governors are responsible at a general meeting for the appointment, re-appointment and removal of the chairperson and the other non-executive directors. B.7.a. All non-executive directors should be submitted for re-appointment or re-election at regular intervals. B.7.1. In the case of re-appointment of non-executive directors, the chairperson should confirm to the governors that following formal performance evaluation, the performance of the individual proposed for re-appointment continues to be effective and to demonstrate commitment to the role. B.7.4 Non-executive directors, including the chairperson should be appointed by the council of governors for the specified terms subject to re-appointment thereafter at intervals of no more than three years and subject to the 2006 Act provisions relating to removal of a director. Reappointment of the Chairman In accordance with B.2.13 and B.7a it will for the governors to re-appointment the chairman after a three year term of office In the spirit of B.7.1, the Senior Independent Director, following:

the Chairman’s 2011/12 and the 2012/13 formal performance evaluations

discussions with the chairman ahead of the formal 2013/14 performance evaluation

informal discussions with board colleagues

informal discussions with the Deputy Chairman of Governors and the Lead Governor

…. Is able to confirm to governors that Mrs Angela Schofield continues to be effective and to demonstrate commitment to the role as Chairman


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E In accordance with B.7.4 the proposed reappointment will be for a period of 3 years from 16 May 2014 to 15 May 2107 The current job description for Chairman is attached (Annex 1). If the reappointment is not approved by the council of Governors the Trust will move to secure the appointment of a new chairman. (Outline timetable attached Annex 2) Recommendations

1. The Recommendation for NREC is that NREC proposes to the Council of Governors the reappointment of Mrs Angela Schofield as Chairman

2. The Recommendation for The Council of Governors is that the proposal from

NREC is accepted and the Council approves the reappointment of Mrs Angela Schofield for a further three year term of office commencing 16 May 2014


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E

ANNEX 1

JOB DESCRIPTION Job Title Chairman Commitment: 2.5 days per week Remuneration: £40,000 LEADERSHIP

Providing coherent leadership to the Trust including, in conjunction with the Chief Executive, representing the Trust to patients, members, suppliers, Government, MPs, fellow NHS bodies, regulators, the media and wider stakeholders.

Providing leadership to the Board of Directors in setting the strategic direction of the Trust and ensuring their effectiveness in all aspects of their role.

Setting the agenda, style and tone of Board discussions to promote effective decision making and constructive debate, ensuring Directors are fully informed about all issues on which the Board will have to make a decision and that the agenda is forward looking, concentrating on strategic matters and allows time for discussion of complex contentious issues.

Ensuring effective and constructive relations are established and maintained between Executive Directors, Non-Executive Directors and Governors.

Building an effective and complementary Board of Directors and with the Nomination Committee, initiate change and succession planning of Non-Executive Directors, subject to Governor approval.

Ensure the continued improvement in quality and calibre of Executives.

Identify the development needs of the Board of Directors as individuals and as a whole, to enhance the overall effectiveness as a team (this will include taking responsibility for, in conjunction with the Board, identifying and addressing the Chair’s own personal development).

Ensure the performance of the Board of Directors is evaluated at least annually, acting on the results of that evaluation by recognising strengths and addressing weaknesses of individuals/the Board.

STRATEGY

Provide leadership to the Council of Governors and the Board of Directors, ensuring their effectiveness in all aspects of their role and agenda.


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E

Provide vision to the Trust to capitalise on the freedoms it enjoys as a result of its status and to ensure the long term sustainability of the Trust.

Work with Board members in developing and promoting the Trust’s vision, values, aims and strategic objectives, delivering a robust and sustainable business and financial plan, challenging conventional approaches and driving change forward when needed.

Proactively direct and manage major Board decisions and their development, ensuring that ‘due process’ has been applied at all stages of decision making and full and complete consideration has been given to all options during the process.

Lead and direct work within the Trust with other Non-Executives, the Chief Executive and other Executive Directors.

Review and evaluate present and future opportunities, threats and risks in the external environment and current and future strengths, weaknesses and risk to the Trust.

Develop a close and constructive working relationship with the Chief Executive and Director of Finance providing support and guidance whilst respecting Executive responsibility individually and as a team.

HUMAN RESOURCES

Support, encourage and where appropriate ‘mentor’ other Board members and senior Executives.

Arrange the regular evaluation of the performance of the Council of Governors and the Board of Directors, their Committees and individual Directors and facilitate the effective contribution of Non-Executive Directors, Directors and Governors and ensure constructive relations

Take responsibility, in conjunction with the Board, for own personal development and ensure that this remains a priority.

OPERATIONS

Take responsibility for ensuring that the Board monitors the progress of the business against the planned objectives.

Use general management and leadership ability and personal knowledge of the community to guide and advise on the work of the Board of Directors and Governors of the Trust.

Ensure that the Board establishes clear objectives to deliver the agreed plans and meet the terms of its authorisation and regularly review performance against these objectives.

Plan and conduct Board meetings, in conjunction with the Chief Executive.

Encourage the best use of resources including the development of effective risk and performance management processes.

Share and use relevant expertise with senior managers and clinicians in a changing healthcare environment.

Promote appropriate processes and procedures to deliver high standards of professional, clinical, administrative and personal behaviours across the Trust.

Be aware of and understand relevant regulatory and central Government policies.


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E

Comply at all times with the Trust’s published health and safety policies, in particular by following agreed safe working procedures and reporting incidents using the Trust’s risk reporting systems.

COMMUNICATION AND RELATIONSHIPS

Ensure effectiveness and constructive dialogue and promote harmonious relations with the following bodies as relevant:

o Board of Directors; o Council of Governors; o Stakeholders in the Trust’s community o National healthcare stakeholders o Regulators such as Monitor and the Healthcare Commission

Ensure the provision of accurate, timely and clear information to Directors and Governors, so that within the boundaries of probity, good governance and risk, the Trust meets all its statutory objectives and remains within the terms of its authorisation.

Participate fully in the work of the Board of Directors and Governors and maintain appropriate links with the Chief Executive and individual Directors, as well as with the wider local and national health and social care community.

Develop high level relationships with key stakeholders, including the Trust’s financiers, but ensuring that the interests of all stakeholders are fairly balanced at all times.

Bring balance to the use and influence of external advisors.

Represent the Trust’s views with national (eg; Foundation Trust Network), regional or local bodies or individuals and ensure that the views of a wider range of stakeholders are considered.

Uphold the values of the Trust, to be an appropriate role model and to ensure that the Board promotes equality and diversity for all its patients, staff and other stakeholders.

Be an ambassador for the Trust, be knowledgeable and aware of local issues, and assist the Trust in its efforts to support local regeneration as a major employer.

Set an example on all policies and procedures designed to ensure quality of employment. Staff, patients and visitors must be treated equally, irrespective of gender, ethnic origin, age, disability, sexual orientation, religion, etc.

GOVERNORS

Chairing Board of Governors and its formal committees, other ad hoc meetings and the Annual Member Meetings of the Foundation Trust.

Ensuring that new Governors participate in a full, formal and tailored induction programme, facilitated by the Company Secretary.

Ensuring, in conjunction with the Company Secretary, that the development needs of the Council of Governors are identified and met.

COMPLIANCE


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E

Ensure that the Foundation Trust applies with its Terms of Authorisation, the Constitution and other applicable legislation and requirements.

With the assistance of the Company Secretary, promote the highest standards of corporate and clinical governance in compliance with the NHS Foundation Trust Code for Governance and other regulatory requirements and best practice, where appropriate.

Maintain the financial viability of the Trust, controlling and reporting on financial affairs in accordance with the requirements set out by the Independent Regulator of NHS Foundation Trusts (Monitor).

Ensure and build constructive relationships with Monitor, and other healthcare inspectorates and regulators.

Ensure and maintain clinical and environmental hygiene to assure robust infection control standards.

MISCELLANEOUS

Uphold the highest standards of integrity and probity, adhering to the Nolan Principles.

Safeguard the good name and reputation of the Trust.

Act as a Trustee of charitable funds when appropriate.


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E

PERSON SPECIFICATION The successful candidate will have a significant track record of leadership, change management and personal achievement in a complex environment in either the private or public sector. S/he is likely to have had Non-Executive Director experience and ideally Chair experience, and possess most or all of the following: Essential Experience and Skills

Highly credible with experience of leading an organisation with significant budgets or complexity gained in the private or public sector;

Held a Chief Executive/Managing Director/Director or equivalent post in a large and successful organisation with a substantial turnover;

Significant track record of leadership with a highly trained workforce including managing a team of multi-disciplinary managers or professionals;

Experience of operating in a regulated environment;

A portfolio of high level organisational and governance skills including strategic planning, financial management, risk management, organisation performance management and service delivery and development;

Politically savvy with an astute grasp of relevant issues underpinned by an understanding of developing partnerships and building relationships with other organisations;

Evidence of high level business acumen with a track record of achievement in a challenging, competitive and market driven business environment;

Experience of achieving change management and transformation in a complex organisation;

Understands the environment in which the Foundation Trust operates and the respective roles of the Chief Executive and the Executive Team in bringing this strategy into operation.

Desirable Experience

An understanding of the NHS and Foundation Trusts is desirable as is experience of working with multi stakeholders and/or involvement in community projects.


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E

Personal Qualities

Strong interpersonal skills – calm under pressure, able to challenge in a constructive manner, develop creative solutions, manage a wide variety of situations in a meeting and ensure that the outcomes are in the best interest of the organisation;

Commitment to and interest in the local health economy as well as a desire to contribute to the local community and the values and principles of the NHS;

Strong financial and business acumen and the intellectual rigour to understand complex issues and risk quickly;

An enthusiastic, enquiring mind, with the confidence to challenge constructively,;

Recognise the importance of supporting collective decisions and of balancing challenge with support;

Strong communication and listening skills, able to draw out the skills and experience of others;

The ability to work with a wide range of individuals and organisations and build productive relationships;

Fully supportive of the principals of Foundation Trusts/Membership organisations;

Strong commitment to public service values of accountability, openness, probity and equality of opportunity;

Commitment to the ongoing process of Board development;

Ability to dedicate sufficient time to the role;

On the electoral register or willing to have local residency and appear on the electoral register.


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E ANNEX 2

New Appointment Outline Timetable (HR to confirm with NREC)

If the reappointment is not approved by the Council of Governors

Date 2014 Action

May Extraordinary NREC meeting (or electronically facilitated) to agree advert and Job Description and required capabilities

May Advert placed in the Echo, on the Trust Website and sent to local organisations

End June Closing date for applications (Letters with supporting CVs)

Late June Applications sent to NREC members with short listing papers

Late June NREC members return short listing papers

Late June Invitations to short listed candidates sent

Late June Interview questions agreed (electronically facilitated)

July Interviews held and recommendations agreed taking into account the views of the board of directors

31 July Council of Governors to receive the proposal of the recommended candidate for appointment for approval


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Agenda Item: 10 Paper No: F

Title:

Reappointment of a non-executive director of the Trust

Purpose:

To recommend the reappointment of a non-executive director

Summary:

Mr Nick Ziebland’s term of office as non-executive is due to expire on 30 August 2014

The attached paper asks that the Nominations Remuneration and Evaluation Committee (NREC) recommend to the Council of Governors that it approves the reappointments of Mr Nick Ziebland for a further period of three years until 30 August 2017:

As the meeting of NREC is on the 1 May 2014 the recommendation from NREC will be made orally to Council.

Recommendation:

To approve the recommendation from NREC on the reappointment of Mr Nick Ziebland.

Prepared by:


Presented by:

ANGELA SCHOFIELD Chairman

CoG�May�14�F1�Part�1�-�NED�(NZ

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F


1 May 2014 Meetings of the

Nominations Remuneration and Evaluation Committee (NREC)

And The Council of Governors

Joint Report on the Reappointment of a Non-Executive Director

Background Mr Nick Ziebland’s current tenure ceases on 30 August 2014. He is willing to be reappointed for a further three year term of office. Monitor’s Code of Governance The following are extracts from Monitor’s Code of Governance in relation to the reappointment of chairman/non-executive directors B.2.13 The governors are responsible at a general meeting for the appointment, re-appointment and removal of the chairperson and the other non-executive directors. B.7.a. All non-executive directors should be submitted for re-appointment or re-election at regular intervals. B.7.1. In the case of re-appointment of non-executive directors, the chairperson should confirm to the governors that following formal performance evaluation, the performance of the individual proposed for re-appointment continues to be effective and to demonstrate commitment to the role. B.7.4 Non-executive directors, including the chairperson should be appointed by the council of governors for the specified terms subject to re-appointment thereafter at intervals of no more than three years and subject to the 2006 Act provisions relating to removal of a director. Reappointment of a Non-Executive Director In accordance with B.2.13 and B.7a it will for the governors to re-appointment the chairman after a three year term of office In accordance with B.7.1, the Chairman, following…:

Mr Ziebland’s 2011/12 and the 2012/13 formal performance evaluations

discussions with the Mr Ziebland ahead of the formal 2013/14 performance evaluation

informal discussions with board colleagues

informal discussions with the deputy chairman of governors and the lead governor

…. Is able to confirm to governors Mr Nick Ziebland continues to be effective and to demonstrate commitment to the role as a non-executive director.


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F

In accordance with B.7.4 the proposed reappointment will be for a period of 3 years from 31 August 2014 to 30 August 2017 The current job description for a non-executive director is attached. (Annex 1) If the reappointment is not approved by the Council of Governors the Trust will move to secure the appointment of a new non-executive director. An outline timetable is attached. (Annex 2) Recommendations

1. The Recommendation for NREC is that NREC proposes to the Council of Governors the reappointment of Mr Nick Ziebland as non-executive director.

2. The Recommendation for The Council of Governors is that the proposal from

NREC is accepted and the Council approves the reappointment of Mr Nick Ziebland as non-executive director a further three year term of office commencing 31 August 2014


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F ANNEX 1

Job Description

Job title: Non-Executive Director

Commitment: minimum 3 days per month (some additional hours may needed in the course of the annual cycle in order to fully support the Board agenda)

LEADERSHIP

Providing leadership to specific Trust Committees and ensuring their effectiveness in all aspects of governance, process and assurance. Setting agendas to promote effective decision making and constructive debate; concentrating on key matters and allows adequate time for discussion and review of complex contentious issues.

Ensuring your own personal leadership style is highly effective and constructive and promotes positive working relationships with fellow Board members and wider stakeholders

STRATEGY

Input and fully support the strategic agenda and objectives, maintain knowledge and work effectively with the senior team in a support, challenge and assurance role as a member of the non-executive team.

Work coherently with the Board team to capitalise on the freedoms it enjoys as a result of its status and to ensure the long term sustainability of the Trust.

Work with Board members in developing and promoting the Trust's vision, values, aims and strategic objectives, delivering a robust and sustainable business and financial plan, challenging conventional approaches and driving change forward when needed.

Proactively operate as a member of the Board team in the decision making process and that full and complete consideration has been given to all options during the process.

Review and evaluate present and future opportunities, threats and risks in the external environment and current and future strengths, weaknesses and risk to the Trust.

HUMAN RESOURCES

Develop a close and constructive working relationship with the Chairman, Executive and Non-Executives - providing support and guidance in areas of particular expertise and knowledge.

Support, encourage and where appropriate 'mentor' senior team members in areas of particular expertise and knowledge.

Take responsibility, in conjunction with the Chairman, for own personal development and ensure that this remains a priority.


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F ANNEX 1

OPERATIONS

Take an active and effective role in ensuring that the Board monitors the progress of the business against the planned objectives.

Use leadership ability and personal knowledge of the community to advise and support colleagues and key work programmes – particularly in areas of personal strength and knowledge

Take an active and effective role as a member of the Board to establish clear objectives to deliver the agreed plans and meet the terms of its authorisation and regularly review performance against these objectives.

Encourage the best use of resources and the development of effective risk and performance management processes.

Promote appropriate processes and procedures to deliver high standards of professional, clinical, administrative and personal behaviours across the Trust.

Be aware of and understand relevant, regulatory and central Government policies.

Comply at all times with the Trust's published health and safety policies, in particular, by following agreed safe working procedures and reporting incidents using the Trust's risk reporting systems.

COMMUNICATION AND RELATIONSHIPS

Be an ambassador for the Trust; be knowledgeable and aware of local issues, and assist the Trust in its efforts to support local regeneration as a major employer.

Uphold the values of the Trust, to be an appropriate role model and to ensure as a Board member you promote equality and diversity for all its patients, staff and other stakeholders.

Ensure effectiveness and constructive dialogue and promote harmonious relations with the following bodies as relevant:

o Board of Directors o Council of Governors o Stakeholders in the Trust's community o National healthcare stakeholders o Regulators such as Monitor and the Healthcare Commission

Ensure the provision of accurate, timely and clear information to Directors and Governors as a member of the Board so that within the boundaries of probity, good governance and risk, the Trust meets all its statutory objectives and remains within the terms of its authorisation.

Participate fully in the work of the Board of Directors and where appropriate with the wider local and national health and social care community.

Develop high level relationships with key stakeholders, ensuring that the interests of all stakeholders are fairly balanced at all times.

Set an example on all policies and procedures designed to ensure quality of employment. Staff, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc.


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F ANNEX 1

COMPLIANCE

As a member of the Board ensure that the Foundation Trust applies with its Terms of Authorisation, the Constitution and other applicable legislation and requirements.

As a member of the Board promote the highest standards of corporate and clinical governance in compliance with the NHS Foundation Trust Code for Governance and other regulatory requirements and best practice, where appropriate.

Maintain the financial viability of the Trust, controlling and reporting on financial affairs in accordance with the requirements set out by the Independent Regulator of NHS Foundation Trusts (Monitor).

Ensure and maintain clinical and environmental hygiene to assure robust infection control standards.

MISCELLANEOUS

Uphold the highest standards of integrity and probity, adhering to the Nolan Principles.

Safeguard the good name and reputation of the Trust. Act as a Trustee of charitable funds (where appropriate).


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F ANNEX 1

Person Specification

The successful candidate will have a proven track record of leadership, change management and personal achievement in a complex environment in either the private or public sector. S/he is likely to have had Non-Executive Director experience and possess most or all of the following:

Essential Experience and Skills

Highly credible with experience of operating at senior level within an organisation with significant budgets/complexity gained in the private or public sector;

Held an Executive/Director or equivalent post in a large, complex and successful organisation with a substantial turnover;

Proven track record of high calibre leadership and delivery – both in an executive capacity and also, ideally, operating as a Non-Executive Director or Trustee

Significant track record of leadership with a highly trained workforce including managing a team of multidisciplinary managers or professionals;

Experience of operating in a regulated environment; A portfolio of high level organisational and governance skills including such

things as strategic planning, financial management, risk management, organisational performance management and service delivery and development;

Politically astute – able to grasp relevant issues underpinned by an understanding of developing partnerships and building relationships with other organisations;

Experience of achieving change management and transformation in a complex organisation;

Understands or has the ability to quickly and effectively grasp the environment in which the Foundation Trust operates

Desirable Experience

Clinical or healthcare leadership experience An understanding of the NHS and Foundation Trusts is desirable as is

experience of working with multi stakeholders and/or involvement in community projects.

Personal Qualities

You must be on the electoral register in Dorset, or willing to have local residency and appear on the electoral register

An enquiring mind, with the confidence to challenge constructively; Recognise the importance of supporting collective decisions and of balancing

challenge with assurance and support; Strong communication and listening skills Strong interpersonal skills - calm under pressure, able to challenge in a

constructive manner, develop creative solutions, manage a wide variety of


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F ANNEX 1

situations in a meeting and ensure that the outcomes are in the best interest of the organisation;

Commitment to and interest in the local health economy as well as a desire to contribute to the local community and the values and principles of the NHS;

Strong financial and business acumen and the intellectual rigour to understand complex issues and risk quickly;

The ability to work with a wide range of individuals and organisations and build productive relationships;

Fully supportive of equal opportunities and minority interests; Supportive of the principles of Foundation Trusts/Membership organisations; Strong commitment to public service values of accountability, openness, probity

and equality of opportunity; Ability to dedicate sufficient time to the role as outlined in the contract for service

END


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FANNEX 2

New Appointment Outline Timetable (HR to confirm with NREC)

If the reappointment is not approved by the Council of Governors

Date 2014 Action

May Extraordinary NREC meeting (or electronically facilitated) to agree advert and Job Description and required capabilities

May Advert placed in the Echo, on the Trust Website and sent to local organisations

End June Closing date for applications (Letters with supporting CVs)

Late June Applications sent to NREC members with short listing papers

Late June NREC members return short listing papers

Late June Invitations to short listed candidates sent

Late June Interview questions agreed (electronically facilitated)

July Interviews held and recommendations agreed taking into account the views of the board of directors

31 July Council of Governors to receive the proposal of the recommended candidate for appointment for approval


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Agenda Item: 12 Paper No: G

Title:

Revised Governors Meeting Schedule for 2014

Purpose:

To receive the updated Governors meeting schedule for 2014

Summary:

The meeting schedule has been updated to accommodate the new clinical presentations which are to take place at 2.00pm on the days the council formally meets

Recommendation:

Council are recommended to receive the updated Governors meeting schedule for 2014

Prepared by:

DEAN BURGIS Administrator

Presented by:


CoG�May�14�G1�Revised�Governor

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COUNCIL OF GOVERNORS MEETING SCHEDULE 2014

NREC Clinical

Presentation Pre Meeting

Briefing CoG

BoD/CoG Development

Session

BoD Governor Briefing

AMM

January 14/01/14 11.00am

--- 16/01/14 3.15pm

16/01/14 4.30pm

--- 30/01/14 5.00pm

Chair of A&G ---

February --- --- --- --- --- 27/02/14 5.00pm

---

March --- --- --- --- --- 27/03/14 5.00pm

Chair of QSPC ---

April --- --- --- --- --- 24/04/14 5.00pm

---

May 01/05/14 1.00pm

01/05/14 2.00pm

01/05/14 3.15pm

01/05/14 4.30pm

--- 29/05/14 5.00pm

---

June --- --- --- --- 11/06/14 2.30pm

26/06/14 5.00pm

---

July 31/07/14 1.00pm

31/07/14 2.00pm

Education Centre*

31/07/14 3.15pm

31/07/14 4.30pm

--- --- ---

August --- --- --- --- --- --- ---

September --- --- --- --- --- 25/09/14 5.00pm

Chair of FIC

25/09/14 TBC

October 30/10/14 1.00pm

30/10/14 2.00pm

30/10/14 3.15pm

30/10/14 4.30pm

--- --- ---

November --- --- --- --- --- 27/11/14 5.00pm

Chair of WFC ---

December --- --- --- --- 17/12/14

Development AM & lunch

--- ---

Red Text- TBC All meetings in Board Rooms unless stated otherwise *Members to Attend

CoG�May�14�G2�CoG�Revised�2014

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CHAIRMANS MEETING SCHEDULE WITH COUNCIL 2014

Chair/CE meeting Staff Governors

Chair meeting with DC & LG

January --- ---

February --- 27/02/14 4.15pm

Chair's Office

March 11/03/13 11.00am CE Office

---

April --- ---

May --- TBC PM

Chair's Office

June 03/06/13 11.00am CE Office

---

July --- TBC

Chair's Office

August --- ---

September 09/09/13 11.00am CE Office

25/09/14 4.15pm

Chair's Office

October --- ---

November --- 27/11/14 4.15pm

Chair's Office

December 02/12/13 11.00am CE Office

---

Red Text- TBC


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COUNCIL OF GOVERNORS REFERENCE GROUP MEETING SCHEDULE WITH COUNCIL 2014

Governor Training &

Development Reference Group

Membership Engagement &

Recruitment Group

January --- ---

February --- ---

March --- ---

April 24/04/14 3.45pm

03.04/14 5.15pm

May --- ---

June 26/06/14 3.45pm

---

July --- 03/07/14 5.15pm

August --- ---

September 25/09/14 3.45pm

---

October --- 16/10/14 5.15pm

November --- ---

December --- ---


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Agenda Item: 13 Paper No: H

Title:

Board and Council Disputes Procedure

Purpose:

To receive the procedure to resolve disputes between the Board Of Directors and the Council Of Governors

Summary:

There are informal mechanisms to resolve and disputes between the Board of Directors and the Council of Governors. Normally a matter would be referred to the Chairman of the Trust who may engage the support of the Senior Independent Director and the Deputy Chairman of Governors. Following such a referral the parties should attempt to negotiate a settlement in good faith. If the matter is in relation to law, power or authority of one of the parties and cannot be resolved it will become a matter for this procedure

Recommendation:

Council is asked to receive the procedure to resolve disputes between the Board Of Directors and the Council Of Governors

Prepared by:


Presented by:


CoG�May�14�H1�Board�and�Counci

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H Poole Hospital NHS Foundation Trust

Council of Governors Meeting 1 May 2014

DISPUTE RESOLUTION PROCEDURE

FOR DISPUTES BETWEEN THE BOARD OF DIRECTORS AND THE COUNCIL OF GOVERNORS Introduction 1.1 There are informal mechanisms to resolve and disputes between the Board of Directors and the Council of Governors normally a matter would be referred to the Chairman of the Trust who may engage the support of the Senior Independent Director and the Deputy Chairman of Governors. Following such a referral the parties should attempt to negotiate a settlement in good faith. Formal dispute resolution procedure 1.2 Where such a dispute, between the Board of Directors and the Council of Governors, is in relation to law, power or authority of one of the parties and cannot be resolved in accordance with Condition 1.1, the dispute may, by agreement between the relevant parties, be referred to mediation in accordance with Condition 1.3. 1.3 The procedure for any such mediation shall be as follows:

1.3.1 A neutral person, being an *accredited mediator, (the "Mediator") shall be chosen by agreement between the two parties. Alternatively, either party may within seven days from the date of the proposal to appoint a mediator, or within seven days of notice to any party that the chosen mediator is unable and unwilling to act, apply to the Centre for Dispute Resolution ("CEDR") to appoint a Mediator. 1.3.2 The parties shall within seven days of the appointment of the Mediator agree a timetable for the exchange of all relevant and necessary information and the procedure to be adopted for the mediation. If appropriate, the parties may at any stage seek from CEDR guidance on a suitable procedure. 1.3.3 All negotiations and proceedings in the mediation connected with the dispute shall be conducted in strict confidence and shall be without prejudice to the rights of the parties in any future proceedings. 1.3.4 All information (whether oral or in the form of documents, tapes, computer disks etc) produced for, during, or as a result of, the mediation will be without prejudice, privileged and not admissible as evidence or discoverable in any litigation or arbitration relating to the dispute. This does not apply to any information which would in any event have been admissible or discoverable in any such litigation or arbitration. 1.3.5 The Mediator's reasonable fees and other expenses of the mediation will be borne by the Foundation Trust. The Foundation Trust will bear the reasonable costs and expenses of the participation in the mediation.

CoG�May�14�H2�Part1�BoD�and�Co

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H 1.3.6 If the parties reach agreement on the resolution of the dispute that agreement shall be reduced to writing and shall be binding upon the relevant parties. 1.3.7 For a period of ninety days from the date of the appointment of the Mediator, or such other period as the parties may agree, neither party may commence any proceedings in relation to the matters referred to the Mediator. 1.3.8 If the parties are unable to reach a settlement at the mediation and only if both parties so request and the Mediator agrees, the Mediator will produce for the parties a non-binding recommendation on terms of settlement. This will not attempt to anticipate what a court might order but will set out what the Mediator suggests are appropriate settlement terms in all of the circumstances. Such opinion shall be provided on a without prejudice basis. 1.3.9 Subject to Conditions 1.3.6 and 1.3.7, should either party decide to pursue the dispute in a court, the Foundation Trust shall not be liable for any of the costs or expenses in relation to such proceedings.

This procedure does not restrict a governor’s to act under Section 14A of the Constitution, namely; 14A. COUNCIL OF GOVERNORS – REFERRAL TO THE PANEL

14A.1 In this Clause, the Panel means a panel of persons appointed by Monitor to which a governor of an NHS foundation trust may refer a question as to whether the trust has failed or is failing:

14A.1.1 to act in accordance with its constitution, or 14A.1.2 to act in accordance with provision made by or under Chapter 5 of the 2006 Act. 14A.2 A Governor may refer a question to the Panel only if more than half of the members of the Council of Governors voting approve the referral.

Recommendation The Council is asked to receive this procedure. *Accredited with either the Law Society or the Civil Mediation Council

CoG�May�14�H2�Part1�BoD�and�Co

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COUNCIL of GOVERNORS


Agenda Item: 15 Paper No: I

Title:

2013/14 Annual Report of the work of the Nominations, Remuneration and Evaluation Committee

Purpose:

To receive the 2013/14 Annual Report of the Nominations, Remuneration and Evaluation Committee

Summary:

The 2013/14 Annual Report on the work of the Nominations, Remuneration and Evaluation Committee is attached.

Recommendation:

To receive the 2012/13 Annual Report of the work of the Nominations, Remuneration and Evaluation Committee

Prepared by:

Company Secretary’s Office Presented by:


CoG�May�14�I1�NREC�2013-14�Ann

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1

I 2013/14 ANNUAL REPORT OF WORK OF THE COUNCIL OF GOVERNORS’

NOMINATIONS, REMUNERATION AND EVALUATIONS COMMITTEE

1. INTRODUCTION

1.1 The council of governors is required to establish a committee consisting of all or some of its members to assist in carrying out the specified functions relating to the appointment of the chair and non-executive directors; the review of the structure, composition and performance of the board; and the remuneration of the chairman and non-executive directors. The committee is chaired by the trust chairman, and comprises two public members, one nominated member, and one staff member. Members during 2013/14 were the trust chairman and:

Kris Knudsen (elected clinical staff governor)

James Pride (elected governor for Poole constituency)

Elizabeth Purcell (elected governor for Poole constituency)

Ann Stribley from June 2013 (appointed governor for Poole Borough Council) 2. MEETINGS 2.1 During the period 1 April 2013 to 31 March 2014 the Committee met three times.

3. MEMBERSHIP AND ATTENDANCE

Name

Constituency Type of

Membership

Meetings

19 A

pril 2

01

3

28 J

uly

201

3

26 S

epte

mb

er

201

3

14 J

anu

ary

201

4

Mrs Angela Schofield

Chairman

Mr Guy Spencer (In attendance)

Senior independent director

x

Cllr Ann Stribley Poole Borough Council

Appointed x

Ms Kris Knudsen Clinical staff Elected 3 years

x

Mr Jamie Pride Poole Elected 3 years

x

Mrs Elizabeth Purcell

Poole Elected 3 years

X


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2

4. BUSINESS FOR THE COMMITTEE DURING 2013/14:

On 19 April 2013 the Committee considered:

The Annual Council of Governors Assessment of Collective Performance

Annual Report of the work of the Nominations, Remuneration and Evaluation Committee

Future re-appointment or appointment of Non-Executive Directors (J Lang, M Mitchell and Y Moores)

Absent Governors

On 28 July 2013 the Committee considered:

The 2012/13 Annual Appraisal of Chair and Non-Executive Directors

Remuneration and allowances for Chair and Non-Executive Directors payable from 1 April 2013 for recommendation to the Council of Governors for approval

On 26 September 2013 the Committee considered:

The Future Reappointment or Appointment of Non-Executive Directors On 14 January 2014 the Committee considered:

The Non-Executive Director Reappointments or New Appointments

The Future Reappointment or New Appointment of the Chairman & Non-Executive Directors

Review the Chairman/Non-Executive Appraisals Process for 2013/14 Evaluation

Review Terms of Reference of NREC

NREC Transitional Arrangements for Tenure of Membership

Review NREC Governance Cycle

Absent Governor

During 2013/14, on the recommendation of the NREC, the council of governors approved:

The chairman’s and non-executive directors’ remuneration and allowances.

The processes for the annual appraisal of the Chairman and non-executives

The re-appointment of five Non-Executive Directors (J Lang, M Mitchell and Y Moores, I Marshall and G Spencer)

Produced by the Company Secretary’s Office on behalf of the Chairman


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Agenda Item: 17 Paper No: J

Title:

Planned Non Executive Review.

Purpose:

Approve the proposals for the planned and progressive refreshing of non–executive directors.

Summary:

Monitor’s Code of Governance B.7.a notes that the council of governors should ensure planned and progressive refreshing of the non-executive directors. The attached paper seeks to make three changes to the team of non-executive directors over a period of 13 months (November 2013 to December 2015)

Recommendation:

Council approve the proposals for the planned and progressive refreshing of non-executive directors.

Prepared by:


Presented by:


CoG�May�14�J1�Part�1�-�Planned

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J


Council of Governors

1 May 2014 Meeting

Report on the Planned and Progressive Refreshing of Non –Executive Directors

Background The content of this paper is somewhat predicated by the decisions made today on the reappointment of the chairman and a non-executive director. Monitor’s Code of Governance B.7.a notes that the council of governors should ensure planned and progressive refreshing of the non-executive directors. Update There are currently three non-executive directors who have taken up a one year extension to their previous six year terms;

Dame Yvonne Moores tenure extended to 31 October 2014

Mrs Jean Lang tenure extended to 30 November 2014

Mr Guy Spencer tenure extended to 24 April 2015 Given the significant changes in the executive director team a sensible and planned approach may be to look for change over an eighteen month period. This has been discussed with each of the three non-executive directors and a timetable considered acceptable by the individuals is;

November 2014 -A new non-executive director would commence at the end of Dame Yvonne Moores tenure

November 2014 Mrs Lang’s tenure extended for a further year

April 2015 - A new non-executive director would commence at the end of Mr Guy Spencer’s tenure.

December 2015 – A new non-executive director would commence at the end of Mrs Jean Lang’s tenure.

Monitor’s Code of Governance In making new non-executive director appointments (possibly with external advice) the governors should pay attention to Monitors Code of Governance including;

Ensuring a formal, rigorous and transparent appointments procedure.

Making appointments on merit against objective criteria with due regard for the benefits of diversity


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J Ensuring an appropriate board balance of skills and experience

Meeting the “fit and proper persons test”

Reviewing the current skills, knowledge and experience of the board

Preparing a description of the role and required capabilities

Taking into account the views of the board of directors Review of the Current Skills, Knowledge and Experience of the Board The current Board comprises of seven independent non-executive members including a non-executive chairman and six executive members including four mandatory posts (chief executive, medical director, director of nursing and director of finance) and two non-mandatory posts (chief operating officer and a director of strategy). The director of strategy post is vacant and will be reviewed by the new chief executive. The backgrounds of the non-executives include accountancy, law, clinical, commercial, regulatory, engineering and senior NHS management experience. Given the current skills knowledge and experience of the board it is important that the clinical background lost from the board at the end of Dame Yvonne Moores’ tenure be addressed. For the first proposed new appointment in November 2014 the Council of Governors is asked to ensure that the appointee has suitable clinical knowledge and experience. New Non-Executive Director Appointment for November 2014 1 Recruitment Process and Procedure The Council of Governors Nominations Recruitment and Evaluation Committee (NREC) is supported in the recruitment procedures and processes by the HR directorate who may seek external support It is for NREC to ensure a formal, rigorous and transparent appointments procedure by;

Planning a timely appointment (outline timetable see 2 below)

Preparing a description of the role and required capabilities

Ensuring the “fit and proper persons test” is met

Taking into account the views of the board of directors

Proposing to the Council of Governors an appointment on merit against objective criteria with due regard for the benefits of diversity

2 New Appointment Outline Timetable (HR to confirm with NREC)

Date 2014 Action

1 May(papers by 24/4)

NREC meeting (or electronically facilitated) to agree advert and Job Description and required capabilities

Late May Advert placed in the Echo, on the Trust Website and sent to local organisations

Mid-June Closing date for applications (Letters with supporting CVs)


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J Mid-June Applications sent to NREC members with short listing papers

Mid-June NREC members return short listing papers

Early July Invitations to short listed candidates sent

Early July Interview questions agreed (electronically facilitated)

Mid July Interviews held and recommendations agreed taking into account the views of the board of directors

31 July(papers by 24/7)

Council of Governors to receive the proposal of the recommended candidate for appointment for approval

Or

Date 2014 Action

June Extraordinary NREC meeting (or electronically facilitated) to agree advert and Job Description and required capabilities

July Advert placed in the Echo, on the Trust Website and sent to local organisations

Early September Closing date for applications (Letters with supporting CVs)

Early September Applications sent to NREC members with short listing papers

Mid-September NREC members return short listing papers

Mid-September Invitations to short listed candidates sent

Mid-September Interview questions agreed (electronically facilitated)

Early October Interviews held and recommendations agreed taking into account the views of the board of directors

30 October Council of Governors to receive the proposal of the recommended candidate for appointment for approval

The Further Two New Non-Executive Director Appointments The above recruitment approach for the proposed November 2014 non-executive director appointment together with any learning will be used for the non-executive director appointments planned for;

April 2015

December 2015 Recommendation Council approve the proposals for the planned and progressive refreshing of non –executive directors. MJB 2014


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1



Agenda Item: 19 Paper No: K

Title: Integrated Performance Report

Purpose: To report on performance against key indicators for the Trust in March 2014.

Summary:

Financial Performance The Trust achieved a surplus for the year of £0.1m after charging a fixed asset impairment of £0.8m. The operating surplus for the year was £0.9m which is in line with the forecast outturn notified to Monitor. Additional income has been received in the year to offset the additional costs of transformation and PbR excluded drugs (primarily chemotherapy drugs). Clinical Performance & Quality

The Monitor A&E metric (95% within 4 hours) was not delivered in March (94.53%), giving a Quarter 4 performance of 94.00% RTT standards for admitted and non-admitted clock stops were met for March at aggregate level. Stroke performance was achieved in March. The Breast Screening access targets were achieved for all 4 metrics. There were no Mixed Sex Accommodation (MSA) breaches in March. There was 1 C-Diff case identified in March, the year to date total is now therefore 10 which is within the planned level for the year of 19. The MRSA year to date total for 2013-14 remains two, following the identification of a case in January 2014. The national DM01 diagnostic target from referral to examination was met as less than 1% of patients (0.9%) were waiting more than six weeks at month end. All but one of the Monitor cancer standards have been confirmed as achieved in February, which the most recently published reporting period available. It is anticipated that all targets have been met in March and the fourth quarter. Fractured Neck of Femur (NoF) targets were not met in March.

The monthly delayed discharges snapshot for March was 3.33%.

CoG�May�14�K�1�2�IPR�March�201

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2

Recommenda

tion:

For discussion and noting.

Prepared by: KATE THOMAS Performance Manager

Presented

by:

Director of Finance Chief Operating Officer HR Director


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3

INDEX

Page No

1. Executive Summary

4

2. Performance Scorecard

6

3. Performance Summary

8

4. Operations Summary

12

5. Workforce Scorecard

18

6. Quality Indicator Dashboard

20

Appendices Appendix 1 ~ Referral To Treatment (RTT) Exception Report

22

Appendix 2 ~ Emergency Department Professional Standards Exception Report

24

Appendix 3 ~ Diagnostic Access Times

25

Appendix 4 ~ Appointment Slot Issue (ASI) Exception Report

27

Appendix 5 ~ Trauma Exception Report

29

Appendix 6 ~ Day Theatre Services Exception Report

31

Appendix 7 ~ Cancer Waiting Times Exception Report 34


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4

1. EXECUTIVE SUMMARY ~ MARCH 2014

FINANCE 1.1 The Trust achieved a surplus for the year of £0.1m after charging a fixed asset impairment of

£0.8m. The operating surplus for the year was £0.9m which is in line with the forecast outturn notified to Monitor. Additional income has been received in the year to offset the additional costs of transformation and PbR excluded drugs (primarily chemotherapy drugs).

WORKFORCE

1.2 The Trust workforce metrics are rated as follows:

Avoidable Staff Turnover (overall) at 0.81% in March, (10.53% year end) rated green. Promotion, relocation and work-life balance were the most frequently cited reasons by staff on leaving the Trust

Avoidable Staff Turnover (Auxiliaries and HCA) at 1.54% in March, (year end 17.47%) red rated. Ongoing support is provided to this staff group in terms of recruitment, training and development, with the support of senior nursing staff and management. Work is on-going by the Education Directorate to devise and roll out a HCA development programme to support this staff group and aid retention.

Staff sickness was reported as 3.77% in March, (3.63% year end) rated amber. The year end rate is the third lowest since the introduction of ESR in 2007. The inter-organisation comparator group now consists of 34 direct health providers in the south and south west. This now excludes CCGs. Poole remained 7th in the latest 12 month data comparison with a rate of 3.63%. The average sickness rate for the whole group was 4.01%. A local benchmark shows an average rate of 3.88% which highlights the Trust's continued excellent performance in this area.

1.3 Compliance with the annual appraisal process for non-medical staff (as recorded on ESR) fell

by 3% in March to 69% (compared to February). Much time and effort has been expended by the HR team, working with Managers to raise the level of compliance and this will continue.

1.4 Demand for temporary nurse staffing rose to its highest monthly level in the year in March.

Some recourse to agency staff is required due to the volume of requests for temporary staffing and in addition opening new beds and the winter ward in order to support patient care. On average, 26 additional beds were opened each day in March, and the daily number of requests for bank and agency nurses was 111. Work continues to ensure Agency spend is carefully managed and is only used in exceptional circumstances.

OPERATIONAL HIGHLIGHTS

1.5 The Trust achieved the targets for admitted RTT clock stops (94.6% against 90% target) and

non-admitted RTT (96.2% against 95% target) clock stops, at aggregate level in March. 1.6 7 out of 8 Monitor cancer standards have been confirmed as achieved in February. 1.7 There were no Mixed Sex Accommodation (MSA) breaches in March. 1.8 During the three month period ended January 2014, (the latest information available from the

Dr Foster information service) the overall hospital standardised mortality rate (HSMR) for the Trust was 84.3, well within the target of 100.

1.9 The Breast Screening target was achieved for all 4 targets monitored in March.


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5

1.10 100% of patients in the Bowel Screening Programme were offered a diagnostic screening appointment within 14 days in March. In addition, the programme continued to meet (100%) of the target stating that all patients must be offered a Specialist Screening Nurse Practitioner clinic appointment within 14 days of their positive FOB test result.

1.11 Main theatre utilisation was achieved at 86% against a target of 85%..

1.12 Stroke performance was achieved in March.

1.13 The DM01diagnostic target of no more than 1% of patients waiting more than 6 weeks for examinations was achieved. The total number of patients waiting for diagnostic exminations at the end of March was 42 compared to 123 in February.

1.14 The National Target for formal Delayed Transfers of Care (DToC) was achieved in March with 3.33 % delayed transfers of care (target < 3.5%).

1.15 The response rate to the Friends and Family Test in March was 25.22% (CQUIN target ≥ 20%). This represents an improving position.

1.16 OPERATIONAL EXCEPTIONS

1.17 The Monitor A&E metric (95% within 4 hours) was not achieved in March (94.53%) or in Q4 2013/14 (94.00%).

1.18 RTT targets were met at aggregate level however at speciality level the non-admitted target was not achieved for the following specialties against a target of 95%:

Urology (92.3%)

Trauma &Orthopaedics (87.8%)

Ophthalmology (91.7%)

Oral Surgery (94.5%)

Elderly (86.4%)

1.19 The Monitor target of ≤ 62 days wait for urgent GP referral to treatment for all cancers was not met in February. 83.7% of accountable patients started treatment ≤ 62 days from receipt of urgent referral (Monitor target ≥ 85%). The CCG target of ≤ 62 days wait for first treatment from consultant upgrade for all cancers’ was not met in February. The Trust achieved 84.6% of accountable patients starting treatment ≤ 62 days from date of Consultant upgrade (CCG target ≥ 90%).

1.20 The local Appointment Slot Issue (ASI) target (with an associated financial penalty, the Trust

risks fines for every week >10%) was not achieved during March at 27%. 1.21 The two 36 hour targets for Fractured Neck of Femur patients were not achieved in March

75% achieved against a target of ≥ 90%(within 36 hours of admission), and 85% achieved against a target of ≥ 95% (within 36 hours of being deemed clinically appropriate for surgery).

1.22 Day Theatre reached 79% utilisation for March 2014 this represents a sustained improvement

but was below the target of 80%. 1.23 There was 1 C-Diff case identified in March, the year to date total is now therefore 10 which is

within the planned level for the year of 19. 1.24 The MRSA year to date total for 2013-14 remains two, following the identification of a case in

January.


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6

1.25 There were 7 SUIs identified in February; 6 of these were reported within the prescribed timescale.

1.26 Average bed occupancy in March was 98%, and did not meet the internal target of 95%.


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7

Year End

Target /

LimitMar-12 Mar-13 Jan-14 Feb-14 Mar-14

current

or YTD

Actual

YTD

Target /

LimitForecast

Jan-00

PATIENT EXPERIENCE

meeting the C-Diff objective (month on month) 19 24 27 2 2 1 ↑ 10 19 1.0

meeting the MRSA objective (month on month)no longer Monitor target w ith effect from 1st October 2013 =<1 1 4 1 0 0

↑2 =<1 0.0

MSA occurances 0 0 1 0 0 0 ↔ 0 0

MSA patients 0 0 5 0 0 0 ↔ 0 0

Family & Friends test - % response rate 20% 17.5% 19.7% 25.2% ↑Family and Friends % reported extremely likely to recommend to a

family member 83% 80% 80%↔

80%

VTE (target 90% to Mar 2013, 95% from Apr 1203) 95% 93.00% 96.30% 95.40% 97.30% ↑ 97.3% 95%

CLINICAL QUALITY

Dr Foster Mortality relative risk rating (3 month rolling) 100% 78.0 101.0 84.3 ↑ 84.3 100%

All deaths - actual as % of expected (Dr Foster) 100% 88.8% 102.4% 72.3% ↑ 72.3% 100%

HSMR deaths - actual as % of expected (Dr Foster) 100% 94.3% 101.3% 75.3% ↑ 75.3% 100%

Number of SUIs reported within appropriate timeframe (ytd) 12 19 51 54 60 ↓ 60

Number of Serious Untoward Incidents (SUIs) for the year to date 12 20 51 54 61 ↓ 61

ACCESS AND TARGETS

Referral to waiting time (weeks) for admitted (95th centile) 23.0 21.3 17.1 17.9 17.0 18.6 ↓ 18.6 -

Referral to waiting time (weeks) for non-admitted (95th centile) 18.3 17.0 16.7 16.6 17.0 17.1 ↓ 17.1 -

Referral to treatment (18 weeks) for admitted 90% 92.5% 98.0% 95.6% 95.6% 94.6% ↓ 94.6% 90% 1.0

Referral to treatment (18 weeks) for non-admitted 95% 96.6% 97.2% 96.7% 96.6% 96.2% ↓ 96.2% 95% 1.0

Referral to waiting time (18 weeks) for incomplete pathways 92% 93.5% 97.5% 96.9% 97.1% 97.0% ↓ 97.0% 92% 1.0

Maximum 62 day wait from referral to treatment for all cancers 85%

90.1%

qtr 92.2%

87.4%

qtr 89.3%85.7% 83.70% ↓ 83.70%

85%

62 day wait for 1st treatment - consultant screening service 90%

100%

qtr 98.2%

100%

qtr 100% 89.50%93.3% ↑ 93.3% 90%

62 day wait for 1st treatment following consultant decision to upgrade

the priority of the patient (all cancers) 90% -100.0% 100.0% 84.6% ↓

84.6% 90%-

31 day wait for 2nd or sub treatment : Anti cancer drug treat 98%

100%

qtr 100%

100%

qtr 100%100.0% 100.0% ↔ 100.0% 98%

31 day wait for 2nd or sub treatment : Surgery 94%

97.9%

qtr 98.8%

100.0%

qtr 98.9%94.3% 100.0% ↑ 100.0% 94%

31 day wait for 2nd or sub treatment : Radiotherapy 94%

99.3%

qtr 99.6%

100.0%

qtr 98.2%98.8% 100.0% ↑ 100.0% 94%

31 days wait decision to start of 1st treatment: All cancers 96%

100%

qtr 98.8%

99.2%

qtr 99.3%98.7% 100.0% ↑ 100.0% 96% 1.0

2 week wait from urgent GP referral to 1st appt (susp cancer) 93%

95.8%

qtr 96.3%

97.3%

qtr 99.3%96.5% 96.2% ↓ 96.2% 93%

2 week wait for Symptomatic Breast Patients 93%

100%

qtr 96.1%

88.7%

qtr 93.5%94.9% 100.0% ↑ 100.0% 93%

percentage of patients within the 4 hour target 95% 96.11%

93.28%

qtr 94.85% 93.69% 93.64%

94.53%

qtr 94.00% ↑94.53%

qtr 94.00% 95%1.0

Total time in A+E (95th centile) =< 4 hours 3hrs 59 4hrs 29 4hrs 38 4hrs 34 4hrs 37 ↓ 4hrs 37 =< 4 hours

Time to initial asessement (95th centile) =< 15 mins 12 21 22 24 23 ↑ 23 =< 15 mins

Time to treatment decision (median) =< 60 mins 67 62 60 63 71 ↓ 71 =< 60 mins

Unplanned reattendance rate =< 5% 2.83% 2.50% 2.00% 2.40% ↓ 2.40% =< 5%

Left without being seen =< 5% 3.35% 3.10% 2.50% 2.59% 2.30% ↑ 2.30% =< 5%

RT

T

2012-13 2013-14

cancer

1.0

2. TRUST PERFORMANCE SUMMARY

Year To Date

March 2014

Dire

ctio

n #

Monitor

targets &

weightings

2011-12

1.0

1.0

A&

E


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8

Year End

Target /

Limit

Mar-12 Mar-13 Jan-14 Feb-14 Mar-14

current

or YTD

Actual

YTD

Target /

Limit

Forecast

Diagnostic patients waiting more than 6 weeks

(DM01 investigations only) <= 1% 31 2 182 114 32↑

32 0

% waits more than 6 weeks for DM01 diagnostic investigations <= 1% 0% 0% 4.55% 2.93% 0.86% ↑ 0.86% <= 1%

Elective Access - rebooking 0 1 1 0 0 0 ↔ 0 0

Patients who spend at least 90% of their time on a stroke unit 80% 68% 82% 81% 77%

=>80%

(tbc)↑ =>80%

(tbc) 80%

Higher risk TIA cases who are treated within 24 hours 60% 70.6% 43% 63% 63% 60%

Outpatient Access : ASIs at =< 4% 4% 8% 27% 10% 20% 27% ↓ 27% 4%

Screening to normal results within 14 days90%

96.8% 90.0% 98.0% 98.0%

=>90%

tbc

=>90%

tbc 90%

Screening to assessment in 21 days - screening to 1st appt offer90%

94.8% 97.0% 97.0% 94.0%

=>90%

tbc

=>90%

tbc 90%

Screening to assessment in 21 days - screening to attended appt90%

92.2% 92.0% 93.0% 91.0%

=>90%

tbc

=>90%

tbc 90%

round length 90% of eligible woman screened within 36 months 90%99.2% 99.0% 98.9% 97.7%

=>90%

tbc

=>90%

tbc 90%

Delayed transfers of care to be maintained at a minimal level 3.5% 6.18% 2.44% 3.86% 4.53% 3.33% ↑ 3.33% 3.5%

Hip fractures who are medically fit for surgery receive treatment within

36 hours95% - 96% 96% 95% 85% ↓ 85% 95%

Hip fractures within 36 hours of admission (NHFD) 90% - 74% 86% 87% 75% ↓ 75% 90%

Other trauma inpatients (fit for surgery) receive treatment within 48 hrs95% 96% 98% 95% 93% 95% ↑ 95%

95%

OPERATIONAL EFFICIENCY

Theatre Utilisation - Main 85% 87.0% 87.0% 84.5% 87.0% 86.0% ↓ 86.0% 85%

Theatre Utilisation - Day (target 85% to Mar 2013, 80% from Apr 2013) 80% 74.0% 74.0% 75.7% 79.0% 79.0% ↔ 79.0% 80%

Day Case Rates (basket of 25) 75% 83.5% 78.7% 82.2% ↓ 82.2% 75%

Bed Occupancy 95% 96% 98% 100% 100% 98% ↑ 98% 95%

WORKFORCE INDICATORS

Staff Turnover (Overall) <=11% 0.92% 1.05% 0.75% 1.01% 0.81% ↑ 10.63% <=11%

Staff Turnover (Auxiliaries and HCAs) <= 13.5% 1.54% 0.62% 0.97% 1.36% 1.54% ↓ 17.47% <= 13.5%

Absence <=3.5% 3.85% 3.57% 4.08% 4.04% 3.77% ↑ 3.63% <=3.5%

FINANCE & ACTIVITY

Cash balance 15.4 15.0 8.9 9.9 10.1 10.1 11.60 10.0

Income 195.10 19.00 17.50 17.80 20.10 210.4 186.50 208.5

Operating Expenditure -182.20 -18.00 -16.40 -16.70 -18.57 -198.0 -175.30 -196.0

EBITDA 12.30 0.80 0.90 0.90 1.35 10.0 9.20 10.0

EBITDA % 6.3% 4.4% 5.2% 5.2% 6.8% 4.8% 5.0% 4.9%

Surplus/Deficit 1.00 -0.10 0.20 0.10 -0.10 0.1 0.20 0.9

SLA over / (under) performance 0.8 0.3 3.0

CIP 0.2 0.2 3.90 4.1

Financial Risk rating - current 3 3 2 2 2 2 3 2

Financial Risk rating - revised 3 4 4 4 4 4 4 4

2011-12

Dire

ctio

n #

Year To Date

Monitor

targets &

weightings

2012-13

# : Arrow direction indicates improvement ↑, deterioration ↓, or no change ↔ in performance since the previous month

access

bre

ast s

cre

en

traum

a a

ccess

2013-14


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9

3. PERFORMANCE SUMMARY

Month Twelve – March 2014

Key Issue Summary RAG Sch

Monitor Targets

Monitor standards for months eleven and twelve.

RTT

The Trust achieved the targets for admitted clock stops (94.6% against 90% target) and non-admitted (96.2% against 95% target) clock stops, at aggregate level in March. The incomplete pathways target was achieved, (97.0% against 92% target).

Performance against both the admitted and non-admitted target has declined again this month. For some specialities this relates to increased demand, for others capacity issues are a factor and for some specialities both elements are affecting performance. Profiles of specialties affected are being drawn up to identify underlying problems.

Cancer

Two of the Monitor cancer standards were not achieved in February, the most recent reporting period available. The 62 day wait for 1st treatment for urgent GP referral to treatment and 62 day wait for first treatment from consultant upgrade achieved 83.7% against the target of 85%, and 84% against a target of 90% respectively.

Ensuring patients are ready willing and able at the time of referral, remains a priority, and continues to be pursued with the Commissioner and GPs.

Emergency Department

The Monitor A&E metric (95% within 4 hours) was not delivered in Quarter 4 (94.0%) or March (94.53%) for the fourth consecutive calendar month. Performance is improving but achieving the target on a daily or weekly basis remains a challenge for a number of reasons including patient flow, bed capacity and acuity of patients.

C-Diff

There was 1 C-Diff case identified in March, bringing the year to date total to 10, well within the target of 19.

Risk Assessment Framework (RAF)

The Risk Assessment Framework has now replaced the Compliance Framework used by Monitor (with effect from 1

st October 2013). The

several key changes that relate to performance, include the following:

All cancer targets are now weighted as 1.0;

MRSA has been removed;

The risk rating calculation is no longer a purely transparent quantitative process in that a variety of reports (e.g. CQC) will also be taken into account in addition to weighting scores.

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ED Quarterly Performance Monitoring

Monitor have now redefined the quarterly reporting period for ED from three calendar months to 13 weeks as reported in weekly SITREPS, and all quarterly figures quoted from Quarter 3 now apply this definition.

Patient Experience

The Patient Experience scorecard is comprised of six key indicators; one of these is part of the Monitor scorecard.

C-Diff

See Monitor section

MRSA

The MRSA year to date total for 2013-14 is now two, since a further cases were identified in January. This metric is no longer part of the monitor framework (RAF), but would still be subject to Monitor scrutiny in the event of an outbreak or sudden increase in cases. Action: Infection Control issues remain under continued scrutiny DoN/Infection Control.

Mixed Sex Accommodation (MSA)

There have been no occurrences of mixed sex accommodation (MSA) breaches in March.

Venous Thromboembolism (VTE)

VTE performance for March was 97.30%, an improvement on previous months.

Friends and Family Test The response rate to the Friends and Family Test in March was 25.22% (CQUIN target ≥ 20%). This represents an improving position.

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Clinical Quality

The Clinical Quality scorecard is comprised of five key indicators (3 relate to Mortality and 2 to SUIs), none of which are part of the Monitor scorecard. For the most recent year to date position (January 2013/ March 2014) there are red rated indicators relates to SUIs only.

Mortality

During the three month period ended January 2014, (the latest information available from the Dr Foster information service) the overall hospital standardised mortality rate (HSMR) for the Trust was 86.6, well within the target of 100, and an improvement on the previous month.

Mortality performance for December 2013 has been green rated as both the overall and HSMR number of deaths was less than the expected level calculated by Dr Foster.

The Mortality group will continue to ensure that; o cases with a zero or very low co-morbidity rating are

reviewed; o deaths are reviewed by clinicians; o pneumonia remains under scrutiny.

Serious Untoward Incidents

There were 7 SUIs identified in March of which 6 were all reported within the prescribed timescale. (Figures reported prior to August are not comparable with those reported in subsequent months.)

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Access and Targets

The Access and Targets scorecard is comprised of 22 key indicators.

RTT

See Monitor section above. An exception report is included in Appendix 1

Cancer

See Monitor section above.

Emergency Department: 4 hour target

See Monitor section above. An exception report is included in Appendix 2, which addresses February performance as the March / Quarter 4 position has not yet been finalised and published.

Diagnostic Access

The DM01 target of no more than 1% of patients waiting more than 6 weeks for examinations was achieved. The total number of patients waiting for diagnostic examinations at the end of March was 42 compared to 123 in February.

An exception report is included in Appendix 3 Breast Screening

The Breast Screening Service achieved all 4 targets for March. Delayed Transfers of Care (Operations Summary Section 4)

The percentage of patients formally delayed on the last Thursday of March 2014 (DH reporting methodology) was 3.33 %.

The focus continues on the reduction of informal delays and all other internal delays in order to further improve inpatient pathways.

Access standards for #NoF and Trauma

The two 36 hour operating target for Neck of Femur (NoF) target were not met in March

An exception report is included in Appendix 6 Stroke

Stroke performance was achieved in March, with more than 80% of patients spending 90% of their stay on a stroke ward.

ASI (Appointment Slot Issues)

ASIs did not achieve the 4% local target (with a potential associated financial penalty for every week >10%) during March (27%).

Actions continue to reduce the level of ASI, targeted at specialty level in the coming months.

An exception report is included in Appendix 5

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Efficiency The Efficiency scorecard is comprised of four key indicators; none of these are part of the Monitor scorecard. For the most recent year to date position (January 2014 / March 2014) there are two red rated indicators which relate to Day Theatre utilisation and bed occupancy:

Theatre Utilisation

Main theatre utilisation (86%) achieved the 85% target in March.

Day theatre utilisation has improved substantially but did not achieve 80% target (79%).

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An exception report is included in Appendix 7

Day case Rates (Basket of 25 procedures)

The day case rate for January was 82.2.0%, achieving the 75% target. This data is extracted from Dr Foster. Bed Occupancy

Average bed occupancy in March was 98%, and did not meet the internal target of 95%.

Workforce Indicators

The Staff Experience Scorecard (See section 5) comprises of eight key measures of HR performance, of note are:

Staff Turnover (overall) at 0.81%, (10.53% year end) rated green

Staff Turnover (Auxiliaries and HCA) at 1.54%, (year end 17.47%) red rated

Staff sickness at 3.77%, (3.63% year end) rated amber

Finance & Activity

The Trust achieved a surplus for the year of £0.1m after charging a fixed asset impairment of £0.8m. The operating surplus for the year was £0.9m which is in line with the forecast outturn notified to Monitor. Additional income has been received in the year to offset the additional costs of transformation and PbR excluded drugs (primarily chemotherapy drugs).

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4. OPERATIONS SUMMARY (For the period of 1

st to 31st March 2014)

4.1 This report summarises various operational aspects year to date. The performance

information relates to actual activity rather than a comparison against contract.

4.2 Total non-elective increased slightly in March as expected, following a similar pattern to previous years. The 2013 -14 outturn compared 2012-13 is showing a slight increase of 1.0%

4.3 The Paediatric non-elective admissions outturn compared 2012-13 is showing a decrease of 0.3%. Activity was excessively high over the summer period in 2012-13, in contrast activity in 2013-14 reduced to normal levels during the summer but high levels of admissions during the winter.

4.4 The number of attendances (including nurse practitioner activity) in the Emergency

Department has increased by 2.2%, compared with 2012-13, with particularly higher number of admissions during quarter 4 .

4.5 Elective Inpatient activity YTD has increased by 3.4% as has the day case rate by 4.0%. 4.6 The number of Maternity admissions year on year has reduced by 17.3%. This reduction

does not reflect reduced activity as it is mainly due to a reclassification of admitted activity to outpatient within the Antenatal Day Assessment Unit.

4.7 Outpatient new attendances YTD show an increase of 6.3% compared to the same period in

2012-13. This follows the trend of increased referrals. 4.8 The variance in Trust activity (YTD) is summarised below

LENGTH OF STAY

4.9 Adult Non Elective average Length of Stay (LOS) for March 2014 was 5.52 days. This shows a decrease of 0.8 days on the previous month, however, the level remains higher than the annual average YTD of 5.4 days.

4.10 The following graph shows monthly comparisons of the average adult non-elective LOS from

April 2011 to date, remaining low over the past 2 month period.

Activity Year to Date

Year to date 12/13

Year to date 13/14

Variance

Adult Non Elective Admissions (Spells) (Inc. emergency & transfers excl maternity)

23,731 23,961 +1.0%

Child Non Elective Admissions (Spells) (Excl maternity and Incl. children under 16)

7,805 7,780 -0.3%

Maternity Admissions (Spells)

10,843 8,969 -17.3%

Emergency Dept. Attendances

59,961 61,310

+2.2%

Elective Inpatient Spells (all ages)

4,038 4,176 +3.4%

Outpatient New Attendances (Adult and Paediatrics)

70,068 74,475 +6.3%


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5.00

6.00

7.00

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

Non-Elective: Adult

Non-Elective - Adult 13/14



4.11 The following graph shows monthly comparisons of the average adult inpatient elective LOS from April 2011 to date. LOS in March 2014 was 3.81 which is above the average for the YTD of 3.5 and marginally lower than in March 2013.

2.00

3.00

4.00

5.00


Inpatient Elective: Adult

IP Elective - Adult 13/14



4.12 The graph below shows the average length of stay for children (elective and non-elective).

0.50

1.00

1.50


LOS - Child

LOS - Child 13/14

LOS - Child 12/13

LOS - Child 11/12

4.13 The graph below shows the average LOS for Maternity. The increase from September 2013

reflects the reclassification of short stay ANDA inpatients as outpatient attendances.

0.00

1.00

2.00

3.00


LOS - Maternity

LOS - Maternity 13/14



increased LoS from sept 13 due to reclassification of short stay ANDA inpatients as outpatient attendances


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4.14 The percentage of time the Trust is in a red bed state is a clear indication of how pressurised the whole system is. The Hospital continued to be in red bed state during March 2014 for 25 days.

0%

25%

50%

75%

100%

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Monthly Bed State: Red, Amber, Green

DELAYED TRANSFERS OF CARE

4.15 The percentage of patients formally delayed on the last Thursday of February 2014 (DH reporting methodology) was 3.33%, within the National target of 3.5%. This is an improvement in performance since last month.

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%


% Delayed Transfers of Care From Acute Beds including Paediatrics

Yr13/14

Yr12/13

Yr11/12

4.16 Delays during March – both as a total of bed days lost to DTOC and the snapshot of patients

delayed at midnight on the last Thursday of the month, as used by NHS England to measure delays.

4.17 The total number of bed days lost during March (442) due to patients waiting for transfer to an alternative provider. This has decreased compared to February 2014 (535).

0

250

500

750

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Total Bed Days Lost (including NHS other - Jan 14 onwards)

TOTAL Delays13/14 (incl NHSother)

TOTAL Delays12/13

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CANCELLATIONS

All Waiting List Cancellations

4.18 The number of Elective admissions cancelled as a percentage of all elective admissions reduced slightly to 16.5% in month compared to 16.5% recorded in February 2014.

4.19 The graph below shows the % of elective admissions cancelled as a % of all elective admissions.

Waiting List cancellations within 1 Day of the TCI (To Come In) Date

4.20 Elective admissions cancelled within a day of their TCI date (subset of the total in the previous paragraph) has remained at 4.2%.

4.21 The graph below shows the % of elective admissions cancelled within 1 day of TCI.

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%


%

month

Elective Admissions cancelled within 1 day of TCI as % of all Elective Admissions

% Elective cancellations <=1 day 13/14





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4.22 The graph below shows monthly numbers of cancelled operations on the day of admission or operation, split by cause.

0

20

40

60

80

100

120

140

160

180


%

month

Elective Admissions cancelled within 1 day of TCI

Elective cancellations(above) <= 1 day13/14



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30

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Cancelled operations per month split by cause

other

no bed

staff sickness

no theatre time

list cancelled

READMISSIONS

4.23 The readmission rate is calculated by dividing the number of discharges that were followed by an emergency readmission within 30 days by total number of discharges (excluding deaths).

4.24 The table below shows the readmission rates by specialty from February 2013 to February

2014

Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14

9.7% 4.3% 4.7% 8.6% 7.4% 5.6% 6.7% 6.3% 10.4% 1.4% 7.8% 6.6% 3.9%

8.8% 11.6% 10.9% 12.0% 8.9% 11.7% 10.3% 11.0% 9.7% 7.4% 10.6% 10.4% 7.2%

9.1% 6.6% 8.9% 5.4% 1.6% 9.5% 6.5% 5.4% 10.8% 2.5% 18.8% 9.7% 6.0%

0.0% 0.6% 1.2% 0.3% 0.4% 0.6% 0.6% 2.3% 1.0% 1.3% 0.6% 1.0% 0.6%

0.8% 0.4% 0.3% 1.5% 1.2% 1.0% 1.3% 1.2% 0.8% 1.1% 1.0% 0.3% 0.4%

5.4% 3.3% 2.0% 2.8% 2.7% 5.9% 2.4% 2.7% 4.9% 2.7% 3.6% 2.1% 5.2%

3.6% 4.4% 2.4% 7.1% 0.0% 9.1% 2.6% 2.1% 5.7% 1.3% 2.8% 0.0% 0.0%

8.0% 8.8% 7.0% 8.0% 10.7% 8.8% 10.6% 8.0% 10.4% 9.3% 12.4% 5.9% 8.2%

5.5% 5.3% 4.6% 6.5% 4.2% 5.3% 5.6% 5.4% 5.8% 8.4% 7.0% 5.4% 5.0%

13.0% 15.0% 15.1% 14.5% 14.6% 11.6% 11.8% 14.6% 10.7% 15.1% 13.6% 14.7% 16.7%

4.7% 3.9% 6.7% 2.4% 5.2% 4.6% 3.2% 1.9% 1.3% 2.2% 3.2% 6.4% 1.5%

0.8% 1.5% 0.4% 0.7% 0.9% 1.0% 2.0% 1.0% 0.9% 2.0% 1.4% 2.1% 0.9%

1.9% 1.7% 2.5% 0.5% 1.2% 1.5% 1.6% 1.2% 1.9% 0.9% 3.2% 2.4% 4.1%

1.2% 1.1% 1.1% 1.6% 3.6% 2.3% 1.0% 1.0% 2.3% 1.4% 2.6% 1.7% 1.5%

3.9% 4.4% 2.2% 0.0% 2.1% 3.8% 2.1% 4.8% 6.2% 3.0% 0.0% 1.5% 1.8%

0.1% 0.1% 0.0% 0.4% 0.5% 0.1% 0.2% 0.0% 0.0% 0.2% 0.2% 0.0% 0.0%

3.8% 4.3% 5.5% 6.9% 4.1% 4.2% 3.5% 5.5% 6.2% 4.8% 3.7% 6.6% 6.7%

1.5% 1.8% 2.2% 0.7% 0.0% 0.0% 3.2% 1.3% 0.0% 0.7% 2.3% 1.9% 2.5%

5.9% 6.3% 6.2% 5.1% 4.4% 4.7% 5.0% 6.5% 4.8% 6.2% 4.2% 3.6% 3.7%

4.5% 4.8% 4.6% 4.8% 4.4% 4.4% 4.4% 4.8% 4.8% 4.8% 5.2% 4.8% 4.9%

Feb-13

CARDIOLOGY

CLINICAL ONCOLOGY

ACCIDENT AND

ACUTE INTERNAL

Discharging Specialty of

First Admission

GENERAL SURGERY

GERIATRIC MEDICINE

GASTROENTEROLOGY

GENERAL MEDICINE

DERMATOLOGY

EAR, NOSE AND THROAT

NEUROLOGY

OBSTETRICS

Max Fax & Oral Surgery

MEDICAL ONCOLOGY

GYNAECOLOGY

HAEMATOLOGY (CLINICAL)

TRAUMA AND

Total

PAEDIATRICS

RHEUMATOLOGY


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4.25 There are significant readmission are being monitored closely by the Directorate teams to ensure safe discharging is in place.


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5. STAFF EXPERIENCE SCORECARD Reporting Month: March 2014


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6. QUALITY INDICATOR DASHBOARD March 2014

6.1 All target/thresholds are marked as a dotted black line.


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APPENDIX 1 ~ REFERRAL TO TREATMENT (RTT) EXCEPTION REPORT

Prepared by: Kate Thomas, Trust Performance Manager Reporting month: March 2014

Summary of Risk: The Monitor Risk Assessment Framework 2013-14 RTT operational standards are: Admitted target: 90% of RTT periods where the patient needs to be admitted (as an inpatient or day case) for their first definitive treatment must be completed within 18 weeks of referral. Non-admitted target: 95% of RTT periods where patients received their first definitive treatment in an outpatient (non-admitted) setting must be completed within 18 weeks of referral. Incomplete target: 92% of patients who have not yet started treatment should have been waiting no more than 18 weeks (patients who have had a clock start but have not had a clock stop). Within the PHFT contract with the CCG, it is expected that each of the main specialties achieves all three targets at specialty level. All remaining ‘sub-specialties’ are grouped together into a category ‘X01’; this category must be achieved at aggregated level.

Current position: The Trust RTT position at the end of March 2014: - Admitted target (90%) 94.6% - Non-admitted target (95%) 96.2% - Incomplete target (92%) 97.0% At aggregate and Unify specialty level, all specialties passed the admitted target for March 2014. The non-admitted target was not achieved for the following unify specialties:

Urology (92.3%)

Trauma &Orthopaedics (87.8%)

Ophthalmology (91.7%)

Oral Surgery (94.5%)

Elderly (86.4%) At the Trust Weekly Performance meeting, monitoring at patient level continues of all patients waiting over 26 weeks for treatment. Reasons for pathway delays are reviewed in more detail with Specialty Managers in addition to this forum.

Actions: Trauma & Orthopaedics (87.8%) The specialty General Manager has been working to clear the T&O backlog and looking ahead, the non-admitted position is likely to remain fragile for some months to come. Orthopaedics has seen a substantial increase (+12%) in outpatient demand over the last year. Urology (93.8%) & Ophthalmology (91.7%) Current indications are that urology non admitted performance will also remain fragile in the months ahead. The urology pathway is one of several that transfer between providers, and both urology and ophthalmology are visiting services. Dialogue will continue with the other providers concerned to review and improve pathways as well as ensure backlogs are sustainably reduced. Oral Surgery (94.5%) The department have undertaken to clear the backlog and the balance between demand and capacity will continue to be monitored. Elderly (86.4%)


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The Elderly specialty usually accrues fewer than 20 non admitted clock stops per month but, in March due to backlog clearance undertaken; this specially has more than 20 clock stops including 3 breaches and is therefore reportable Unify specialty.


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APPENDIX 2 ~ EMERGENCY DEPARTMENT PROFESSIONAL STANDARDS EXCEPTION

REPORT

Prepared by: Martin Smith, Matron/General Manager Reporting month: March 2014

The Position: The 4-hour target for March was not met at 94.53%, giving a Quarter Four performance of 94.00%. The remaining professional standards are monitored on a weekly basis and reported to the Trust’s performance meeting. Whilst the standards do not carry Monitor weighting, they are a key gauge for quality within the department. The final performance for March, previous months and Quarter 4 is outlined below:

Standard Target

Performance in

January 2014

Performance in

February 2014

Performance in

March 2014

Performance in

Q4 2013/14

% of patients seen within 4 hours ≥ 95% 93.69% 93.64% 94.53% 94.00%

Total time in the departmetn 95th percentile ≤ 240 Mins 278 274 267 274

Clinican seen time Median ≤ 60 mins 60 63 71 65

Left without being seen < 5% 2.5% 2.6% 2.3% 2.4%

Time to nurse asssessment ≤ 15 mins 20 24 23 22

Unplanned re-attendance at A&E (all) Between 1% & 5% 6.6% 6.2% 5.7% 6.2% Note: as required by Monitor the quarterly ‘% of patient seen within 4 hours’ is based on the 13 week period 30/12/13 – 30/03/14. All other quarterly data relates to the calendar quarter – 01/01/14 – 31/03/14 Performance is mixed across the range of performance standards. ‘Total time in department’ has significantly favourably decreased and overall performance has improved. The last weekend in March saw significant bed pressures which caused monthly performance to drop from 95.5% to 94.5% over three days.

Current Position and Actions:

Medical staffing has been improved and will continue to improve in the short-term as new registrars and junior

doctors arrive. Work is still on-going to ensure that staff work at the most appropriate times, ensuring

resilience in the event of unusually high attendances.

Action:

An 11-bed extension to Ansty (EAU) was opened to relieve bed pressures.

Two new Consultants will start work in April.

A replacement registrar was found and started work in February.

Changes made to the registrar rota to ensure better coverage and sustainability.

Extra Nurse Practitioner shifts, paid for by the Urgent Care Board, began in late November.

In progress:

Review of medical staffing and rotas to provide maximum cover across the 24-hour period.

Recruitment of more medical staff to ensure continuity and quality.

Implementation of ED Task & Finish Group chaired by the Medical Director.


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APPENDIX 3 ~ DIAGNOSTIC ACCESS TIMES: PATIENTS WAITING IN EXCESS OF SIX WEEKS EXCEPTION REPORT

Prepared by: David Clark, Mandy Tanner, Ian Sprigmore

General Managers for Medicine, Radiology & Gynaecology Reporting month: March 2014

The Risk: 42 examinations in total were waiting more than 6 weeks from referral to diagnostic test at the end of March 2014. The mandated national return that provides waiting list and activity data for a selection of diagnostic examinations (also known as the DM01) is produced and published on the 10

th working day of the month. The

target of less than 1% of patients waiting more than six weeks was met at the end of March. There were 32 examinations waiting over six weeks which represents 0.9% of the DM01 total. This comprised of 11 MRI examinations, 1 non-obstetric ultrasound examination, 2 CT examinations, 10 Endoscopy examinations and 8 echocardiography examinations. This report provides an overview of all breaches of the 6-week target, from referral to all diagnostic tests, not just those tests included in the DM01 statutory return

Current Position: Radiology There were 14 examinations waiting over six weeks at the end of March (107 at the end of February). This is comprised of 1 non-obstetric ultrasound, 11 MRI, and 2 CT examinations. MRI The MR cases consist of 2 patients for spinal scans who delayed their scans, and 8 cardiac scans. The cardiac availability is limited by Cardiologist availability Actions: Cardiologists will now cover their colleagues’ absence and MRI will take priority. Non-Obstetric Ultrasound The non-obstetric ultrasound patient breach was due to a booking error. Actions: Ensure that there is clear understanding of patient status. CT The CT breaches relate to 1 patient and were due to patient choice. Endoscopy There were 18 patients waiting over 6 weeks at the end of March including 8 patients under active surveillance. There were 450 patients on the waiting list as at 31

st March (403 at the end of February) and over 95% of

patients referred to the department are being seen within six weeks.

Actions:

Extra lists were booked for alternate Saturdays throughout the month of March. The need for Saturday working has arisen as a result of the building works in the department to meet JAG accreditation, the impact of Consultant Annual leave in March and an increase in fast track referrals. Without these additional lists the month end breach figure would have been far higher. Building work in the department is scheduled to be completed by 4

th April 2014.


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Neurophysiology There was 1 patient waiting over 6 weeks for Neurophysiology examinations at the end of March. This was a patient requiring admission to the specialist beds for Telemetry on Portland Ward which due to bed pressures was unable to be accommodated. This patient is booked for April. Actions: A system used at Kings in London is being reviewed that will enable low risk patients to have telemetry done at home, this would be supported / funded by the Epilepsy charity and mean that only high risk ie Drug reduction patients would need be admitted. Cardiology There were 8 echocardiography examinations waiting over 6 weeks These were due to patient choice and reduced capacity due to annual leave. Urodynamics There was 1 Gynaecology patient waiting over six weeks for a Urodynamic test at the end of March This patient was originally listed for Urodynamic procedure on 28/11/13, booked for Urodynamics on 13/12/13 and due to UTIs was removed from the waiting list in accordance with clinical advice from the specialist nurse. The patient was re referred for Urodynamics on 10/1/14 per clinical advice that she was clear from UTI’s and booked for 31/1/14. Unfortunately she was unable to undertake the Urodynamics process due to a further UTI and was again removed from the waiting list per clinical advice. Actions: The patient is having cystoscopy and scan booked for 22/2/14, and is out of the country between 25/2/14-22/3/14 and has been rebooked for Urodynamic procedure on 28/3/14


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APPENDIX 4 ~ APPOINTMENT SLOT ISSUE (ASI) EXCEPTION REPORT

Prepared by: Barry Duell/Yvonne Hunter/Toby Mulvey/Ian Sprigmore

General Managers – Medical & Surgical

Reporting Month: March 2014

Appointment Slot Issue (ASI): Trust performance for March was 27%

Summary: Provider to ensure that ‘sufficient appointment slots’ are made available on the Choose and Book system. Standard: <4% slot availability issues. The Trust risks fines for every week >10%.

Current Position: For the month of March 2014, the 10 Specialties with the most ASIs were:

Specialty No. of ASIs Polling Range (Weeks)

Rheumatology 158 12

Orthapaedics – Adult 69 8

ENT 51 6

Gynaecology 46 General 5, Urogynae 8

OMF 45 6

Children’s & Adolescent* 41 Multiple Specialties

Urology 39 10

GI & Liver (Medicine & Surgery 37

Surgery Breast 36 2

Opthalmology 26 8

Actions for March/April 2014:

Rheumatology:

ASI concerns continue to be discussed at performance meetings. CCG remain appraised of continuing impact of 24% increased referral rates on departmental capacity.

Business case agreed to support recruitment into a 10 PA Consultant post. This will be proposed at April HEG. JD with college for approval. A 3 month extension to the current locum contract has been agreed until substantive post commences.

SpR now left. No cover provided by Deanery reflecting national shortage of middle grades. This is being raised and future planning discussed.

ESP cover continues to provide cover for SpR clinics, sessions remain on choose and book.

Agreement to return chronic pain management to community now agreed. Handover of patients on a monthly basis commences in June.

Resignation of Lead Practitioner (Nursing) affecting capacity until new post holder commences in May.

Some additional capacity will be realised with additional session from new post-holder and reduction of repeat injections.

Orthopaedics - Adult:

Adult orthopaedic elective outpatients’ service is overachieving compared with last year by around 7.5% in relation to new patients seen.

In order to reduce ASIs, the waiting times to first appointment and to lower the polling ranges again the specialty is trying to arrange some additional capacity but the availability of suitably experienced medical staff is currently a limiting factor due to the range of sub-specialties covered

The potential expansion of this OPD only elective service to meet local demand is being considered as part of the Directorate’s Transformation Programme.

ENT:

Capacity has become a problem as predicted due to the retirement of a consultant and unsuccessful recruitment of a locum to ‘bridge’ the gap until a substantive post is recruited to.

The current consultant team are picking up additional sessions in the meantime to try and minimise the impact. Additionally an advert is out for a locum specialty Doctor.


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Gynaecology:

As with February there was a lack of capacity for Urogynaecology and gynaecology outpatient slots in March due to annual leave. To provide additional Urogynaecology capacity Mr Hillard has agreed to release outpatient slots on both his and his registrars standard outpatient clinics. This has provided additional capacity for Urogynaecology referrals.

OMF:

There have been a number of clinic cancellations due to annual leave within the polling range. Additional clinics are being put on over the next month to attempt to minimise the ASIs.

*Children’s & Adolescent Services ~ Includes all Children booked into the following Specialties

Surgery 16 ASIs ENT 10 ASIs Opthalomology 9 ASIs Gastroenterology 6 ASIs General Paediatrics (Allergy) 5 ASIs Dermatology 1 ASI Rheumatology 1 ASI

Urology:

Increase in referrals experienced this financial year within this specialty

In relation to new patient seen the specialty is currently performing 7.3 % above last year’s activity for the end of month 10 and 14.7 % above contract

The potential and cost effectiveness of expanding this service to meet local population needs will form part of the Transformation Programme work

GI & Liver:

Loss of some clinic slots due to leave and upcoming Bank Holidays over Easter and during May. This will automatically resolve after this period. After review of capacity extra slots have been opened supported by mid-grade clinics alongside Consultant sessions.

Surgery - Breast:

ASIs have been kept to a minimum during this period and should be more sustainable once the new breast consultant commences in post.

Opthalmology:

ASIs in this specialty largely due to personnel changes implemented by RBCH that have resulted in changes in practice, loss of a small amount of adult capacity and some new slots being used for follow ups. Currently working with RBH to rectify this but at this present time the resource to provide additional adult capacity is not available from RBH.

Loss of some clinic sots due to leave, which is not routinely backfilled, has contributed to the ASI’s again this month.

However, majority of patients treated at first appointment so not causing RTT issues


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30

APPENDIX 5 ~ TRAUMA EXCEPTION REPORT

Prepared by: Yvonne Hunter, General Manager – Trauma & Orthopaedics

Reporting month: March 2014

Target Compliance Level

Exception Report

90% of Fractured Neck of Femur patients operated on within 36 hrs. of admission. (Best Practice Tariff Criteria – internal target set at 90%)

75%

In total 17 patients breached this target. Seven patients

breached due to being unfit upon admission. One of

these patients had a high INR but once fit subsequently

breached the 36 hours from fit target due to changes in

the prioritisation of other patients on the theatre lists.

95% of Fractured Neck of Femur patients operated on within 36 hrs. of being deemed clinically appropriate for surgery.

85%

Ten patients who were deemed fit upon admission did

not go to theatre within 36 hours; the reasons are given

in the breakdown below. All patients have been looked

at in detail and will be reviewed at an MDT meeting – see

actions below.

95% of Trauma patients (excluding NOF’s) operated on within 48 hrs of being deemed clinically appropriate for surgery.

95%

Target achieved.

Breakdown of NOF breaches during March 2014 = 17

Patients not fit pre-op & needed optimising 7

Other trauma cases taking priority 1

Delay in patient being transferred from RBH 1

Awaited specialist surgeon for THR 5

Issues with available kit 1

Volume of NOF’s in 24 Hrs 2


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31

70 8067

82 79 77 74 73 7591 100

7968

0

50

100

150

200

250

300

350

400

450

500

0%

20%

40%

60%

80%

100%

Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

% o

pera

ted

wit

hin

36h

rs o

f ad

mis

sio

n

Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Patients Operated on within 36 hrs 74% 86% 90% 86% 87% 77% 77% 81% 77% 75% 86% 87% 75%

Number of NOF's admitted 70 80 67 82 79 77 74 73 75 91 100 79 68

Number of trauma admissions 363 388 425 432 433 432 414 459 383 421 391 355 358

Patients Operated on within 36 hrs Number of NOF's admitted Number of trauma admissions

Actions:

Despite a lower number of fractured neck of femur patients being admitted in March the Directorate

was non-compliant for at the end of the month against the two targets and as can be seen above

there was a combination of reasons for this. However, the greatest contributing factor was that eight

fractured neck of femur patients were admitted on Saturday 8 March between 08.54 and 11.11 all of

whom would have required surgery on the following day to avoid breaching.

Following detailed analysis of the breaches during the last three months an MDT meeting is being

arranged to review specific patients, the pre-operative pathway to ensure previously agreed

practices are still in place and to agree and implement any further actions required. The date for this

is to be confirmed.

As previously reported the Orthogeriatricians are reviewing the management of fractured neck of

femur patients considered unfit upon admission due to a high INR. The required cohort of 50

patients has been reached and Dr Perry is currently collating the data. Report is awaited.


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32

APPENDIX 6 ~ DAY THEATRE SERVICES EXCEPTION REPORT

Prepared by: Vivian Stevens, Head of Theatres

Reporting month: March 2014

The Risk: Day Theatres is not reaching the 80% target

Current Position: Booked utilisation 86% Expected utilisation 80% Actual utilisation 79% Losses on day of surgery 7% Previous calculations have shown that best achievement for Day Theatres ranges between 80 and 82%. This is based on the number of patients that is reasonable to put on each session which range from 2 patients to 6 patients. Based on these levels of activity it is impossible for every list to achieve 85% as any list with three patients or more is already unable to achieve the target. Working on the potential operating time available for each list based on the number of cases utilisation would be expected: 2 patients excluding team brief and turnaround time – 92% 3 patients - 89% 4 patients – 85% 5 patients – 82% 6 patients – 79% Based on the above matrix utilisation available for March 2014 was 84% Day Theatre achieved 79% utilisation for March 2014 which is the same utilisation as February 2014

Day Theatre

utilisation This quarter(Q4)

Previous quarter

(Q3)

Jan

14

Feb

14

Mar

14

% % % % %

OVERALL 78 76 74 76 79

ENT 80 80 65 80 78

General surgery 88 88 77 88 90

Gynae 78 73 85 73 79

OMF 76 66 70 66 78

Trauma 70 73 72 73 69

RAG rating 80% and above 79% - 76% 75% and below


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33

The table above shows the total utilisation in Day Theatres. There is now a break down by speciality. Comparisions are made quarter on quarter with movement in efficieny shown. There was a decrease in activity in both General Surgery and Trauma this month

4

17 43

9

45

8

37

3

52

9

41

3 47

2 50

5

46

8

37

5

38

7

38

9

45

9

43

2 47

1

35

9

49

9

43

4

43

5 49

6

45

9

31

8

46

5

41

8

0

100

200

300

400

500

600

Nu

mb

er

of

pat

ien

ts

Day Theatre patient activity

13-14

12-13

The graph above shows the number of completed patient episodes. The patient cancellations on the day for March 2014 were 2.1% which is outside the agreed acceptable level of 2%. The was due to a major incident in theatres that resulted in the cancellation of patients as theatres only had 50% capacity available for the rest of the day.

Time lost on day of surgery This quarter (Q4) Previous quarter (Q3)

Jan 14

Feb 14 Mar 14

% % % % %

Patient unfit 1 1.6 1.6 0.5 0

Cancellations/DNA’s 1.3 1.8 1.8 0.7 0.7

Procedure – less time 0.5 0.7 0.7 0.3 0.2

Trauma – no patients waiting 2 1.8 1.1 2.8 4.3

Patient declined surgery 0 0 0 0 0

Operation no longer required 0.5 0.5 0.5 0 0

Session under booked 1.7 1.8 2.3 1.2 1.5

Beds not available 0 0 0 0 0

Clinical/Staff shortages 0 0 0 0 0

Kit availability 0 0 0 0 0

RAG rating ≤ 2% >2%

The table above shows the percentage of time lost across total sessions in Day Theatres as indicated by the reasons on the chart and the movements, month on month and quarter on quarter. - Sessions under booked 4.3% - Trauma numbers for patients suitable for day theatres was exceptionally low this month - There was 1.6 hours lost for DNA and pts who were not fit for surgery compared to 11 hours in January 3 hours in February, many pts cancelling with less than 48 hours notice. The Preassessment Team continue to monitor the outcomes


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34

Actions:

Head of Theatres and Elective Admissions Coordinator have reviewed 12 months data and adjusted

the procedural time for ENT and OMF surgery – note improved output. Now reviewing Gynae and

General Surgery

- Continue to monitor all lists

- continue to monitor all patients not fit for surgery – note improved output for second month in row


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35

APPENDIX 7 ~ CANCER WAITING TIMES - EXCEPTION REPORT

Prepared by: Anne Foulkes

Business & Performance Manager

Reporting month: February 2014

The Risk: the following Cancer Waiting Times targets were breached in February 2014

- 62-Day (Urgent GP Referral To Treatment) Wait For First Treatment: All Cancers

- 62-Days Wait For First Treatment From Consultant Upgrade: All Cancers

Current Position: 62-Day (Urgent GP/GDP Referral To Treatment) Wait For First Treatment: All Cancers

In February, 83.7% of accountable patients started treatment ≤ 62 days from receipt of urgent referral

(MONITOR target ≥ 85%). 12 patients breached the target, equivalent to 8 accountable breaches.

Of the 12 patients who breached, 8 were patients transferred to PHT for first treatment from other Trusts and,

of these, 4 were patients who were referred to PHT after their treatment target date, consequently it was not

possible to avoid breaching the target.

For the remaining 8 patients, factors resulting in a breach of the target were patient choice; complex pathway

including multiple diagnostic tests; waiting for a CT scan; waiting for a biopsy result to be reported.

Current estimates indicate that the target will be met for the both March and the quarter (MONITOR reporting

period) – formal reports will be published 9th May 2014

Actions:

a) In addition to the ongoing tracking of each pathway by the team of Cancer MDT Facilitators, a weekly

discussion between Cancer Managers in each Trust takes place to review all potential cross Trust breaches

with a view to expediting appointments/admissions appropriately in other Trusts

b) Discussions are being held with both Royal Bournemouth and Dorset County Hospitals to jointly review the

Head & Neck and Urology pathways

c) For patients referred to PHT after their 62-day target, attempts have been made to get agreement to full

breach reallocation to the referring Trust. This approach has had little success to date. Using processes

developed elsewhere, notably in the London Cancer Alliance, a formal draft Cancer Reallocation Policy has

been developed based on the guidelines included in the MONITOR Risk Assessment Framework. The CCG

are supportive of this approach and will be involved in discussions with other Trusts to reach agreement

d) Daily email communications are in place with both Radiology and Pathology to expedite

appointments/reporting.

Current Position: 62-Days Wait For First Treatment From Consultant Upgrade: All Cancers

In February, the Trust achieved 84.6% of accountable patients starting treatment ≤ 62 days from date of

Consultant upgrade (CCG target ≥ 90%). 1 patient breached the target, out of a total of 7.5 accountable

patients starting treatment in the month

The patient (breach) was booked for an excision within target but on admission underwent an incisional biopsy

of a skin lesion rather than an excision – this is not classed as a definitive treatment under CWT rules. There

was a long wait for the histology report which confirmed a cancer diagnosis. The patient then had to be

booked for a formal excision of the lesion which was not possible within target


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36

The number of patients treated in this target category each month is very small, typically less than 10 patients.

As a result, in order to achieve the CCG target of ≥ 90%, the Trust cannot, on average, have any more than

0.5 of accountable patient breach in a month.

Current estimates indicate that the target will be met for the both March and the quarter – formal reports will be

published 9th May 2014

Actions:

a) The Skin Cancer MDT Facilitator is now highlighting any incisional biopsy as a priority for reporting with the

Pathology department in cases where there a suspicion of a cancer diagnosis.

b) The pathways for individual patients who are at risk of breaching the target continue to be discussed at the

Weekly Performance meeting with the Chief Operating Officer, Divisional Directors, Directorate Managers and

service leads. Actions are identified to try to avoid patients breaching the target with appointments,

admissions, diagnostic reporting expedited by the relevant senior managers in conjunction with the Cancer

MDT facilitators.


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Agenda Item: 19 Paper No: L

Title:

Monitor: Results of Quarter 3 Monitoring

Purpose:

To provide the Council of Governors with details of Monitors assessment of the Trust’s performance for the third quarter of 2013/14

Summary:

The following documents are attached:

Monitors feedback letter following their assessment of the Trust’s Q3 performance

Monitor’s reporting executive summary for Q3

Recommendation:

The Council is requested to note the attached documents from Monitor

Prepared by:

PAUL D TURNER Director of Finance

Presented by:

PAUL MILLER Director of Finance

CoG�May�14�L1�Q3�Monitor�feedb

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5 March 2014 Mr Chris Bown Chief Executive Poole Hospital NHS Foundation Trust Longfleet Road Poole Dorset BH15 2JB

Dear Mr Bown Q3 2013/14 monitoring of NHS foundation trusts Our analysis of Q3 is now complete. Based on this work, the Trust’s current ratings are:

Continuity of services risk rating - 4

Governance risk rating - Investigation open The Trust’s governance risk rating is under review, which reflects that Monitor is investigating governance concerns at the Trust, triggered by a forecast deterioration in financial performance. As per our letters of 4 June 2013 & 5 June 2013, Monitor is investigating the Trust for a potential breach of its provider licence and the Trust’s governance risk rating will remain under review until such time as Monitor has concluded its investigation and determined what if any regulatory action may be appropriate. Should Monitor decide not to take formal enforcement action, the Trust’s governance rating will revert to Green. Where Monitor decides to take formal enforcement action to address its concerns, the Trust’s governance rating will be Red. In determining whether to take such action, Monitor will take into account as appropriate its published guidance on the licence and enforcement action including its Enforcement Guidance1 and the Risk Assessment Framework2. I have attached a one page executive summary (Appendix 1) of your Trust’s Q3 results for your information and a report on the aggregate performance of the NHS foundation trust sector will shortly be available on our website (in the News, events and publications section) which I hope you will find of interest. For your information, we issued a press release on 21 February 2014 setting out a summary of the key findings across the NHS foundation trust sector from the Q3 monitoring cycle.

1 www.monitor-nhsft.gov.uk/node/2622

2 www.monitor.gov.uk/raf

Wellington House 133-155 Waterloo Road London SE1 8UG T: 020 3747 0000 E: [email protected] W: www.monitor.gov.uk

CoG�May�14�L2�POOLE�1314�Q3�fe

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http://www.monitor-nhsft.gov.uk/node/2622

http://www.monitor.gov.uk/raf


Please note that due to staff changes within the Provider Regulation Department at Monitor, your relationship management team at Monitor has changed as below: Regional Director: Paul Streat (020 3747 0283, [email protected]) Senior Regional Manager: Rachael Shaw (020 3747 0294, [email protected]) Regional Manager: Steve Atkins (020 3747 0558, [email protected]) If you have any queries relating to the above, please contact me by telephone on 020 3747 0294 or by email ([email protected]). Yours sincerely

Rachael Shaw Senior Regional Manager cc: Ms Angela Schofield, Chair Mr Paul Turner, Director of Finance, Information & Estates

CoG�May�14�L2�POOLE�1314�Q3�fe

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mailto:[email protected]




Key risks Action taken / committed Gaps and residual concerns

Financial viability

• The Trust wrote to Monitor in April 2013 stating that the Trust is unable

to achieve the level of savings needed or grow its income to remain

viable as a standalone organisation.

• The Trust is working with commissioners to negotiate funding to support

the Trust during 2014/15.

• The Board is considering the Trust’s latest detailed 2014/15 plans and

expects further information to be incorporated in the coming weeks.

• The Trust has appointed a Turnaround Director and has commissioned a

external consultancy to review the Trust’s financial baseline, case mix

and service line analysis, and potential for future savings through

benchmarking and other methods.

• The Trust has a shortfall in recurrent CIPs of £0.7m in the

year-to-date.

• At Dec 2013, the Trust was forecasting a year-end cash

position of £8m (£3m below the original plan).

• The Trust will need to ensure that quality standards are

maintained as financial pressures increase.

Long term strategy

• The Competition Commission decided to prohibit the proposed merger

between Poole Hospital NHS Foundation Trust and the Royal

Bournemouth and Christchurch Hospitals NHS Foundation Trust,

announcing its decision on 17 October 2013.

• The Trust is continuing to work closely with Dorset CCG to support

commissioners’ plans for a Dorset-wide review of services.

• The Competition Commission has published its final undertakings for the

parties.

• The Trust needs to work with the local health economy to

develop a long-term strategy and manage the short-medium

term risks.

• The Trust will need to ensure that any future strategy takes

account of the final undertakings as appropriate.

Governance

• Several key positions on the Trust Board are changing: the Chief

Executive is leaving post at the end of March, the Chief Operating

Officer left in Oct 2013, and the Finance Director and the Nursing

Director will also leave the Trust during Q4 2013/14. A vacancy remains

for the Strategy Director post.

• The Trust has appointed a new CEO who will join the Trust on 1 April

2014.

• The Trust appointed Joint Acting Chief Operating Officers from 1 Nov

2013.

• The Trust has identified successful candidates for the posts of Finance

Director and Nursing Director.

• The Trust has arrangements in place for deputies to cover any gap for

the COO, FD and ND positions.

• The Trust will need to ensure that the transition is managed

as smoothly as possible in order to deliver ‘business as

usual’ and maintain the quality of patient experience.

Next steps • The Trust is currently under formal investigation by Monitor to determine whether it is in breach of its licence. The Trust’s Governance Risk Rating (GRR) was amended to

a narrative rating on 1 Oct 2014 to reflect the ongoing investigation. Continue monthly financial monitoring.

Risk Ratings Continuity of Service Risk Rating

13/14:

YTD Actual

4

Governance Risk Rating:

Declared

risks at

APR:

• No declared risks

YTD Actual: Investigation open

Declared

Risks in

Year: • No declared risks Monitor is investigating financial sustainability

and governance concerns at the Trust following

a forecast deterioration in financial

performance. Breaches

for Current

Period:

• At Q3 2013/14, the Trust has delivered EBITDA of £6.8m against plan of £7.6m. The Trust has a

deficit YTD of £0.2m. The Trust’s COS RR is 4 (reflecting relatively strong debt service cover).

• The Trust narrowly met the A&E target in Q3 2013/14 but has breached the target in five of the seven

weeks in Q4 to date.

• The Trust is currently under investigation due to the Trust forecasting a significant financial deficit in

both 2014/15 and 2015/16.


Q3 2013 - 14 Reporting Executive Summary Summary Income & Cash Flow vs Plan

£m

Plan Actual Variance Plan Actual Variance

Op. Rev for EBITDA 50.1 51.0 0.9 151.2 153.2 2.0

Employee Expenses (32.6) (32.5) 0.1 (97.4) (96.9) 0.5

PFI Op. expense 0.0 0.0 0.0 0.0 0.0 0.0

All other Op. costs (15.1) (16.7) (1.6) (46.2) (49.5) (3.2)

EBITDA 2.5 1.8 (0.7) 7.6 6.8 (0.8)

Surplus/(Deficit) pre exceptionals 0.7 0.4 (0.3) 2.2 2.0 (0.2)

Net Surplus/(Deficit) 0.0 (0.2) (0.3) 0.2 (0.0) (0.2)

EBITDA % 5.0% 3.6% (1.4%) 5.0% 4.4% (0.6%)

CapEx (Accruals Basis) (5.4) (3.3) 2.0 (8.3) (6.7) 1.6

Net cash flow (1.1) (1.8) (0.7) (5.2) (5.8) (0.6)

Cash & Equiv 9.8 9.2 (0.6) 9.8 9.2 (0.6)

CoSRR Liquidity days (8.5) (2.9) 5.5 (8.5) (2.9) 5.5

CIP % OpEx less PFI 2.1% 0.8% (1.3%) 1.9% 1.7% (0.2%)

Net current assets (2.7) 0.3 3.0 (2.7) 0.3 3.0

Borrowing (excluding PFI) 0.0 0.0 0.0 0.0 0.0 0.0

2013/14 Q3 2013/14 YTD

CoG�May�14�L3�POOLE�1314�Q3�ex

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POOLE HOSPITAL NHS FOUNDATION TRUST COUNCIL OF GOVERNORS

GOVERNANCE CYCLE (Apr 14)

Code of Governance Reference

REPORTS Q4 May 14

Q1 July 14

Q2 Oct 14

Q3 Jan 15

LEAD

Committee/Reference Groups

Constitution Receive report/minutes from Nominations, Remuneration and Evaluations Committee

AD HOC

AD HOC

AD HOC

AD HOC

Chair

Reference Groups

Receive updates from any of the three Reference Groups:

Membership Engagement

Future Plans and Priorities

Quality Report (Ad Hoc)

X

X X X

MERG Chair

FPP Chair

DoNPS

Regular Reports

Monthly Report Cycle

Receive Chairman's Comments X X X X Chair

A.5.9. Receive Trust Performance Report (assurance of according with terms of authorisation)

X X X X CEO

Good Practice

Receive Strategic Risk Report (Part 2)

X X X X DoNPS

Good Practice

Receive Quarterly Submissions to Monitor (Part 2)

X X X X DoF

Good Practice

Receive Feedback from Monitor on Quarterly Submissions (Part 2)

X X X X DoF

Annual Report Cycle

B.6. Receive outcome of the Chairman’s and non-executive directors’ annual performance evaluation (Part 2)

X Chair/ SID

D.2.4. Approve recommendations from Nominations, Remuneration and Evaluation Committee on Chairman’s and non-executives’ remuneration/ allowances/terms & conditions

X Chair/ CEO

B.6.5. Receive Council of Governors Assessment of collective Performance

X Chair/ Co Sec

A.5.e. Receive Trust's Annual Plan

X CEO/ DoF

Governance�Cycle�Apr�14.doc

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REPORTS Q4 May 14

Q1 July 14

Q2 Oct 14

Q3 Jan 15

LEAD

Constitution & A.5.e.

Receive Trust’s Annual Report & Accounts

X DoS/ DoF

Good Practice

Quality Accounts and Financial Accounts audits from Deloitte to the September meeting.

X Ext. Audit

C.3.2. Receive Annual Audit and Governance Report

X

Chair A&GC

Constitution Agree changes to the Constitution (3 yearly - April 16)

X Co Sec

Good Practice

Receive Annual Report/statement on the work of the Nominations, Remuneration and Evaluations Committee

X Chair/ Co Sec

Good Practice

Discuss Content of current year's Quality Accounts

X DoNPS

Good Practice

Review the Register of Interests X Co Sec/ BM

Good Practice

Agree the Governance Cycle X Co Sec/ BM

Good Practice

Receive the Annual Complaints Report

x MD


Ad Hoc Reports LEAD

Constitution If necessary, review/update the Constitution on ad hoc basis

Co Sec

A.5.6. Receive Statement on Engagement with the Board of Directors (last done Nov 07)

Chair

B.2.13. Agree with Nominations, Remuneration and Evaluation Committee the process for nomination of new Chairman and non-executive directors

Chair/ SID

B.2.6. B.7.4.

Appoint Chairman and non-executive directors

Chair/ SID & DoHR

B.2.12. Approval of appointment of Chief Executive

Chair

B.6. Agree the process of performance evaluation for the Chairman and non executive directors (last time April 2011).

Chair


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Ad Hoc Reports LEAD

C.3. Agree with Audit & Governance Committee the criteria for the appointment/reappointment and removal of the Trust’s auditors (appointment Oct 12 for 3 years) Receive the Letter of Engagement from the Auditor Appoint Auditors

Chair A&GC/ DoF Chair/ DoF Chair A&G

Constitution Review policy for Composition of CoG and non- executive directors (CoG (Constitution Review) April 15 & NEDs April 14)

Chair

Constitution Review Membership Strategy (June 14)

Co Sec

NREC ToR Review the Terms of Reference of the Nominations, Remuneration and Evaluation Committee (postponed)

Co Sec

MJB Jan 2014


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POOLE HOSPITAL NHS FOUNDATION TRUST

COMMONLY USED ABBREVIATIONS

ABBREVIATION EXPLANATION

18-week target Delivery of a maximum 18-week wait from GP referral to start of treatment (RTT)

A & E Accident and Emergency

A&GC Audit & Governance Committee

AfC Agenda for Change is the pay system for NHS staff implemented in 2004. A summary of the system is available on the Department of Health website

AHPs Allied Health Professionals – physiotherapists, occupational therapists, speech therapists and orthotists. Previously PAMs (Professions Allied to Medicine)

AIRS Adverse Incident Recording System – the Trust’s no-blame system for reporting all clinical and non-clinical adverse incidents and near misses

AQP Any Qualified Provider – this scheme means that, for some conditions, patients will be able to choose from a range of approved providers, such as hospitals or high street service providers.

ASI Appointment Slot Issue

ASU Acute Stroke Unit

c.difficile Clostridium difficile - the major cause of antibiotic-associated diarrhoea and colitis, an intestinal infection that mostly affects elderly patients with other underlying diseases.

CEA Clinical Excellence Awards - given to recognise and reward the exceptional contribution of NHS consultants, over and above that normally expected in a job, to the values and goals of the NHS and to patient care

CHKS CHKS is a national independent provider of comparative performance and benchmarking healthcare data

CEPOD CEPOD (Confidential Enquiry into Perioperative Death) lists are theatre lists specifically dedicated for the provision of emergency surgery

CHC Continuing Healthcare

CIP Cost Improvement Plan

CMT Clinical Management Team

CoG The Council of Governors comprises:

14 public governors who are elected by members of their own constituency – Poole (8); Purbeck, East Dorset & Christchurch (3); Bournemouth (2); North Dorset, West Dorset , Weymouth & Portland (1);

4 staff governors who are elected by members of Trust staff – clinical (3); non-clinical (1);

6 appointed governors nominated by the Trust’s partner organisations – Bournemouth & Poole PCT (1); Dorset PCT (1); Dorset County Council (1); Poole Borough Council (1) Bournemouth Borough Council (1); Bournemouth University (1).

CQC The Care Quality Commission is the independent regulator of health and social care in England. The CQC regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations, and protects the rights of people detained under the Mental Health Act

CQUIN Commissioning for Quality and Innovation - the CQUIN payment framework makes a proportion of providers' income conditional on quality and innovation. Its aim is to support the vision set out in High Quality Care for All of an NHS where quality is the organising principle. The framework was launched in April 2009 and helps ensure quality is part of the commissioner-provider discussion everywhere.

CRES Cost Releasing Efficiency Saving

CRT Clinical Record Tracking – a bar-code based system for recording the location of patients’ medical records.

Glossary�of�abbreviations�Feb�

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DATIX National software programme for Risk Management

DME Department of Medicine for the Elderly

Dr Foster Dr Foster Intelligence, a joint venture between the Department of Health’s Information Centre and a private sector company Dr Foster LLP. Dr Foster provides a range of health information to the public (online and via supplements in the national media) and makes NHS performance data available under licence to health sector organisations

DToC Delayed Transfer of Care

EBITDA Earnings Before Interest, Taxation, Depreciation and Amortisation

EBME Electrical, Biomedical Equipment

ENT Ear, Nose and Throat

ESR Electronic Staff Record - the national, integrated Human Resources (HR) and Payroll system used by all NHS organisations throughout England and Wales. The ESR has a bi-directional interface with NHS Pensions. Personal data for all staff will be transferred to a data warehouse. This will include contact details, salary information, HR records, trainings, qualification, occupational health and other records. It will also include sensitive information such as sickness record absence, disabilities, ethnic origin

EWTD European Working Time Directive - lays down minimum requirements in relation to working hours/rest periods/annual leave for all workers and working arrangements for night workers. The current limit is an average of 48 hours work per week.

FCE Finished Consultant Episode is a measurement which assigns a patient’s episode of care to a consultant

FFCE First Finished Consultant Episode identifies the first consultant episode of care during a patients hospital stay

FIC Finance & Investment Committee

Foundation Trust/FT

NHS foundation trusts are autonomous organisations, free from central Government control. They decide how to improve their services and can retain any surpluses they generate, or borrow money, to support these investments. They establish strong connections with their local communities; local people can become members and governors. These freedoms mean NHS foundation trusts can better shape their healthcare services around local needs and priorities. NHS foundation trusts remain providers of healthcare according to core NHS principles: free care, based on need and not ability to pay. Poole Hospital NHS Foundation Trust was authorised on 1 November 2007

FRP Financial Recovery Plan.

H@N Hospital at Night - the provision of multi disciplinary teams working in hospital Out of Hours who between them have the full range of skills and competencies to meet patients’ immediate needs

HDU High Dependency Unit, for patients requiring close monitoring and high levels of care but not life support

HR Human Resources

HRG Healthcare Resource Group – groupings of treatment episodes which are similar in resource use and in clinical response

HSE Health & Safety Executive

ICU or ITU Intensive Care Unit or Intensive Therapy Unit

I&E Income and Expenditure

IT or IM&T Information Technology or Information Management & Technology

KSF Knowledge & Skills Framework - identifies the knowledge and skills that individuals need to apply in their post. Used to provide a fair and objective framework on which to base review and development for all staff

LNC Local Negotiating Committee – the main management/medical staff forum


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LoS Length of Stay

LTFM Long Term Financial Model

MDT Multi-Disciplinary Team

Monitor The independent regulator of NHS Foundation Trusts. Monitor rigorously assesses applicants for NHS foundation trust status and subsequently monitors their activities to ensure that they comply with the requirements of their terms of authorisation. Monitor has powers to intervene in the running of a foundation trust in the event of failings in its healthcare standards or other aspects of its activities, which amount to a significant breach in the terms of its authorisation

Mortality rate The ratio of total deaths to total population in a specified community or area over a specified period of time. The death rate is often expressed as the number of deaths per 1,000 of the population per year.

MRSA Methicillin Resistant Staphylococcus Aureus – an antibiotic resistant infection commonly found on the skin and/or in the noses of healthy people. Although usually harmless at these sites, it may occasionally get into the body (eg through breaks in the skin such as abrasions, cuts, wounds, surgical incisions or indwelling catheters) and cause infections. These infections may be mild (eg pimples or boils) or serious (eg infection of the bloodstream, bones or joints). An infection of the bloodstream is called a bacteraemia

MSC Medical Staff Committee

NCEPOD NCEPOD (National Confidential Enquiry into Perioperative Death) lists are theatre lists specifically dedicated for the provision of emergency surgery

NHSLA National Health Service Litigation Authority – the NHS clinical “insurance” scheme

NICE National Institute for Health & Clinical Excellence

NICU Neonatal Intensive Care Unit

NPfIT National Programme for Information Technology

NPSA National Patient Safety Agency

NSF National Service Framework - sets national standards and identifies key interventions for a defined service or care group. Also sets measurable goals within specified time frames.

NREC Nominations, Remuneration & Evaluations Committee - a sub-committee of the CoG responsible for the making recommendations to the CoG regarding the appointment, remuneration and performance review of the Chairman and non-executive directors

NVQ

National Vocational Qualification

OMF Oral Maxillo Facial

OFT Office of Fair Trading

PA/SPA Programmed Activities and Supporting Professional Activities. PAs identify medical staff clinical sessional commitments. SPAs are defined as “activities that underpin direct clinical care. This may include participation in training, medical education, continuing professional development, formal teaching, audit, job planning, appraisal, research, clinical management and local clinical governance activities.”

PACS Picture Archiving and Communications System – the digital storage of x-rays

PALS Patient Advice and Liaison Service - provide information, advice and support to help patients, families and their carers

PBC Practice Based Commissioning – an initiative which enables clinicians and other front line staff to redesign services that better meet the needs of their patients

PbR Payment by Results - the funding system for the NHS in England. This pays a standard tariff for the treatment of different conditions. Not all hospital activity is funded by PbR and hospitals still have to negotiate “block funding” to cover these areas – eg. diagnostic and screening tests.


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PCT Primary Care Trust. The two local PCTs are now known as NHS Bournemouth & Poole and NHS Dorset.

PEAT Patient Environment Action Team - PEAT team Inspections are a national initiative coordinated by the Department of Health

PFI Private Finance Initiative

PEWS Poole Early Warning System – a system to identify and alert staff of the deteriorating patient based on scoring patient observations against a number of criteria. Patients causing ‘alarm’ are reviewed by the nurse in charge of the ward and an emergency call made to switchboard requesting attendance of a member of the patients medical team or on call team

PHFT Poole Hospital NHS Foundation Trust

PMETB Postgraduate Medical Education and Training Board

PMO Programme Management Office

PROM Patient Recorded Outcomes Measures

PTIP Post Transaction Implementation Plan

PYLL Potential Years of Life Lost

QIPP The Quality, Innovation, Productivity and Prevention Programme. This is about ensuring that each pound spent is used to bring maximum benefit and quality of care to patients.

QSP Quality, Safety and Performance Committee

RBH Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust

RCI/Reference costs

Reference Cost Index – reference costs are the average cost to the NHS of providing a defined service within a given financial year. The RCI compares the actual cost of activity with the same activity at national average costs - organisations with costs equal to the national average score 100 whilst an organisations with a score of 80 or 115 has costs 20% below/ or 15% above the national average. The RCI is used for benchmarking and as the basis of PbR

RTT Referral to Treatment. The current RTT Target is 18 weeks.

Self-funding patients

This relates to patients who are not eligible for funding of future long-term care due to personal assets over the agreed threshold of £23,250, therefore they are deemed to be responsible for funding their care themselves.

SHA Strategic Health Authority – NHS South West is one of the ten Strategic Health Authorities in England formed on 1 July 2006

SLA Service Level Agreement - a SLA is an agreement that sets out formally the relationship between service providers and customers for the supply of a service by one or another.

SLM Service Line Management

SLR Service Line Report

SMR Standardised Mortality rate – see Mortality Rate

SpR Specialist Registrar – medical staff grade below consultant

SPF Staff partnership Forum – the main management/ staff forum, previously known as the JCNC (Joint Negotiating & Consultation Committee)

STEIS Strategic Executive Information System

SUI Serious Untoward Incident

TAL

NHS Direct provides The Appointments Line service as part of the Choose & Book system. Choose and Book is the electronic hospital appointments booking system. It allows people to make their first outpatient appointment online, at their GP practice, or by calling the Appointments Line (TAL). Patients can choose the place, date and time of the appointment to suit them.

VTE Venous Thromboembolism

WTE Whole Time Equivalent

Apr 2014


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Documents

AGENDA - Poole Hospital 1 May 2014 Website... · 2014-04-24 · Top Poole Hospital NHS Foundation Trust Council of Governors Council of Governors May 2014 01 May 2014 - 16:30 Board