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Trust Board Meeting
Agenda PART A (in public)
Date: Thursday 26 July 2012 at 1:30 pm.
Venue: Board Room, Princess Alexandra Hospital
Members of the public are welcome to attend so as to observe the meeting.
Questions about any aspects of the running of Trust are welcome and should be
addressed to the Chair at the end of the meeting
Item Subject
1 Welcome and Procedural Information
2 Apologies for Absence
Mark Devonshire, Dr Jolanta McKenzie,
3
4
Declaration of Interests
To receive any new or amended
declarations of interest from Board
Members.
To receive updated written declarations
from members.
Minutes of the Meeting Held on 31st May
2012
To confirm and sign the minutes of the
meeting held on 31 st May 2012.
5 Matters Arising from the Minutes
6 Action Points (Log)
To review progress against previous actions
and to discuss the structure of the
document.
7 Chief Executive’s Report
To receive a written report from the CEO on
issues to be brought to the Board’s
attention.
1
Report From Time & Page
Chair - verbal 1:30 – 1:35
Chair - verbal
Chair – verbal
Chair -
attached
1:35 – 1:40
Chair - verbal 1:40 – 1:50
Chair –
attached
CEO -
attached
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Item Subject
Chair’s Report Chair – verbal
Quality,
Governance and Risk
8
Patient Experience Assurance
Committee (PEAC)
To receive the Patient Experience
Assurance Committee Exception Reports
from 15 June 2012 and 20 July 2012
(cancelled).
9 Audit & Risk Assurance Committee
(ARAC)
To receive the Audit & Risk Assurance
Committee Exception Report from 20 July
2012.
10 Emergency Planning:
- Quarterly Report
- Presentation
11
Terms of Reference
a) To agree the existing Terms of
Reference for Business and
Performance Assurance Committee.
b) To agree the revised Terms of
Reference for Remuneration and
Nominations Committee.
Finance and Performance
12
Business Performance Assurance
Committee ( BPAC) and Trust Dashboard
a) To receive a verbal report from the
committee of 26 June 2012 and 24 July
2012 and to receive a verbal update on
discussions on the Trust Dashboard
which is attached.
b) PEAC quality indicators review
(following cancellation of PEAC meeting
20 July 2012)
13 Sign off SHA Self Certification Return
To note and approve.
2
Report From Time & Page
Chair of PEAC
– attached
Chair of ARAC
– to follow
Verbal
COO
- attached
- verbal
Head of
Corporate
Governance
Chair of BPAC
Dashboard -
attached
Chief
Executive. -
attached
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1:55 – 2:00
2:00 – 2:05
2:05 – 2:25
2:35 – 2:45
2:40 – 3:10
3:10– 3:20
14 Finance Report Director of 3:20 – 3:35

Item Subject
To receive an update from the Director of
Finance & Information.
15 Scheme of Delegation
16 Board Assurance Framework & Strategic
Risk Management
To receive an update on the BAF including
Corporate Risk Register for review.
Information
17 Input from the Public at Chair’s
Discretion
18 AOB
19
Closure of Part A
Date of Next Meeting
Thursday 25 September 2012 at 1:30
3
Report From Time & Page
Finance and
Information –
attached
Director of
Finance and
Information –
attached.
Head of
Corporate
Governance –
attached
Chair
Chair
3:35 – 3:40
3:30- 3:40
Chair 3:45
To resolve the representations of the media and other members of the
public be excluded from the rest of the meeting, having regard to the
confidential nature of the business to be transacted publicly on which
would be prejudicial to the public interest: Section 1 (2) Public Bodies
(Admissions to Meetings Act) 1960.
:
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SUMMARY REPORT
Item 4
Trust Board Meeting (Part A) 26 July 2012
Subject: Minutes of the meeting held on 31 May 2012
Prepared by; Mr. Geoff Stokes – Interim Head of Corporate Governance
Approved by: Ms. Melanie Walker, Chief Executive Officer
Presented by: Mr. David Barron, Chair
Purpose
To confirm and sign the minutes of the meeting held on 31 May
2012012.
Decision
Approval
Noting
Information
Corporate Objectives
Safety / Financial Workforce Estates- Regulatory / Relationships
outcomes
Environmental Statutory / Partnerships
Executive Summary
N/A
Key Recommendations
To note and approve
Assurance Framework
This complies with requirements for an Assurance Framework within the Statement
of Internal Control.
Next Steps
N/A
Corporate Impact Assessment
CQC Regulations 10
Financial Implications
Legal implications
Equality & Diversity
Other
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Trust Board Meeting (Part A)
Minutes of the Public Trust Board Meeting
Present:
(Voting Members)
Held on: Thursday 31 May 2012 at 1:30 pm. at
The Board Room, Princess Alexandra Hospital, Harlow
David Barron Chairman (DB)
Melanie Walker Chief Executive Officer (MW)
Dr Jolanta McKenzie Medical Director (JMcK)
Jules Martin Chief Operating Officer (JM)
Ken Sharp Interim Director of Finance (KS)
Sharon Cullen Deputy Director of Nursing (SC)
Dr Claire Feehily Non-Executive Director (CF)
Mark Devonshire Non-Executive Director (MDV)
Paula Kerr Non-Executive Director (PK)
Richard Stead Non-Executive Director (RS)
In Attendance:
(Including Non- voting Members)
Dr Sylvia Thompson Associate Member (ST)
Geoff Stokes Interim Head of Corporate Governance (GS)
Lynne Marriott Minute Secretary (LM)
Members of the Public, Staff in Attendance:
Adam Harridence Interim Head of Communications (AH)
Julie Burgess IMD (JB)
Dr Lisa Harrod-Rothwell Chair Designate –
Mid-Essex Clinical Commissioning Group (LHR)
Tony Skidmore Aspiring NED (TS)
Dr. S Visuvanathan* Director of Infection Prevention & Control (Dr. V)
Ally McInroy* Head of Customer Services & Complaints (AMcI)
(* in part - to present an item)
1 WELCOME AND PROCEDURAL INFORMATION
A171/12
The Chairman welcomed Board members and members of the public to the
meeting and requested that all mobile telephones and other electronic
devices be switched off.
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The Chairman welcomed back the Board’s Chief Executive, Melanie Walker,
on a phased programme of return. A warm welcome was also extended to
Jules Martin (Chief Operating Officer), Ken Sharp (Interim Director of
Finance) and to Geoff Stokes (Interim Head of Corporate Governance). Best
wishes were passed on to Charles McNair for a full and speedy recovery and
to Derek Greening for a long and happy retirement.
It was noted that a substantive appointment to the Head of Communications
role had been agreed and the positions of Director of Nursing and Director of
HR were out to advert. Interviews for the two vacant Non-Executive Director
(NED) positions would take place towards the end of June.
Thanks were noted for Richard Stead who was attending his final Board
meeting in his capacity as a NED.
The Chairman informed members he had been made aware that week that
Harlow College is one of the 15 approved colleges through to the next
tranche in its bid to become a University Technical College (focusing on
medical technology). The Chairman had congratulated the College’s
Principal and had offered his full support to the college going forward.
2 APOLOGIES FOR ABSENCE
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Marc Davis – Interim Director of Integrated Patient Care
It was noted for future meetings that Mark Gammage, Director of Workforce,
is not a Member of the Board and is not, as such, required to submit
apologies for non-attendance at Board meetings.
3 DECLARATION OF INTERESTS
A178/12
The Board noted that:
● Paula Kerr is currently Chair of Livability (a disability charity).
● Ken Sharp is a currently a Director of Blackett Sharp Limited which has
contracts within the NHS and Social Services.
4 MINUTES OF THE MEETING HELD ON 29 MARCH 2012
A179/12
The minutes were presented and approved by the Board as a true and
accurate record, with no amendments.
5 MATTERS ARISING FROM THE MINUTES
A180/12 There were no matters arising.
6 ACTION POINTS (LOG)
A181/12
Board Actions
It was noted that in light of sickness and handovers there had not been as
much progress as expected on certain actions.
To note:
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A165/12 – Timescale for Stroke Services Review
These were reported by KS as:
January - June 2012: Planning
July 2012 - January 2013: Deciding on preferred option/public consultation
2013 - 2014: Implementation
A117/12 – Effect on Full Year Cancer Targets to be Reported Back
Agreed not relevant as the year-end has passed.
A116/12 – Missing Data in Dashboard – Clinical Quality 1
PK reported that this had been picked up at the Business Performance
Assurance Committee (BPAC) that week and continues to be a problem.
MW agreed there are issues around the general quality of the dashboard and
its fitness for purpose which are being picked up by PwC. It was agreed the
action would remain open.
5.3 – Action Log Discussions
These would take place before the next meeting between the Chairman and
GS.
BPAC Actions
4.4, 4.7, 4.9, 4.10 – Electronic Patient Record (EPR) Programme
GS reported a deferment of this project to allow time for clinical engagement
and an overarching IT strategy - pushing the timetable back to October 2012.
8.4 – Dashboard to Include ‘recovery’ related information in relation to red
indicators
This would be included in the next Dashboard.
12.6 Board Assurance Framework (BAF) Review
GS to pick up with the Chairman and CEO in the next month.
13.5 – East of England Self Certification
Both actions under this item to be closed.
4.4 – EPR – Outline Business Case/8.7 Trust Dashboard Month 10
Both items to be closed.
5.4 – Workforce Overview – Review of Pay by Remuneration Committee
To be closed as pay issues are being reviewed as part of the CIP
programme.
5.7 – Effective deployment of sickness management by clinical managers
Concluded that this issue did not need to revert to BPAC as it should form
part of the formal reporting through the new mechanisms.
7 CHIEF EXECUTIVE’S REPORT/CHAIR’S REPORT
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A195/12
MW thanked GS for preparing the report. The report would be taken as read
but the CEO was happy to take any questions from members.
GS highlighted one point of action namely to change the name of the Trust’s
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charity. The amendment being proposed, and approved by the Trust
Chairman, is ‘The Princess Alexandra Hospitals Charity’.
The Board:
Approved the change of name.
MDV requested further detail re: the impact to the Trust on proposed
changes to the vascular network.
MW reported that the biggest risk to the organisation is not financial, but the
impact it presents for clinical teams. The Trust boasts two of the best
vascular surgeons in the area and offers high level services which are very
attractive to patients. Multi-speciality teams undertake much of the Trust’s
core work with the added bonus being provided by vascular work. There will
be an impact on patients who will have to travel to specialist centres and
proposals are frustrating in light of the Trust’s current positive outcomes in
this area. Final decisions are due on 7 September.
8 PATIENT EXPERIENCE ASSURANCE COMMITTEE (PEAC)
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A201/12
MDV reported that the Committee had seen a positive step forward in terms
of directorate ownership and accountability for plans and performance. The
Committee historically has striven for improvement in levels of serious
incident reporting and this has been evidenced in both March and April data.
Assurance was also provided that other reds on the dashboard are being
addressed and tracked, leaving scope for the Committee to now start
discussing the patient ‘experience’. Thanks were noted for SC and JMcK for
their efforts in this area.
PK requested assurance that the organisation would not become complacent
in its quest against serious incidents and in particular pressure ulcers,
bearing in mind that new pressure ulcer targets would be very challenging.
In response SC agreed that the new targets would be challenging. However
assessment processes and monitoring interventions are now sufficiently
resilient and the move forward will be towards achieving the SHA Ambition of
elimination of all grade 2, 3 and 4 pressure ulcers from December onwards.
To this end a Clinical Scrutiny Panel has been established to scrutinise each
individual incident with a view to changing practice/sharing learning going
forward.
9 AUDIT & RISK ASSURANCE COMMITTEE (ARAC)
A202/12
A203/12
A204/12
CF reported continued concerns around data quality which would be the
subject of a detailed review at the next Audit Committee.
With regard to the Head of Internal Audit Opinion there had been a significant
improvement on the previous year’s position with credit due to those who had
been able to turn the position around.
It was encouraging was that statutory timetables of reporting requirements
had all been met and the Trust’s external auditors are content, identifying a
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small number of minor adjustments to the accounts. CF again commended
all those involved in the Finance Team, as did the Chairman.
The Committee is now working towards strengthening the quality of its suite
of reports (Governance Statement, Annual Report & Quality Account) for the
next financial year.
10 ELIMINATION OF MIXED SEX ACCOMMODATION COMPLIANCE
A206/12
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A208/12
SC reported that the Board is required to renew the Declaration of
Compliance to the elimination of mixed sex accommodation for 2012. The
area of risk for the organisation remains in Adult Critical Care i.e. High
Dependency Unit and Coronary Care Unit, when patients are ready to step
down to a general bed. There is an Action Plan in place which continues to
address that risk.
The Board was asked to note the Action Plan and approve the Compliance
Statement for posting on the Trust’s website.
The Board:
Noted the Action Plan and approved the Compliance Statement.
11 LEARNING DISABILITIES IMPROVEMENT PLAN
A209/12
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SC presented the Plan. The Board was asked to approve the content of the
draft self-assessment and improvement plan for delivering services to adults
with learning disabilities including autism, prior to submission to the PCT and
SHA. The Board was also asked to agree the board approval process as
described in the body of the paper.
The improvement plan focuses on 5 priorities and once Board approval was
obtained, a formal validation process would need to be followed with the
Trust’s commissioners and others to ensure the organisation is meeting the
quality assurance framework for clients with learning disabilities/autism.
It was noted that the Non-Executive Champion for this cause is now Paula
Kerr (not the Chairman as indicated in the Plan).
RS had concerns as to the Trust’s capacity to deliver such a detailed Plan. In
response SC confirmed the Plan has been populated with realistic targets
and would be monitored closely. In addition there are plans for the
appointment of a Disability Liaison Nurse to ensure delivery of the Plan.
The Board:
1) Approved the content of the draft self-assessment and improvement plan
for delivering services to adults with learning disabilities including autism.
2) Agreed the approval process described in the body of the paper.
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12 R&D OPERATIONAL CAPABILITY STATEMENT FOR NIHR
A215/12
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A218/12
JMcK presented this item. The National Institute of Health Research (NIHR)
Research Support Services Framework includes a requirement for all
participating NHS Trusts to complete and submit their R&D Operational
Capability Statement as a pre-requisite for receiving NIHR funding. This is to
ensure that the Trust is competent to receive funding to carry out research
and development in conjunction with the NIHR. The Board was asked to
approve the Operational Capability Statement.
In addition ST reported that the Trust’s funding (circa £360K this year) from
the Comprehensive Local Research Network (CLRN) is dependent upon
approval of the statement by the Board.
RS queried whether those assigned responsibilities in the statement are not
only aware but have accepted that role. In response ST confirmed that the
statement had been through the R&D Committee and those assigned
responsibilities are fully aware.
The Board:
Approved the R&D Operational Capability Statement.
13 INFECTION CONTROL – ANNUAL REPORT
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A222/12
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This was presented by Dr. Shico Visuvanathan – Director of Infection
Prevention & Control. Highlights are:
● Low levels of MRSA bacteraemia (1 case in 2011-12 against a threshold
of 2) demonstrate commitment from everyone in the Trust to maintaining high
standards to control MRSA colonisation and infection including septicaemia.
The threshold for 2012-13 has been tightened to 1. Unfortunately the
organisation has already had that 1 case this year. This may be attributed to
changes in roles and responsibilities over the last few months or, that the
organisation is becoming complacent.
● Again the organisation compares well nationally for MSSA cases with 7
post 48 hour cases during 2011/12.
● For C-diff the Trust had a challenging threshold of 14 cases last year as
past improvements have increased expectations. This is one of the tightest
thresholds for any district general hospital and was exceeded by 2 cases. It
has been recognised by the SHA and PCT that the threshold was challenging
and that it was an improvement on the previous year’s figure of 24.
● Antibiotic Resistance – Mupirocin (nasal ointment used as part of the
MRSA suppression regime) resistance in MRSA is monitored by the Infection
Control Team. For 2011/12 only 10 cases were detected which is a very
positive finding for the organisation.
● Decontamination incident involving bronchoscopes – at the end of
January 2012 an investigation commenced to scrutinise a pseudo-outbreak
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when specimens taken through ITU bronchoscopes from 2 consecutive
patients grew the same fungus. The scope was removed from use. The
MHRA were informed and worked with the manufacturer of the bronchoscope
on this matter. Final recommendations from the MHRA will follow.
● C-diff associated deaths – 7 were recorded for 2011/12.
● Sharps injuries – there are still many injuries which could be avoided
through good practice, in particular where sharps are left around or not
disposed of appropriately after use. Most incidents are caused by poor
disposal and the Infection Control Team (ICT) aim to address this through
education in the clinical areas.
● Infection Control Dashboard – this highlights that most problems with Cdiff
occurred on Henry Moore Ward, as did the most deaths.
PK offered her congratulations to the ICT for a remarkable performance and
suggested that the Trust endeavour to communicate this to the public. In
response to a question from PK as to the organisation’s biggest risk going
forward, Dr. V confirmed this to be MRSA.
The Chairman requested that his and the Board’s thanks be passed onto the
ICT for a phenomenal achievement and a fascinating Annual Report.
14 COMPLAINTS – ANNUAL REPORT
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This was presented by Ally McInroy – Head of Customer Services &
Complaints.
There had been a 10% increase on 2010/11 in the number of complaints
received by the Trust, although ‘unsatisfied’ complaints had reduced by 11%.
Only 1 complaint had been formally investigated by the Parliamentary and
Health Service Ombudsman.
‘Communication’ complaints have soared this year to 147 (from 81 in
2010/11). A&E and Outpatients again have the highest number of complaints
whereas Henry Moore saw a significant reduction this year from 15 to 6.
Further trend analysis must be undertaken to identify the real issues of
complaints and whether action taken in response is leading to lessons being
learned – and in turn, making a difference to the patient experience.
In response to a question from the Chairman it was confirmed the
organisation is very much on a par with other organisations of a similar size
for numbers of complaints.
In response to a question from RS it was confirmed that some complaints can
be attributable to certain (known) individuals whereas others are down to the
organisation’s ‘culture’.
With regard to the organisation’s Complaints ‘Vision’ for the year ahead,
AMcI confirmed it is for complaints management to be effectively owned and
handled by the directorates responsible.
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15 BUSINESS PERFORMANCE ASSURANCE COMMITTEE (BPAC) AND
TRUST DASHBOARD
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BPAC
RS reported that the Committee had not held a meeting in April but had met
for their May meeting that week. To be applauded was the surplus of £461K
made during the last financial year but the organisation should not
underestimate the efforts taken to achieve this. Congratulations to all those
involved in the achievement of this financial performance.
The new financial year has started with income streams where they should
be, but with higher than expected costs. These need to be reined in over the
rest of the year.
Last year’s CIP had been highly successful and delivered a record-breaking
amount nationally, whilst not impacting on patient safety. The coming year’s
CIP would be challenging but with the processes already in place the Trust
has the ability to deliver in excess of the required target.
Dashboard
KS highlighted the amendment to the Activity page of the Dashboard (which
had been tabled) and clarified that Emergency Admissions were 1881 (not
2311).
In reference to an earlier item in the Action Log in regard to the nonavailability
of April figures for Clinical Quality 1, KS reported a deliberate 2
month lag in order for data verification before publication. Improvements do
need to be made to the Dashboard and KS confirmed these are in hand with
a proposal to be presented at the next BPAC.
RS queried whether the non-availability of data was an indication that the tool
was not a useful management indicator and that if the data was not being
utilised then it should not be collected.
PK highlighted the importance of linking the Dashboard to the Trust’s Risk
Register to enable the organisation to concentrate on areas requiring
attention, particularly in the move towards FT status.
MDV raised a concern that whilst data and reporting appear to be correct,
they are not consistent with the Summary Dashboard – members agreed.
In response KS asked members for their views on the Dashboard and
whether something much more concise would still fulfil requirements. MW
confirmed discussions had already taken place as to its fundamental purpose
and whether or not it is being used correctly and/or effectively. The
Chairman requested a plan for a review of the Dashboard for next month.
Action:
Review of Trust Dashboard to take place and a plan to be presented at the
Trust Board on 26 July 2012.
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KS asked members to note the improvement in April’s Length of Stay figures.
Whilst Month 1 figures are notoriously unreliable, it should give the
organisation some encouragement in moving forward.
16 SIGN-OFF SHA SELF CERTIFICATION RETURN
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GS reviewed the report with the Board and highlighted that amendments had
been made to the Return since its presentation at BPAC earlier that week,
namely:
The C-diff indicator should be green not red – there had been 1 case in April
against a threshold of 14 for the year – in turn bringing the organisation’s
overall governance score down from 3.5 to 2.5 and to amber/red.
POST MEETING NOTE: A further adjustment was made to the ‘learning
disability’ indicator which should have been red, not amber (only green or red
can be used on the return). This meant that the overall governance score
was 3.0.
Missing data on Quality:
● VTE Screening = 94.98%
● Red rated areas on Maternity Dashboard = 0
● Grade 3 or 4 Pressure Ulcers = 7
The Board:
Approved the document for sign-off and return.
17 FINANCE REPORT
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This was presented by Ken Sharp.
KS reported that the April position was an overspend against plan of £239K
with an overspend on medical staffing of £235K against plan. Action is being
taken on this in terms of better controls on the employment of temporary
staff, particularly agency staff.
With regard to the income position this ‘over’ recovered in April largely as a
result of non-elective and emergency activity which was higher than planned.
The Board:
Noted the Finance Report and accompanying caveats.
18 BOARD ASSURANCE FRAMEWORK
A257/12
GS reported that this had not yet been adjusted to take account of the Annual
Plan and objectives for the year. Additionally, the strategic risks recently
identified by Board members also needed to be factored in. As reported at
the last meeting there is a requirement to review how risks are reported to the
Board. As reported at BPAC that week there are still too many red risks,
scoring needs to be more consistent and duplication of operational and
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strategic risks needs to be avoided.
The current report was presented to the Board with the proviso that
improvements need to be made over time.
CF enquired whether the Trust had undertaken any assessment of the risk
which would be posed by the Olympic Games and the impact this will have
on the organisation. In response JM confirmed that an external assessment
is currently taking place with figures being provided as to where possible
growth areas may be. The Trust is working with the Health Community to
produce a ‘whole systems’ plan and regular briefing meetings are currently
taking place. This is coupled with internal meetings in relation to growth
areas e.g. A&E front door and sexual health. A comprehensive
communications strategy is also planned.
19 INPUT FROM THE PUBLIC AT THE CHAIR’S DISCRETION
A260/12
20 AOB
A261/12 None.
TS thanked the Board for an interesting meeting and agreed, with them, that
the Dashboard needed to be consolidated.
23 DATE OF NEXT MEETING
A262/12
Next meeting:
Thursday 26 July 2012
1.30 p.m.
Board Room - Trust Headquarters PAHT
CLOSURE OF PART A
To resolve the representatives of the media and other members of the public
be excluded from the rest of the meeting, having regard to the confidential
nature of the business to be transacted prejudicial to the public interest:
Section 1 (2) Public Bodies (Admissions to Meetings Act) 1960.
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SUMMARY REPORT
Item 6
Trust Board Meeting (Part A) 26 July 2012
Subject: Action Points (Log)
Prepared by; Mr. Geoff Stokes, Trust Secretary
Approved by: Ms. Melanie Walker, CEO
Presented by: Mr. David Barron, Chair
Purpose
To review progress against previous actions.
Decision
Approval
Noting
Information
Corporate Objectives
Safety / Financial Workforce Estates- Regulatory / Relationships
outcomes
Environmental Statutory / Partnerships
Executive Summary
N/A
Key Recommendations
To review current progress made against actions from previous Board meetings.
Assurance Framework
Other
This is a requirement under Best Practice from the National Learning Centre’s paper on
“Healthy Boards”
Next Steps
N/A
Corporate Impact Assessment
CQC Regulations 10
Financial Implications
Legal implications
Equality & Diversity
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Trust Board (Part A)
Action Log
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Meeting Date Ref Agenda Item
Action Owner Due Date Status Comments/ Update
29 Sep 2011 5.3 Action Log Develop a new action log format for
the next Board and that this is rolled
out to all committees of the Board,
with a proviso on the timeline for
Geoff Stokes 26 Jul 2012 Open Draft to be discussed with Chairman
circulation.
28 Mar 2012 A116/12 Trust Dashboard Missing data in Clinical Quality 1 to be Ken Sharp
followed up by CMcN.
26 Jul 2012 Open 31 May: Data still incomplete
28 Mar 2012 A117/12 Trust Dashboard Effect on full year cancer target results Jules Martin 31 May 2012 Closing JS reported that 'Cancer Standards
to be followed up and reported back
relating to two week wait and 62 day
by JS.
treatments had not been achieved in
January 2012. Reasons for this are: a
change in management, a change in
process, plus the team have merged
to become MDT Co-ordinators and
Pathway Managers and are struggling
with the increase in workload.
However, with a new manager, a new
plan and a new team, performance is
expected to improve as of April’
28 Mar 2012 A118/12 Trust Dashboard Non-achievement of cancer targets to
be picked up and reviewed at PEAC by
Mark Devonshire
28 Mar 2012 A165/12 Chief Executive's Report Timescale for Stroke Services review
to be reported back by CMcN.
31 May 2012 15 (Business and Performance
Assurance Committee and) Trust
Dashboard
Plan for review of dashboard to be
formulated, in conjunction with the
Chairman
Updates on actions from the last meeting are shown in bold. Closed items are shown once form information as 'Closing'
Mark Devonshire 31 May 2012 Closing Presentation received at PEAC
meeting, 18 May 2012
Ken Sharp 31 May 2012 Closing Preparation is currently taking place,
plan being developed between July 12
and Jan 13.
Ken Sharp 26 Jul 2012 Open Dashboard is being revised - see item
12 on agenda

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To: Trust Board
Subject: Chief Executive’s Report
Date: 26 July 2012
Author: Chief Executive
Introduction
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Item 7
The purpose of this paper is to update the Trust Board on important changes in local
and national environment and issues of interest to The Princess Alexandra NHS
Trust.
1. SHA Review of the Trust’s Annual Plan
A formal review of the Trust’s Annual Plan was held by the SHA on Monday, 9
July 2012, during which Executive Directors outlined the key aspects of the
Plan and answered questions arising from it.
2. Performance Management Meetings with PCT
Following discussions with the Chief Executive of North Essex PCT cluster,
we have initiated weekly performance review meetings. These take place on a
Friday morning between key executive leads from the CCG, the Trust and the
PCT Chief Executive and I attend these every month.
These meetings are being held to help the PCT understand the progress the
Trust is making so that they can be assured of our ability to deliver the
commissioned services.
3. Director Appointments
Interviews are being held in July for the Directors of Nursing, Development
and Human Resources and I may be able to give more updates on these at
the meeting.
4. Information Governance Toolkit
There is a requirement by the Department of Health for all NHS organisations
to be compliant with level 2 of the Information Governance toolkit. This
requirement was for March 2012, and unfortunately, this Trust is one of 5
acute Trusts in the Eastern region that are currently only compliant to level 1.
The key actions that need to be in place to achieve level 2 are;

• Ensuring at least 95% of ALL staff (plus non-executive directors) are
trained in Information Governance
• Setting up an information asset database and populating it with key
facts about information owners, access, security etc.
• Carrying out an information security audit
• Carrying out a corporate records audit.
Plans are in place for the last 2 of these but currently more action is needed to
address the first two which are more substantive and difficult to achieve.
The Trust has to declare its Information Governance Toolkit level at the end of
each quarter and the quarter 1 submission is due on 27 July.
The Board is asked to note the fact that we are currently reporting compliance
with level 1 only.
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Item 7

SUMMARY REPORT
Item 8
Trust Board Meeting (Part A) 26 July 2012
Subject: Exception Report from Chair of Patient Experience Assurance
Committee of 15 June 2012.
Prepared by; Mr. Mark Devonshire
Approved by: Jolanta McKenzie/Sharon Cullen
Presented by: Mr. Mark Devonshire
Purpose
To note and approve.
Decision
Approval
Noting
Information
Corporate Objectives
Safety / Financial Workforce Estates- Regulatory / Relationships
outcomes
Environmental Statutory / Partnerships
Executive Summary
Key Recommendations
Assurance Framework
Next Steps
Corporate Impact Assessment
CQC Regulations 10
Financial Implications
Legal implications
Equality & Diversity
Other
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PEAC Exception Report
Report from (Committee): Patient Experience Assurance Committee
Report by (Chair): Mark Devonshire
Meeting date: 15 th June 2012
Report to: Trust Board
Minutes (Are minutes available): Yes
Next Meeting: 20 July 2012
Key Points;
The key points presented and discussed were:
• PS&Q Progress Reports (Meeting of the 1 st June). A report was presented by Sharon
Cullen in a new format showing performance, exceptions, risks and accountability at a
Directorate and Trust level. The PEAC provided feedback that this was a significant
improvement and provided further assurance of the Directorates taking responsibility
and full accountability as was planned through the restructuring. Across the directorates
significant progress was demonstrated in the reduction of all Serious Incidents,
excluding Pressure Ulcers. All such reported pressure ulcers are now subjected to a
scrutiny panel. The plan for Maternity Services was reported as on track, however it was
reported that a moderate concern has been raised by the CQC following the formal
report on the TOP service. Verbal assurance was provided that the action plans for
improvement against Stroke and Cancer targets were on track, however the PEAC
requested that a more specific and documented record of progress against agreed
action plans be provided at future PEAC meetings.
• Coral Roberts, Clinical Safety Manager, provided an update on Serious Incidents. For
April there had been 4 Serious Incidents declared. Whilst May data was still to be
validated, 11 incidents had been declared, 4 occurred in May whilst 7 occurred in April
(6 pressure ulcers and 1 retained foreign object). The PEAC was assured that significant
improvement had been achieved in the reduction of SI’s (apart from Pressure Ulcers)
through the implementation of the action plan formulated in late 2011. The Trust has
now implemented a further focus on Pressure Ulcers in line with the SHA ambition.
• Jolanta McKenzie presented a report on HSMR. This report provided an initial analysis
and plan to address the high HSMR – the annual rebase is likely to score at 111, the
highest HSMR across the SHA. The Trust has now instigated Mortality Audits on specific
disease groups, alongside the appointment of a Trust Mortality Investigator to scrutinize
and analyse all deaths. The PEAC was assured that the focus was of the highest
priority for the Trust, and that further analysis and an improvement plan would be
brought back to the next PEAC and maintained as a monthly agenda item going forward.
An action was taken to ensure that the risk associated with the high HSMR score is
captured within the BAF.
1 of 2
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.
The PEAC continues to see significant progress and improvement across all areas of
Patient Safety and Experience which should now become more visible via the tangible
performance metrics within the Trust Dashboard. PEAC was assured that the action
plans are being delivered, that is resulting in tangible improvements. However the
Trust’s culture operates reactively in some areas, with the need to think much more
proactively and with data being more real time rather than 1-2 months behind in some
cases.
Key Risks identified
Brief description of risk Current
RAG
rating
High HSMR
R
On Risk
Register
Y/N
N
2 of 2
Risk
Owner
YM
Action Report
Back to
PEAC
As above
Items referred elsewhere (to other groups or committees for consideration of decision)
Item Referred to Reason Date of relevant
Executive Meeting
Other items to note (if any)
Monthly
Report Back to PEAC
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The Princess
Alexandra NHS Trust
Emergency Preparedness
Title: Emergency Preparedness-Quarterly Report
Date: 12 st July 2012
Executive
Summary:
Action
Requested:
Author:
Contact Details:
Resource
Implications:
Public or Private:
(with reasons if
private)
References:
(eg from/to other
committees)
Appendices/
References/
Background
Reading
NHS
Constitution:
(How it impacts
on any decisionmaking)
This report covers the following areas:
Activities undertaken for Emergency Planning during quarter
one.
Major incident Planning
Partnership working
Business Continuity
Training & Exercises
Olympic Games preparation
Risks
Resource
Plans for the 2 nd quarter
1
Created by: Gareth Powell – Duty Team Manager & EPLO
Item 10
Note the activities undertaken for emergency planning during Quarter 1,
accept the report and support recommendations.
Gareth Powell – Duty Team Manager & Emergency Planning Liaison
Officer.
Gareth.powell@pah.nhs.uk
Public
Emergency Planning Committee
Emergency Planning – Sub Group
Appendix 1 – Emergency Planning Programme
Appendix 2 – Emergency Planning Equipment- Non-Pay Spend Request
In determining this matter, the Trust Management Team should have
regard to the Core principles contained in the Constitution of: Equality of
treatment and access to services High standards of excellence and
professionalism Service user preferences Cross community working
Best Value Accountability through local influence and scrutiny
Emergency Planning Quarter 1 Update
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Created by: Gareth Powell – Duty Team Manager & EPLO
Item 10
Background Information
As a requirement under the Civil Contingencies Act 2004 in terms of informing and sharing
information a quarterly update has been produced to advise the Trust Board on the activities
that have taken place during quarter 1.
This report covers the following areas:
Partnership Working
Industrial Action
Tests and Exercises
Introduction
As part of the trust wide restructuring of services, the Emergency Planning & Business
Continuity responsibility and workload has been combined with the Duty Team manager role.
This became active as of April 2012.
1. Policy’s & Plans
Document
Title
Major
Incident Plan
CBRNe Plan
(Chemical,
Biological,
Radiological,
Nuclear,
Explosive)
Lockdown
Plan
Mass
Casualty
Plan
Mass
Evacuation
Plan
Position - April
2012
R=No Document or
document out of date,
no evidence of training,
not exercised
A= Draft, no training
complete, not exercised
G=In-Place, training &
exercised
Created:
August 2007
Last review:
August 2007
Created:
August 2007
Last review:
August 2007
Created:
January 2012
(unfit for purpose)
End of
Quarter 1
Position
(R,A,G)
Document
developed &
peer reviewed
Document
developed &
peer reviewed
Currently
under review
No Policy Document
developed &
peer reviewed
No Policy Document
scoped
VIP Policy No Policy Document
scoped
Pandemic Created:
Document
Plan
July 2009
Last review:
July 2009
scoped
End of
Quarter 2
Position
(R,A,G)
End of
Quarter 3
Position
(R,A,G)
End of Year
Position
Once ratified there will be a programme developed to train all associated staff. This will be a
combination of exercises and microteaching. This training will be delivered by the EPLO & EP
assistant.
2. Major Incident Planning
The Major Incident plan has been reviewed and rewritten, following approval by the Trust Board, the
Major Incident Plan will be launched through the following channels:
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Item 10
Published on the Emergency Preparedness Intranet Site
Presented at Senior Managers Briefing where a hard copy of the Major Incident Plan will be
distributed to all who attended.
All current departmental copies will be replaced with the latest version.
Also, copies of the plan will be shared with partner agencies in order to comply with the
requirements of being a Category 1 Responder under the terms of the Civil Contingencies Act
2004.
Hospital Major Incident Control Room
An exercise was undertaken to setup the incident room by the emergency planning assistant, this
process took 2hr 30mins, the following issues were identified:
Broken phones
Out of date policies & procedures
Unrequired equipment
Whiteboards inaccurate and out of date
Boxes unlabelled
Lack of supplies
The emergency planning assistant has addressed immediate risks and is developing a list of essential
supplies to allow us to manage and incident.
Action card training will be undertaken by the emergency planning team for all relevant groups of staff.
Exercises are planned as set out in appendix 1
3. Partnership Working
The trust attends and contributes to a range of meetings both within the health economy with category
1 and 2 responders. Included in these are:
Essex Reliance forum
Essex Heath trusts
Essex –Emergency Planning Liaison EPLO meeting
4. Business Continuity
Fuel
Strike action did not take occur, however a fuel plan has been developed to ensure the trust
has robust arrangements in the event of fuel shortages.
Industrial Action
Unite voted in favour of strike action, which was held on 10 th May. PAH was unaffected by the
strike and there was minimal impact on the winder health economy.
BMA voted in favour of Industrial action, which took place on 21 st June, The trust took actions
to mitigate risk, impact detailed below:
Actions taken to mitigate risk:
o Letters sent to patients to explain the action being undertaken by the union and that
there is a potential for cancellations. Letters sent to consultant and junior doctor
workforce to outline the Trust position and that of the BMA to carry out Urgent work.
Impact:
o Number of staff involved: 7 consultants, 4 Associate specialist/Staff Grade, 6 Junior
Doctors
o 13 non-urgent surgical cases cancelled and rescheduled
o 73 non-urgent outpatient appointments cancelled and rescheduled
o No media interest
British Standard – Business Continuity Management – BS25999
The Trusts vision is to strive for excellence and a long-term aim is to achieve BS25999
Sampling of business continuity plans within the trust indicates they are current and fit for
purpose. A formal rolling review timetable will be developed in Q2.
Basildon Hospital are currently the only trust in the country to have attained the British standard
trust wide for business continuity. Discussions with the Basildon EPLO indicated this was an 18

4
Created by: Gareth Powell – Duty Team Manager & EPLO
Item 10
month intensive process. Working towards this standard would require an initial review of
resource and significant planning to ensure this is delivered within an achievable timeframe.
5. Tests, Exercises & Training
As part of the Trusts statutory obligations the following training has been delivered to the relevant staff
through the Princess Alexandra Emergency Planning Team in Q1:
Trust induction – Monthly
The Emergency planning team have attended the following:
Olympic table-top exercise
Crowd safety management
The Emergency planning team has conducted a training need analysis with the following key areas
identified to ensure the trust meets is statutory obligations and is in a robust position to respond to
incidents.
Senior Manager & Executive– Incident awareness training
Senior Manager & Executive – Command & Control training
Media Training
CBRNe
Lockdown
Mass evacuation
Loggist
The EP assistant is undertaking Loggist training and will then cascade this to an identified
group of staff who will act as Loggist in the event of an incident.
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Emergency Planning Team Training
During June the EPLO & EP assistant undertook Hospital Incident Medical Management &
Support(HMIMMS) training
The EPLO & EP will be required to undertake further training to ensure the Trust has a robust
platform to operate from, training will then be cascaded by the Emergency planning team to the
executive team senior managers, Duty matrons and other trust staff this will include:
o Gold Commander Course
o Silver Commander Course
o Bronze Commander Course
o Skills for Briefing & Debriefing
o Business Continuity Awareness
o Special Operations Response Team Training
o SORT/Decontamination Train the Trainer
6. Olympics Games – London 2012
The Olympic Games will be held in London between 27 th July & 12 th August 2012, PAH not official
hospital, although all trusts have been asked to review their emergency preparedness in light of the
games representing a heightened risk to the public
The torch relay passed through Harlow on 07/07/2012 and was in the surrounding areas on
06/07/2012, there was no impact on activity.
Profiling has taken place which suggests the following:
8.9% increase in Urgent Care
Sexual Health Services increase
5% increase in GP activity
Other information:
North Weald will be hosting a park and ride service approx.. 3,000 cars
There are a number of official and unofficial campsites in and around the Epping & Harlow area
approx.. 12,000 people

Item 10
Willow Farm – Gay Music Festival Approx... 5,000 people
Epping – The peoples Fringe camping & entertainment up to 25,000 people per day.
Early intelligence for the torch relay suggests greatest impact is on Ambulance service but also
on transferring patients out of hospitals.
13 th August is predicted Stansted Airports busiest day due the close of the games.
Assessment & Actions
LOCOG have provided sign posting for all spectators in terms of healthcare access
Urgent Care
PCT to increase skill mix & investigate access to diagnostics & supplies of medication at PAH
Sickness Absence & Annual leave
Potential for increased sickness
o Comms will replay a message regarding sickness policy
Annual Leave
o Heads of Nursing asked to assess all rosters to ensure they comply with trust policy
o Medical Staffing to carryout same process as nursing teams
SitRep
There will be reporting via a Unify 2 Monday to Friday
Weekend arrangements to be confirmed
A specific report is to be completed for any activity or issues that may impact on the Olympics
Conference Call
There will be a daily Conference call between, PCT, PAH, Ambulance service, social care
following the winter format
Additional Capacity
PCT will investigate opening capacity on Beech Ward x8 beds to reduce pressure on Acute
services
Forrest Place capacity is limited due to the number of patients booked in for rest bite care
during the Olympics
CARS
PCT will investigate increasing the CARS nursing team availability over the Olympic period
Increase in rental
This may impact upon number of patients not registered with a local GP
To be managed in current way
Torch impact
PAH to review processes in A&E to ensure that ambulance delays are minimised.
PAH to consider how patients requiring transport will be managed
PAH asked to review A&E position & develop tool to monitor any increase in activity
Staffing levels and processes in Dept to be reviewed and robust plan to be described and
implemented.
Eligibility to Healthcare
Posters will be circulated regarding eligibility criteria for the Olympic family
Emergency Care is free to all; however normal process applies with regard to in-patient spells.
Communications
Strategy being developed to ensure a consistent message is received by all staff and the public
7. Risks
Consequence/
Likelihood
Insignificant Minor Moderate Major Catastrophic
Rare 1 2 3 4 5
Unlikely 2 4 6 8 10
Possible 3 6 9 12 15
Likely 4 8 12 16 20
Almost Certain 5 10 15 20 25
1-4 = Very Low (Green), 5-11 Low (Yellow), 12-16 Medium (Orange), 17=25 High (Red)
5
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Created by: Gareth Powell – Duty Team Manager & EPLO
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Item 10
Risk Description Risk
Score
Plan
No Loggist available for major 20 EP assistant to undertake training and cascade
incidents
this training
The trust currently has 1 trained
Each Department to identify 1 loggist to act as
loggist
part of a loggist pool.
Workload v Workforce
20 Appoint current Emergency planning assistant to
PAH Emergency preparedness
a 12 month fixed term contact –
workload is managed 0.5WTE Band
8b, this is not in line with local trusts
and represents a mismatch which will
impact on the trusts ability to comply
with the civil contingencies act.
Band 4
Site Lockdown
20 Develop a Lockdown plan containing actions card
Currently unable to lockdown PAH
site
and exercise
Mass Evacuation
20 Develop a Mass evacuation plan containing
Currently no process in place
actions card and exercise
Incident Control Room
20 Review current equipment & purchase shortfall
Current equipment unfit for purpose
immediately
Process for setup protracted and does
Develop process for setup and train all Duty
not provide the trust with a safe
platform to operate from
Matrons & Senior Managers to setup control room
Equipment
12 Purchase required equipment to ensure trust can
Equipment identified in previous
exercises as required to maintain
effective & safe systems has not been
purchased
operate effectively
Executive Team Preparedness 12 Training being developed to strengthen
knowledge
Senior Manager Preparedness 12 Training being developed to strengthen
knowledge
8. Resource
Workforce
The Emergency preparedness workload is currently supported by an Emergency Planning
Assistant who is seconded to the Duty Management team.
Recommendation is to extended the secondment by 12 months and increased to a band 4 to
reflect the increased scope of the role.
Benchmarking
The trust has compared its Emergency Planning workforce with that of neighbouring trusts,
each trust has one full time member of staff dedicated to Emergency Planning and associated
activities.
Equipment
Exercise EMERGO and Aquarius reported areas of improvement with regard to equipment
9. Recommendations
The board is asked to:
Receive this report as a statement of assurance of the preparedness of the Trust to provide an
effective response to a range of incidents and emergencies

Appendix 1
Created by: Gareth Powell – Duty Team Manager & EPLO
7
Item 10
The Princess Alexandra NHS Trust - Emergency Planning Programme 2012
(Please note that this is an outline plan and will be refined further during quarter 2)
Month Training Exercises Policies/Plans Incidents/Events
January 2012 Trust Induction
Training
February 2012 Trust Induction
Training
March 2012 Trust Induction
Training
April 2012 Trust Induction
Training
May 2012 Trust Induction
Training
June 2012 Trust Induction
Training
CBRN Refresher
training
July 2012 Trust Induction
Training
Senior Manager &
Executive– Incident
awareness training
Loggist training
August 2012 Trust Induction
Training
Senior Manager &
Lockdown – (1 announced & 1
unannounced)
COMMEX
Major Incident Plan
CBRNe (Chemical,
Biological, Radiological,
Nuclear, Explosive)
Lockdown
Mass Casualty
VIP
Launch Heat Wave plan
Mass Evacuation
Pandemic Plan - Review
Adverse weather -
Snow
Relaunch of Major
Incident Group
Heat wave return
Olympic games
sexual health return
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Executive– Incident
awareness training
September 2012 Trust Induction
Training
Senior Manager &
Executive –
Command & Control
training
October 2012 Trust Induction
Training
Senior Manager &
Executive –
Command & Control
training
November 2012 Trust Induction
Training
Loggist training
Senior Manager &
Executive –
Command & Control
training
December 2012 Trust Induction
Training
Created by: Gareth Powell – Duty Team Manager & EPLO
Mass Evacuation – Table-top
Table-top exercise
COMMEX
8
Item 10
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Appendix 2
Created by: Gareth Powell – Duty Team Manager & EPLO
9
Item 10
The Princess Alexandra NHS Trust - Emergency Planning Equipment & Non-Pay Spend Breakdown
(Please note that this is an outline plan and will be refined further during quarter 2)
Item Supplier Cost per item Number Total Comments
Speed Shelter SP Services £1,000.00 1 £1,000.00
Quazar QuadPod Sign (casualty
clearing station) SP Services £300.00 1 £300.00
Mega Phones SP Services £100.00 5 £500.00
Ultility Belts SP Services £9.00 10 £90.00
Electricity and Water Supply Internal £500.00 1 £500.00
Wellington Boots ? £7.00 15 £105.00
Following Exercise Aquarius it was highlighted that there was
no shelter for patients to wait in before decontamination
Feedback from Exercise Aquarius was that there was no
clear signage of where patients should do, which caused
confusion
Currently only 1 on site which is not fit for purpose, to be
used to aid communication during incidents, both decon,
majax and mass evac.
Identified in Exercise Aquarius that when in scrubs etc no
place to attach radios
Hot water and power supply for decon tent to enable safer
use of equipment such as not using generators
Currently the Trust only has size 10 boots available for staff
carrying out decontamination to allow range of sizes 5 of
each size 4, 6, 8
Hig Visibility waistcoats www.Hivis.co.uk £9.00 18 £162.00
Current waistcoats are all yellow so do not aid identification
of key staff during a major incident
Bronze Training EOE Amb Service £300.00 2 £600.00 Training for EP team, to Cascade down
Silver Training EOE Amb Service £650.00 2 £1,300.00 Training for EP team, to Cascade down
Gold Training EOE Amb Service £300.00 2 £600.00 Training for EP team, to Cascade down
CBRN Training EOE Amb Service £300.00 3 £900.00 Training for EP team, to Cascade down
CBRN Train the Trainer Training
Briefing and De-Briefing Skills
EOE Amb Service £300.00 3 £900.00 Training for EP team, to Cascade down
Course EOE Amb Service £150.00 2 £300.00 Training for EP team, to Cascade down
Business Continuity Training EOE Amb Service £120.00 2 £240.00 Training for EP team, to Cascade down
Peterborough
Training for 4 members of duty team then cascade down (2x
HMIMMS
Hospital £400.00 2 £800.00 already booked and paid)
Major Incident Plan Printing Preferred Supplier £2,000.00 1 £2,000.00
Fuel Plan, Mass Cas and Preferred Supplier £1,500.00 1 £1,500.00
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CBRNe Printing
All exclude VAT
Created by: Gareth Powell – Duty Team Manager & EPLO
Total £11,797.00
10
Item 10
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Terms of Reference
Business Performance Assurance Committee
Version: 1.1
Ratified by: CEO via the risk management
Strategy
Date ratified: 17 th January 2012
Name of Sponsor/ Owner//author: Sponsor;
Non Executive Director with
Responsibility for Business
Performance:
Trust Board Secretary
Name of responsible individual
(sponsor) and committee (If
appropriate):
Name……………………………………Signed ……………………………………..
Chairman of the Board
Sponsor (Board Level):
Chairman
Date issued: First draft November 2011
Review date: One year from ratification (January
2012 for first review)
Target audience: • Members of the Board
• Executive Team
• Audit & Risk Assurance Committee
• NHSLA
• CQC
• Commissioners
• Senior Clinicians and Managers
Item 38 37 11 39 of of 175 174 172
182 176
RATIFIED
1

Versio
n
Date Author Status Comment
1.0 22/11/11 Trust Board
Secretary
1.1 22/1/11 Trust Board
Secretary
Draft First draft to stimulate discussion at
formal BPAC meeting.
Final
Update
Further update by the Chair in
response to comments and
approved..
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2

1 Objective:
Business Performance Assurance Committee
Terms of Reference
1.1 To provide assurance to the Trust Board on management or mitigation of key
financial and manpower risks or opportunities that could materially impact the
successful delivery of the Trust’s annual and long term business plans.
2 Duties / Functions:
2.1 To provide assurance to the Trust Board that:
• PAH financial performance (including the transformation programme, capital
investment programme, cash flow management and contract management) is
meeting the Board’s agreed business objectives
• Key risks identified and tagged to the Committee through the risk
management processes are being managed appropriately.
• The PMR self-certification returns relating to Financial risk rating, Financial risk
triggers and contractual risk rating are accurately reported and reflect the
Trust’s position
• The annual and long term financial plans., including the annual capital budget
are sufficiently robust and only then will BPAC recommend their adoption by
the Trust Board
• Any plans that require significant departure from the Board approved annual
and long term financial plans are scrutinised before recommending their
approval by the Trust Board
• All business cases with investment of greater than £500k meet required
investment and purchasing criteria prior to formal submission to the Trust
Board for approval;
3 Accountability & Reporting Procedures:
3.1 The Business Performance Assurance Committee is a committee of the
Board and accountable to it.
3.2 The Minutes of the Business Performance Assurance Committee shall be
formally recorded and submitted to the Board in line with Board ‘cycles’.
3.3 In addition, the Chair of the committee will provide an exception-based
risk/assurance report to the Board following each meeting.
3.4 In order to underpin its assurance role the Committee will require Clinical
Directors to give a verbal assurance, based upon a written Integrated
Governance Report, update at each meeting on key business performance
and risk issues within their Directorate.
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3

3.5 The Committee shall undertake an annual self assessment of 41 40 its 42 of of 175 174 172
182 176
performance for scrutiny by the Audit Committee based upon a standardised
toolkit for all committees.
3.6 Terms of Reference will be reviewed by BPAC annually and any
recommended changes will need Trust Board approval prior to adoption.
3.7 BPAC Chair will discuss assurance processes and any issues arising at
planned meetings with the Trust Chair.
3.8 BPAC will forward any arising assurance issues covered by Audit and Risk
Assurance Committee (ARAC) and/or Patient Experience Assurance
Committee (PEAC) to those committees within 48hours of the issue coming
to light. Any such arising issues will be formally documented in the BPAC
monthly report. The Chair of BPAC will discuss any arising issue with the
respective Chair of ARAC and PEAC.
3.9 Update reports to other groups will be made as appropriate.
4 Membership
4.1 Membership of the committee will comprise three non-Executive Directors;
one of whom will chair the committee.
4.2 In addition, the following will normally attend committee meetings:
• Director of Finance
• Chief Operating Officer
• Clinical Directors – by invitation and on a cycle to be agreed
• Associate Director of Strategy & Contracting
• Trust Board Secretary
• AD of Nursing
4.3 The Chief Executive will attend, at a minimum, quarterly in April, July,
October and January to discuss with the Committee the year to date
performance of the Trust and additionally at the request of the committee.
4.4 The Director Workforce will attend, at a minimum, quarterly to discuss with
the Committee manpower issues and opportunities with particular emphasis
on the impact on manpower of PAH major change programmes.
4.5 NEDs who are not members of the Committee may attend subject to a
courtesy request to the Chair.
4.6 The Committee may ask any other officials of the organisation to attend to
assist it with its discussions on any particular matter.
4.7 The Committee may ask any or all of those who normally attend but who are
not members to withdraw to facilitate open and frank discussion of particular
matters.
4.8 In the event of unavoidable absence designated attendees will be required to
ensure that a suitable and fully briefed deputy attends
4

5 Frequency of Attendance
The expectation is that all meetings will be attended by all members. When
attendance falls below 75% over an annual period the issue will be raised with
the individual by the Chair and any steps taken to improve attendance.
6 Authority
BPAC is authorised by the Trust Board to seek any information it requires from
any employee, group or committee in pursuit of its Terms of Reference and all
are directed to co-operate with any request made by the Group.
7 Frequency of Meetings
The Committee will meet monthly immediately prior to Board meetings. The
Chair will decide upon such extra-ordinary meetings as are considered
necessary to transact the Trust’s business in an effective and timely manner.
8 Quorum
Two NED members of the committee.
9 Monitoring arrangements
The effectiveness of the Committee will be monitored by the Board through its
regular reports to the Board as per the planning cycle and also by the Risk and
Assurance Committee as part of its review of all Board Committees.
Attendance will be monitored through the meeting attendance matrix, with
exceptions being addressed by the Chair.
The Terms of Reference will be reviewed yearly by the Chair of the committee
with the NED members bringing any significant changes to the notice of the
Board for ratification.
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5

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Terms of Reference
Remuneration and Nominations Committee
Purpose of the Committee
The Committee is a non-executive committee of the Trust Board and has no executive
powers, other than those specifically delegated in these Terms of Reference.
Membership
Members of the Committee are all the non-executive directors, including the Trust
Chair.
The Chief Executive will be entitled to attend the Committee and be consulted on when
the appointment and remuneration of Executive Directors is being considered. They
will be excluded from these meetings when their own position is under discussion.
Other individuals will be invited to attend as required.
Minutes secretary to be the Head of Corporate Governance.
Quorum
A quorum shall be two members plus the Chair, or in their absence the Trust Vice-
Chair.
Nominees
Nominated substitutes are not permitted at this committee, except the Trust Chair who
can be substituted as Chair by the Trust Vice-Chair
Frequency
Meetings shall be held not less than twice per annum and may be held or more
frequently as convened by the Chair
Meetings will be held whenever the appointment or the removal of the CEO or an
Executive Director is to be considered or where changes to the Board structure are to
take place.
Members are expected to attend a minimum of 1 meeting in any one year, and not
miss more than 3 in succession. An attendance matrix will be maintained by the
minutes secretary.
Reporting
Given the sensitive nature of many of its discussions, the Chair will determine what, if
any, reports are made to the Trust Board.
Authority
The Committee is authorised by the Trust Board to investigate any activity within its
Terms of Reference. It is authorised to seek any information it requires from any
employee and all employees are directed to cooperate with any request made by the
Committee.
v1.1 1 of 3 July 2012
Item 11
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The Committee is authorised by the Trust Board to obtain outside legal or other
independent professional advice and to secure the attendance of outsiders with
relevant experience and expertise if it considers this necessary.
The Committee is authorised to:
• Approve the appointment and remuneration packages for a new Chief
Executive and Executive Director appointments to the Trust Board.
• Approve the performance objectives (including, where appropriate, direct
reference to national objectives) and assessment criteria of the Chief Executive
and, in consultation with the Chief Executive, the Executive Directors of the
Trust Board.
• Consider and approve annual pay and remuneration packages, following
satisfactory assessment of the performance of the Chief Executive and
Executive Directors This will take have proper regard to the organisation's
circumstances and performance and to the provisions of any national
arrangements for such staff where appropriate.
Appointments of Chief Executive and Executive Directors
The Committee will put in place arrangements to appoint the Chief Executive and other
Executive Directors.
Duties and Responsibilities
• To receive from the Chairman, details of appraisal of the Chief Executive
• To make recommendations to the Trust Board on the remuneration and terms
of service of the Chief Executive to ensure individual contribution to the
organisation is fairly rewarded (having proper regard to the organisation's
circumstances and performance and to the provisions of any national
arrangements for such staff where appropriate).
• Should the occasion arise, recommend to the Chair and all non-executive
directors, any disciplinary action necessary in relation to the performance
and/or conduct of the Chief Executive, as felt to be necessary.
• With the Chief Executive, monitor and evaluate the performance of individual
Executive Directors annually and more frequently if the Chief Executive
considers it appropriate.
• To consider succession planning arrangements for the Chief Executive and
Executive Directors
• Keep under review the management costs of the Trust; and, in particular, make
such recommendations to the Trust Board on the remuneration and terms of
service of Executive Directors to ensure they are fairly rewarded for their
individual contribution to the organisation (having proper regard to the
organisation's circumstances and performance and to the provisions of any
national arrangements for such staff where appropriate)
• Advise on, and oversee, appropriate contractual arrangements for such staff,
including the proper circulation and scrutiny of termination payments, taking
account of such national guidance as is appropriate.
• Monitor and make recommendations on all discretionary policies in lieu of a
supplement to pay, benefit or expenses entitlements of employees.
• To review the structure, size and composition (including the skills, knowledge
and experience) required of the Trust Board and any on-going development
needs both individually and collectively as identified through the appropriate
assessment/appraisal process.
v1.1 2 of 3 July 2012
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Monitoring arrangements
The Minutes of the Committee shall be formally recorded and submitted to the Trust
Board by the secretary to the Committee. The Chair of the Committee shall draw to the
attention of the Trust Board any issues that require disclosure to them or require
executive action.
The Committee will review its terms of reference on an annual basis
The Committee will review its own performance no less than once every two years.
An annual report of activities of the Committee shall be presented to the Trust Board,
reporting that it has discharged its responsibilities as set out in these terms of
reference.
A separate section of the Trust’s annual report will describe the work of the Committee
in discharging its responsibilities.
v1.1 3 of 3 July 2012

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SUMMARY REPORT
Item 12
Trust Board Meeting (Part A) 26 July 2012
Subject: Trust Board Dashboard – June 2012
Prepared by; Levon Quilter, Head of Information
Approved by: Ken Sharp, Director of Finance
Presented by: Ken Sharp, Director of Finance
Purpose
To receive the Trust Dashboard showing performance in June 2012.
Corporate Objectives
Safety /
outcomes
Financial Workforce Estates-
Environmental
Regulatory /
Statutory
Decision
Approval
Noting
Information
Other
Relationships
/ Partnerships
Executive Summary
The Trust Board Dashboard highlights any particular risks and issues in relation to
organisational performance.
Key Recommendations
The Board is asked to note the contents of this report.
Assurance Framework
There is a legal requirement for all NHS organisations to receive regular reports in
order to give the Board assurance that financial plans are being delivered and that
statutory requirements will be met.
Next Steps
N/A
Corporate Impact Assessment
CQC Regulations 2.02, 2.03
Financial Implications
Legal implications
Equality & Diversity
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Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
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TDB 2012-13 Mth 3 v6 1 of 10

Clinical Quality 1 Year to date
Monthly Position
11/12 Actual Plan Variance RAG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
CQUIN (Schemes with red rated elements) n/a 5/10 0/10 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 5/10
VTE risk assessment ** 94.83% 95% -0.17% A 90.8% 90.4% 92.5% 93.6% 92.2% 92.8% 90.7% 92.1% 92.1% 93.5% 94.98% 94.7% **
Adverse Events R
SIs - Not Ulcer, Falls or Medication 2 7 n/a -5 G 2 2 4 3 5 2 3 8 8 3 0 1 6
Grade 3/4 pressure ulcers - SIs only ** 11 n/a ** ** 6 6 2 1 2 1 3 2 7 3 7 4 **
Falls - SIs only ** 5 n/a ** ** 1 0 0 0 0 2 2 7 0 2 1 4 **
Medication errors SIs ** 0 n/a ** ** 0 1 0 2 0 0 0 3 2 0 0 0 **
Never Events ** 0 n/a ** ** 2 0 0 0 1 0 0 0 0 0 0 0 **
All SIs ** 17 n/a ** ** 11 9 6 6 8 5 8 20 17 8 8 9 **
All currently open SIs n/a 24 n/a ** R 74 71 72 32 31 28 40 41 62 57 29 38 24
Grade 2,3,4 presure ulcers - incl non-SIs ** ** n/a ** ** n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
CQC concerns R
CQC registration without conditions ** Yes n/a n/a G Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
CQC Other Concerns ** 5 0 0 R 2 2 2 2 0 0 0 0 0 4 4 5 5
Central Alert System (CAS) Alerts ** 0 0 0 G 0 0 0 0 0 0 0 0 0 0 1 3 0
** Data not yet available due to reporting timetable
VTE risk assessment will not be available until 27th July
Explanatory notes:
Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
CQUIN. The dashboard shows performance against the total number with no red rated areas of performance. This section also identifies one particular, high profile, scheme (VTE) for particular
attention. This is now reported quarterly, the first report of the year will be in July. Last year's figures have been removed as they do not relate to this year's schemes and cannot be used as a
comparator.
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SIs. SIs are shown as both the number of incidents in the month (and over the period YTD) as well as the number of incidents open at the point the report is generated each month. Falls and medication
errors are those classified as SIs only
TDB 2012-13 Mth 3 v6 2 of 10

Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
Clinical Quality 2 Year to date
Monthly Position
11/12 Actual Plan Variance RAG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
HSMR (Dr Foster) n/a 102.5 n/a n/a R 89.3 90 105.8 110.9 96.6 87.9 113.4 110.7 103.8 110.8 97.7 ** **
HSMR (QIE) n/a 107 n/a n/a ** 106.0 110.0 110.0 110.0 ** ** ** ** ** ** ** ** **
SHMI 99.3 100.01 n/a n/a ** 95.61 95.61 95.97 95.97 ** ** ** ** ** ** ** ** **
MRSA R
MRSA infection > 48hrs n/a 1 0 1 R 0 0 0 0 0 0 0 1 0 0 0 1 0
Elective MRSA screening n/a 99.1% 100% -0.9% A 98.7% 99.7% 98.7% 99.0% 99.0% 99.4% 98.9% 99.2% 98.7% 99.4% 98.9% 99.1% 99.4%
Emergency MRSA screening n/a 94.1% 100% -5.9% R 86.9% 91.2% 95.8% 95.3% 94.8% 91.9% 91.2% 88.6% 89.2% 89.2% 92.5% 93.8% 96.0%
C Diff infection > 72hrs n/a 2 4 2 G 2 2 0 0 3 0 1 0 0 1 1 0 1
Stroke A
% with 90% of stay on a Stroke Unit n/a 89% 80% 9% G 55% 65% 73% 71% 76% 69% 45% 70% 68% 70% 83% 96% 88%
% admitted direct to SU within 4 Hrs n/a 45% 95% -50% R 13% 12% 11% 27% 14% 8% 15% 9% 11% 33% 48% 48% 35%
% eligible scanned within 1 Hr n/a 81% 60% 21% G 73% 75% 100% 86% 100% 50% 83% 56% 40% 57% 90% 100% 55%
100% compliance with WHO surgical checklist n/a Yes n/a n/a R Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No
Red rated areas on Maternity dashboard n/a n/a n/a n/a 3 3 3 2 2 2 1 3 3 2 0 1 2
** Data not yet available due to reporting timetable
Explanatory notes:
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Emergency MRSA. Swabbing includes patients transferred to Ambulatory Ward
Maternity dashboard. Based on the RCOG dashboard
HSMR. Because of the data source used by Dr. Foster for HSMR which is subject to refresh after the latest reporting month and the impact of deaths attributed to the Trust subsequently, the complete
monthly series of HSMR scores may change to some degree in comparison with previous months reports. Year to data figure refers to the rolling 12 month total.
HSMR - QIE. Data prepared by Quality Intelligence East which describes the rolling 12 month figure based on the previous four quarters data. The most recent figure available is quarter 2, quarter 3
will be available at end of July 2012
SHMI - Summary Hospital Mortality Indicator. Will become the tool for use by all Trusts in reviewing mortality rates. It is calculated differently from HSMR and the only data available currently is for
2011-12 to q2, reported here.
TDB 2012-13 Mth 3 v6 3 of 10

Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
Patient Experience Year to date
Monthly Position
11/12 Actual Plan Variance RAG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Net Promoter Score n/a 92.9% 95.0% -2.1% A 96.3% 96.3% 95.7% 96.6% 96.1% 95.2% 96.6% 95.9% 96.0% 95.6% 95.3% 93.4% 91.8%
Patient Engagement n/a 92.0% n/a n/a 93.9% 93.2% 91.9% 92.8% 91.9% 93.9% 89.7% 93.0% 92.4% 91.7% 93.2% 90.9% 92.0%
Complaints 159 136 n/a 23 R 60 62 54 49 57 60 39 75 62 48 44 40 52
Hospital Cancellations R
Total cancelled by Hosp non clinical 9.7% 9.7% n/a 0.0% R 9.0% 9.2% 7% 8.2% 8.0% 8.4% 8.2% 12.2% 11.8% 15.3% 9.9% 7.9% 11.2%
Number cancelled two or more times 96 53 n/a 43 A 29 34 20 23 21 30 23 48 35 47 29 24 31
Cancelled at last minute 0.81% 1.16% 0.80% 0.36% R 0.74% 1.17% 0.55% 0.52% 0.55% 1.49% 0.93% 1.91% 1.95% 0.84% 0.31% 1.45% 1.31%
Last minute not admitted < 28 days 7.50% 7.27% 5.00% ** 9.1% 3.0% 14.3% 0.0% 6.7% 7.9% 5.0% 11.4% 5.0% 5.9% 10.0% 6.8% **
Cleanliness G
Very high risk areas n/a 97.30% >95% 2.30% G 95.4% 96.1% 95.47% 94.90% 96.97% 98.00% 93.73% 95.90% 97.90% 98.21% 97.76% 97.30% 96.85%
High risk areas n/a 97.21% >90% 7.21% G 94.2% 94.5% 95.01% 95.61% 97.88% 97.94% 97.60% 92.60% 95.50% 96.10% 98.16% 95.89% 97.57%
Single Sex Accommodation n/a 3 0 3 R 14 6 0 9 6 0 0 0 0 2 3 0 0
PROMs Score (participation rate) n/a 84% 80% 3.7% n/a ** ** ** 83.7% ** ** ** ** ** ** ** ** **
** Data not yet available due to reporting timetable
Explanatory notes:
Patient experience. The Net Promoter score is based on answers patients gave to the question “How likely is it that you would recommend this service to friends and family?” The Patient engagement
score is based on answers patients gave to the question “Were you given enough information to enable you to make choices about your care?”
Hospital cancellations. Defined as follows:
- Total cancelled by hospital – non clinical. This is the total number of admissions cancelled by the hospital for non-clinical reasons
- Number cancelled two or more times. This is defined as the total number of admissions cancelled by the hospital for non-clinical reasons for a second or subsequent time
- Cancelled at the last minute. These are admissions cancelled by the hospital for non-clinical reasons on the day of admission
- Last minute not admitted

Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
Activity Year to date
Monthly Position
11/12 Actual Plan Variance RAG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
A&E Attendances 21,248 20,551 20,011 540 G 7,009 6,705 6,636 6,907 7,012 6,830 6,819 6,438 6,192 6,981 6,463 6,968 7,120
1st OP Attends 16,883 16,834 16,070 764 G 6,598 5,852 5,622 5,599 5,671 6,045 5,105 5,607 6,351 5,916 5,459 5,994 5,381
Follow-Up OP Attend 32,707 30,378 29,567 811 G 12,849 11,339 11,453 11,093 10,384 12,260 10,792 10,599 10,656 10,764 9,609 11,369 9,400
OP Procedures 4,235 8,496 8,211 285 G 1,621 1,885 1,692 2,648 3,483 4,168 3,117 3,364 4,130 3,604 1,848 3,428 3,220
Day Case Admissions 6,362 5,909 5,744 165 G 2,455 2,305 2,067 2,136 2,235 2,134 1,637 2,002 1,683 1,773 1,824 2,255 1,830
In-patient Admissions 1,268 1,319 1,172 147 G 504 450 481 539 510 423 377 303 371 477 436 499 384
Emergency Admission 5,608 5,934 5,454 480 G 1,928 1,820 1,835 1,918 2,000 1,964 1,936 1,921 1,999 2,126 1,881 2,114 1,939
Ambulatory Care (Virtual Ward) ***
Maternity
n/a 878 ** ** ** 171 175 174 241 265 274 232 273 277 321 306 272 300
Deliveries n/a 1,089 1,121 -32 A 354 346 366 349 407 376 335 351 350 323 347 398 344
Caesarean Section rate n/a 23.1% 25.8% -2.70% A 27.1% 28.9% 24.9% 22.9% 21.6% 21.8% 20.9% 26.2% 25.1% 24.1% 24.5% 19.8% 25.6%
** Data not yet available due to reporting timetable
Note Activity traffic lights substantial over performance Green minimal variation (< +/- 2.5%) Amber substantial under performance Red
*** Please note that quantity of ambulatory activity is included within Emergency Admissions.
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TDB 2012-13 Mth 3 v6 5 of 10

Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
Access & Targets 1 Year to date
Monthly Position
11/12 Actual Plan Variance RAG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
18 week RTT g
Admitted Percentage within 18 weeks ** 93.9% 90.00% 3.9% G 80.5% 82.0% 83.3% 86.4% 91.1% 91.1% 92.1% 90.3% 84.2% 81.2% 93.5% 94.1% **
Non Admitted Percentage within 18 weeks ** 97.8% 95.00% 2.8% G 97.2% 96.7% 96.7% 97.3% 97.4% 96.7% 97.4% 96.9% 97.0% 96.8% 97.5% 98.1% **
Incomplete Percentage within 18 weeks ** 97.8% 92.00% 5.8% G 94.6% 94.5% 94.8% 95.1% 95.7% 95.7% 97.1% 97.1% 96.1% 97.5% 97.6% 98.0% **
Admitted Backlog >18 wks ** 96 96 0 G 472 398 342 173 141 115 140 183 233 108 114 96 **
Non-admit Backlog >18 wk ** 86 n/a n/a 82 96 185 315 284 171 134 91 106 108 88 86 **
A&E quality standards a
Unplanned re-attend within 7days ** 6.9%

Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
Access & Targets 2 Year to date
Monthly Position
11/12 Actual Plan Variance RAG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Cancer Wait indicators g
14 day GP Urgent n/a 86.7% 93.0% -6.3% R 94.6% 93.4% 93.4% 94.2% 93.4% 93.8% 95.6% 88.5% 91.0% 87.4% 84.1% 89.0% **
14 day Breast Symptomatic n/a 87.7% 93.0% -5.3% R 94.4% 93.8% 96.0% 94.5% 95.5% 94.9% 96.9% 93.1% 87.9% 89.8% 80.5% 93.8% **
31 day 1st treatment n/a 99.2% 96.0% 3.2% G 100.0% 100.0% 97.9% 100.0% 100.0% 98.2% 100.0% 96.4% 98.3% 96.6% 100.0% 98.6% **
31 day Subsequent Drug n/a 100.0% 98.0% 2.0% G 100% 100% 100% 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% **
31 day Subsequent Surgery n/a 92.9% 94.0% -1.1% G 100% 100% 100% 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 85.7% **
62 day GP Urgent n/a 89.1% 85.0% 4.1% G 94.4% 85.1% 86.8% 95.7% 95.7% 91.1% 89.8% 79.6% 83.3% 81.1% 88.3% 89.7% **
62 day Screening n/a 100.0% 90.0% 10.0% G 93.3% 91% 92.9% 100.0% 91.7% 100.0% 100.0% 100.0% 95.5% 85.7% 100.0% 100.0% **
62 day Consultant Upgrade n/a 94.5% 90.0% 4.5% G 93% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.7% 95.3% 93.3% **
Emergency Readmissions r
< 30 days (initial non-elective adm) 9.8% 9.9% 8.45% 1.5% R 10.3% 12.1% 11.1% 11.0% 11.5% 11.0% 10.8% 9.4% 10.7% 11.9% 10.3% 9.3% **
Ambulatory Care patients as % of re-adm 25.6% 20.6% ** ** ** 13.3% 11.7% 14.6% 13.6% 15.5% 13.9% 13.3% 17.0% 29.9% 30.2% 25.7% 15.6% **
< 30 days (initial elective adm) 2.5% 3.1% 0.0% 3.1% R 2.6% 2.9% 3.2% 2.6% 3.5% 3.8% 3.6% 3.0% 3.2% 3.9% 3.2% 2.9% **
Ambulatory Care patients as % of re-adm 20.5% 23.9% ** ** ** 19.35% 15.15% 19.7% 24.1% 23.0% 12.1% 21.0% 33.3% 35.3% 34.7% 25.0% 22.8% **
Diagnostic Waits < 6 weeks G
Magnetic Resonance Imaging ** 100% >99% 1.00% G 100.0% 100.0% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Computed Tomography ** 99.15% >99% 0.15% G 99.0% 100.0% 100% 100% 100% 100% 99% 100% 100.0% 100% 100% 98.50% 99.30%
Non-obstetric ultrasound ** 99.97% >99% 0.97% G 100.0% 100.0% 100% 100% 100% 100% 100% 100% 100.0% 100% 100% 100% 99.95%
Colonoscopy 54% 99.41% >99% 0.41% G 74.2% 73.3% 79.4% 94.4% 100.0% 100.0% 100% 100% 100% 100% 100% 100% 98.07%
** Data not yet available due to reporting timetable
Cancer data for May will be available 10th July
Target changed for Diagnostic Waits to greater than 99% from 1st April 2012
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TDB 2012-13 Mth 3 v6 7 of 10

Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
Efficiency (QIPP) Year to date
Monthly Position
11/12 Actual Plan Variance RAG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Bed utilisation
Emergency LoS 5.7 5.2 4.7 0.4 A 5.4 5.5 5.5 5.3 5.2 5.9 5.4 5.7 5.8 5.3 4.8 5.4 5.2
Elective LoS 3.5 2.6 2.7 0.0 G 3.2 3.2 3.3 3.1 3.0 2.7 2.8 3.0 2.9 2.5 2.5 2.6 2.8
Maternity Bed occupancy 63.8% 67.4% n/a n/a n/a 66% 66% 66% 76% 68% 72% 62% 70% 75% 69% 63% 72% 67%
Paediatric Bed occupancy (inc NICU) 68.2% 75.7% n/a n/a n/a 74% 76% 57% 76% 74% 85% 69% 82% 74% 65% 65% 82% 80%
Adult acute Bed occupancy (excl CC) 92.5% 94.3% n/a n/a n/a 93% 90% 90% 92% 93% 95% 92% 95% 90% 89% 94% 94% 95%
Outpatient DNA Rate n/a 8.6% n/a n/a n/a 11.3% 11.2% 11.6% 10.4% 10.0% 9.5% 11.3% 10.7% 9.6% 9.4% 8.3% 8.7% 8.6%
OP Follow-up above limit & not paid 4543 1690 2025 -335 G 2546 1603 1880 -1781 820 1396 1227 751 790 967 631 622 437
Internal referral activity
Theatre utilisation
n/a 968 1219 -251 G 690 628 653 559 479 502 375 466 446 480 454 514 **
Main theatres 85% 84% 85% -1% A 88% 85% 88% 85% 84% 79% 76% 72% 82% 83% 85% 82% 84%
ADSU theatres 81% 86% 90% -4% R 86% 82% 83% 84% 90% 88% 83% 87% 84% 88% 85% 87% 86%
** Data not yet available due to reporting timetable
Explanatory notes:
Emergency and Elective LoS. This is calculated as adult acute LOS and excludes Maternity, Well Baby and Paediatric activity but includes EAU, against a target of reduction phased over month 1-12
Bed occupancy. Split into adult acute, maternity and paediatric activity
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TDB 2012-13 Mth 3 v6 8 of 10

Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
Workforce Year to date
Monthly Position
11/12 Actual Plan Variance RAG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Sickness Absence Rate ** 4.42% 3% 1.42% R 4.28% 3.80% 3.72% 3.70% 4.06% 4.59% 4.25% 4.02% 4.28% 4.19% 3.88% 4.42% **
Long Term Sickness ** 2.34% ** ** ** 1.91% 2.01% 2.20% 1.88% 2.17% 2.62% 1.85% 2.59% 2.31% 1.61% 1.73% 2.34% **
Short Term Sickness ** 2.08% ** ** ** 2.37% 1.79% 1.52% 1.82% 1.89% 1.97% 2.40% 1.43% 1.97% 2.58% 2.15% 2.08% **
Turnover Rate ** 14.4% 12% 2.4% R 11.4% 11.1% 11.2% 11.1% 11.4% 11.7% 11.3% 11.8% 12.8% 14.2% 14.3% 14.2% 14.4%
Vacancy Rate 7.3% 7.6% n/a n/a 5.4% 4.3% 5.7% 6.9% 6.7% 6.2% 4.2% 5.5% 5.9% 7.5% 9.0% 7.6% 7.3%
Agency and bank spend as a % of turnover 5.4% 8.72% n/a n/a 5.5% 6.2% 6.4% 6.5% 5.8% 6.5% 6.8% 6.2% 6.6% 7.1% 9.3% 8.5% 8.4%
PRDP completion n/a 63.0% 80.0% -17.0% R ** ** ** ** 80.0% 77.0% 72.0% 71.0% 66.0% 66.0% 61.0% 65.0% 65.0%
** Data not yet available due to reporting timetable
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TDB 2012-13 Mth 3 v6 9 of 10

Trust Dashboard for Month 3 2012/13
(ending 30th June 2012)
Finance Year to date
Monthly Position
11/12 Actual Plan Variance RAG Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Risk rating n/a 1 2 1 R 2 2 2 2 3 3 2 2 2 3 1 1 1
I&E variance from plan (£000s) n/a -1,588 0 -1,588 R -80 88 -420 -38 -30 -192 -350 576 -389 1,881 -239 -435 -914
Actual I&E surplus/deficit (£000s) n/a -3,066 -1,478 -1,588 R -115 -33 -268 11 768 364 -880 896 55 795 -1,084 -571 -1,412
Performance v income plan (£000s) n/a -42,390 -42,367 -23 G 15,058 14,833 14,676 15,163 15,783 15,158 13,601 15,507 15,245 17,770 13,734 14,831 13,825
Cost Improvement Plan (£000s)
Market Share
n/a -618 -884 266 -587 -540 -631 -644 -1,215 -1,065 -1,303 -1,213 -1,258 -1,484 -111 -117 -390
Outpatient Referrals n/a 60.20% n/a n/a 62.7% 61.9% 62.0% 60.3% 80.1% 60.2% 61.8% 60.6% 61.5% 60.9% 60.2% ** **
Elective Admissions n/a 63.20% n/a n/a 70.0% 71.6% 67.7% 67.0% 81.6% 65.2% 67.5% 63.1% 61.0% 63.1% 63.2% ** **
Maternity Deliveries n/a 83.90% n/a n/a 82.9% 87.4% 84.9% 88.2% 96.8% 84.9% 85.8% 83.7% 88.9% 89.9% 83.9% ** **
** Data not yet available due to reporting timetable
Market Share - Taken from Dr Foster, data available two months in arrears, hence May and June not yet available.
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TDB 2012-13 Mth 3 v6 10 of 10

Month 2
Indicator
Variation From Plan
RED
AMBER
TRUST Performance Exception Report
Standard
Clinical Director
Author
Clinical Quality
Sharon Cullen
All currently open serious incidents (SI’s)
Reason for Variation
Impact of Variation Patient Experience or
Outcome
Actions to address
Variation
Forecast return to plan
Forecast outturn
Monitoring
arrangements
A plan for the number of open SI’s has not been set. The aim is to meet the
deadlines for reporting with submission of final report no later than 45 days after
incident is reported.
Whilst indicated as red on the month 2 dashboard, the trend of open SI’s is
reducing and there is demonstrable evidence of improvements in
the timeliness of reporting
quality of the reports
completion of the final reports
Unexpected death
Avoidable harm
Breach of confidentiality
Allegations of abuse
Financial Position Indirect impact if extended length of stay
Performance Targets Reputational issue
Likely to impact upon levels of assurance
experienced by commissioners, service users and
SHA associated with patient safety and quality care
Adverse media interest
Date Description
April 2012 Introduction of Datix web to facilitate timely reporting
July 2012 Implementation of STEIS national reporting system should
enable timely closure of completed serious incidents
Directorate PS&Q forums with exception reporting to Trust PS&Q
and identification of actions to address
Not set as no plan
Not set
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• Daily Serious clinical incident group available to ensure timely review and
identification of severity of incident.
• CEO Scrutiny panel initiated by unexpected/avoidable deaths or serious harm
events to ensure learning and actions to prevent recurrence
• Trust wide sharing of incidents and the learning form root cause analysis
through Directorate PSQ meetings, MDT meetings and professional forums
• Numbers, themes and evidence of actions to address errors or omissions
shared at PEAC and with commissioners through Clinical Quality Review
Group

Month 2
Indicator
Variation From Plan
RED
AMBER
TRUST Performance Exception Report
Standard
Clinical Director
Author
CQC concerns
Reason for Variation
Impact of Variation Patient Experience or
Outcome
Actions to address
Variation
Forecast return to plan
Forecast outturn
Monitoring
arrangements
Clinical Quality
Sharon Cullen
Currently the Trust has 5 moderate concerns identified by the CQC:
Outcome 4 Care and welfare of people who use services
Outcome 13 Staffing
Outcome 14 Supporting staff
Outcome 16 assessing and monitoring the quality of service provision
These relate to the unannounced inspection of the Emergency Department on 6 th
March 2012. An action plan to address concerns was developed and is currently
being implemented. At the end of June an updated action plan was shared with
the CQC.
Outcome 21 Records
This relates to an unannounced CQC inspection of the Termination of Pregnancy
service.
The service was initially suspended to allow a review of processes and
procedures. The service has now been reinstated.
Financial Position
Potential for a failure to deliver acceptable standards
of care.
Performance Targets Concerns impact on the commissioners assurance re
the safety and quality of our services.
Date Description
All aspects of the action plan expected to be completed by October 2012.
• Through UAC PS&Q forum and updates to PEAC
• With commissioners through CQRG
• Compliance manager monitors implementation of action plan and updates
CQC officer on regular basis
• Evidence of implementation of all CQC outcome standards is done through
Star chambers
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Month 3
Indicator
Variation From Plan
AMBER
TRUST Performance Exception Report
Standard
Author
100%
MRSA Emergency Screening June 2012
Sam Elden-Lee, Head of Operations UAC
The Swabbing Rate for the month was 98.05% (Fig1). This is the best un-validated
% achieved in a single month.
1270 Patients were shown as admitted. 1210 Patients were swabbed and 60
patients were not swabbed (Fig2 & 3). Of those not swabbed 14 were shown on the
A&E system as being admitted to EAU and 46 to Other Wards including AMBUL
(28) (Fig4).
As you can see 8 patients were either not admitted, or were given mis-matched
Discharge from A&E Date and Admn to Ward Date.
8 Patients were admitted and Discharged from AMBU (all after an Overnight Stay)
This report has now been validated
Reason for Variation Of 27 missed 4 errors in admission data (the admission is not an
inpatient ward)
13 missed as result of pressure to move patients without notes
being made up, breach avoidance
10 were to other wards also missed
Impact of Variation Patient Experience or
Outcome
Actions to address
Variation
Forecast return to plan
Forecast outturn
Monitoring
arrangements
Financial Position
Performance Targets
Potential risk of missed MRSA carrier.
Potential for wound infection/colonisation.
No known financial impact
100%
Date Description
6/6/12 At the moment we are awaiting clarification, from the SHA / PCT,
as to whether patients admitted to AMBU with a length of Stay
greater than 0 Days can be omitted from the monthly submission
for MRSA Swabbing.
September 2012
Monthly monitoring by information department, cascaded to Senior
Nurse ED and B&P Manager
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Fig1
Fig2
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Month 3
TRUST Performance Exception Report
Clinical Quality – Stroke Metrics –
Standard
Percentage of patients admitted to the
Stroke Unit within 4 hours
Executive sponsor Jules Martin, Chief Operating Officer
Author Jill Troup/Lorraine Talbot
Indicator National Stroke Strategy
Variation From
Plan
RED
95% of patients admitted to hospital with diagnosis of stroke must
be admitted to the Stroke Unit within 4 hours of admission.
June 2012
Actual Plan 11/12 Variance RAG
45% 95% n/a -50% R
2012/12
Jun Jul Aug Sep Oct Nov
13% 12% 11% 27% 14% 8%
Dec Jan Feb Mar Apr May Jun
15% 9% 11% 33% 48% 48% 35%
Although there was improvement in the number of patients being
admitted to the Stroke Unit within four hours of admission in April
and May, there was a deterioration of this improvement in June.
Reason for
An audit has identified that patients present to hospital late in
their condition.
• Lack of awareness and understanding of the stroke pathway
Variation
amongst various levels of key medical staff and duty team.
• Failure to appropriately prioritise the admission of patients
direct to the Stroke Unit during times of operational pressure.
• Audit has identified that variation largely occurs out of hours.
Impact of Variation Patient Experience or
Outcome
Risk to patient safety
Financial Position Risk to attainment of ‘Best Practice Tariff’
Actions to address
Variation
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Performance Targets Risk to LOS
Risk to Stroke Metric - Network
Date Description
On-going • Action plan in place to recover delivery of all
Stroke Metrics including four hour target
Commenced • Stroke pathway on display and visible to
20.06.12
and Ongoing
medical teams
Commenced • All Medical Staff including those in Emergency
13.06.12 Department trained on use of stroke pathways
and on- by Stroke Consultants and Stroke Specialist
going
Nurse.
Commenced • Duty Team aware of the pathways and the
13.06.12 priority to allocate patients direct to the Stroke
and on- Unit within four hours.
going • Meeting taking place with duty team w/c

Forecast return to
plan
Forecast outturn
Monitoring
arrangements
16.07.12.
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on-going • Prevention of Stroke patients being admitted to
EAU but sent direct to Stroke Unit
on-going • Blocked escalation beds on Stroke Unit
In line with trajectory of improvement on a month by month basis
plus recovery of June position.
• Metrics and actions are monitored by weekly performance
meetings.
• Spread sheet being produced to plot completion of Medical
Staff training and identify gaps.
• Daily exception reporting to CD and CSG Service Manager
• Daily audit takes place and monitors the specific reason for
delay so that problem areas can be addressed.
• Cover provided to ensure audit takes place if Specialist Nurse
absent.

Month 2
Indicator
Variation From Plan
RED
AMBER
TRUST Performance Exception Report
Standard
Clinical Director
Author
Complaints
Reason for Variation
Impact of Variation Patient Experience or
Outcome
Actions to address
Variation
Forecast return to plan
Forecast outturn
Monitoring
arrangements
Patient Experience
Sharon Cullen
Risk of patients losing confidence in Trust and
choosing to go elsewhere – Patients may experience
unnecessary or avoidable harm.
Financial Position If negative impact on National Patient Survey or Net
Promoter; may affect CQUIN payments
Performance Targets Impact on Friends and Family test
Potential for impact upon organisation reputation
and Patient Choice
Date Description
Appointment of new post: Head of Patient Engagement
(commences 1 st August)
• Locally through Directorate PS&Q forums
• Exception reports from directorates to Trust PSQ Committee
• Monthly report of trends to PEAC as well as formal reporting of concerns
identified from Trust PSQ Committee
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Month 2
Indicator
Variation
From Plan
RED
Reason for
Variation
Standard
Executive
sponsor
TRUST Performance Exception Report
Hospital Cancellations
Patient Experience
Jules Martin, Chief Operating Officer
The total cancelled by the hospital for non- clinical reasons and the
total cancelled at the last minute are both showing as Red in both
the monthly and year to date positions.
It should be noted though that the performance for those cancelled
for non-clinical reasons is the best since August of last year and is
one of only two occasions when the figure has fallen below 8%.
As there is no target set for this indicator, the parameters for
measurement need to be more clearly defined going forwards
otherwise it will always be rated as Red even though the
performance has improved both in month and when compared to
last year.
The number cancelled at the last minute has had an adverse
variance in month which has impacted the YTD position.
An analysis of the reasons for non- clinical cancellations reveals the
following variances from previous months’ performances.
• There was a significant increase in the number cancelled due
to consultant unavailability with this being 66 for month 3.
• No theatre time had reduced from 9 to 3 in month.
Again, data recording was an issue with the number defaulting to
‘Treatment Deferred’, which means no reason was recorded on
PAS, being 18 in month.
The main reason for the increase in the number cancelled at the last
minute was due to no beds being available.
In May this figure was 18 but has rose to 21. This is consistent with
the monthly average but this was skewed by large numbers of
cancellations in the winter months. Elective patients are being
cancelled as a result of the Emergency activity.
The overall cancellation figure has risen each month since April to
June – 223, 228, 249
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Impact of
Variation
Actions to
address
Variation
Forecast
return to plan
Patient
Experience
or Outcome
Financial
Position
Performance
Targets
Date Description
On-going
On-going
End of July
.
• Cancelling patients on the day of surgery
results in a very poor patient experience
• Leads to complaints.
If there is a delay in being able to rebook the patient
then this could adversely affect their outcome.
Cancellations, particularly those on the day, lead to
under-utilisation of theatre resources and also means
that those patients originally scheduled for that day
have to be fitted in elsewhere. This defers the
treatment of others and results in extra lists being
required to deliver the same workload.
This will impact on the delivery of 18 weeks and the
financial position. It will also have a direct impact on
patient experience and will result in an increase in
patient complaints and poor feedback in patient
surveys.
Working with those that record data to ensure that
reasons recorded are done so accurately in order to
understand fully the trends and where action needs
to be targeted.
Review the number of medical outliers on a daily
basis and request repatriation to a medical ward.
Continue to recruitment process for Anaesthetists
and review workforce requirements
As indicated earlier, there does not appear to be a plan figure for
cancellations for non -clinical reasons. Whilst we would always
attempt to keep these to a minimum, to measure this against 0 is
unrealistic.
The aim is to have the total for non-clinical reasons below 9.0%
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Cancellations at the last minute will not return to plan in June as there
have already been cancellations due to no beds. We would be
aiming, therefore to recover the monthly position by July.

Forecast
outturn
Monitoring
arrangements
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The aim is to have the total for non- clinical reasons below 9.0% and to
achieve the plan of 0.8% for cancellations at the last minute.
• SITREP figures sent out to Operational Managers on a daily
basis from both the Information Team and Theatres.
• Monthly CSG Meetings and Directorate Board Meetings.
• Authorisation for the cancellations of operations is give at Head
of Operations level.

Month 3
Indicator
Variation From Plan
RED
TRUST Performance Exception Report
Standard
Author
Below 5%
Unplanned re-attendance rate June 2012
Sam Elden-Lee, Head of Operations UAC
Unplanned re-attendance rate for June is currently 7.1%.
(cannot insert this in the box below)
Patient Experience or Outcome; Potential increase in readmissions due to
poor discharge information, poor patient experience or inability to gain
further support or information from primary care services.
Reason for Variation Background – there is not a defined process for validating re-attendance
data at present. Information is gathered from patients at the time of
arrival, a process is being developed to clean up the data submitted.
Impact of Variation Patient Experience or
Outcome
Actions to address
Variation
Forecast return to plan
Forecast outturn
Monitoring
arrangements
Financial Position
Performance Targets
Part of 30 readmission CIP increased ED reattendance
can lead to increase 30 day readmission
5% national CQI
Date Description
01/09/12 Redesign of current RA7 form to allow for scanning, which will
improve data quality. Introduction of FORMIC
01/10/12
Monthly RA7 audit by ED Matron, figures fed back to ED
performance meeting.
Links to 30 day readmission CIP
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Month 2
Indicator
Variation From
Plan
RED
Reason for
Variation
TRUST Performance Exception Report
Standard
Author
Access & Targets 2 – Cancer waiting times
(14 days GP urgent)
Bernadette Roach – Service Manager for Cancer
Lead co-ordinator
93% of all GP referrals received should be seen within 14 days
In the month of May the Trust achieved 89% An improvement on
the previous month which achieved 84%
Primary Cause
• Of the 68 patients that breached, 63 of them had appointments
greater than 14 days due to patient choice (92%).
• Of the 63 patients, 56 of them made 1 alteration, whilst 7 altered
their appointment twice.
11 of the 63 patients did not attend (DNA’d) at some point before
electing to wait for a specific date for an appointment.
GP engagement has been cited as the main cause. The GPs do not
seem to convey the urgency of the appointment to the patient.
In July an audit of the patients referred on the two week pathway
have been asked whether they had received a Fast Track referral
leaflet from their GP, only 1 patient responded yes out of the 79.
Secondary Cause
Booking of appointments late in the 14 day pathway due to demand
and capacity miss match.
1 to 7 8 to 14 15+
21.3% 56.7% 22.0%
This is occurring in particular areas where we have:
• Seasonality resulting in high volume
• National Campaign
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Impact of
Variation
Actions to
address
Variation
Forecast return
to plan
Forecast
outturn
Monitoring
arrangements
Patient Experience or Nil impact for those making a choice.
Outcome
Financial Position Currently unaffected, though financial
penalties could be imposed.
Performance Targets
Failure to achieve the 93% target.
Date Description
Audit undertaken to demonstrate lack of
July 2012 engagement with GPs throughout July, to be
presented back to the PCT at the beginning of
August 2012.
July –
September
2012
• Additional sessions at premiums costs are
being put in place to deal with the increased
demand.
• Active recruitment programme.
• Continued Job Plan reviews and clinic
template alignment.
September 2012 is dependent on the PCT actions as a result of
audit presentation and GP compliance.
Green
Cancer directorate to monitor performance on a weekly basis.
• Weekly CWT meetings to be attended by other directorates
service managers.(attendance to these meetings by service
managers to be monitored by Head of Operations CDP, any
areas of regular non-attendance to be reported to Head of
Operations for the areas of concern).
• Performance exception reports and plans are discussed at the
Directorate Scrutiny Panels, enabling Executive challenge.
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Month 2
Indicator
Variation From
Plan
Amber
Reason for
Variation
TRUST Performance Exception Report
Access & Targets 2 – Cancer waiting times
Standard (31 day subsequent surgery)
Clinical Director
Author Bernadette Roach Cancer Service Manager
Lead Co-ordinator
94% of all patients should have their subsequent surgery within
31 days
In the month of May the Trust achieved 85% failing the target.
There were 7 patients in all who were on a 31 day subsequent
treatment pathway, one of whom failed to be treated within the
specified time frame.
The patient was on a dermatology pathway and was on holiday
from 12 th – 19 th May, they requested their surgery after this
period.
Had as a Trust, we offered them a date for the surgery
regardless of this request; we would not have recorded a
breach.
Impact of Variation Patient Experience No negative impact or outcome on patient
or Outcome experience.
Financial Position Not affected by this one breach.
Actions to address
Variation
Forecast return to
plan
Monitoring
arrangements
Performance Failure of 94% target to treat all patients
Targets
within 31 days for subsequent surgery.
Date Description
By 31 st
Education of the clinicians and the Patient Contact
July 3012 Centre complex booking staff to ensure dates are
offered for surgery regardless of patients request
to wait.
August 2012
Cancer directorate to monitor performance on a weekly basis.
Weekly CWT meetings to be attended by other directorates
service managers. (attendance to these meetings by service
managers to be monitored by Head of Operations CDP, any
areas of regular non-attendance to be reported to Head of
Operations for the areas of concern).
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TRUST Performance Exception Report
Month 3 Standard Emergency Readmissions
Executive
Sponsor
Jules Martin, Chief Operating Officer
Author Jim McLeish/Lorraine Talbot
Indicator < 30 days readmission to hospital – non elective
Variation From Emergency Readmissions
Plan
Year to date
Actual Plan 11/12 Variance RAG
9.9% 8.45% 9.8% 1.5% R
Red
Reason for
Variation
2011/12
Jun Jul Aug Sep Oct Nov
10.3% 12.1% 11.1% 11.0% 11.5% 11.0%
11.9% 8.45% 11.3% 3.5% R
Dec Jan Feb Mar Apr May
10.8% 9.4% 10.7% 11.9% 10.3% 9.3%
Emergency Readmissions is below plan. There has however,
been a month on month improvement for three months running.
The YTD variance has therefore also improved and is now 1.5%
below plan.
Impact of Variation Patient
Experience or
Outcome
Actions to address
Variation
Initial Audit identified two key areas of how readmissions could
be avoided:
• Better primary care assessment and management
• Service provided in the community
Financial
Position
Performance
Targets
Date Description
Ongoing –
daily
Risk to patient safety
Readmission to hospital creating negative
patient experience
Increased risk of infection
Decrease in patient satisfaction
Risk of financial penalties
Risk to clinical efficiency
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Failure to meet Readmission target
Inability to meet A & E Performance Indicator –
total time in A & E and Re-attendance
Risk to RTT target – elective admissions – bed
availability
• Senior clinical decision making on Medical
Wards in relation to discharge/daily ward
rounds by Consultants.
Ongoing • Multi-disciplinary approach to complex
discharges
July 2012 – • Further readmissions audit in conjunction
completed with PCT – this has now taken place. A
a/w analysis sample of approximately 100 patient notes
was reviewed.
Commenced • Commencement of pilot Health and Social
16.07.12
Care Coordinator role
Commenced • Ward Based physio/OT team for each
July 2012 complex care ward ensuring therapy fit
patients

Forecast return to
plan
Forecast outturn
Monitoring
arrangements
Lead to be
identified
July 2012
• Early supported community discharge 75 74 82 76 of of 175 174 172
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provision – part of LOS project
Trajectory of month on month improvement
• Repeat readmissions audit took place 05.07.12 and
11.07.12 in conjunction with the PCT to evaluate what can
be done to avoid readmissions to hospital within 30 days
of discharge. The Trust awaits the outcome of this audit
which will enable evaluation of current processes.

Month 2
Indicator
Variation
From Plan
RED
Reason for
Variation
Impact of
Variation
Actions to
address
Variation
Standard
Executive
sponsor
TRUST Performance Exception Report
Access and Targets 2
Emergency Readmissions (elective)
Jules Martin, Chief Operating Officer
The target for this standard is 0%
June data is not currently available.
The performance for month 2 has deteriorated by 1.5%
With the latest available data, May showed an increase from 2.6%
(April) to 4.1% (May) with elective readmissions.
YTD the performance is 2.7% against a target of 0%
• Robust systems have still to be put in place to monitor this in a
rigorous way
• An aspirational target unachievable, and unrealistic, as there
will always be a degree of readmissions following surgical
intervention
Patient Experience
or Outcome
Variances in readmission rates suggest that
initial treatment was not carried out adequately
or relevant information was not given to the
patient on discharge. This could have a negative
impact on both patient experience and outcome.
Financial Position Readmissions will not be paid for and
therefore that is lost income to the Trust.
Performance
Targets
Date Description
July –
September
Could impact adversely on LOS and 18 weeks
if are additional emergency admissions which
then impact on elective bed availability.
• CSG Leads are looking at the reports and
investigating individual cases within their
specialties, but not in all areas.
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19/06/2012 • Standard to be reviewed. Discussion at
Surgery and Critical Care Directorate Board
Meeting about appropriateness of the target

Forecast
return to plan
Forecast
outturn
Monitoring
arrangements
End of July
0 % unachievable
and the process in each CSG to monitor the
data.
Directorate to consider the possibility of telephone
follows post discharge to deal with any immediate
concerns that patients have and investigate options
around ambulatory care rather than readmission
through A&E
Year End position to be no greater than 3 %
Directorate Board Meetings
CSG Leads – devise a method for circulating to individual
consultants.
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Month 2
Indicator
Variation
From Plan
RED
Reason for
Variation
Impact of
Variation
Standard
Executive
sponsor
TRUST Performance Exception Report
Theatre Utilisation
Efficiency (QIPP)
Jules Martin, Chief Operating Officer
ADSU Theatre Utilisation is Red with a 4% variance against the
target (86%). The performance for month 3 has decreased by 1%
from month 2 and failure to meet the 90% target so far this
financial year.
Main Theatre Utilisation is Amber for month 3 with a 1% variance
(84%). The performance for month 3 has increase by 2% from
month 2, despite several bed cancellations in month.
• Performance varies across specialties (the worst offender
being Ophthalmology) and the reasons for variance can differ
but common issues are start times of lists, number of
template cases and on the day cancellations due to patient
being unfit, displaced by an emergency or equipment issues.
Patient
Experience
or Outcome
Financial
Position
Running under -utilised lists will inevitably result in
in patients having to wait longer for treatment as
some capacity is being wasted.
Running under-utilised lists has an adverse impact on
the financial position as the same activity could have
been carried out in fewer lists.
This is a particular issue currently as Theatres are
budgeted to run 83 lists per week but are currently
running between 90-100.
In addition to this the specialty income are not being
achieved due to theatre cancellations.
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Actions to
address
Variation
Forecast
return to plan
Forecast
outturn
Monitoring
arrangements
Performance
Targets
This could impact on the delivery of 18 weeks if
insufficient activity is completed within required
timeframes. It will definitely impact on the delivery
of several key CIP schemes such as the Theatre
Project and reduction in clinical PAs
Date Description
Some theatre templates have already been increased
where utilisation has been poor. All theatre templates
are now being reviewed as part of the Theatre Project
and once agreement has been reached changes will be
implemented where necessary.
CSG Lead to speak to individual Ophthalmologist about
on-going issue of under -utilisation of lists and
cancellations on the day due to emergency cases
The Productive Theatre Project will look at many
elements of how theatres run which will impact positively
on theatre utilisation.
With the implementation of the actions highlighted above, it is
anticipated that ADSU utilisation will return to plan by August.
We are still aiming to meet 90% for the year for ADSU.
but 85% for Main Theatres
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Weekly as part of the Theatre Scheduling Meeting.
Weekly as part of the Productive Theatre Project.
Service Managers to review specialty performance monthly and report
to CGS Leads.

SUMMARY REPORT
Item 13
Trust Board Meeting (Part A) 26 July 2012
Subject: NHS Midlands and East PMR Self Certification
Prepared by; Geoff Stokes, Head of Corporate Governance
Approved by: Executive Team
Presented by: Geoff Stokes, Head of Corporate Governance
Purpose
To present the Provider Management Regime Self Certification.
Corporate Objectives
Safety /
outcomes
Financial Workforce Estates-
Environmental
• • • •
Executive Summary
Regulatory /
Statutory
Decision
Approval
Noting
Information
Other
Relationships
/ Partnerships
The Trust is required to submit the PMR Self Certification each month to NHS Midlands and
East. This document consists of a series of governance, financial, contractual and Board
indicators and statements which are weighted to determine overall scores in these areas.
The Trust’s ‘score’ will trigger various levels of responses form the Provider Development
Team at the SHA.
Key Recommendations
The Board is asked to approve the self assessment in preparation for its return to the SHA.
Assurance Framework
Links to the Safety/Outcomes, Financial, Workforce and Estates/Environmental objectives
within the Assessment Framework.
Next Steps
The approved self-assessment will be returned to the SHA.
Corporate Impact Assessment
CQC Regulations Primary link to Regulation 16 –
Assessing and monitoring the
quality of service provision
Financial Implications N/A
Legal implications N/A
Equality & Diversity N/A
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SUMMARY REPORT
Item 14
Trust Board Meeting (Part A) 26 July 2012
Subject: Finance Report
Prepared by; Mr. Simon Rudkins, Deputy Director of Finance
Approved by: Ms. Melanie Walker, CEO
Presented by: Mr. Ken Sharp, Director of Finance & Information
Purpose
The purpose of this report is to provide detailed financial analysis on
the current situation and to bring to attention to the Board any issues
or risks.
Corporate Objectives
Safety /
outcomes
Financial Workforce Estates-
Environmental
Regulatory /
Statutory
Decision
Approval
Noting
Information
Other
Relationships
/ Partnerships
Executive Summary
The financial report as attached.
Key Recommendations
The Board is asked to note the contents of this report and to:
• Review the reported position and action being taken.
Assurance Framework
There is a legal requirement for all NHS organisations to receive regular reports in order to
give the Board assurance that financial plans are being delivered and that statutory
requirements will be met.
Next Steps
N/A
Corporate Impact Assessment
CQC Regulations 2.02, 2.03
Financial Implications
Legal implications
Equality & Diversity
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THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST
BOARD MEETING – 26 th JULY 2012
EXECUTIVE SUMMARY
Issue: Finance Report for period to 30 June 2012
Status: For Information
Introduction
This paper provides the Board with details of the Trust’s financial performance for the period
to 30 June and comprises the following sections:
1. 2012/13 Performance
• Year to Date Performance
• Forecast Year End Position 2012/13
• Financial Risks & Mitigations
• Capital Programme 2012/13
• Cash Position
• Balance Sheet
• Better Payment Policy Performance
• Action
The Trust is reporting an adverse variance to plan for the period to 30 June of £1,583k. The
financial plan takes account of the spread of expenditure across the year and reflects
expected income and expenditure profiling and phasing of the cost improvement programme
during the financial year.
The Trust’s income position is ahead of plan by £23k. Expenditure plans are overspent
cumulatively by £1,654k comprising excess pay costs of £655k and non-pay costs of £999k.
The overall position for the period is a deficit of £3,061k against the planned deficit of
£1,478k. An impairment of £5k has been incurred in the overall financial position but this is
not reported as part of the financial performance of the Trust in-year.
Month 3: Income & Expenditure Summary
The reported position reflects the application of the cost improvement plan to date and
anticipated transitional funding support, which is treated as an income receivable in the
analysis. The overall position is summarised in the table below, with the supporting detail
attached in Appendix 1.
Page 1 of 12
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Current Month Year to Date
Annual
Description Actual Budget Variance Actual Budget Variance Budget
£'000 £'000 £'000 £'000 £'000 £'000 £'000
NHS Clinical Income 12,583 12,869 (286) 39,099 39,023 76 160,463
Other Income 1,241 1,238 3 3,291 3,344 (53) 11,806
Total Income 13,824 14,107 (283) 42,390 42,367 23 172,269
Pay 9,989 9,749 (240) 30,024 29,369 (655) 112,921
Non Pay 4,493 4,105 (388) 13,180 12,181 (999) 48,085
Total Expenditure 14,482 13,854 (628) 43,204 41,550 (1,654) 161,006
EBITDA (658) 253 (911) (814) 817 (1,631) 11,263
Less Net Interest 4 5 1 10 15 5 60
Less Depreciation 466 467 1 1,399 1,442 43 6,123
Less PDC Dividend 279 279 0 838 838 0 3,350
Net Surplus/(Deficit) -
excluding impairments (1,406) (498) (909) (3,061) (1,478) (1,583) 1,730
Expenditure Performance
The pay budget was overspent against budget in June by £240k and is cumulatively
overspent by £655k against plan. The monthly bank and agency bill for June was £1,155k
having been £1,277k in April and £1,266k in May; all monthly figures are higher than the
average of £935k per month in 2011/12. This represents 12% of the total pay spend; action
is urgently being taken to review and correct the ongoing pressure in bank & agency
spending, including further improving the controls over authorisation.
The pay overspend is primarily a consequence of £633k overspending in medical staff pay,
particularly in:
• Medicine (£216k), particularly expenditure being incurred on the ‘Hit’ discharge team
• Urgent & Ambulatory Care (£259k), where EAU (£157k) and A&E (£102k) are the
main pressures
• Surgery (£335k), where ENT (£54k), General Surgery (£57k) and the costs of
additional sessions to achieve the 18-week standard (£133k) are the main pressures.
Nursing pay is now overspent by £288k with the primary areas being A&E (£122k), Medicine
is (£140k) and Surgery (£92k).
Non-pay overspent is overspent in June by £388k; bringing the position for the period to
£999k. The reasons for this are:-
• Drugs expenditure in the first three months includes £119k above plan relating to non-
PbR Drugs, the cost of which is reclaimed as additional income.
• Additional transformation costs (£238k above plan) required to achieve the
transformational programme to deliver service, quality and cost improvements. A review
of these costs has been undertaken to ensure they are minimised.
• Unplanned service outsourcing costs (£161k above plan).
• Estates costs (£143k above plan) including higher energy costs due to the unreasonable
weather and higher than plan building and engineering maintenance costs.
Income Performance
NHS clinical income was £286k below plan for June but is £76k above plan year to date.
Whilst non-elective activity continues to exceed plan by 7%, elective activity was below plan
for June.
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The table below shows income performance by patient type:
Current Month Year to Date
Page 3 of 12
Annual
Description Actual Budget Variance Actual Budget Variance Budget
£'000 £'000 £'000 £'000 £'000 £'000 £'000
Accident & Emergency 824 756 68 2,381 2,292 89 9,193
Critical Care 644 558 86 1,511 1,685 (174) 6,750
Direct Access 428 510 (82) 1,650 1,609 40 6,706
Elective Income 1,100 1,193 (93) 3,855 3,768 87 15,702
Day Cases 1,227 1,271 (44) 3,798 4,014 (216) 16,724
Non Elective Income 4,987 4,849 138 15,312 14,557 755 58,090
Outpatient Firsts 961 925 35 2,983 2,922 61 12,175
Outpatient Follow-ups 894 895 (0) 2,895 2,825 69 11,772
Outpatient Procedures 540 463 77 1,703 1,462 241 6,091
Block - excluding CQUIN 1,187 1,187 (0) 3,562 3,562 (0) 14,249
CQUIN 448 448 0 1,047 1,047 0 3,593
Transitional Funding 167 167 0 400 400 0 1,400
Pbr Drugs 0 0 117 0 117 0
Other Patient Income (71) 28 (99) 62 29 34 2,645
SLA Validations (753) (380) (373) (2,176) (1,149) (1,027) (4,625)
Total NHS Clinical Income 12,583 12,869 (286) 39,099 39,023 76 160,463
Non Patient SLA 146 155 (9) 387 398 (11) 1,593
Education, Training 480 489 (9) 1,339 1,364 (25) 4,795
Other Non Patient Income 615 594 21 1,565 1,581 (17) 5,419
Total Other Income 1,241 1,238 3 3,291 3,344 (53) 11,807
Total Income 13,825 14,107 (283) 42,390 42,367 23 172,269
2. Forecast Position 2012/13
The financial plan for 2012/13 is to deliver a 1% surplus on income at £1.7m; whilst the first
quarter has presented some significant challenges as described, at this stage the forecast
remains as per the plan. However, a number of significant actions are being put in place to
support delivery of the financial plan:
i Deliver maximum CIP saving
The Trust has a plan to deliver £12.1m in 2012/13 including stretch targets; it is
imperative that all opportunities to deliver this sum are identified. The current forecast is
£7.3m excluding those items rated as red-risk, significantly below the required sum.
Included in the ‘red’ items are the closure of a further ward and savings from increased
Medical workforce productivity (releasing £700k and £1,000k respectively in-year).
ii Reduce Medical and Nursing pay bill
Current expenditure is running significantly above the expected levels; this Is not
sustainable. Directorates are required to produce plans to bring monthly expenditure
back to budgeted levels by 24 July 2012.
iii Achieve maximum income
The Trust will need to:
• Ensure full delivery of CQUIN plan
• Minimise contract penalties (with zero tolerance internally)
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• Ensure full transition support funding received
• Finalise 2011/12 SLA figures with PCTs
• Ensure appropriate means for additional non-elective activity
• Correct underperformance of elective activity
iv Enhance financial controls
A number of measures will be enacted, including:
• Vacancies to be held unless essential
• Restrictions to the procurement of goods and services
• Deferment of capital expenditure as necessary
3. Financial Risks and Mitigations
3.1 A cost improvement programme has been established with a target of £12.1m; the
profile is as follows:-
Monthly
£1,800,000
£1,600,000
£1,400,000
£1,200,000
£1,000,000
£800,000
£600,000
£400,000
£200,000
£0
CIP 2012/13
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Monthly Actual Cumulative Cum Actual
Page 4 of 12
£14,000,000
£12,000,000
£10,000,000
£8,000,000
£6,000,000
£4,000,000
£2,000,000
Against the profiled spend to date of £884k actual CIP delivery under-performed by £267k in
the first quarter. The majority of schemes are profiled from June onwards and for schemes
that have slipped in delivery to date, mitigations are being assessed. The amount originally
required to meet the Trust’s financial plan was £9.8m. The full target of £12.1m will now be
needed and additional schemes amounting to £2m are required.
The progress against the CIP plan can be seen in Appendix 3 at the end of this report. Good
progress has been made in the Women & Children and Surgery directorates with both overperforming
in the first quarter. The slippage against CIP plan predominantly centres on
Development Phasing, Non-recurrent and Unidentified CIP targets for the period. The CIP
target to reduce Bank & Agency began in June with a target for the month of £37k; this has
also not been achieved.
3.2 Other Key Risks
There are a number of other significant risks facing the Trust in delivery of the 2012/13
financial position.
£0
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Cumulative

These include:-
• Continuing high non-elective activity at a tariff which does not cover costs
• Inability to reduce re-admissions for which no income is required
• Continuing high staff usage at premium rates
• Outsourcing service costs
• Unfunded transformation and redundancy costs
• Settlement of previous years’ SLA performance variation
• Contract penalties
• Other non-recurrent issues arising
Mitigations against each of these risks are being considered.
4. Capital Programme 2012/13
A schedule of expenditure against the capital programme is at Appendix 5. Capital
expenditure up to 30 June was £2.094m. The Trust is on track to deliver the £10.6m capital
plan by the end of the year. The Capital Plan is dependant upon delivery of the Trust
financial position and cash generated; this is under review as is part of the highlighted set of
actions to address the 2012/13 financial position.
5. Cash Position
The cash held at 30 June was £5.726m
6. Statement of Financial Position
The Statement of Financial Position as at 30 June 2012 is attached at Appendix 4. The
Trade and Other Receivables figure is analysed in the table below between sales ledger
debtors NHS and non-NHS and other types of receivables:
7. Better Payment Practice Code
The Better Payment Practice Code sets a target for payment of all invoices received from
both NHS and non-NHS trade creditors, in value and volume, to be paid within 30 days of
receipt of goods or a valid invoice (whichever is later) unless other payment terms have been
agreed.
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At least 95% of invoices paid within 30 days or within agreed contract terms is required for
compliance.
The Trust’s performance against the target to June 2012 was:
Better Payment Practice Code Number £'000s
Total non-NHS trade invoices paid in the year 8,897 15,129
Total non-NHS trade invoices paid within target 8,343 12,191
Percentage of trade invoices, paid within target 93.8% 80.6%
Total NHS trade invoices paid in the year 577 2,896
Total NHS trade invoices within target 490 2,531
Percentage of NHS invoices paid within target 84.9% 87.4%
8. Action
The Board is asked to note the contents of this report and to:
• Review the reported position and action being taken.
Ken Sharp
Director of Finance & Information
18 July 2012
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8. Appendices
8.1. Appendix 1
THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST Appendix 1
MONTH 3 2012-13
Exp 1Exp 4 WTE Bud. WTE Cont.
WTE
Worked.
WTE Paid.
Page 7 of 12
Annual
Budget.
Current
Month
Budget.
Current
Month
Actual.
Current
Month
Variance.
YTD
Budget.
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182 176
YTD
Actual.
YTD
Variance.
DEPARTMENT OF HEALTH 0.00 0.00 0.00 0.00 -79 -20 -7 -13 -20 -22 3
DONATION RESERVE 0.00 0.00 0.00 0.00 0 0 0 0 0 -20 20
0 EDUCATION, TRAINING & RESEARCH 0.00 0.00 0.00 0.00 -4,795 -489 -480 -9 -1,364 -1,339 -25
0 INCOME FROM SERVICE AGREEMENTS 0.00 0.00 0.00 0.00 -162,055 -13,025 -12,729 -296 -39,422 -39,486 64
0 NON NHS OTHER 0.00 0.00 0.00 0.00 -402 -34 -10 -24 -101 -33 -67
0 NON NHS PRIVATE PATIENTS 0.00 0.00 0.00 0.00 -428 -36 -39 3 -107 -120 13
0 OTHER INCOME 0.00 0.00 0.00 0.00 -3,696 -437 -537 100 -1,150 -1,275 125
0 RTA INCOME 0.00 0.00 0.00 0.00 -815 -68 -23 -45 -204 -95 -109
INCOME Total 0.00 0.00 0.00 0.00 -172,269 -14,107 -13,825 -283 -42,367 -42,390 23
PAYADMIN & CLERICAL 462.59 438.76 452.60 444.77 11,707 979 975 4 2,921 2,889 33
0 ANCILLARY 247.16 230.89 245.55 288.86 5,529 453 468 -15 1,373 1,432 -59
0 MAINTENANCE & WORKS STAFF 28.79 25.26 28.61 29.72 853 71 72 -1 212 218 -5
0 MEDICAL 387.94 363.08 401.09 361.24 37,251 2,987 3,192 -205 8,979 9,612 -633
0 NURSING 1,113.57 1,057.45 1,134.27 1,135.55 42,629 3,493 3,625 -132 10,543 10,831 -288
OTHER EMPLOYEES 0.00 0.00 0.00 0.00 109 0 0 0 109 109 0
0 QiPP EFFICIENCIES - PAY 26.61 0.00 0.00 0.00 -5,956 33 0 33 92 0 92
0 SCIENTIFIC, THERAPEUTIC & TECH 374.73 336.24 348.35 341.75 14,752 1,226 1,159 66 3,648 3,478 170
0 SNR MANAGERS 92.31 81.57 95.80 94.87 6,047 508 498 10 1,491 1,455 36
PAY Total 2,733.70 2,533.25 2,706.27 2,696.76 112,921 9,749 9,989 -240 29,369 30,024 -655
BLOOD PRODUCTS 0.00 0.00 0.00 0.00 1,334 111 104 7 334 302 32
0 DRUGS DRESSINGS & GASES 0.00 0.00 0.00 0.00 12,179 1,003 1,046 -44 3,045 3,177 -132
0 ESTABLISHMENT EXPENSES 0.00 0.00 0.00 0.00 2,585 215 227 -12 652 622 29
0 GENERAL SUPPLIES & SERVICES 0.00 0.00 0.00 0.00 2,747 241 228 13 681 690 -9
0 INTERNAL RECHARGES 0.00 0.00 0.00 0.00 315 29 29 -0 70 72 -3
0 LAB EQUIP & CONSUMABLES 0.00 0.00 0.00 0.00 2,114 176 177 -0 533 552 -18
0 MED & SURG EQUIPMENT 0.00 0.00 0.00 0.00 9,805 817 867 -50 2,399 2,458 -59
0 MISCELLANEOUS 0.00 0.00 0.00 0.00 6,566 566 529 36 1,607 1,511 96
0 NON NHS PURCHASE OF HEALTHCARE 0.00 0.00 0.00 0.00 2,110 191 358 -167 667 1,067 -400
0 PATIENT APPLIANCES 0.00 0.00 0.00 0.00 626 56 53 2 157 154 3
0 PREMISES & FIXED PLANT 0.00 0.00 0.00 0.00 4,350 383 404 -22 1,104 1,240 -137
0 RESERVES 0.00 0.00 0.00 0.00 -1,538 -72 9 -81 -261 -21 -240
0 SERVICES FROM OTHER NHS BODIES 0.00 0.00 0.00 0.00 2,941 246 255 -10 749 821 -73
0 UTILITIES 0.00 0.00 0.00 0.00 1,456 103 143 -40 324 413 -89
0 X RAY EQUIP & CONSUMABLES 0.00 0.00 0.00 0.00 495 41 63 -21 124 123 1
NON PAY Total 0.00 0.00 0.00 0.00 48,085 4,105 4,493 -388 12,181 13,180 -999
EXPENDITURE Total 161,006 13,854 14,482 -628 41,550 43,205 -1,655
Net Total 2,733.70 2,533.25 2,706.27 2,696.76 11,263 253 -657 -910 817 -815 -1,631
0 DEPRECIATION 0.00 0.00 0.00 0.00 6,123 467 466 0 1,443 1,399 44
0 DIVIDEND PAYMENT 0.00 0.00 0.00 0.00 3,350 279 279 0 838 838 0
INTEREST 0.00 0.00 0.00 0.00 60 5 4 1 15 10 4
Total as per FIMS Month 3 2,733.70 2,533.25 2,706.27 2,696.76 1,731 -498 -1,406 -908 -1,478 -3,061 -1,583
IMPAIRMENTS 0 0 5 -5 0 5 -5
GRAND TOTAL 1,731 -498 -1,412 -914 -1,478 -3,066 -1,588

8.2. Appendix 2
YTD @ Month 3 Income Pay Non-pay Total
Plan Actual Variance Plan Actual Variance Plan Actual Variance Plan Actual Variance
Cancer & Core Services (3,961) (3,968) (7) 4,309 4,261 (49) 1,801 1,961 160 2,149 2,253 104
Clinical Support (20) (36) (16) 1,347 1,339 (8) 91 108 17 1,418 1,411 (8)
Medicine (9,133) (9,677) (544) 5,021 5,340 320 712 909 197 (3,401) (3,428) (27)
Surgery & Critical Care (13,024) (12,955) 69 7,293 7,675 383 2,435 2,394 (42) (3,296) (2,886) 410
Urgent & Ambulatory Care (2,294) (2,383) (88) 2,062 2,460 397 133 254 122 (99) 331 431
Women & Children (7,601) (7,546) 55 4,491 4,338 (153) 461 495 34 (2,649) (2,713) (64)
Total clinical (36,034) (36,564) (531) 24,523 25,413 890 5,633 6,120 488 (5,878) (5,031) 847
Estates (12) (20) (7) 342 350 8 875 1,018 143 1,204 1,348 144
Hotel Services (443) (443) (0) 1,357 1,409 53 1,027 1,062 36 1,941 2,028 88
Corporate (5,878) (5,362) 515 3,148 2,853 (295) 4,647 4,980 333 1,917 2,470 553
Total non-clinical (6,333) (5,826) 508 4,846 4,612 (235) 6,548 7,060 512 5,061 5,846 785
Financing 0 0 0 0 0 0 2,295 2,247 (49) 2,295 2,247 (49)
Total PAH (42,367) (42,390) (23) 29,369 30,024 655 14,476 15,427 951 1,478 3,061 1,583
June 2012 Income Pay Non-pay Total
Plan Actual Variance Plan Actual Variance Plan Actual Variance Plan Actual Variance
Cancer & Core Services (1,268) (1,219) 49 1,432 1,446 14 560 712 152 724 939 215
Clinical Support (7) (14) (8) 434 428 (5) 28 41 13 455 456 0
Medicine (3,021) (3,057) (37) 1,648 1,749 102 233 337 104 (1,140) (971) 169
Surgery & Critical Care (4,215) (4,328) (113) 2,439 2,592 153 906 804 (102) (870) (931) (61)
Urgent & Ambulatory Care (756) (826) (70) 686 785 100 49 102 53 (22) 61 83
Women & Children (2,497) (2,431) 66 1,501 1,453 (48) 146 167 21 (851) (811) 39
Total clinical (11,764) (11,876) (112) 8,139 8,454 315 1,922 2,163 242 (1,703) (1,259) 444
Estates (4) (6) (2) 114 113 (1) 282 339 57 392 447 55
Hotel Services (164) (164) 0 450 463 13 339 355 16 625 654 30
Corporate (2,175) (1,778) 396 1,046 958 (88) 1,563 1,636 73 434 815 381
Total non-clinical (2,343) (1,948) 395 1,610 1,535 (76) 2,184 2,330 146 1,451 1,916 466
Financing 0 0 0 0 0 0 751 749 (2) 751 749 (2)
Total PAH (14,107) (13,825) 283 9,749 9,989 240 4,856 5,242 386 498 1,406 908
Financing includes Depreciation, Dividend payments and Interest
Page 8 of 12
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182 176

£ 000
8.3. Appendix 3
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Monthly I&E 12 month rolling
PAY NON PAY INCOME
Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12
Month
Page 9 of 12
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8.4 Appendix 4
The Princess Alexandra Hospital NHS Trust
Cost Improvement Programme 2012/13
PLAN
Sub Category Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 TOTAL
LOS & Bed Management - -
-
-
- - - 111,995 - 111,995 - 111,995 - 111,995 - 111,995 - 111,995 - 671,971
Outpatients - -
- - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 500,000
Theatre Utilisation - -
-
-
- - - 133,333 - 133,333 - 133,333 - 133,333 - 133,333 - 133,333 - 800,000
Emergency Readmissions - 24,333 - 24,333 - 24,333 - 24,333 - 24,333 - 24,333 - 24,333 - 24,333 - 24,333 - 24,333 - 24,333 - 24,333 - 292,000
Diagnostics - -
- - 66,667 - 66,667 - 66,667 - 66,667 - 66,667 - 66,667 - 66,667 - 66,667 - 66,667 - 600,000
Back office - 34,982 - 34,982 - 34,982 - 34,982 - 34,982 - 60,441 - 60,441 - 60,441 - 60,441 - 60,441 - 60,441 - 60,441 - 597,997
Integration of Medical Records - -
-
-
- - - 26,667 - 26,667 - 26,667 - 26,667 - 26,667 - 26,667 - 160,000
Medical Records Automation - -
-
-
- - - 8,333 - 8,333 - 8,333 - 8,333 - 8,333 - 8,333 - 50,000
Procurement - - - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 500,000
Income Generation - - - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 500,000
Medical Workforce - -
-
-
- -
-
- - 250,000 - 250,000 - 250,000 - 250,000 - 1,000,000
Outsourcing Facilities - -
-
-
- - - 133,333 - 133,333 - 133,333 - 133,333 - 133,333 - 133,333 - 800,000
Repatriation - - - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 50,000 - 500,000
Patient Note Initiative - -
- - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 55,556 - 500,000
Development Phasing - 41,667 - 41,667 - 41,667 - 41,667 - 41,667 - 41,667 - 41,667 - 41,667 - 41,667 - 41,667 - 41,667 - 41,667 - 500,000
Bank / Agency - - - 37,000 - 37,000 - 37,000 - 37,000 - 37,000 - 37,000 - 37,000 - 37,000 - 37,000 - 37,000 - 370,000
Medicine - -
- - 18,461 - 18,461 - 18,461 - 21,511 - 21,511 - 21,511 - 21,511 - 21,511 - 21,511 - 184,449
Women & Children - 3,979 - 9,525 - 9,525 - 11,620 - 11,620 - 11,620 - 31,953 - 31,953 - 31,953 - 31,953 - 31,953 - 31,953 - 249,606
Surgery & Critical Care - 36,416 - 36,416 - 36,415 - 61,581 - 90,331 - 90,331 - 106,072 - 106,072 - 106,072 - 106,072 - 106,072 - 106,062 - 987,912
Urgent & Ambulatory Care - 15,000 - 15,000 - 15,000 - 15,000 - 15,000 - 15,000 - 12,086 - 12,086 - 12,086 - 12,086 - 12,086 - 12,086 - 162,515
Non-recurrent - - - 100,000 - 100,000 - 100,000 - 100,000 - 100,000 - 100,000 - 100,000 - 100,000 - 100,000 - 100,000 - 1,000,000
Stretch targets - - - 117,000 - 117,000 - 117,000 - 117,000 - 117,000 - 117,000 - 117,000 - 117,000 - 117,000 - 117,000 - 1,170,000
Grand Total - 156,377 - 161,923 - 565,922 - 789,422 - 818,172 - 843,631 - 1,293,502 - 1,293,502 - 1,543,502 - 1,543,502 - 1,543,502 - 1,543,493 - 12,096,451
ACTUAL
Sub Category Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 TOTAL
LOS & Bed Management - -
-
-
Outpatients - -
-
-
Theatre Utilisation - -
-
-
Emergency Readmissions - -
-
-
Diagnostics - -
-
-
Back office - 10,211 - 22,183 - 15,724
- 48,118
Integration of Medical Records - -
-
-
Medical Records Automation - -
-
-
Procurement - -
-
-
Income Generation - - - 76,000
- 76,000
Medical Workforce - -
-
-
Outsourcing Facilities - -
-
-
Repatriation - -
-
-
Patient Note Initiative - -
-
-
Development Phasing - -
-
-
Bank / Agency - -
-
-
Medicine - -
-
-
Women & Children - 88,469 - 78,348 - 80,662
- 247,480
Surgery & Critical Care - - 13,568 - 180,305
- 193,873
Urgent & Ambulatory Care - - 14,665 - 10,054
- 24,719
Non-recurrent - - - 27,050
- 27,050
Stretch targets - -
-
Grand Total - 98,680 - 128,765 - 389,795
-
- -
-
-
-
-
-
- - 617,240
Underachievement of CIPs - 57,697 - 33,158 - 176,127
- 266,982
Page 10 of 12
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8.5 Appendix 5
STATEMENT OF FINANCIAL POSITION AS AT 30 JUNE 2012
Opening Year to Date
1 April
2012
30 June 2012
£000 £000
Non-current assets
Property, plant and equipment 99,729 100,420
Intangible assets 10 9
Trade and other receivables 5 3
Total non-current assets
Current assets
99,744 100,432
Inventories 4,227 4,227
Trade and other receivables 4,858 6,479
Cash and cash equivalents 7,611 5,726
Total current assets 16,696 16,432
Total assets
Current liabilities
116,440 116,864
Trade and other payables (14,914) (18,645)
Provisions (353) (215)
Borrowings (989) (976)
DH working capital loan (600) (600)
Total current liabilities (16,856) (20,436)
Net current assets/(liabilities) (160) (4,004)
Total assets less current liabilities
Non-current liabilities
99,584 96,428
Trade and other payables (9) (30)
Provisions (433) (415)
Borrowings (1,083) (995)
DH working capital loan (2,100) (2,100)
Total non-current liabilities (3,625) (3,540)
Total assets employed 95,959 92,888
Financed by taxpayers' equity:
Public dividend capital 74,133 74,134
Retained earnings (2,008) (5,001)
Revaluation reserve 23,834 23,755
Total taxpayers' equity 95,959 92,888
Page 11 of 12
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8.6 Appendix 6
THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST
CAPITAL PROGRAMME 2012/2013
ACTUAL SPEND AND FORECAST OUT-TURN AS AT 30TH JUNE 2012
Project Planned Expenditure Forecast
Lead Spend to date Out-turn
2012/2013 at 31/03/13
£000 £000 £000
BACKLOG
LIFT REFURBISHMENT/REPLACEMENT M Mizen 20.0
20.0
20.0
REFRIGERATION GAS REPLACEMENT C Austin 100.0
0.9
100.0
THEATRE LIGHTS IN 6, 7, 8 & 9 C Austin 30.0
-
30.0
CSSD AUTOCLAVES C Austin 200.0
-
200.0
MULTITONE BLEEP SYSTEM C Austin 30.0
0.4
30.0
Sub total -
380.0
21.3
380.0
SITE IMPROVEMENT
SITE SIGNAGE C Austin 10.0
1.3
10.0
SITE IMPROVEMENT C Austin 279.0
55.0
279.0
Sub total 289.0
56.3
289.0
SALIX ENERGY EFFICIENCY LOAN SCHEME
LED LIGHTING PHASE 2 (SALIX) M Mizen 168.0
58.3
168.0
Sub total 168.0
58.3
168.0
HEALTH & SAFETY - GENERAL
GENERAL FLOORING C Austin 53.0
7.9
53.0
PATHWAY REAR ADU C Austin 15.0
0.5
15.0
ROAD AND PATHWAY WORKS C Austin 40.0
33.2
40.0
CAR PARK LIGHTING C Austin 30.0
0.1
30.0
FIRE ACT C Austin 10.0
0.5
10.0
FLAT ROOF OPD REPLACE C Austin 50.0
6.9
50.0
KITCHEN OVENS C Austin 19.4
19.4
19.4
Sub total 217.4
68.5
217.4
DEVELOPMENT AGREED
RADIOLOGY DEPARTMENT DEVELOPMENT C Austin 712.8
407.8
712.8
NEONATAL UPGRADE C Austin 82.2
14.1
82.2
CAR PARKING AND EXPANSION C Austin 154.6
118.8
154.6
SECRETARIAL HUBS C Austin 122.3
78.4
122.3
MATERNITY UPGRADE PROJECT C Austin 200.0
0.3
200.0
JAG ENDOSCOPY C Austin 50.0
2.1
50.0
URGENT CARE CENTRE C Austin 1,700.0
0.4 1,700.0
TO BE APPROVED -
380.0
-
380.0
Sub total 3,401.9
621.9 3,401.9
IT
ESSA DISAGGREGATION C McNair 300.0
136.2
300.0
CHEMOCARE - ELECTRONIC PRESCRIBING OF CHEMOTHERAPY R Duncombe 126.7
40.1
126.7
ELECTRONIC INCIDENT REPORTING P Harris 26.0
-
26.0
PAS/EPR REPLACEMENT PROJECT C McNair 2,000.0
59.8 2,000.0
PC REPLACEMENT C McNair 100.0
-
100.0
COMMENCING MEDICAL RECORDS DIGITISATION C McNair 50.0
33.9
50.0
ESSENTIAL SYSTEM RESILIENCE WORK (SERVERS & NETWORK) C McNair 77.0
-
77.0
VIDEO-CONFERENCING MDT's C McNair 33.0
-
33.0
BASIC INFRASTRUCTURE IMPROVEMENTS C McNair 84.0
-
84.0
PROJECT SUPPORT C McNair 33.0
-
33.0
INTRANET/INTERNET AND DEVELOPING IN-HOUSE CAPABILITY C McNair 10.0
-
10.0
SCANNERS & EQUIPMENT C McNair 23.9
-
23.9
E-WHITE BOARD S Rudkins 5.5
-
5.5
SOFTWARE FOR CONSULTANT APPRAISAL C McNair 20.0
-
20.0
PACS C McNair -
0.8
0.8
Sub total
OTHER
2,889.1
270.8 2,889.9
CAPITALISATION OF REVENUE ITEMS -
-
-
-
UNALLOCATED FUNDS ISG -
-
-
CONTINGENCY FUND ISG -
-
-
Sub total -
-
-
EQUIPMENT
MEDICAL EQUIPMENT
Mortuary Chiller & Trolleys Rob Duncombe 13.4
13.4
13.4
Digital Diagnost (Radiology Development) Rob Duncombe 228.0
228.0
228.0
Juno (Radiology Development) Rob Duncombe 348.0
-
348.0
Ingenuity 128 CT (Radiology Development) Rob Duncombe 570.0
570.0
570.0
Allura (Radiology Development) Rob Duncombe 594.0
-
594.0
2* Flexible Ureterorenoscopes Natalie Butt 13.6
13.6
13.6
To be approved -
1,020.1
-
1,020.1
Other - Purchased Leases 95.2
40.6
95.2
FINANCE LEASES
Current Year Renewals 540.3
DONATED EQUIPMENT 20.0
Sub total 3,442.6
TOTAL 10,788.0
LESS DONATED ASSET INCOME (20.0)
TOTAL CHARGE AGAINST CRL 10,768.0
TOTAL CRL 10,768.0
CRL OVERSHOOT / (UNDERSHOOT) -
FUNDING
DEPRECIATION 6,100.0
SURPLUS 1,500.0
CASH GENERATED IN 2011/12 3,000.0
SALIX ENERGY EFFICIENCY LOAN SCHEME 2012/13 168.0
TOTAL FUNDING 10,768.0
Page 12 of 12
111.6
20.0
997.2
2,094.3
540.3
20.0
3,442.6
10,788.8
(20.0)
10,768.8
10,768.0
0.8
6,100.0
1,500.0
3,000.0
168.0
10,768.0
PROGRAMME DEFICIT/(SURPLUS) 0.0 0.8
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The Princess Alexandra Hospital NHS Trust
Update of Scheme of Delegation
A review of the interim scheme of delegation has been undertaken, resulting in a number of changes
to add clarity to the document and reflect current committees.
This paper details the main changes to the interim scheme of delegation, which are
• Some of the authorisation limits in the scheme of delegation were too low. Clinical
Directors’ upper authorisation limits for requisitions have been increased from £24,999 to
£49,999. Executive Directors’ upper authorisation limits for requisitions have been
increased from £74,999 to £99,999. The list of posts which have delegated authority has
been simplified, and a reference to orders exceeding 12 months has been removed to add
clarity.
• Items which do not require a requisition have been listed, as it was not clear from the
document that requisitions were not required for every type of expenditure. For example,
requisitions are not required for each gas or electricity bill.
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Item 15
• The scheme of delegation has been updated to distinguish between interim, consultancy
and agency staff, as the terminology in the document was not clear. The reference to ‘nonmedical
consultancy’ staff has been replaced with ‘interim staff or consultancy assignments’.
• Booking of bank, agency and locum staff is authorised by the budget holder in accordance
with local Human Resources processes, rather than non-pay processes, and so does not
require a non-stock requisition.
• Similarly, interim staff in established posts are dealt with under Human Resources processes,
and do not require a requisition.
• Interim staff or consultancy assignments other than to established posts need authorisation
by an Executive Director if under £75k, or else by the Chief Executive or Director of Finance.
• Limits for authorisation of invoices have been added to the scheme of delegation. This adds
clarity, as there was previously no guidance in relation to invoices.
• The Governance Committee reports to the Audit and Risk Assurance Committee and submits
reports to the Management Team, not the Board.
• Keeping a Declarations of Interests Register is delegated to the Head of Corporate
Governance, not the Trust Secretary.
• Authority relating to compliance with the Data Protection Act and Access to Records Act is
delegated to the Medical Director (Caldicott Guardian) not the Chief Operating/Nursing
Officer.
1

• Authority relating to insurance policies and risk management is delegated to the Head of
Risk and Director of Finance, not the Chief Operating /Nursing Officer.
• References to the Remuneration & Terms of Service have been changed to the
Remuneration & Nominations committee.
• References to the Audit Committee have been changed to the Audit and Risk Assurance
Committee.
• References to Head of Estates have been replaced with Capital Budget Holder because the
Head of Estates is not the budget holder for all capital schemes.
• References to NHS Supplies have been changed to NHS Supply Chain.
• References to the Chief Workforce Officer and Director of Workforce Development have
been replaced with Director of Human Resources.
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Item 15
2

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST
RESERVATION OF POWERS
TO THE BOARD
AND
DELEGATION OF POWERS
Version:- July 2012
20 July 2012
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The Princess Alexandra Hospital NHS Trust
CONTENTS
1 INTRODUCTION ................................................................................................... 3
1.1 REQUIREMENTS UNDER OTHER FRAMEWORK DOCUMENTS ................................................ 3
1.2 APPLICATION OF POWERS AND RESPONSIBILITIES OF OFFICERS ........................................ 3
1.2.1 The Role of the Chief Executive ................................................................................... 3
1.2.2 Caution over the Use of Delegated Powers ................................................................. 4
1.2.3 Directors’ Ability to Delegate their own Delegated Powers ........................................... 4
1.2.4 Absence of Directors or Officers to Whom Powers have been Delegated .................... 4
2. DECISIONS RESERVED TO THE BOARD........................................................... 5
2.1 GENERAL ENABLING PROVISION ...................................................................................... 5
2.2 REGULATIONS AND CONTROL .......................................................................................... 5
2.3 APPOINTMENTS / DISMISSAL ............................................................................................ 6
2.4 POLICY DETERMINATION ................................................................................................ 6
2.5 STRATEGY, BUSINESS PLANS AND BUDGETS .................................................................... 6
2.6 AUDIT ............................................................................................................................ 7
2.7 ANNUAL REPORTS AND ACCOUNTS .................................................................................. 8
2.8 MONITORING ................................................................................................................... 8
3. DECISIONS / DUTIES DELEGATED BY THE BOARD TO COMMITTEES .......... 9
4 AUDIT AND RISK ASSURANCE COMMITTEE .................................................. 10
4.1 INTERNAL CONTROL AND RISK MANAGEMENT ................................................................. 10
4.2 INTERNAL AUDIT ............................................................................................................ 10
4.3 EXTERNAL AUDIT ........................................................................................................... 11
4.4 FINANCIAL REPORTING .................................................................................................. 11
5 REMUNERATION AND TERMS OF SERVICE COMMITTEE ............................. 12
5.1 EXECUTIVE DIRECTORS’ REMUNERATION AND TERMS AND CONDITIONS OF SERVICE ........ 12
5.2 PERFORMANCE MANAGEMENT ....................................................................................... 12
5.3 CONTRACTUAL ARRANGEMENTS .................................................................................... 13
6 GOVERNANCE COMMITTEE............................................................................. 14
7 CHARITABLE FUNDS COMMITTEE .................................................................. 14
7.1 INTERNAL CONTROL AND RISK MANAGEMENT ................................................................. 14
7.2 FINANCIAL REPORTING .................................................................................................. 15
8 R & D COMMITTEES .......................................................................................... 16
8.1 INTERNAL CONTROL AND RISK MANAGEMENT ................................................................. 16
8.2 FINANCIAL REPORTING .................................................................................................. 16
8.3 ONGOING MONITORING AND DEVELOPMENT .................................................................... 17
8.4 QUALITY RESEARCH ENVIRONMENT ............................................................................... 17
8.5 SCIENCE ....................................................................................................................... 18
8.5.1 Assign reviewed proposals to one of three categories ............................................... 18
9 SCHEME OF DELEGATION DERIVED FROM THE ACCOUNTABLE OFFICER
MEMORANDUM .......................................................................................................... 20
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The Princess Alexandra Hospital NHS Trust
SCHEME OF DELEGATION DERIVED FROM THE CODES OF CONDUCT AND
ACCOUNTABILITY...................................................................................................... 22
10 SCHEME OF DELEGATION DERIVED FROM STANDING ORDERS AND
STANDING FINANCIAL INSTRUCTIONS ................................................................... 25
10.1 SCHEME OF DELEGATION DERIVED FROM STANDING ORDERS (SOS) ............................... 25
10.2 SCHEME OF DELEGATION DERIVED FROM STANDING FINANCIAL INSTRUCTIONS (SFIS) ...... 28
11 DETAILED SCHEME OF DELEGATION ............................................................. 37
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1 Introduction
The Princess Alexandra Hospital NHS Trust
The Scheme of Delegation, together with the Standing Financial Instructions and
Standing Orders, sets out the accountability framework for The Princess Alexandra
Hospital NHS Trust (“The Trust”).
The purpose of this document is to set out how powers are reserved to the Board,
generally matters for which it is held accountable to the Secretary of State, while at the
same time delegating to the appropriate level the detailed application of Trust policies
and procedures. The Board remains accountable for all of its functions, even those
delegated to the Chairman, individual directors or officers or committees of the Board,
and must therefore receive information about the exercise of delegated functions to
enable it to maintain a monitoring role.
1.1 Requirements under Other Framework Documents
Details of the reservation of powers by the Trust Board and of where powers may be
delegated are laid out within several documents. These include the “Corporate
Governance Framework Manual for NHS Trusts – April 2003”, The Accountable Officer
Memorandum and issued codes of accountability (included within the Trusts Standing
Orders)
In particular, Standing Orders (§ 4.1) provide that “subject to such directions as may be
given by the Secretary of State, the Trust may make arrangements for the exercise, on
behalf of the Trust, of any of its functions by a committee or sub-committee or by the
Chairman or a director or by an officer of the Trust, in each case subject to such
restrictions and conditions as the Board thinks fit”. The Code of Accountability also
requires that there should be a formal schedule of matters specifically reserved to the
Trust Board.
1.2 Application of Powers and Responsibilities of Officers
1.2.1 The Role of the Chief Executive
All powers of the Trust which have not been retained as reserved by the Board or
delegated to an executive committee or sub-committee shall be exercised on behalf of
the Board by the Chief Executive. The Chief Executive has a responsibility to prepare a
Scheme of Delegation identifying which functions he/she shall perform personally and
which functions have been delegated to other directors and officers.
All powers delegated by the Chief Executive can be re-assumed by him/her should the
need arise. As Accountable Officer the Chief Executive is accountable to the
Accounting Officer of the NHS Executive for the funds entrusted to the Trust.
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1.2.2 Caution over the Use of Delegated Powers
The Princess Alexandra Hospital NHS Trust
Powers are delegated to directors and officers on the understanding that they would not
exercise delegated powers in a matter which in their judgement was likely to be a cause
for public concern.
1.2.3 Directors’ Ability to Delegate their own Delegated Powers
The Scheme of Delegation (“The Scheme” – §4 through §6) provides direction on the
“top level” of delegation within the Trust and on certain detailed delegated powers (§ 7).
The Scheme is to be used in conjunction with the system of budgetary control and other
established procedures within the Trust.
1.2.4 Absence of Directors or Officers to Whom Powers have been Delegated
In the absence of a director or officer to whom powers have been delegated those
powers shall be exercised by the director or officer’s superior unless alternative
arrangements have been approved by the Board. If the Chief Executive is absent
powers delegated to him/her may be exercised by the Chairman or Vice Chairman in
the Chairman’s absence after taking appropriate advice from the Director of Finance.
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2. Decisions Reserved to the Board
The Princess Alexandra Hospital NHS Trust
The Code of Accountability that has been adopted by the Trust requires the Board to
determine those matters on which decisions are reserved unto itself. These reserved
matters are set out in paragraphs below:
2.1 General Enabling Provision
2.1.1 The Board may determine any matter, for which it has delegated or statutory
authority, it wishes to be addressed as a full Board within its statutory
powers.
2.2 Regulations and Control
2.2.1 Approve Standing Orders (SOs), a schedule of matters reserved to the
Board and Standing Financial Instructions for the regulation of its
proceedings and business.
2.2.2 Suspend Standing Orders.
2.2.3 Vary or amend the Standing Orders.
2.2.4 Ratify any urgent decisions taken by the Chairman and Chief Executive in
public session in accordance with SO 4.3
2.2.5 Approve a scheme of delegation of powers from the Board to committees.
2.2.6 Require and receive the declaration of Board members’ interests that may
conflict with those of the Trust and determining the extent to which that
member may remain involved with the matter under consideration.
2.2.7 Approve arrangements for dealing with complaints.
2.2.8 Adopt the organisation structures, processes and procedures to facilitate the
discharge of business by the Trust and to agree modifications thereto.
2.2.9 Receive reports from committees including those which the Trust is required
by the Secretary of State or other regulation to establish and to take
appropriate action thereon.
2.2.10 Confirm the recommendations of the Trust’s committees where the
committees do not have executive powers.
2.2.11 Establish terms of reference and reporting arrangements of all committees
and sub-committees that are established by the Board.
2.2.12 Approve arrangements relating to the discharge of the Trust’s
responsibilities as a corporate trustee for funds held on trust.
2.2.13 Approve arrangements relating to the discharge of the Trust’s
responsibilities as a bailee for patients’ property.
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2.2.14 Authorise use of the seal.
The Princess Alexandra Hospital NHS Trust
2.2.15 Ratify or otherwise instances of failure to comply with Standing Orders
brought to the Chief Executive’s attention in accordance with SO 4.10.
2.2.16 Approval of the disciplinary procedure for officers of the Trust
2.2.17 Discipline members of the Board or employees who are in breach of
statutory requirements or SOs.
2.3 Appointments / Dismissal
2.3.1 Appointment of the Vice Chairman of the Board.
2.3.2 Appoint and dismiss committees (and individual members) which are directly
accountable to the Board.
2.3.2 Appoint, discipline and dismiss executive directors (subject to SO2.6).
2.3.4 Confirm appointment of members of any committee of the Trust as
representatives on outside bodies.
2.3.5 Appoint appraise, discipline and dismiss the Secretary (if the appointment of
a Secretary is required under standing orders).
2.3.6 Approve proposals of the Remuneration Committee regarding directors and
senior employees and those of the Chief Executive for staff not covered by
the Remuneration Committee.
2.4 Policy Determination
To receive details quarterly of the Trust’s policies and procedures (approved by the
Governance Committee (Executive Committee of the Board)) for the management of:-
• Risk
• Personnel (incorporating the arrangements for the appointment, removal and
remuneration of staff).
Approved policies will be published within the Trust’s intranet site (”Public Folders”)
2.5 Strategy, Business Plans and Budgets
2.5.1 Define the strategic aims and objectives of the Trust.
2.5.2 Approve proposals for ensuring quality and developing clinical governance in
services provided by the Trust, having regard to any guidance issued by the
Secretary of State.
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The Princess Alexandra Hospital NHS Trust
2.5.3 Will approve Outline and Final Business Cases for Capital Investments
above £1,000,000 prepared by the Trust’s Capital Group.
2.5.4 Approve budgets.
2.5.5 Approve annually the Trust’s proposed Business/organisational development
plan
2.5.6 Ratify proposals for acquisition, disposal or change of use of land and/or
buildings
2.5.7 Approve PFI proposals.
2.5.8 Approve the opening of bank accounts.
2.5.9 Approve proposals on individual contracts (other than NHS contracts) of a
capital or revenue nature amounting to, or likely to amount to over £600,000
over a 3 year period or the period of the contract if longer.
2.5.10 Approve proposals in individual cases for the write off of losses or making of
special payments above the limits of delegation to the Chief Executive and
Director of Finance (for losses and special payments) previously approved
by the Board.
2.5.11 Approve individual compensation payments.
2.5.12 Approve proposals for action on litigation against or on behalf of the Trust.
2.5.13 Decide whether or not to use the NHS risk pooling schemes or to self insure
2.5.14 Approve the introduction or discontinuance of any significant activity or
operation. An activity or operation shall be regarded as significant if it has
gross annual income or expenditure (that is before any set off) in excess of
£500,000.
2.5.15 To agree all permanent changes to bed allocation.
2.6 Audit
2.6.1 Approve the appointment (and where necessary dismissal) of internal
auditors and advise the Audit Commission on the appointment (and where
necessary change/removal) of external auditors including arrangements for
the separate audit of funds held on trust, and to receive reports of the Audit
Committee meetings and take appropriate action.
2.6.2 Receive the annual management letter from the external auditor and
agreement of Executive Committee’s proposed action, taking account of the
advice, where appropriate, of the Audit and Risk Assurance Committee.
Receive an annual report from the Internal Auditor and agree action on
recommendations where appropriate of the Audit and Risk Assurance
Committee.
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The Princess Alexandra Hospital NHS Trust
2.6.3 Receive an annual report from the Internal Auditor and agree action on
recommendations where appropriate of the Audit and Risk Assurance
Committee.
2.7 Annual Reports and Accounts
2.7.1 Receipt and approval of the Trust's Annual Report and Annual Accounts as
prepared by the Executive Committee.
2.7.2 Receipt and approval of the Annual Report and Accounts for funds held on
trust.
2.8 Monitoring
2.8.1 Receive such reports as the Board sees fit from committees in respect of
their exercise of powers delegated.
2.8.2 Continuous appraisal of the affairs of the Trust by means of reports to the
Board as the Board may require from directors, committees, and officers of
the Trust as set out in management policy statements. All monitoring
returns required by the Department of Health and the Charity Commission
shall be reported, at least in summary, to the Board.
2.8.3 Receive reports from the Director of Finance on financial performance against
budget and business plan.
2.8.4 Receive reports from the Chief Operating/Nursing Officer on performance
against service level agreements.
2.8.5 Receive reports from the Chief operating/Nursing Officer on the performance
against the Trust’s annual governance plan.
2.8.6 Receive an annual report from the Clinical Director of Infection Control on the
Management of Control of Infection within the Trust.
2.8.7 Receive an annual report from the Chair of the Trust’s Research and
Development Committee.
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3. Decisions / Duties Delegated by the Board to Committees
The Princess Alexandra Hospital NHS Trust
The Board may determine that certain of its powers shall be exercised by Standing Committees. The composition and terms of reference
of such committees shall be that determined by the Board from time to time taking into account where necessary the requirements of the
Secretary of State and the Charity Commissioners (including the need to appoint an Audit Committee and a Remuneration and Terms of
Service Committee). The Board shall determine the reporting requirements in respect of these committees. In accordance with SO 5.5
committees may not delegate executive powers to sub-committees unless expressly authorised by the Board.
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4 Audit
Committee
The Princess Alexandra Hospital NHS Trust
The duties of the Committee can be categorised as follows:
4.1 Internal Control and Risk Management
The Committee shall review the establishment and maintenance of an effective system of
internal control and risk management. The Committee will interface with the Governance
Committee in the management of risk. In particular, the committee will review the adequacy
of:
4.2 Internal Audit
• All risk and control disclosure statements, together with any accompanying audit
statement, prior to endorsement by the board;
• The structures, process and responsibilities for identifying and managing key risks
facing the organisation;
• The policies for ensuring that there is compliance with relevant regulatory, legal and
code of conduct requirements as set out in the Controls Assurance Standards and
other relevant guidance;
• The operational effectiveness of policies and procedures, and
• The policies and procedures for all work related to fraud and corruption as set out in
Secretary of State directions and as required by the Directorate of Counter Fraud
Services.
The Committee shall review the Trust’s internal audit service and shall:
• consider the appointment of the internal audit service, the audit fee and any questions
of resignation and dismissal;
• review the internal audit programme, consider the major findings of internal audit
investigations (and management’s response), and ensure co-ordination between the
Internal and External Auditors; and
• Ensure that the Internal Audit function is adequately resourced and has appropriate
standing within the organisation.
Page 10 of 52
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Corporate
Governance
Manual
section
1.4
SFI 2.1
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4.3 External Audit
The Princess Alexandra Hospital NHS Trust
The Committee shall review the Trust’s external audit service and shall:
• consider the appointment of the External Auditor, as far as the Audit Commission’s
rules permit;
• discuss with the External Auditor, before the audit commences, the nature and scope
of the audit, and ensure coordination, as appropriate, with other External Auditors in
the local health economy;
• review External Audit reports, including value for money reports and annual audit
letters, together with the management response
4.4 Financial Reporting
The Committee will review the annual financial accounts and losses and compensation return
before submission to the board, focusing particularly on:
• changes in, and compliance with, accounting policies and practices;
• major judgmental areas; and
• Significant adjustments resulting from the audit.
• Following completion of the review, the Committee will report to the Trust Board on the
Annual Accounts statements and on any significant issues.
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5 Remuneration
and Terms of
Service
Committee
The Princess Alexandra Hospital NHS Trust
The purpose of the Committee is to advise the Board about appropriate remuneration and
terms and conditions of service for the Chief Executive and other Executive officers. Advice to
the Board on remuneration should include all aspects of salary (including any performance
related elements/bonuses and any allowances), provisions for other benefits including
pensions as well as arrangements for termination of employment and other contractual terms.
The main functions of the Committee can be categorised into the following areas:
5.1 Executive Directors’ Remuneration and Terms and Conditions of Service
Make recommendations to the Board on the remuneration and terms and conditions of service
of Executive directors and senior managers to ensure they are fairly rewarded for their
contributions to the organisation, having proper regard to the organisation’s circumstances
and to the provisions of any national arrangements for such staff where appropriate.
Determine and ensure that annual pay increases and allowances are agreed in relation to
performance and that the levels and balance of pay and non-pay benefits is maintained on a
sensible, competitive and appropriate level.
5.2 Performance Management
• To establish mechanisms to monitor and evaluate the performance of individual
Executive directors and senior mangers.
• To review the management costs of the Trust and the annual statement on disclosures
made as regards guidance on reporting Director’s salaries (As per the "Codes of
Conduct & Accountability" requirements developed from the recommendations of the
Cadbury Committee’s 1992 report on The Financial Aspects of Corporate Governance
(the Greenbury Disclosures).
• To receive from the Chairman of the Trust, on a six-monthly basis, details of the
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Corporate
Governance
Manual
section
1.5
SFI 8.1
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appraisal and performance of the Chief Executive. Should the occasion arise that the
Non-Executives on the remuneration committee agree the need for action to address
poor performance, the Trust Chairman will take responsibility for briefing all Non-
Executive Directors and for determining the appropriate action with the Chief Executive
of the East of England Strategic Health Authority.
• To receive from the Chief Executive, on an annual basis, details of the appraisal and
performance of the Executive Directors and to ensure that a fair and consistent
approach is applied.
5.3 Contractual Arrangements
• To advise on and oversee appropriate contractual arrangements for such staff
including the proper calculation and scrutiny of termination payments taking account of
such national guidance as is appropriate.
• To ensure that contractual obligations to individual directors are honoured and the
contracts themselves are reviewed to ensure they remain up to date and appropriate.
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6 Governance
Committee
7 Charitable
Funds
Committee
The Princess Alexandra Hospital NHS Trust
Its functions are derived from HSC 1999/065 and include the following:
1. To meet at least four times a year.
2. To oversee the development, implementation and audit of a Governance & Risk
Management Strategy and approve an annual Improvement Plan.
3. To oversee the development, implementation and audit of an integrated Trust wide “all
risks” register and the related prioritisation, action planning and implementation
processes.
4. To monitor performance against all risk related Improvement Plans.
5. To report regularly to the Audit and Risk Assurance Committee and contribute to the
Annual Report.
6. To submit reports on all Governance and Risk related issues to the Management
Team and other bodies as required.
7. To advise the Board on ways of working that promote the involvement of patients,
carers and the public, together with means of ensuring co-operation and collaboration
with partner organisation including Primary Care Organisations.
8. To monitor the effectiveness of the Governance & Risk Management arrangements
and advise the Board accordingly.
9. Ratification on behalf of the Trust Board of Policies, Procedures & Protocols received
from Specialist Groups and Committees.
10. To formally receive minutes from local Governance and Risk Management Forums
and other subordinate Committees.
The duties of the Committee can be categorised as follows:
7.1 Internal Control and Risk Management
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HSC
1999/065
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The Committee shall review the establishment and maintenance of an effective system of
internal control and risk management for the management of charitable funds. In particular,
the committee will review the adequacy of:
• All risk and control disclosure statements, together with any accompanying audit
statement, prior to endorsement by the board;
• The structures, process and responsibilities for identifying and managing key risks
facing the funds;
• The policies for ensuring that there is compliance with relevant regulatory, legal and
code of conduct requirements as set out by the Charities Commission together with
any other relevant guidance; and
• The operational effectiveness of policies and procedures.
7.2 Financial Reporting
The committee will review the financial position of the Charitable Funds at each meeting,
focusing particularly on:
• Fund balances and their performance in the financial year;
• Asset management; and
• Any other relevant general charitable fund management issues.
The Committee will review the annual financial statements before submission to the Audit
Committee, focusing particularly on:
• changes in, and compliance with, accounting policies and practices;
• major judgmental areas; and
• Significant adjustments resulting from the audit.
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8 R & D
Committees
The Princess Alexandra Hospital NHS Trust
The Terms of Reference for this committee are:
The duties of the Committee can be categorised as follows:-
8.1 Internal Control and Risk Management
The Committee shall review the establishment and maintenance of an effective system of
internal control and risk management. In particular, the committee will review the adequacy
of:
• The completion of the registration form together with adherence to statements of
declaration, both general and financial;
• All risk and control disclosure statements, together with any accompanying research
statement, prior to endorsement by the board;
• The structures, process and responsibilities for identifying and managing key risks
facing the organisation;
• The policies for ensuring that there is compliance with relevant regulatory, legal, code
of conduct and good clinical practice requirements as set out in the Research
Governance Framework and other relevant guidance;
• The operational effectiveness of policies and procedures; and
• The policies and procedures for all work, both internal and external, related to fraud
and corruption as set out in the Secretary of State directions and as required by the
Directorate of Counter Fraud Services.
8.2 Financial Reporting
The Committee will:-
• Ensure financial probity within all research activity undertaken within the Trust;
• Ensure accurate and comprehensive submissions, as required, are made to Directorate of
Health & Social Care (DHSC);
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• Ensure that research activity optimises use of available funding sources; and
• Locate and disseminate information about new and innovative funding streams.
The committee will review the financial tables of the DHSC annual report before submission to
the board, focusing particularly on:-
Changes in, and compliance with, accounting policies and practices
Major judgmental areas; and
Significant adjustments resulting from the research.
Following completion of the review, the Committee will report to the Trust Board on the R&D
Annual Report statements and on any significant issues.
8.3 Ongoing Monitoring and Development
The Committee will continue to develop new practices for the Trust, the will include the
following:-
• Engage in collaborative working with partner organisations where opportunities arise;
• Maintain positive working relationships with the local Research Ethics Committee;
The Committee has delegated responsibility for maintaining the quality of research and
development. In order to ensure quality is in accordance with national guidance the
Committee will approve all research undertaken within The Princess Alexandra Hospital NHS
Trust. This shall not include activities defined as Clinical Audit, Management audit or
Financial audit.
8.4 Quality Research Environment
The Committee will provide:
• Leadership on R&D issues to all staff groups; and
• a Trust Research and Development Strategy to the Trust Board and review this strategy on
an annual basis
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Ethics
The Committee will:
The Princess Alexandra Hospital NHS Trust
• Receive and review all R&D applications within Princess Alexandra Hospital NHS Trust;
and
8.5 Science
The Committee will provide independent, multi-professional reviews of all projects. This will
include review of;
• Initial Protocols;
• Sub Protocols;
• Any Protocol amendments;
• Revised Protocols for unapproved proposals submitted for re-reviews.
8.5.1 Assign reviewed proposals to one of three categories
These are:-
• Approved;
• Approved subject to certain conditions that must be complied with prior to the start of the
study;
• Unapproved.
• Authorise the Chairman to give final approval to proposals ‘approved subject to…’ on
receipt of satisfactory responses to all queries/actions.
• Maintain a record of the process and outcome of the review;
• Publicise details of meetings to enable applicants to submit proposals in adequate time for
a prompt response;
• Monitor compliance with governance standards. Monitoring will involve receiving pro
forma reports on projects at intervals determined on approval;
• Where projects deviate from protocols agreed at commencement of the project (or revised
with the Committee approval) the Committee shall take action to:
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• Immediately discontinue the project;
• Promote the safety of all participants during discontinuation;
• Ensure that closure of accounting is undertaken correctly;
• Provide a specific report to the Princess Alexandra Hospital NHS Trust Board.
Information
The Committee will:
• Collect, monitor and disseminate information about R&D throughout The Princess
Alexandra Hospital NHS Trust concerning:
research activity within the Trust
support arrangements
funding opportunities
national R&D guidance
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9 Scheme of Delegation Derived from the Accountable Officer Memorandum
The Accountable Officer Memorandum implies delegated duties. These are detailed, and referenced, as follows:
Delegated to Duties delegated Reference in
Accountable
Officer
Memorandum
Chair
Implement requirements of corporate governance 12
Chief Executive
Accountable through NHS Accounting Officer to Parliament for stewardship of Trust resources
Sign a statement in the accounts outlining responsibilities as the Accountable Officer.
Ensure effective management systems that safeguard public funds and assist Trust Chairman to
implement requirements of corporate governance including ensuring managers:
“have a clear view of their objectives and the means to assess achievements in relation to those
objectives
be assigned well defined responsibilities for making best use of resources
have the information, training and access to the expert advice they need to exercise their
responsibilities effectively.”
Achieve value for money from the resources available to the Trust and avoid waste and
extravagance in the organisation's activities.
Follow through the implementation of any recommendations affecting good practice as set out on
reports from such bodies as the Audit Commission and the National Audit Office (NAO).
Primary duty to see that Chief Financial Officer discharges this function of effective and sound
financial management.
Ensuring that expenditure by the Trust complies with Parliamentary requirements
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7
10
12 (a), (b), (c)
13
15
16

The Princess Alexandra Hospital NHS Trust
The Codes of Conduct and Accountability incorporated in the Corporate Governance Framework
issued to NHS Boards by the Secretary of State are fundamental in exercising the Trust’s
responsibilities for regularity and probity. The Chief Executive will ensure that Board members
explicitly subscribe to the Codes; and promote their observance by all staff.
If Chief Executive considers the Board or Chairman is doing something which might infringe
probity or regularity, he/she should set this out in writing to the Chairman and the Board. If the
matter is unresolved, he should ask the Audit Committee to inquire and if necessary the Strategic
Health Authority and Department of Health.
If the Board is contemplating a course of action which raises an issue not of formal propriety or
regularity but affects the Chief Executive’s responsibility for value for money, the Chief Executive
should draw the relevant factors to the attention of the Board. If the outcome is that the Chief
Executive is overruled it is normally sufficient for the Chief Executive to ensure that his/her advice
and the overruling of it are clearly apparent from the papers. Exceptionally, the Chief Executive
should inform the Strategic Health Authority and the DoH. In such cases, and in those described
in paragraph 19, the Chief Executive should as a member of the Board vote against the course of
action rather than merely abstain from voting.
Chief Executive and Director of Finance
Ensure the accounts of the Trust are prepared under principles and in a format directed by the
Secretary of State. Accounts must disclose a true and fair view of the Trust’s income and
expenditure and its state of affairs.
Sign the accounts on behalf of the Board.
Director of Finance
Chief Executive, supported by Director of Finance, to ensure appropriate advice is given to the
Board and Executive Committee on all matters of probity, regularity, prudent and economical
administration, efficiency and effectiveness.
Operational responsibility for effective and sound financial management and information.
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17
19
21
9
18
15

The Princess Alexandra Hospital NHS Trust
Scheme of Delegation Derived from the Codes of Conduct and Accountability
Duties derived form the Codes of Conduct and Accountability can be categorised as follows:
Delegated to Duties delegated Ref in Corporate
Governance Manual
(Codes of Conduct
and Accountability)
Chair
Chair and Directors
It is the Chairman's role to:
• provide leadership to the Board,
• enable all Board members to make a full contribution to the Board's affairs and
ensure that the Board acts as a team,
• ensure that key and appropriate issues are discussed by the Board in a timely
manner,
• ensure the Board has adequate support and is provided efficiently with all the
necessary data on which to base informed decisions,
• lead non-executive Board members through a formally-appointed remuneration
committee of the main Board on the appointment, appraisal and remuneration of
the chief executive and (with the latter) other executive Board members,
• appoint non-executive Board members to an audit committee of the main Board,
and
• advise the Secretary of State on the performance of non-executive Board
members.
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1.3.2.5
Declaration of conflict of interests. 1.3.2.8
Chair and Non-executive Directors
Chair and Non-executive directors are responsible for monitoring the executive
management of the organisation and are responsible to the Secretary of State for the
discharge of those responsibilities.
1.3.2.4
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Delegated to Duties delegated Ref in Corporate
Governance Manual
(Codes of Conduct
and Accountability)
Non Executive Directors
Chief Executive
Board
Non-executive Directors are appointed by the Secretary of State to bring independent
judgement to bear on issues of strategy, performance, key appointments and
accountability through the Department of Health to Ministers and to the local community
The Chief Executive is accountable to the Chairman and non-executive members of the
Board for ensuring that its decisions are implemented, that the organisation works
effectively, in accordance with Government policy and public service values and for the
maintenance of proper financial stewardship.
The Chief Executive should be allowed full scope, within clearly defined delegated
powers, for action in fulfilling the decisions of the Board.
The other duties of the Chief Executive as accountable officer are laid out in the
Accountable Officer Memorandum
Approve procedure for declaration of hospitality and sponsorship
Ensure proper and widely publicised procedures for voicing complaints, concerns about
maladministration, breaches of Code of Conduct, and other ethical concerns.
Board members share corporate responsibility for all decisions of the Board.
The Board has four key functions for which it is held accountable by the Department of
Health on behalf of the Secretary of State:
• to ensure effective financial stewardship through value for money, financial control
and financial planning and strategy
• to ensure that high standards of corporate governance and personal behaviour
are maintained in the conduct of the business of the whole organisation,
• to appoint, appraise and remunerate senior executives,
• on the recommendation of the Executive Committee, to ratify the strategic
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1.3.2.6
1.3.2.5
1.3.1.7
1.3.1.8
1.3.2.4
1.3.2.4
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The Princess Alexandra Hospital NHS Trust
Delegated to Duties delegated Ref in Corporate
Governance Manual
(Codes of Conduct
and Accountability)
direction of the organisation within the overall policies and priorities of the
Government and the NHS, define its annual and longer term objectives and agree
plans to achieve them.
It is the Board’s duty to:
• act within statutory financial and other constraints
• be clear what decisions and information are appropriate to the board and draw up
standing orders, a schedule of decisions reserved to the board and standing
financial instructions to reflect these,
• ensure that management arrangements are in place to enable responsibility to be
clearly delegated to senior executives for the main programmes of action and for
performance against programmes to be monitored and senior executives held to
account,
• establish performance and quality targets that maintain the effective use of
resources and provide value for money.
• specify its requirements in organising and presenting financial and other
information succinctly and efficiently to ensure the board can fully undertake its
responsibilities,
• establish audit and remuneration committees on the basis of formally agreed
terms of reference which set out the membership of the sub-committee, the limit to
their powers, and the arrangements for reporting back to the main board.
NHS Boards must comply with legislation and guidance issued by the Department of
Health on behalf of the Secretary of State, respect agreements entered into by
themselves or on their behalf and establish terms and conditions of service that are fair to
the staff and represent good value for taxpayers' money
All Board members and Executive Committee members
Subscribe to Code of Conduct 1.3.2.2
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The Princess Alexandra Hospital NHS Trust
10 Scheme of Delegation Derived from Standing Orders and Standing Financial Instructions
Standing Orders and Standing Financial Instructions set out in some detail the financial responsibilities of the Chief Executive, the Chief
Financial Officer and other directors. Their applicability as regards delegated powers is detailed below. Each director is responsible for the
delegation within his/her directorate and where this is not covered within this Scheme, should produce a scheme of delegation for matters
within his/her directorate. In particular the scheme of delegation should include how the directorate budget and procedures for approval of
expenditure are delegated. A detailed scheme of delegation including financial limits is given in Section 7 below.
10.1 Scheme of Delegation Derived from Standing Orders (SOs)
Delegated
to
Chairman
Authorities / Duties Delegated Standing
Orders
Reference
Final authority in interpretation of SOs. 1.1
Call meetings. 3.5
Chair all Board meetings and associated responsibilities. 3.14
Give final ruling in questions of order, relevancy and regularity of meetings. 3.21
Having a second or casting vote 3.22
Chairman & Chief Executive
The powers which the Board has retained to itself within these Standing Orders (Standing Order 4.2) may
in emergency be exercised by the Chair and Chief Executive after having consulted at least two non-officer
members
Chief Executive
The Chief Executive shall prepare a Scheme of Delegation identifying his/her proposals which shall be
considered and approved by the Board, subject to any amendment agreed during the discussion.
4.7
Maintain Register(s) of Interests. 6.8
Tendering and contract procedure 9
Report waivers of tendering procedures to the Board. 9.5
Ensure best value for money is demonstrated for all services provided under contract or in-house. 9.16
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4.2

Delegated
to
The Princess Alexandra Hospital NHS Trust
Authorities / Duties Delegated Standing
Orders
Reference
Demonstrate that the use of private finance represents best value for money and transfers risk to the 9.17
private sector.
Determining any items to be sold by sale or negotiation. 10.1
Keep seal in safe place and maintain a register of sealing. 12.1
Approve and sign all documents which will be necessary in legal proceedings 13
Existing Board members, officers and employees and all new appointees are notified of and understand
their responsibilities within Standing Orders and SFIs.
14.1
Designate an officer responsible for receipt and custody of tenders before opening. App A s2
Nominate an officer to oversee and manage a contract on behalf of the Trust. 9.18
Nominate officers to enter into contracts of employment, re-grading staff, agency staff or consultancy
service contracts.
9.20
Nominate officers with power to negotiate commissioning contracts/service agreements with providers of
healthcare and other authorities.
9.21
Nominate an officer to oversee and manage a contract (for in-house services) on behalf of the Trust 11.4
Chief Executive and Director of Finance or nominated officers
Approve and sign all building, engineering, property or capital documents. 12.3
Waive formal tendering procedures (subject to points a) to g) in SO 9.5). 9.5
Chief Executive or nominated officer
Decide whether any late tenders should be considered. App A s4
Evaluate the quotations and select the one which gives the best value for money 9.13
Sign where authorised by resolution of the Board on behalf of the Trust any agreement or document not 13
requested to be executed as a deed.
Director of Finance
Board
Keep lists of approved firms for tenders. App A s5
Appointment of Vice Chairman 2.8
Suspension of Standing Orders 3.32
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Delegated
to
Audit Committee
The Princess Alexandra Hospital NHS Trust
Authorities / Duties Delegated Standing
Orders
Reference
Variation or amendment of Standing Orders 3.37
Formal delegation of powers to Executive Committee, other committees, sub committees or joint
4.4
committees and approval of their constitution and terms of reference. (Constitution and terms of reference
of sub committees may be approved by the Chief Executive.)
Authorise use of the Seal 12
See the register of sealing quarterly. 12.4
Audit Committee to review every decision to suspend Standing Orders (power to suspend Standing Orders
is reserved to the Board)
All Board and Executive Committee members
Declare relevant and material interests 6.1
Two Senior officers
All
Open tenders. App A s3
Disclosure of non-compliance with Standing Orders to the Chief Executive as soon as possible. 4.10
Disclose relationship between self and candidate for staff appointment. (Chief Executive to report the
disclosure to the Board.)
8.8
Comply with national guidance contained in HSG 1993/5 “Standards of Business Conduct for NHS Staff. 8.1
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The Princess Alexandra Hospital NHS Trust
10.2 Scheme of Delegation Derived from Standing Financial Instructions (SFIs)
Delegated to Authorities / Duties Delegated Standing
Financial
Instructions
Reference
Chair
Board
Raise the matter at the Board meeting where Audit Committee considers there is evidence of ultra
vires transactions or improper acts.
Establish a Remuneration & Terms of Service Committee 8.1.1
Approve proposals presented by the Chief Executive for setting of remuneration and conditions of
service for those employees and officers not covered by the Remuneration Committee.
8.1.4
Proposal to use PFI must be specifically agreed by the Board. 11.2.1
Approve write off of losses (within limits delegated by DH). 13.2.5
Approve and monitor risk management programme 19.1
Decide whether the Trust will use the risk pooling schemes administered by the NHS Litigation
Authority or self-insure for some or all of the risks. Decisions to self-insure should be reviewed
annually.
19.3
Disclosure of non-compliance with SFIs as soon as possible to the Director of Finance. The Director
of Finance to report to the Audit Committee.
1.1.6
Responsible for security of the Trust's property, avoiding loss, exercising economy and efficiency in
using resources and conforming to Standing Orders, Financial Instructions and financial procedures.
1.3.8
Appropriate Executive Director
Make a written case to support the need for a prepayment. 9.2.4
Audit Committee
Remuneration Committee
Provide independent and objective view on internal control and probity. 2.1.1
Ensure cost-effective external audit 2.5
Report in writing to the Board its advice and its basis about remuneration and terms of service of
directors and senior employees.
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2.1.2
8.1.2
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Chief Executive
The Princess Alexandra Hospital NHS Trust
Advise the Board on and make recommendations on the remuneration and terms of service of the
Chief Executive, other officer members and senior employees to ensure they are fairly rewarded
having proper regard to the Trust’s circumstances and any national agreements
Monitor and evaluate the performance of individual senior employees.
Advise on and oversee appropriate contractual arrangements for such staff, including proper
calculation and scrutiny of termination payments
Responsible as the accountable officer to ensure financial targets and obligations are met and has
overall responsibility for the system of internal control.
To ensure all Board members, officers and employees, present and future, are notified of and
understand Standing Financial Instructions.
Ensure that any contractor or employee of a contractor who is empowered by the Trust to commit the
Trust to expenditure or who is authorised to obtain income are made aware of these instructions and
their requirement to comply
Compile and submit to the Board an annual business plan which takes into account financial targets 3.1.1
and forecast limits of available resources. The annual business plan will contain:
a statement of the significant assumptions on which the plan is based;
details of major changes in workload, delivery of services or resources required to achieve the plan.
Delegate budget to budget holders 3.2
Identify and implement cost improvements and income generation activities in line with the Business 3.3.3
Plan.
Submit monitoring returns 3.5
Ensure the Trust enters into suitable Service Agreements (SA) with service commissioners for the 7.1
provision of NHS services
As the accountable officer, ensure that regular reports are provided to the Board detailing actual and 7.2
forecast income from the SA
Advise the Board on the remuneration and terms of service for staff not covered by the Remuneration 8.1.4
Committee.
Approval of variation to funded establishment of any department. 8.2.2
Staff, including agency staff, appointments and re-grading. 9.2
Determine, and set out, level of delegation of non-pay expenditure to Budget Holders, including a list 9.1
of managers authorised to place requisitions, the maximum level of each requisition and the system
for authorisation above that level.
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8.1.2
1.3.4
1.3.6
1.3.9
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Set out procedures on the seeking of professional advice regarding the supply of goods and services. 9.1.2
Authorise who may use and be issued with official orders. 9.2.5
Capital investment programme
11.1.1 &
ensure that there is adequate appraisal and approval process for determining capital expenditure 11.1.2
priorities and the effect that each has on business plans
responsible for the management of capital schemes and for ensuring that they are delivered on time
and within cost
ensure that capital investment is not undertaken without availability of resources to finance all
revenue consequences
ensure that a business case is produced for each proposal.
Issue procedures for management of contracts involving stage payments. 11.1.3
Issue manager responsible for any capital scheme with authority to commit expenditure, authority to 11.1.6
proceed to tender and approval to accept a successful tender.
Issue a scheme of delegation for capital investment management (on advice from the Director of
Finance)
Maintenance of asset registers (on advice from the Director of Finance). 11.3.1
Overall responsibility for fixed assets. 11.4.1
Delegate overall responsibility for control of stores (subject to Director of Finance responsibility for 12.2
systems of control). Further delegation for day-to-day responsibility subject to such delegation being
recorded.
Identify persons authorised to requisition and accept goods from NHS Supply Chain stores. 12.8
Responsible for ensuring patients and guardians are informed about patients' money and property 15
procedures on admission.
Retention of document procedures in accordance with HSC 1999/052. 18
Risk management programme 19.1
Chief Executive / Director of Finance
Ensure that Standing Orders are compatible with Department of Health requirements re building and
engineering contracts.
Ensure that the arrangements for financial control and financial audit of building and engineering
contracts and property transactions comply with the guidance contained within CONCODE and
ESTATECODE. The technical audit of these contracts shall be the responsibility of the relevant
Director.
Accountable for financial control but will, as far as possible, delegate their detailed responsibilities. 1.3.5
Monitor and ensure compliance with Secretary of State Directions on fraud and corruption including 2.4
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Director of Finance
The Princess Alexandra Hospital NHS Trust
the appointment of the Local Counter Fraud Specialist.
Training and communication programme for staff on SFIs. 1.1.1
Approval of all financial procedures. 1.1.3
Advice on interpretation or application of SFIs. 1.1.4
Responsible for:
1.3.7
Implementing the Trust's financial policies and co-ordinating corrective action
Maintaining an effective system of financial control including ensuring detailed financial procedures
and systems are prepared and documented
Ensuring that sufficient records are maintained to explain Trust’s transactions and financial position
Providing financial advice to members of Board and staff
Maintaining such accounts, certificates etc as are required for the Trust to carry out its statutory
duties.
Ensure an adequate internal audit service, for which he/she is accountable, is provided (and involve 2.1.3 &
the Audit Committee in the selection process when/if an internal audit service provider is changed.) 2.2.1
Decide at what stage to involve police in cases of misappropriation and other irregularities not 2.2.1
involving fraud or corruption.
Submit budgets to the Board for approval.
3.1.2
Monitor performance against budget, submit to the Board financial estimates and forecasts.
Ensure adequate training is delivered on an on going basis to budget holders. 3.1.5
Devise and maintain systems of budgetary control. 3.2.1
Preparation of annual accounts and reports. 4.1
Managing banking arrangements, including provision of banking services, operation of accounts, 5.1
preparation of instructions and list of cheque signatories.
(Board approves arrangements.)
Income systems, including system design, prompt banking, review and approval of fees and charges, 6.
debt recovery arrangements, design and control of receipts, provision of adequate facilities and
systems for employees whose duties include collecting or holding cash.
Payroll
8.4.1 and
specifying timetables for submission of properly authorised time records and other notifications 8.4.2
final determination of pay and allowances
making payments on agreed dates
agreeing method of payment
issuing instructions.
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The Princess Alexandra Hospital NHS Trust
Ensure that the chosen method for payroll processing is supported by appropriate (contracted) terms
and conditions, adequate internal controls and audit review procedures and that suitable
arrangements are made for the collection of payroll deductions and payment of these to appropriate
bodies.
Advise the Board regarding the setting of thresholds above which quotations (competitive or 9.2.3
otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be
incorporated in standing orders and regularly reviewed;
Prepare procedural instructions [where not already provided in the Scheme of Delegation or
procedure notes for budget holders] on the obtaining of goods, works and services incorporating the
thresholds;
Be responsible for the prompt payment of all properly authorised accounts and claims;
Be responsible for designing and maintaining a system of verification, recording and payment of all
amounts payable.
A timetable and system for submission to the Director of Finance of accounts for payment; provision
shall be made for the early submission of accounts subject to cash discounts or otherwise requiring
early payment.
Instructions to employees regarding the handling and payment of accounts within the Finance
Department.
Be responsible for ensuring that payment for goods and services is only made once the goods and
services are received
Approve proposed prepayment arrangements. 9.2.4
Lay down procedures for payments to local authorities and voluntary organisations made under the 9.3
powers of section 28A of the NHS Act
Ensure that Board members are aware of the Financial Framework and ensure compliance 10
Certify professionally the costs and revenue consequences detailed in the business case for capital 11.1.2
investment.
Assess the requirement for the operation of the construction industry taxation deduction scheme. 11.1.4
Issue procedures for the regular reporting of expenditure and commitment against authorised capital 11.1.5
expenditure.
Issue procedures governing financial management, including variation to contract, of capital
11.1.7
investment projects and valuation for accounting purposes.
Demonstrate that the use of private finance represents value for money and genuinely transfers 11.2.1
significant risk to the private sector.
Approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on
fixed asset registers.
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Reservation of Powers to the Board and Delegation of Powers – Interim 2012
8.4.4
11.3.5
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The Princess Alexandra Hospital NHS Trust
Calculate and pay capital charges in accordance with Department of Health requirements. 11.3.8
Approval of fixed asset control procedures. 11.4.2
Responsible for systems of control over stores and receipt of goods. 12.2
Set out procedures and systems to regulate the stores. 12.4
Agree stocktaking arrangements. 12.5
Approve alternative arrangements where a complete system of stores control is not justified. 12.6
Approve system for review of slow moving and obsolete items and for condemnation, disposal and
replacement of all unserviceable items.
12.7
Prepare detailed procedures for disposal of assets including condemnations and ensure that these
are notified to managers.
13.1
Prepare procedures for recording and accounting for losses and special payments and informing 13.2.1
police in cases of suspected arson or theft.
Where a criminal offence is suspected Director of Finance must inform the police if theft or arson is 13.2.2
involved. In cases of fraud and corruption Director of Finance must inform the Local Counter Fraud
Specialist in line with Secretary of State directions.
Notify LCFS and External Audit of all frauds. 13.2.3
Notify Board and External Auditor of losses caused theft, arson, neglect of duty or gross
13.2.4
carelessness (unless trivial).
Consider whether any insurance claim can be made. 13.2.7
Maintain losses and special payments register.
Responsible for accuracy and security of computerised financial data.
Satisfy himself that new financial systems and amendments to current financial systems are
developed in a controlled manner and thoroughly tested prior to implementation. Where this is
undertaken by another organisation assurances of adequacy must be obtained from them prior to
implementation.
Ensure that contracts with other bodies for the provision of computer services for financial
applications clearly define responsibility of all parties for security, privacy, accuracy, completeness
and timeliness of data during processing, transmission and storage, and allow for audit review.
Seek periodic assurances from the provider that adequate controls are in operation.
Where computer systems have in impact on corporate financial systems satisfy himself that:
systems acquisition, development and maintenance are in line with corporate policies
data assembled for processing by financial systems is adequate, accurate, complete and timely, and
that a management trail exists
Director of Finance and staff have access to such data
Such computer audit reviews are being carried out as are considered necessary.
Page 33 of 52
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
14.4 & 14.5
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Head of Internal Audit
The Princess Alexandra Hospital NHS Trust
Provide detailed written instructions on the collection, custody, investment, recording, safekeeping,
and disposal of patients' property (including instructions on the disposal of the property of deceased
patients and of patients transferred to other premises) for all staff whose duty is to administer, in any
way, the property of
Ensure all staff are made aware of the Trust policy on the acceptance of gifts and other benefits in
kind by staff
Consult NHS LA in case of doubt as to the power to use commercial insurers.
Where the Board decides to use the NHS risk pooling Scheme the Director of Finance shall ensure
that the arrangements entered into are appropriate and complementary to the risk management
programme. The Director of Finance shall ensure that documented procedures cover these
arrangements.
Where the Board decides not to use the risk pooling schemes administered by the NHS Litigation
Authority for any one or other of the risks covered by the schemes, the Director of Finance shall
ensure that the Board is informed of the nature and extent of the risks that are self insured as a result
of this decision. The Director of Finance will draw up formal documented procedures for the
management of any claims arising from third parties and payments in respect of losses which will not
be reimbursed.
Ensure documented procedures cover management of claims and payments below the deductible
(contribution to the settlement of claims).
Review, appraise and report in accordance with NHS Internal Audit Manual and best practice.
Designated Estates Officer
Responsible for control of stocks of fuel oil and coal.
Chief Executive & Budget Holders
Must not exceed the budgetary total or virement limits set by the Board.
Budget holders
Ensure that all items due under a prepayment contract are received (and immediately inform the
Director of Finance if problems are encountered).
Ensure that
a) no overspend or reduction of income that cannot be met from virement is incurred without prior
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Departmental Managers
The Princess Alexandra Hospital NHS Trust
consent of Board
b) approved budget is not used for any other than specified purpose subject to rules of virement
c) no permanent employees are appointed without the approval of the Chief Executive other than
those provided for within available resources and manpower establishment.
Inform staff of their responsibilities and duties for the administration of the property of patients. 15.6
Designated Pharmaceutical officer
Responsible for controls of pharmaceutical stocks 12.2
Managers and Nominated Officers
Ensure that they comply fully with the guidance and limits specified by the Director of Finance 9.2.6
Ensure that all employees are issued with a Contract of Employment in a form approved by the Board 8.5
and which complies with employment legislation; and
Deal with variations to, or termination of, contracts of employment.
Submit time records in line with timetable
8.4.2
Complete time records and other notifications in required form
Submitting termination forms in prescribed form and on time.
Security arrangements and custody of keys 12.3
Operate system for slow moving and obsolete stock, and report to the Director of Finance evidence 12.7
of significant overstocking.
Send proposals for general computer systems to Director of Finance 14.2
Requisitioners
All senior staff
In choosing the item to be supplied (or the service to be performed) shall always obtain the best
value for money for the Trust. In so doing, the advice of the Trust's adviser on supply shall be
sought.
Responsibility for security of Trust assets including notifying discrepancies to Director of Finance, and
reporting losses in accordance with Trust procedure.
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Reservation of Powers to the Board and Delegation of Powers – Interim 2012
9.2.1
11.4.4
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All employees
The Princess Alexandra Hospital NHS Trust
Duty to inform Director of Finance of money due from transactions which they initiate/deal with. 6.2.3
Disclosure of non-compliance with SFIs as soon as possible to the Director of Finance. Director of 1.1.6
Finance to report to the Audit Committee.
Responsible for security of the Trust's property, avoiding loss, exercising economy and efficiency in 1.3.8
using resources and conforming to Standing Orders, Financial Instructions and financial procedures.
Discovery or suspicion of loss of any kind must be reported immediately to either head of department 13.2.2
or nominated officer. The head of department / nominated officer should then inform the Chief
Executive and the Director of Finance.
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11 Detailed Scheme of Delegation
The Princess Alexandra Hospital NHS Trust
Delegated matters in respect of decisions that may have a far-reaching effect must be reported to the Chief Executive. The delegation
shown below is the lowest level to which authority is delegated. Delegation to lower levels is only permitted with written approval of
the Chief Executive who will, before authorising such delegation, consult with other Senior Officers as appropriate. All items concerning
Finance must be carried out in accordance with Standing Financial Instructions and Standing Orders.
Delegated Matter
1. Management of Budgets
Responsibility of keeping expenditure within budgets
At individual budget level (Pay and Non Pay)
Page 37 of 52
Authority Delegated To
Budget Holder
At service level Clinical Director/Clinical Service Group
Lead
For the totality of services
2. Maintenance / Operation of Bank Accounts
3. Non Pay Revenue Expenditure/Requisitioning/
Ordering/Payment of Goods & Services
a) Authorisation of Requisitions
• requisitions up to £7,499
• requisitions from £7,500 to £14,999
• requisitions from £15,000 to £49,999
•
Chief Executive
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
SFIs Section 3
Director of Finance SFIs Section 5
Budget Holder
Clinical Service Group Lead
Clinical Director
Executive Director
SFIs Section 9
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Delegated Matter
•
•
•
requisitions from £50,000 to £99,999
•
•
•
•
•
requisitions over £100,000
The transactions below do not require a requisition:
Interim staff in established posts, covered by HR processes
BT and mobile phone invoices, once initial contract agreed
Eye vouchers
Refund of interview expenses
Gas, water and electricity bills
Compensation under legal obligation
The Princess Alexandra Hospital NHS Trust
Page 38 of 52
Authority Delegated To
Chief Executive and Director of Finance
b) Authorisation of Orders
orders up to £150,000 Head of Procurement
orders from £150,000
Director of Finance
Approve proposals on individual contracts (other than NHS
contracts) of a capital or revenue nature amounting to, or
likely to amount to over £600,000 over a 3 year period or the
period of the contract if longer.
c) Authorisation of Invoices
invoices up to £7,499
Chief Executive and Director of Finance
Budget Holder
Clinical Service Group Lead
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
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Delegated Matter
invoices from £7,500 to £14,999
invoices from £15,000 to £49,999
invoices from £50,000 to £99,999
invoices over £100,000
invoices of any value without a requisition,
NHS Supply Chain
d) Non-pay Expenditure for which no specific budget has
been set up and which is not subject to funding under
delegated powers of virement. (Subject to the limits specified
above in (a))
e) Orders exceeding 12 month period (subject to limits in
(a))
f) All contracts for goods & services and subsequent
variations to contracts (excluding leases)
i) Compensation under legal obligation (any value)
The Princess Alexandra Hospital NHS Trust
Page 39 of 52
Authority Delegated To
Clinical Director
Executive Director
Director of Finance Chief Executive and
Director of Finance
Director of Finance
Director of Finance
Chief Executive and Director of Finance
See section 3a and 3b
In accordance with Levels implied in (a)
above
g) Granting, signing and termination of leases < £99,999 Director of Finance or Deputy Director of
Finance
h) Granting, signing and termination of leases>£100,000
A Non Executive Director together with
either the Chief Executive or an Executive
Director
4. Capital Schemes
Finance Director
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
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Delegated Matter
a) Selection of architects, quantity surveyors, consultant
engineer and other professional advisors within EU
regulations
b) Financial monitoring and reporting on all capital scheme
expenditure
c) Granting, signing and termination of leases with annual
rent < £100k
The Princess Alexandra Hospital NHS Trust
Page 40 of 52
Authority Delegated To
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
Director of Finance SFIs Section 11
& Standing
Orders Section 9
Director of Finance
Director of Finance
d) Granting, signing and termination of leases of > £100k A Non Executive Director together with
either the Chief Executive or an Executive
Director
e) Authorisation of Non Pay Capital Expenditure/Requisitioning/
Ordering/Payment of Goods & Services
Capital Scheme Budget Holder
Up to £74,999
£75,000 to £149,999
£150,000 plus
For projects managed by external project managers the
above applies but in addition
Capital Scheme Budget Holder together
with Chief Executive or Director of
Finance
Capital Scheme Budget Holder together
with Chief Executive and Director of
Finance
Director of Finance or Deputy Director of
Finance
For Trust projects
that have
external
management
arrangements the
appointed project
management
team must
ensure that
invoices are
approved under
an agreed
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Delegated Matter
5. Quotation, Tendering & Contract Procedures
Quotes/tenders should be obtained and opened/approved by
(according to value):
a) Obtaining 2 minimum verbal quotations for
goods/services up to £7,499
The Princess Alexandra Hospital NHS Trust
Page 41 of 52
Authority Delegated To
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
scheme of
delegation and
that a copy of this
scheme, together
with sample
signatures, is
provided to the
Trust
Budget Holder SFIs Section 9,
Standing
Orders Section
9 & Annex
Budget Holder or Head of Procurement
b) Obtaining 3 written quotations for goods/services from
£7,500 to £24,999
c) Obtaining written competitive tenders for goods/services
Clinical Director and Head of
from £25,000 to £99,999
Procurement
d) Obtaining written competitive tenders for goods/services
Clinical Director, Executive Director,
above £150,000
Director of Finance and Head of
Procurement
e) Waiving of quotations & Tenders subject to SFIs. Chief Executive or Director of Finance
(reported to Audit and Risk Assurance
Committee)
f) Opening Tenders
from£25,000 to £249,999
Nominated Officers
from£250,000 to £749,999
Chief Executive and an other Executive
Director
from£750,000 +
Chief Executive and Chair
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Delegated Matter
6. Setting of Fees and Charges
a) Private Patient, Overseas Visitors, Income Generation
and other patient related services
b) Price of NHS Service & Financial Framework
Agreements
7. Engagement of Staff Not On the Establishment
a) Interim staff or consultancy assignments
Where aggregate commitment in any one year (or total
commitment) is less than £74,999
Where aggregate commitment in any one year is more than
£75,000
b) Engagement of Trust’s Solicitors
c) Booking of bank,locum and agency staff in accordance
with local procedures
e)
8. Expenditure of Charitable and Endowment Funds
The Princess Alexandra Hospital NHS Trust
Page 42 of 52
Authority Delegated To
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
Director of Finance SFIs Section 6
Director of Finance SFIs Section 7
Executive Director
Chief Executive or Director of Finance
Executive Director
Budget Holder
SFIs Section 8
a) to £5,000 per request Fund Manager SFIs Section 16
b) £5,000 and over per request Director of Finance
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Delegated Matter
9. Agreements/Licences re Properties
The Princess Alexandra Hospital NHS Trust
Page 43 of 52
Authority Delegated To
a) Preparation of all tenancy agreements/licences for all
staff subject to Trust Policy and accommodation for staff
Head of Facilities Management
b) Extension to existing property leases Director of Finance
c) Letting of premises to outside organisations Director of Finance
d) Approval of rent based on professional assessment Director of Finance
10. Condemning & Disposal
a) Items obsolete, obsolescent, redundant, irreparable or
cannot be repaired cost effectively
With current/estimated purchase price £100 Budget Holder, Condemning Officer and
Clinical Service Group Lead (or
equivalent)
11. Losses, Write-off & Compensation
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
SFIs Section 13
a) Losses and Cash due to theft, fraud, overpayment &
others Up to £50,000
Chief Executive and Director of Finance SFIs Section 13
b) Fruitless payments (including abandoned Capital
Schemes) Up to £250,000
Chief Executive and Director of Finance
c) Bad debts and claims Abandoned, up to £50,000 In accordance with the Trust’s Bad debts
policy
d) Damage to buildings, fittings, furniture and equipment
and loss of equipment and property in stores and in use due
to: Culpable causes (e.g. fraud, theft, arson) or other up to
£50,000
Chief Executive or Director of Finance
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Delegated Matter
The Princess Alexandra Hospital NHS Trust
Page 44 of 52
Authority Delegated To
e) Compensation payments made under legal obligation Chief Executive or Director of Finance
f) Extra Contractual payments to contractors up to £50,000 Chief Executive or Director of Finance
g) ex-Gratia Payments
Patients personal effects
Less than £99 Budget Holder
Between £100 and £999 Clinical Director of Clinical Service Group
Lead
£1,000 to £25,000 Chief Executive & Director of Finance
h) For personal injury claims involving negligence where
Chief Executive & Director of Finance
legal advice has been obtained and guidance applied. Up to
CNST limit (including plaintiff’s costs)
i) Other, except cases of maladministration where there
was no financial loss by claimant , over £25,000
j) Write off of NHS Debtors Audit Committee
Recommendation from Chief Executive
and Director of Finance to Remuneration
and Nominations Committee for approval.
Reported to Audit and Risk Assurance
Committee for Information.
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
12. Reporting of Incidents to the Police SFIs Section 2
&13
a) Where a criminal offence is suspected
i) Criminal offence of a violent nature Director of Human Resources
ii) other Director of Human Resources
b) Where a fraud is involved Director of Finance, in line with the
counter-fraud policy/Local Counter Fraud
Specialist
13. Petty Cash Disbursements (not applicable to central
Cashiers Office)
SFIs Section 9
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Delegated Matter
The Princess Alexandra Hospital NHS Trust
Page 45 of 52
Authority Delegated To
Expenditure up to £75 per item Petty Cash Holder
Re-imbursement of Patients Monies up to £100 Patient’s Affairs Officer
Re-imbursement of Patient’s Monies over £100 Directorate Manager
14. Receiving Hospitality
Applies to both individual and collective hospitality
receipt items. Please refer to the Trust Hospitality Policy
Implementation of Internal and External Audit
Recommendations
16. Maintenance & Update on Trust Financial Procedures Director of Finance
17. Investment of Funds (including Charitable & Endowment
Funds)
Declaration required in Trusts Hospitality
Register
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
Director of Finance SFIs Section 2
Charitable Funds Committee & Director of
Finance
SFIs Sections 5,
11, 15 & 16
18. Personnel & Pay SFIs Section 8
Authority to fill funded post on the establishment with
permanent staff
Authority to appoint staff to post not on the formal
establishment:
With allocated financial funding
c) Additional Increments
Budget Holder
Executive Director with Director of Human
Resources
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Delegated Matter
The Princess Alexandra Hospital NHS Trust
Page 46 of 52
Authority Delegated To
The granting of additional increments to staff within
budget
Director of Human Resources
Consultant Medical Staff Medical Director
d) Upgrading & Regrading
All requests for upgrading/regrading shall be dealt with in
accordance with Trust Procedure
e) Pay
Director of Finance and Director of
Human Resources
Authority to complete standing data forms effecting pay,
new starters, variations and leavers
Line Manager
Authority to complete and authorise positive reporting forms Line Manager
Authority to authorise overtime Budget Manager
Authority to authorise travel & subsistence expenses Budget Manager
Authority to authorise travel & subsistence expenses in
exceptional cases not submitted for over 3 months.
Director of Finance
f) Leave
i) Approval of annual leave (over 2 weeks)
Medical Staff
Nursing Staff
Other Staff
ii) Annual leave - approval of carry forward up to maximum
of 5 days
Medical Director
Director of Nursing
Clinical Director/Clinical Service Group
Lead
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
Whitley Council
Line Manager Conditions of
Service
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iii) Annual leave - approval of carry over in excess of 5 days
but less than 10 days
The Princess Alexandra Hospital NHS Trust
Page 47 of 52
Clinical Director/Clinical Service Group
Lead
iv) Annual Leave carry over more than 10 days Director of Human Resources
v) Compassionate leave Line Manager – in accordance with Trust
Policy
vi) Special leave arrangements Line Manager – in accordance with Trust
Policy
Paternity leave Line Manager – in accordance with Trust
Policy
Carers leave Line Manager – in accordance with Trust
Policy
vii) Leave without pay Line Manager – in accordance with Trust
Policy
Medical Staff Leave of Absence (unpaid) Clinical Service Group Lead
Maternity Leave - paid and unpaid Automatic approval with guidance
ix) Time off in Lieu Budget Manager
g) Sick Leave
i) Extension of sick leave on half pay up to three months Director of Human Resources with
Budget Holder
ii) Return to work part-time on full pay to assist recovery Budget Holder
iii) Extension of sick leave on full pay Director of Human Resources or Chief
Executive
i) Study Leave
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The Princess Alexandra Hospital NHS Trust
i) Study leave outside the UK Chief Executive or Executive Director
ii) All other study leave (UK) Budget Holder
iii) Medical Staff study leave (UK) Medical Director
j) Removal Expenses, Excess Rent and House Purchases
Authority of payment of removal expenses incurred by
officers taking up new appointments (providing consideration
was promised at interview)
up to £5,000
£5,000+
k) Trust Car and Mobile Phone Users
Posts to be designated as Car Users
Post to be designated as Mobile phone users
l) Grievance Procedure
All grievances cases must be dealt with strictly in
accordance with the Grievance Procedure and the advice of
a Human Resources Officer must be sought as soon as is
appropriate and in line with the grievance procedure.
m) Renewal of Fixed Term Contracts Budget Holder
n) Staff Retirement Policy
Authorisation of extension of contract beyond normal
retirement age in exceptional circumstances
Page 48 of 52
Director of Human Resources
Chairman of the Remuneration and
NominationsCommittee
Director of Human Resources
Line Manager Trust Grievance
Procedure
Director of Human Resources
o) Redundancy Chief Executive or Remuneration and
Nominations Committee
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
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Delegated Matter
p) Ill Health Retirement
The Princess Alexandra Hospital NHS Trust
Page 49 of 52
Authority Delegated To
Decision to pursue retirement on the grounds of ill-health Director of Human Resources
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
q) Dismissal Nominated Dismissing Officer Disciplinary
Procedure
19. Authorisation of Sponsorship deals
Chief Executive,
20. Authorisation of Research Projects Chief Executive & Chairman of Research
Committee. Local Research Ethics
Committee approval is also required.
21. Authorisation of Clinical Trials Chief Executive, Medical Director &
Chairman of Research Committee. Local
Research Ethics Committee approval is
also required.
22. Authorisation of
New Drugs
New technologies and procedures
Drugs and Therapeutics Committee and
Director of Finance
Medical procedures & Technologies
Committee and Director of Finance
23. Insurance Policies and Risk Management Head of Risk, Director of Finance
24. Contact with Press
SFIs Section 19
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Delegated Matter
The Princess Alexandra Hospital NHS Trust
Page 50 of 52
Authority Delegated To
a) Non-Emergency General Enquiries
Within Hours Head of Communications
Outside Hours On Call Manager
b) Emergency
Within House Head of Communications
Outside Hours On Call Manager or Executive Director
25. Infectious Diseases & Notifiable Outbreaks On Call manager with Control of Infection
Doctor
and Clinical Director for Infection Control
26. Review of Fire precautions Head of Estates
27. Review of all statutory compliance legislation and Health
and Safety requirements including control of Substances
Hazardous, Health Regulations and Major Incident.
28. Review of compliance with environmental regulations, for
example those relating to clean air and waste disposal
29. Review of Trusts compliance with the Data Protection
Act
30. Review of Trust’s compliance with the Access to
Records Act
31. Review of the Trust’s compliance code of Practice for
handling confidential information in the contracting
environment and the compliance with “safe haven” per EL
Head of Estates/ Chief Operating Officer /
Director of Human Resources
Head of Governance/Risk
Head of Estates
Medical Director (Caldicott Guardian)
Medical Director (Caldicott Guardian)
Director of Nursing
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
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Delegated Matter
92/60
32. Patient’s and Relatives Complaints
Responsibility for ensuring all complaints are dealt with
correctly including the completion of a thorough
investigation
Medical – Legal complaints are managed with the
NHSLA
The Princess Alexandra Hospital NHS Trust
Page 51 of 52
Authority Delegated To
Chief Operating/Nursing Officer
Head of Risk Management
33. The keeping of a Declaration of Interests Register Head of Corporate Governance
34. Attestation of sealings in accordance with Standing
Orders
Chairman /Non Executive Director &
Chief Executive/ Executive Director
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
SOs Section 6
SOs Section 12
35. The Keeping of a register of sealing Head of Corporate SOs Section 12
36. The Keeping of the Hospitality Register Head of Corporate
37. Retention of Records Head of Corporate SFIs Section 18
38. Clinical Audit Medical Director, Clinical Audit Lead SFIs Section 19
39. Review of Medicines Inspectorate Regulations Chief Pharmacist
40. Monitor proposals for contractual arrangements between
the Trust and outside bodies
41. Extended Role Activities
Approval of Nurses to undertake duties/procedures which
can properly be described as beyond the normal scope of
Nursing Practice.
Chief Operating Officer and Director of
Finance
Director of Nursing Officer
Nurse/Midwives
/Health Visitors
Act Midwives
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Delegated Matter
42. Patient Services
Variation of operating and clinic sessions within existing
numbers
Outpatients
Theatres
Other
All proposed changes in bed allocation and use
Temporary Change
Contract monitoring & reporting
43. Facilities for staff not employed by the Trust to gain
practical experience
Professional Recognition, Honorary Contracts, & Insurance
of Medical Staff, Work experience students and apprentices.
The Princess Alexandra Hospital NHS Trust
Page 52 of 52
Authority Delegated To
Chief Operating Officer/
Chief Operating Officer
Director of Human Resources
Reservation of Powers to the Board and Delegation of Powers – Interim 2012
Reference /
Comment
Rules/Code of
Practice UKCC
Code of
Professional
Conduct
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Report for Trust Board
Date 26 July 2012
From Geoff Stokes, Head of Corporate Governance
Subject Board Assurance Framework and Strategic Risk Register
1. Purpose of the Paper
Attached, as usual is the strategic risk register for review by the Trust Board. The paper also
updates the Board on initial developments taking place to further improve the board
assurance framework and strategic risk register.
2. Introduction
The Trust has improved its approach to risk management over the past 12 months or so and
updated its Risk Management Strategy in January 2012. There are some developments that
could be made to further improve this, such as linking each strategic risk to one of the
objectives set out in the Annual Plan for 2012/13, which have been agreed as being:
1 Excellent safety and clinical outcomes for patients: benchmarked against the
best
2 Excellent experience for patients and their carers: delivering personalised care
3 Excellent operational performance: meeting regulatory and national operating
standards
4 Excellent value: improving efficiency and productivity and reducing costs
5 Excellent morale and staff engagement: ensuring organisational health by
investing in our staff and infrastructure to ensure we are fit for the future
3. Development Issues
There are several development areas that are currently being discussed amongst the
Executive Team the first of which is to capture the 5 high level risks identified a couple of
months ago, which are as follows;
Risk of avoidable harm to patients -Present services, information and
processes are insufficient to ensure consistently high quality services and
outcomes for patients
Failing National Targets: Emergency Care Pathway - The Trust is failing to
deliver the national four hour wait target for emergency care
Organisational Structure/ Capacity within the Organisation - The
implementation of the new structure has identified significant measurable
capacity weaknesses in the organisation and this coupled with the inevitable
change causes a risk to the speed of implementation and improvement
Patient Engagement / Reputational Risk - The trust continues to perform
poorly in national patient surveys and complaints have increased,
1 of 2
164 163 161 171 165 of of 175 174 172
182 176
Item 16

High level of financial savings required - The Trust has an estimated
£11million 6.5% savings requirement for 2012/13 and there is a risk that this
may impact on patient care or not be delivered
In the light of the above, the Executive Team have also agreed that the current risks need to
be reviewed, both in terms of removing duplication and ambiguity and in bringing greater
clarity to controls and actions to implement missing controls. This will be helped by adopting
a revised method for describing the risks in a structured way that makes more explicit the
cause and consequence of risks, using an ‘IF…THEN…LEADING TO...’ framework. For
example, the first risk listed above could be reworded as;
IF information and processes are insufficient THEN the Trust may be unable to
ensure consistently high quality services LEADING TO reduced quality
outcomes for our patients.
In revising risks it is important that there is an audit trail to show any risks that have been
reworded, deleted or split. The Board will receive a list of all changes made to accompany
the revised risk register at their next Board meeting.
4. Conclusion
Further developments will be discussed amongst the Executive Team before being
presented to the Board.
2 of 2
165 164 162 172 166 of of 175 174 172
182 176
Item 16

Strategic Risk Reference
SR02
SR07
Primary Strategic Objective and
Source of Risk*
KEY
CQC regulation
1a 10/9
SR37 1a 10/9
Business, Financial, Reputation,
Safety (B, F, R, S)
S
(R, F)
B
(F,S)
Mitigated Risk Score
4
4
Risk Assessment Ref and Date
Moderated
EMER B.U. /
S02 Mod
PH/JMc
21.12.10
FIN01
Mod
JS/KH
30.1.12
TOP LEVEL RISK REGISTER BY RISK RATING - 16+
RATING
VARIANCE FROM LAST
ASSESSMENT
10 OR OVER INCREASE ▲
6 - 10 NO CHANGE◄►
5 OR LESS REDUCTION▼
Description of risk affecting achievement of
stated objective
Pressure on planned and unplanned standards with
regard to internal emergency care pathways leading
to risks associated with: failure to deliver four hour
A & E standards and ability to deliver access
standard.
15.05.12. - KS 14.04.11 Failure to effectively
manage reduction in Social Care Funding and
its impact on service provision at PAH.
Key Controls currently in place Key Gaps in Controls Board Assurance or Gaps in Red Action Required
10.05.12. - JS April 2012 Standard met
throughout. DOH intensive support team
currently in place. Improved discharge
arrangements also in place.
10.05.12. - JS Performance Dashboard and SHA
Return discussed at every Board meeting.
10.05.12. - JS Ongoing review throughout
the year. Accountable Executive Director
changing from Jon Scott to Jules Martin.
17.07.12. - KS To review re-ablement
funding with Essex C.C. - to discuss with
MD.
Lead
Accountable Executive Director
MONTH OF REVIEW
July 2012
VISION TO DELIVER THE BEST HEALTH OUTCOMES FOR THE LOCAL POPULATION
VALUES PUTTING PATIENTS FIRST - STRIVING FOR QUALITY AND EXCELLENCE - KEEPING PATIENTS SAFE AND DOING NO HARM - WORKING TOGETHER INTERNALLY AND EXTERNALLY -
* OBJECTIVES - to meet overarching regulatory and legal requirements
Monitoring Committee
1
SAFETY / OUTCOMES - to continually improve the patient experience through patient safety, effective patient care and right place first time
P.E.A.C.
2
FINANCIAL - to achieve all financial targets
B.P.A.C.
3
WORKFORCE - to deliver a workforce fit for purpose
B.P.A.C.
4 ESTATES / ENVIRONMENTAL - to ensure at all time the facilities and accommodation are fit for purpose
P.E.A.C.
5
REGULATORY AND STATUTORY REQUIREMENTS - to meet overarching regulatory and legal requirements pertaining to N.H.S Trusts / Foundation Trusts
GOV.COM
6
RELATIONSHIPS / PARTNERSHIPS - to develop the Business through greater integration and collaboration
B.P.A.C.
* SOURCES OF RISK - How the original risk was identified
A Audit, Inspection, Hazard Spotting
C
Complaints, Concerns
I Incidents
L Legal
P Performance, Targets
E External Reviews e.g. H.S.E., NHSLA, CNST, CQC
1 of 9
NOTE - COLUMN FOR "MITIGATED" RISK SCORE NOW INCLUDED Mitigated risk score is the risk rating that would apply if all reasonable control measures are currently in place.
1) SAFETY / OUTCOMES -(PSQ) to continually improve the patient experience through patient safety, effective patient care and right place first time
2) FINANCIAL - (BPC) to achieve all financial targets
Q1 Risk Rtg. 2012/13
166 165 163 173 167 of of 175 174 172
182 176
NOTE - ONLY VALUES OF 16 OR
OVER WILL NORMALLY BE
INCLUDED
Q2 Risk Rtg - 2012/13
Q3 Risk Rtg - 2012/13
Q4 Conseq. 2012/13
Q4 Likely. 2012/13
Q4 Risk Rtg - 2012/13
Variance - Last Assessment
PB JM 20 20
KS KS 16 16
X:\Corporate Services\Trust Board Meetings\2012\07 July\Part A\16_BAF\
BAF ph010712lkhfinaljuly2012

Strategic Risk Reference
Primary Strategic Objective and
Source of Risk*
CQC regulation
Business, Financial, Reputation,
Safety (B, F, R, S)
Mitigated Risk Score
SR07 2a 10 B 5
SR35 5 20 R (B) 4
SR39 5 20 B 5
2 of 9
Risk Assessment Ref and Date
Moderated
FINANCE
S01 MOD
AB/PH
22.12.10
TrustSec0
1Mod
30.01.12
FIN02 Mod
30.01.12
Description of risk affecting achievement of
stated objective
191011 - lack of confidence in existing plans to
control urgent (non-elective) activity. May 2012 -
no review.
10.05.12. - GS/DG Failure to achieve
Information Governance requirements by end
of March 2013.
15.05.12. - KS Risk of sub-optimal decision
making processes based on incomplete
information.
TOP LEVEL RISK REGISTER BY RISK RATING - 16+
Key Controls currently in place Key Gaps in Controls Board Assurance or Gaps in Red Action Required
191011 - West Essex Urgent Care Programme
Board established April 2011. 15.11.11 work
streams identified as follows: end of life, primary
care access, single point of access, ambulatory
care, urgent care centre/A&E front door
15.11.11 some work streams more advanced than
others. Leadership of work streams (with the
exception of ambulatory care) is led by other
outside organisations. Variable progress in
establishing these work streams. Inconsistent
system wide reporting on KPI's. Incentives and
penalties not aligned.
15.11.11 Via COO operational report to Trust
board. Weekly system wide meetings with stake
holders and other providers being held. Winter
planning/monitoring of progress.
3) WORKFORCE - to deliver a workforce fit for purpose
4) ESTATES / ENVIRONMENTAL - to ensure at all time the facilities and accommodation are fit for purpose
5) REGULATORY AND STATUTORY REQUIREMENTS - to meet overarching regulatory and legal requirements pertaining to N.H.S Trusts / Foundation Trusts.
15.05.12. - KS Dashboard for the Board in place
and protocol for ensuring that a validated return for
the SHA is in place. Anthony Lundrigan - Chief
Information Officer now has responsibility for this
item.
Lead
Accountable Executive Director
MONTH OF REVIEW
July 2012
15.11.11 board to board meeting with
commissioners to discover over performance
and payments due to be held on 17.11.11.
18.1.12 - Urgent Care Programme Board
Schemes to achieve reduction in activity still
to materialise or impact on emergency
demand. Negotiations with Commissioners on
funding of over-performance on-going. D of F
formal letter to Commissioners seeking
resolution to this issue sent 18.1.12. Board to
JMcL
Board meeting due 8.2.12. 13.2.12 board to
board meeting held with positive outcome.
Demand management schemes for all system
wide providers to present to the 'urgent care
programme' board at February meeting. To
be based on outcomes from 11/12 to inform
QUIP decisions for 12/13. 18.07.12 QUIP
plans for 12/13 still unresolved PCT has given
assurance that it will forward proposals by end
of july 2012. MD to chase
MD 25 25
10.05.12. - GS/DG Board Paper prepared
March 2012 identifying failure to meet six
objectives. These actions to be completed
throughout 2012/13. 17.07.12 Action plan
developed however unlikely to be
achieved before the end of October 2012.
17.07.12 To complete dashboard update
through sessions with CIO & COO
Q1 Risk Rtg. 2012/13
167 166 164 174 168 of of 175 174 172
182 176
Q2 Risk Rtg - 2012/13
Q3 Risk Rtg - 2012/13
Q4 Conseq. 2012/13
Q4 Likely. 2012/13
Q4 Risk Rtg - 2012/13
Variance - Last Assessment
TG GS 20 20 20
AL KS 20 20 20
X:\Corporate Services\Trust Board Meetings\2012\07 July\Part A\16_BAF\
BAF ph010712lkhfinaljuly2012

Strategic Risk Reference
Primary Strategic Objective and
Source of Risk*
CQC regulation
Business, Financial, Reputation,
Safety (B, F, R, S)
Mitigated Risk Score
SR09 2 10 F 5
7.2.1 1a S 4
3 of 9
Risk Assessment Ref and Date
Moderated
FINANCE
22/07/11
DIRNUR0
1 Mod
30.01.12
YB/PH
Description of risk affecting achievement of
stated objective
15.05.12 - KS Delivery of Statutory Financial
Duties.
A) Risk if robust financial plans are not in place
and signed of by Commissioners and SHA.
B) Risk to financial viability from income not
being realised.
C) Significant risk if expenditure is not
controlled.
D) Risk to the Trust if financial savings are not
successfully implemented as per DOH
guidance.
E) Risks from Liquidity management.
F) The operational services have to maintain
strict financial controls.
G) Without a robust CIP programme the
financial plans previously mentioned can not
be obtained nor maintained.
H) There is a significant risk if the Trust does
not receive payment for work carried out in
2012/13
TOP LEVEL RISK REGISTER BY RISK RATING - 16+
Key Controls currently in place Key Gaps in Controls Board Assurance or Gaps in Red Action Required
A). Agree managed financial plan and associated
support with main Commissioners and SHA.
B) .Establish comprehensive income performance
monitoring, including claims validation, and
forecast activity projection, integrated within
Performance and Commissioning Framework (SLA
process)
C). Ensuring control of underlying expenditure and
Business Unit performance through budgetary
control mechanisms; PMG, Business and
Performance Committee, Trust Board
D).Oversee and scrutiny of successful
Transformation Plan, and establishing recovery
plans as required. Scrutiny via Transformation
Board, the Executive ISG, Business and
Performance Committee and Trust Board.
E). Maintenance of system of liquidity
management, through accurate cash management
and loan facility as required.
F). Star Chamber process provides continuous
operational review and opportunity for innovative
efficiency delivery.
G). Board approved CIP Programme.
H). Escalation process as set out in SLA and
Business Unit implementation of activity
requirements which is monitored by the Business &
Performance Committee
A&E) Final agreement with SHA and main
commissioners (transitional support).
Embedded Service Line Reporting within the Trust.
E) Securing of cash loan facility (imminent -
deferred).
D) . Certainty of QIPP, pricing agreement for
Ambulatory Care Service.
C, D&F) . Inability to control Emergency
Admissions and impact on activity and income
(reduced tariff for emergency work in excess of
margin) and Elective activity over funded levels
creating a significant backlog.
15.05.12. - KS Finance and Dashboard reports
to Board and BPC and reports to ARAC. Cost
improvement programme in place.
15.05.12. - KS 1. Agreement on
transitional support. 17.07.12 current
meeting with CCG, FD's & COO's
2. SLR to be fully embedded. 17.07.12 No
change
3. Ensure success of QIPP plan between
Trust and Commissioners. 17.07.12 no
change
4.Implementation of initiatives to improve
whole system working e.g. Care Closer to
Home. Plan currently being implemented.
17.07.12 Representative agreed for
program board
5. Delivery of CIP. 17.07.12 No change
6) RELATIONSHIPS / PARTNERSHIPS - to develop the Business through greater integration and collaboration 17.07.12 Implement management team action from 17.07.12 meeting
Patient Survey May 2012 Patient Survey to be
risk assessed.
Learning disabilities and autism quality
assurance framework - to be risk assessed - for
compliance with Standards.
16.05.12. - SC Unable to maintain focus on
CQC and other key standards & targets during
embedding phase putting patient care at risk
Workshop undertaken with directorates 10.07.12
16.05.12. - SC Essence of care monthly audits.
Ward Manager supervisory role undertaking
essential care PSQ Audits.
7) STRATEGIC RISKS - other than those relating to an objective.
7.1 Failure to Deliver Financial Plan ( Boards one of six)
7.2 Failure to Achieve CQC Standards
16.05.12. - SC Directorate monthly exception
reports to PS&Q Committee - P.E.A.C. Dash
Board
16.07.12 Formulation of action plans with
priority area for improvement identified
16.07.12 Improvement plan developed
awaiting validation by commissioners
august 8th 2012
16.05.12. - SC 1. Launch of nurses and
midwives and operating department
practitioners strategy for 2012/13 in the
summer of 2012. 17.07.12 Current meeting
with CCG,FD's & COO's 2. Introduction of
Star Chamber for monitoring each CQC
outcome. 17.07.12 no change 16.07.12
monitoring of evidence to address
moderate concerns raised by CQC
Lead
Accountable Executive Director
MONTH OF REVIEW
July 2012
Q1 Risk Rtg. 2012/13
Q2 Risk Rtg - 2012/13
Q3 Risk Rtg - 2012/13
Q4 Conseq. 2012/13
Q4 Likely. 2012/13
Q4 Risk Rtg - 2012/13
Variance - Last Assessment
KS KS 25 25 0
P.E.M. SC
SC SC
168 167 165 175 169 of of 175 174 172
182 176
SC SC 16 16
X:\Corporate Services\Trust Board Meetings\2012\07 July\Part A\16_BAF\
BAF ph010712lkhfinaljuly2012

Strategic Risk Reference
Primary Strategic Objective and
Source of Risk*
CQC regulation
Business, Financial, Reputation,
Safety (B, F, R, S)
Mitigated Risk Score
7.2.2 1a S 4
7.2.3 1a S 4
7.3.1 1a B 4
7.3.3 1a B 4
7.3.4 1a 21 S 4
4 of 9
Risk Assessment Ref and Date
Moderated
DIRNUR0
2 mod
30.1.12
YB/PH
DIRNUR0
3 Mod
30.1.12
Mod
YB/PH
DIRNUR04
mod 30.1.12
Mod 30.01.12
YB/PH
CEO01 Mod
30.01.12
MW/PH
CEO02 Mod
30.01.12
MW/PH
Description of risk affecting achievement of
stated objective
16.05.12. - SC CIP programme - adverse impact
on safety.
16.05.12. SC - Failure to meet National C.Diff/
M.R.S.A. BACT Trajectory / targets.
16.05.12. - SC - Lead and accountability for
project team to be clarified. Due to low morale
and poor levels of staff engagement the
transformation and quality programmes are not
delivered.
10.05.12. - GS/DG With a high proportion of new
Board or inexperienced members there is a risk
that the Board may not be able drive through a
significant change programme in conjunction with
clinicians.
May 2012 - No Review Without an excellent
Communication framework there is a risk that key
messages to stakeholders are not delivered
impacting on the delivery of the Transformation
plan and maybe patient safety.
TOP LEVEL RISK REGISTER BY RISK RATING - 16+
Key Controls currently in place Key Gaps in Controls Board Assurance or Gaps in Red Action Required
16.05.12. - SC 1. QIA assessment for each
CIP. 2. Star Chamber to review progress.
16.05.12. - SC I.C. Plan - hand hygiene audits -
P.E.A.G. - 49 Steps Cleanliness Audits.
Communication through regular updates from the
CEO and consultation process in place. 12.1.12 -
Engagement by Directors with individual teams.
New teams in place 9.1.12.
10.05.12. GS/DG - Appointment of I.M.D.
Consultants to manage all development
programme to ensure 'fit for purpose'.
7.3 Poor organisation capability and leadership
Discussions at ET on how to improve
communications with the staff to get over key
messages, agreement on improving
communication and attendance at team meetings
etc. by Directors working in pairs to ensure the
corporate message in delivered and concerns
identified ASAP
The ET are discussing ways in which to improve
the communication processes and will develop
proposals.
7.5 Failure to Deliver Strategic Plans
16.05.12. SC - Star Chamber exception reports
to management team - B.P.A.C. - Board
16.05.12. - SC - regular reports to the Board via
the SHA self certification report and Dashboard.
Regular item at PSQ and Infection Control
Group. Exception report P.E.A.C. - Board.
Regular updates at ET. 20.10.11 AS appointed to
manage consultation papers and their
implementation. MY appointed as interim COMMS
director to develop revised COMMS strategy
10.05.12. - GS/EG Board Papers and Board to
Board action plan.
The Executive team have now received the first
draft of a communication plan and it is being
updated following comments.
16.05.12. & 16.07.12 - SC - Ongoing
monitoring.
16.05.212 & 16.07.12 - SC - Ongoing
monitoring.
Directors to attend relevant team meetings or
equivalent. 12.1.12 - LB - Regular updates
provided following CEO Brief. Strong
partnership working with staff side
representatives. YB - CD's now held
accountable via new structure. H of N now
have responsibility for all PS & Q issues.
16.2.12 SC newly appointed senior
management team undertaking leadership
development programme by the SHA
15.03.12 supported by PWC programme of
improvement 16.07.12 no change
10.05.12. - GS/DG Programme planned for
completion 2012/13. Recruitment of two
new N.E.D.'s under way. 17.07.12
Recruitment process for NEDS ongoing.
3x substantive Exec Directors posts being
interviewed by end of July 2012
To develop an updated communication
strategy.
18.01.12 DG - This is on-going and will be
discussed with the Board through the
development programme being developed as
part of the Aspirant Foundation Trust
Governance Review. 22.3.12 ongoing
18.07.12 Comms action plan agreed and to
be reviewed in September 2012 when new
head of Comms takes up post
Lead
Accountable Executive Director
MONTH OF REVIEW
July 2012
Q1 Risk Rtg. 2012/13
169 168 166 176 170 of of 175 174 172
182 176
Q2 Risk Rtg - 2012/13
Q3 Risk Rtg - 2012/13
Q4 Conseq. 2012/13
Q4 Likely. 2012/13
Q4 Risk Rtg - 2012/13
Variance - Last Assessment
SC SC 16 16
SC SC 16 16
LB SC 16 16
GS MW 16 16 0
AH MD 16 16
X:\Corporate Services\Trust Board Meetings\2012\07 July\Part A\16_BAF\
BAF ph010712lkhfinaljuly2012

Strategic Risk Reference
Primary Strategic Objective and
Source of Risk*
CQC regulation
Business, Financial, Reputation,
Safety (B, F, R, S)
Mitigated Risk Score
7.5.1 1a B 4
7.5.2 1a
7.5.3 1a
B,F,R
,S
B,F,R
,S
7.5.4 1a B 4
7.5.5 1a B 4
5 of 9
4
5
Risk Assessment Ref and Date
Moderated
IPC01 Mod
30.1.12
MD/PH
IPC02 Mod
30.01.12
MD/PH
IPC03 Mod
30.01.12
MD/PH
FIN03 Mod
30.01.12
CMcN/PH
IPC04 Mod
30.01.12
MD/PH
Description of risk affecting achievement of
stated objective
May 2012 - No Review Risk from a lack of clear
strategic focus.
May 2012 - No Review 191011 - lack of
capacity/demand modelling facility.
May 2012 - No Review 191011 - lack of coherent
Estates Strategy.
15.05.12. KS Risks from poor strategic
enablers such as IT & Information
15.05.12. - KS - Failure to achieve financial
aspects of FT status requirements.
TOP LEVEL RISK REGISTER BY RISK RATING - 16+
Key Controls currently in place Key Gaps in Controls Board Assurance or Gaps in Red Action Required
Process in place to develop a clinical strategy that
will then inform all other strategic planning.
15.11.11 discussion document currently being
finalised and due for completion by end of
November.
191011 - delay in development of clinical strategy -
awaiting new clinical leaders to be appointed.
15.11.11 - no change.
191011 - more detailed market analysis required.
Capacity issue with lack of support with
development process. 15.11.11 CEO/MD met with
company with regard to market analysis. Awaiting
formal proposal / decision on implementation.
191011 - dependant upon outcome of Clinical
Strategy.
To develop a clinical strategy and then align
all other strategies to this. 191011 -
appointment of clinical leads in accordance
with clinical discussion paper. 15.11.11
workshop to be arranged. 18.1.12 - Workshop
with Non-Execs to be held 26.1.12.
Discussion document issued before
15.11.11discussion document to be shared with non Christmas. 13.2.12 MD workshop well
execs and joint clinical leadership. Workshop received, joint clinical leadership and board
scheduled for January/February 2012. meeting due on 21.2.12 to inform prioritisation
of clinical strategy.14.03.12 System wide
QUIP being developed as part of 2012/13
contract discussion trust seeking assurances
and contractual clarification on penalty to be
applied if demand exceeds commissioners
plan in 2012/13. 18.07.12 Work ongoing as
part of the development programme with IMD
191011 - market analysis - external support to
be obtained. Strategic and Business
Development Plan being prepared. 15.11.11
decision on analysis proposal to be made.
18.1.12 - feedback from company to MW/MD
due on 31.1.12. To be shared with Clinical
Leaders on 7.2.12. 13.2.12 MD preliminary
work completed/development of model
awaiting commissioner activity assumption for
12/13 - due week ending 17.2.12. 14.03.12
Ongoing work about clinical strategy and
prioritisation of strategy initiatives due to be
finalised in May 18.07.12 Director of Ops &
Dev to meet with representative from
Cornwall provider to review interim model
arrangements. Head of IT also tasked with
identifying solution for review by the Exec
team
191011 - to be prepared following
consolidation of clinical strategy. 15.11.11 no
change. 18.1.12 - no change. 13.2.12 MD no
change 14.03.12 trust currently reviewing
activity assumption in 2012/13 in line with
Commission QUIP proposals contract
negotiations ongoing. 18.07.12 No change
15.05.12. KS - Embedding revised IT &IM
Structure. Ensuring robust functioning of
IM&T Steering Group. To develop an
agreed programme of work.
Responsibility for this topic now with
Anthony Lundrigan - CIO 17.07.12 No
change
15.05.12. - KS - Awaiting verification of
timetable for acquisition of FT status to
review when timetable is clear. 17.07.12 No
change
Lead
Accountable Executive Director
MONTH OF REVIEW
July 2012
Q1 Risk Rtg. 2012/13
170 169 167 177 171 of of 175 174 172
182 176
Q2 Risk Rtg - 2012/13
Q3 Risk Rtg - 2012/13
Q4 Conseq. 2012/13
Q4 Likely. 2012/13
Q4 Risk Rtg - 2012/13
Variance - Last Assessment
MD 16 16
KS 16 16
KS 16 16 15
AL KS 16 16 0
KS KS 16 16
X:\Corporate Services\Trust Board Meetings\2012\07 July\Part A\16_BAF\
BAF ph010712lkhfinaljuly2012

Strategic Risk Reference
Primary Strategic Objective and
Source of Risk*
CQC regulation
Business, Financial, Reputation,
Safety (B, F, R, S)
Mitigated Risk Score
7.6.1 1a 10 B 4
7.6.2 1a
B,F,R
,S
7.6..3 1a B 4
1a S 4x1=4
4
Risk Assessment Ref and Date
Moderated
CEO04 mod
30.01.12
MW/PH
CEO05 Mod
30.01.12
MW/PH
CEO01 Mod
30.01.12
WM/MAT01
& 07 M
250510 KH
SS MC
R ELPU055
6 of 9
Description of risk affecting achievement of
stated objective
Inconsistent approach to strategic partnerships risks
the Trusts ability to deliver high quality services
that fit the requirements of the local health
economy such as by not being able to explain to
the public our actions and the impact this may
have on our reputation. In particular: *
Stakeholders. * Public; * Commissioners; *
SHA; * Local Authority etc. 20.10.11 Following
on from the Board meeting it was decided that the
emphasis of the risk relating to partnership working
should be redefined as that arising from the
capacity and capability of staff to take us through to
FT status.
Risk of not having robust Relationships with stake
holders and the public
Lack of Strategic relationship with customers.
Failure of partnership arrangements with Primary
care which are sufficient to enable us to work hand
in glove and ensure community capacity develops
at the required pace
10.05.12. - JS - Inadequate number of midwives,
better ratio required to increase midwife / woman
relationship
Loss of reputation with 4 patients being cross
contaminated with an infection which is
unacceptable for staff trying to deliver a good and
safe service for patients
TOP LEVEL RISK REGISTER BY RISK RATING - 16+
Key Controls currently in place Key Gaps in Controls Board Assurance or Gaps in Red Action Required
10.05.12. GS.DG - I.M.D. Consultants have
recommended the setting up of a shadow FT
Board and to commence working as an FT as
soon as possible.
See 7.6.1
See 7.6.1
Risk highligted and a business case to be written
7.6 failure to deliver robust Relationship Working and patient Public Involvement
10.05.12. GS/DG - Shadow Board not yet
established.
7.7 Risks Reported to the Board from the Audit & Risk Assurance Committee None in September
7.8 Risks Reported to the Board from the Business & Performance Assurance Committee 1 in December
7.9 Risks Reported to the Board from the Executive Team - None in December
7.10 Risks Reported to the Board from the Patient Experience Assurance Committee - One in December but this was amber and not shown here.
8) OPERATIONAL RISKS - by exception.
It currently appears that the decom of scopes at
POAH in main theatres and critical care does not
have the correct facilities or equipment to clean
Lead
Accountable Executive Director
MONTH OF REVIEW
July 2012
10.05.12. DS/DG - Shadow FT working
arrangements to be established. 17.07.See
MD
action 7.6.2 & 7.6.3 18.07.12 Board
development programme initiated
MW 16 16
17.07.12 Communication strategy
being developed
17.07.12 Clinical meeting held with
CCG, Marketing approach for GP's
being developed. Clinical starategy
being developed
10.05.12. - JS - Current midwife to patient
ratio now at 1:34. PH to verify with JF
current position and actions being
planned to improve ratio further.
10.05.12. - JS - To be reviewed by Mags
Farley. Risk highlighted and business case
written. 20.07.12 SUI written 1st washer
installed 2nd washer currently in process of
being installed
Q1 Risk Rtg. 2012/13
171 170 168 178 172 of of 175 174 172
182 176
Q2 Risk Rtg - 2012/13
Q3 Risk Rtg - 2012/13
Q4 Conseq. 2012/13
Q4 Likely. 2012/13
Q4 Risk Rtg - 2012/13
Variance - Last Assessment
MD MW 16 16
MD MW 16 16
JF JM 16 16
MF JM 16 16
X:\Corporate Services\Trust Board Meetings\2012\07 July\Part A\16_BAF\
BAF ph010712lkhfinaljuly2012

Strategic Risk Reference
Primary Strategic Objective and
Source of Risk*
CQC regulation
Business, Financial, Reputation,
Safety (B, F, R, S)
7 of 9
Mitigated Risk Score
Risk Assessment Ref and Date
Moderated
4x1=4 PHAR
Description of risk affecting achievement of
stated objective
Shortage of pharmacy staff and the correct skill mix
resulting in patient safety being compromised
TOP LEVEL RISK REGISTER BY RISK RATING - 16+
Key Controls currently in place Key Gaps in Controls Board Assurance or Gaps in Red Action Required
Ward pharmacy provision in paeds,
surgery,haemato-oncology, care of the elderley and
prescription validation and procurement for HIV/anti
TNF/interferon, home oxygen paediatric resource
on X-Drive
lack of specialist pharmacist and pharmacy support
compromise service provision. Paediatric specialist
pharmacist required to support new NICU and
ongoing drug errors. Lead pharmacist for surgical
services and care of the elderely required band 6 &
4 technician for extra volume of patients.
(HIV/healthcare at home and HOOF) required,
haematology oncology support pharmacist to
support increased workload. Cancer trials, risk
assessments, implementation of chemocare
Additional workload in cancer and complexity
requires greater pharmacy input. Band 7
pharmacist requested as part of budget
review (Jan 09) Business case put forward for
specialist paediatric pharmacy post due to
need to formulate drug policy, minimise drug
errors and build of new NICU. Lead
pharmacist for surgery has been lost from
establishment Required for specialist input
and risk management. To be put back into
establishment. Original bid for care of the
elderly pharmacist placed in Jan 06 bit no
further progress since then. Budget review
meeting request made for band 6 pharmacist
and band 4 technician to manage in
increasing workload for HIV/anti
TNF/interferon/home oxygen. No progress
has been made in surgery and paediatrics.
An hameto-oncolgy support pharmacist has
been appointed but this has come from the
net pool of pharmacists and therefore the
benefit has not been realised. Some progress
has been made with HIV/antiTNF/interferons
with the introduction of a band 4 post but this
post also covers drug exclusions.. (may 2010)
Rob Duncombe to review with finance with
regards to putting post back into
establishment (jan 2009). Not in current
establishment (Sept 2009). No additional
staffing resource (Sept 2009). Same issue
remain (May 2010) Discussed at budget
setting exercise (Jan 2009) with a view to
getting 1 wte band 6 pharmacist post and 1
wte band 4 technician post No additional
staffing resource (Sept 2009). Same issues
remain although band 4 post has been
created with primary function of drug
exclusions (may 2010). No further progress
in this area (Jan 2011). HIV/healthcare at
home and HOOF forms continue to rise in
numbers (HIV 114 - Jan 2009, healthcare at
Lead
Accountable Executive Director
MONTH OF REVIEW
July 2012
Q1 Risk Rtg. 2012/13
172 171 169 179 173 of of 175 174 172
182 176
Q2 Risk Rtg - 2012/13
Q3 Risk Rtg - 2012/13
Q4 Conseq. 2012/13
Q4 Likely. 2012/13
Q4 Risk Rtg - 2012/13
Variance - Last Assessment
16 16
X:\Corporate Services\Trust Board Meetings\2012\07 July\Part A\16_BAF\
BAF ph010712lkhfinaljuly2012

Strategic Risk Reference
Primary Strategic Objective and
Source of Risk*
CQC regulation
Business, Financial, Reputation,
Safety (B, F, R, S)
Mitigated Risk Score
Risk Assessment Ref and Date
Moderated
1P F 4x1=4 CACS PHAR
8 of 9
Description of risk affecting achievement of
stated objective
Out of date information is used from a variety of
sources for improvements to safe and secure
handling of medicines which compromises patient
safety
TOP LEVEL RISK REGISTER BY RISK RATING - 16+
Key Controls currently in place Key Gaps in Controls Board Assurance or Gaps in Red Action Required
trust drug policy was updated in feb 2008 & 2010
which included review of national guidance and
response to incidents. Response to NPSA alerts -
Pottassium, methotrexate, oralliquid, epidurals, IV's
anticoagulant, intrathecal, lithium,neonatal
gentamicin, high dose opiates, safer use of insulins,
delayed/omitted doses
NPSA alerts in relation to drug reconcilation,
require further work to be done. Trust clinical
guidelines and drug policy (vaccine, drug history,
covert administration) approval need to be actioned
by patient safety and quality. NPSA alert on loading
dose is progressing. Further drug policy has been
ratified. No clinical guideline in the Trust remain a
significiant issue (Sept 2009) Clinical guidelines
group is due to be set up. Controlled drug policy
and high dose opiod policy are still be ratied (May
2010) These have now been ratified (Jan 2011)
NPSA alert for reconcilation cannot be completed
as 24 hour drug histories have not been achieved
(may 2010). 25.5.11 Some clinical guidelines have
now been produced but numbers are limited.
Above policies still to be ratified. 5.8.11Vaccine
policy, medicine reconcilliation policy and covert
admin policy now approved 12.12.11 - Loading
dose achieved for NPSA alert. No further progress
noted with clinical guidelines 05.03.12 Discussing
with John Biddulph the rating with regards to
incidents ove the last year and the completion of
clinical guidelines. 28.3.12 The most significant
problem is the lack of clinical guidelines within the
organisation. This needs to be raised through PSQ
forum. 21.6.12 To be raised at local PS&Q forum
and adding to the exception report.
Lead
Accountable Executive Director
MONTH OF REVIEW
July 2012
Q1 Risk Rtg. 2012/13
173 172 170 180 174 of of 175 174 172
182 176
Q2 Risk Rtg - 2012/13
Q3 Risk Rtg - 2012/13
Q4 Conseq. 2012/13
Q4 Likely. 2012/13
Q4 Risk Rtg - 2012/13
Variance - Last Assessment
JM 16 16
X:\Corporate Services\Trust Board Meetings\2012\07 July\Part A\16_BAF\
BAF ph010712lkhfinaljuly2012

Strategic Risk Reference
Primary Strategic Objective and
Source of Risk*
CQC regulation
Business, Financial, Reputation,
Safety (B, F, R, S)
Mitigated Risk Score
Risk Assessment Ref and Date
Moderated
Description of risk affecting achievement of
stated objective
TOP LEVEL RISK REGISTER BY RISK RATING - 16+
Key Controls currently in place Key Gaps in Controls Board Assurance or Gaps in Red Action Required
Lead
Accountable Executive Director
MONTH OF REVIEW
July 2012
Regulation 17 (Outcome 1)
Respecting and involving people who
use services
CQC Regulations
Involvement & Information
People understand the care and treatment choices available to them. They can express their views and are involved in making decisions about their care. They have their privacy, dignity and independence
respected, and have their views and experiences taken into account in the way in which the service is delivered.
Regulation 18 (Outcome 2) Consent to care and treatment
People give consent to their care and treatment, and understand and know how to change decisions about things that have been agreed previously.
Personalised Care, treatment and support
Regulation 9 (Outcome 4)
Care and welfare of people who use
services
People experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.
Regulation 14 (Outcome 5)
Meeting nutritional needs
People are encouraged and supported to have sufficient food and drink that is nutritional and balanced, and a choice of food and drink to meet their different needs.
Regulation 24 (Outcome 6) Cooperating with other providers
People receive safe and coordinated care when they move between providers or receive care from more than one provider.
Safeguarding and safety
Regulation 11 (Outcome 7)
Safeguarding people who use services
from abuse
People are safeguarded from abuse, or the risk of abuse, and their human rights are respected and upheld.
Regulation 12 (Outcome 8) Cleanliness and infection control
People experience care in a clean environment, and are protected from acquiring infections.
Regulation 13 (Outcome 9) Management of medicines
People have their medicines when they need them, and in a safe way. People are given information about their medicines.
Regulation 15 (Outcome 10) Safety and suitability of premises
People receive care in, work in or visit safe surroundings that promote their wellbeing.
Regulation 16 (Outcome 11)
Safety, availability and suitability of
equipment
Where equipment is used, it is safe, available, comfortable and suitable for people's needs.
Suitability of Staffing
Regulation 21 (Outcome 12) Requirements relating to workers
People are kept safe, and their health and welfare needs are met, by staff who are fit for the job and have the right qualifications, skills and experience.
Regulation 22 (Outcome 13)
Staffing
People are kept safe, and their health and welfare needs are met, because there are sufficient numbers of the right staff.
Regulation 23 (Outcome 14)
Supporting workers
People are kept safe, and their health and welfare needs are met, because staff are competent to carry out their work and are properly trained, supervised and appraised.
Quality and Management
Regulation 10 (Outcome 16)
Assessing and monitoring the quality of
service provision
People benefit from safe, quality care because effective decisions are made and because of the management of risks to people's health, welfare and safety.
Regulation 19 (Outcome 17) Complaints
People and those acting on their behalf have their comments and complaints listened to and acted on effectively, and know that they will not be discriminated against for making a complaint.
Regulation 20 (Outcome 21)
Records
People's personal records are accurate, fit for purpose, held securely and remain confidential. The same applies to other records that are needed to protect their safety and wellbeing.
These Registers are updated on a bi-monthly basis following a review with Executive Directors and Directorates. The month of review is included in the Header title, however individual text entries must be preceded with the review date. The latest review entry
must be coloured blue with the exception of entries denoting gaps in Board Assurance which should be in red.
9 of 9
Q1 Risk Rtg. 2012/13
174 173 171 181 175 of of 175 174 172
182 176
X:\Corporate Services\Trust Board Meetings\2012\07 July\Part A\16_BAF\
BAF ph010712lkhfinaljuly2012
Q2 Risk Rtg - 2012/13
Q3 Risk Rtg - 2012/13
Q4 Conseq. 2012/13
Q4 Likely. 2012/13
Q4 Risk Rtg - 2012/13
Variance - Last Assessment

175 174 172 182 176 of of 175 174 172
182 176