EAST LANCASHIRE HOSPITALS NHS TRUST TRUST BOARD ...

EAST LANCASHIRE HOSPITALS NHS TRUST 

TRUST BOARD MEETING PART ONE PAPERS 

31 st OCTOBER 2012 

BOARD ROOM 

ROYAL BLACKBURN HOSPITAL 

14:00 

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V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\Agenda Part 1 October.doc

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EAST LANCASHIRE HOSPITALS NHS TRUST BOARD MEETING 

31 st OCTOBER 2012, BOARD ROOM, ROYAL BLACKBURN HOSPITAL 14:00 

AGENDA 

1 Chair's Welcome Oral Report Mrs H Harding 

2 Apologies Oral Report Mrs H Harding 

3 Minutes of the Previous Meetings Enclosed Mrs H Harding 

4 Action Matrix/ Matters Arising Enclosed Mrs H Harding 

5 Declarations of Interest Oral Report Mrs H Harding 

6 Chair’s Report Oral Report Mrs H Harding 

7 Chief Executive’s Report Enclosed Mr M Brearley 

Strategy 

8 Strategic Objectives Progress Enclosed Mr M Hodgson 

Assurance 

9 Winter Plan Enclosed Mrs L Wissett 

10 Integrated Performance Report Enclosed 

a) Quality and Safety Mrs L Wissett 

b) Finance Mr J Wood 

c) Human Resources Mr I Brandwood 

11 Assurance Framework Enclosed Mrs L Wissett 

12 Foundation Trust Update Enclosed Mr M Hodgson 

13 Reports of Sub Committees Enclosed Mrs H Harding 

14 Any Other Business Oral Report Mrs H Harding 

15 Time and Date of Next Meeting 14:00, 28 th November 2012, Trust Headquarters, Royal 

Blackburn Hospital 

Resolution: That publicity will be prejudicial to the public interest by reason of the confidential nature of 

the business to be transacted and that the public should be excluded. 

Apologies: 

Mrs V Bertenshaw 

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Meeting Date: 

31 st October 2012 

Report Author: 

Frances Murphy 

Company Secretary 

Previously Considered By: 

Committee 

NA 

Implications For Partners: 

REPORT TO TRUST BOARD 

PART ONE 

Report Purpose: 

For Decision 

 

Performance Monitoring □ 

For Information 

Report Sponsor: 

Hazel Harding 

Chairman 

Related to key risks identified on 

Assurance Framework: 

Related to Corporate 

Commitments: 

(Delete as appropriate) 

Legal Implications Identified: 

Date 

□ 

None identified 

All risks considered 

Agenda Item: 3 

Report Title: 

Minutes of the Previous 

Meetings 

Declaration of 

Confidentiality Required: 

Yes No 

• To further develop clinical services with key 

internal & external stakeholders to reduce 

health inequalities, improve public health & 

reduce cost across the health economy 

• To maintain & improve patient experience 

& outcomes through achievement of the 

key indicators/ objectives outlined in the 

Trust’s Quality Account 

• To invest in & develop our workforce & 

improve staff engagement & satisfaction 

levels 

• To maintain all regulatory requirements 

with the CQC & be licensed to provide 

services without conditions 

• To improve the Trust’s liquidity position & 

deliver a cost improvement programme of 

5% 

• To develop services of the highest quality 

through innovation, pathway reform & the 

implementation of best practice 

• To continually promote equality & diversity 

at every level within the organisation 

To maintain an accurate record of corporate 

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V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(3) Previous Minutes.docx

Data Protection Implications 

Identified: 

Diversity and Equality 

Implications Identified: 

Related to NHS Constitution: 


Related to CQC Regulation & 

Outcomes: 


Executive Summary: 

Recommendation/ What Is 

Required From The Committee: 

meetings 



• A comprehensive service available to all 

• Access based on clinical need 

• Aspiring to highest standards of excellence 

& professionalism 

• Reflecting needs and preferences of 

patients & families 

• Working in partnership across 

organisational boundaries 

• Providing best value & effective & fair 

sustainable use of finite resources 

• Accountable to public, patients & 

communities 

• Involvement & Information 

• Personalised care, treatment & support 

• Safeguarding & Safety 

• Suitability of staffing 

• Quality & management 

• Suitability of management 

The minutes of the previous meeting are 

presented for ratification 

Members are requested to approve or amend 

the minutes as appropriate 

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EAST LANCASHIRE HOSPITALS NHS TRUST 

TRUST BOARD MEETING, 26 th SEPTEMBER 2012 

PART ONE MINUTES 

PRESENT 

Mr M Hill (Chair) - Non Executive Director 

Mr M Brearley - Chief Executive 

Mrs C Schram - Medical Director 

Mr J Wood - Director of Finance 

Mr G Boyer - Non Executive Director 

Mrs L Wissett - Deputy Chief Executive 

Mr S Sarwar - Non Executive Director 

Mr P Fletcher - Non Executive Director 

Mrs V Bertenshaw - Director of Operations 

IN ATTENDANCE 

Mr I Brandwood - Director of HR and OD 

Mr M Hodgson - Director of Service Development 

Mrs L Barton - Head of Communications 

Mrs F Murphy - Company Secretary 

Mrs W Latham - Minute Taker 

Lisa Rowlands - Clinical Advisor, Becton Dickinson 

Jennifer Richardson - Sales Specialist, Becton Dickinson 

Alison Entwistle - Regional Business Manager, 3M Healthcare 

APOLOGIES 

Mrs H Harding - Chairman 

Mrs E Sedgley - Non Executive Director 

Mr R Duckworth - Non Executive Director 

TB/2012/130 CHAIR'S WELCOME 

Mr Hill welcomed members to the meeting. 

TB/2012/131 APOLOGIES 

Apologies were received as recorded above. 

TB/2012/132 

MINUTES OF THE PREVIOUS MEETING 

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Members having had the opportunity to review the minutes of the previous meeting and the 

minutes of the extraordinary Trust Board meeting held on 4 th September approved them as a 

true and accurate record with the following amendments: 

p 1 – Date of meeting to be amended 

Dr Gavan to have title of Director Infection Prevention and Control to be 

recorded 

p 6 - paragraph numbering to be corrected 

RESOLVED: With the above amendments, the minutes of the previous meeting were 

received as a true and accurate record. 

TB/2012/133 ACTION MATRIX/ MATTERS ARISING 

Members noted that the dementia screening questions had not been circulated and it was 

agreed that Mrs Murphy would resolve this issue. There were no matters arising not already 

on the agenda. 

RESOLVED: Members noted the position of the action matrix. 

TB/2012/134 DECLARATIONS OF INTEREST 

Members were reminded of their duties under the Nolan Principles and the NHS Codes of 

Conduct. There were no changes to the Directors’ Register of Interests declared and Mr 

Brearley reminded members that his son is currently employed by Twitter which related to 

Communication Strategy referred to in agenda item 8. 

RESOLVED: Members noted the update provided. 

TB/2012/135 CHAIR'S REPORT 

Mr Hill advised members that there was nothing for him to report. 

RESOLVED: Members noted the above. 

TB/2012/136 CHIEF EXECUTIVE'S REPORT 

Mr Brearley presented the previously circulated report highlighting the “Stoptober” campaign 

and commended the efforts of staff on the year on year improvement in performance within 

the national hip fracture database. 

RESOLVED: Members received the report and noted the contents. 

TB/2012/137 ANNUAL PLAN STRATEGIC THEMES 

Mr Hodgson introduced the previously circulated report reminding members that the 

Integrated Business Plan and the Annual Plan were built up from the divisional business 

plans developed and amended by the Divisions on an ongoing basis. He explained how the 

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key strategic themes had been developed and the proposed model of monitoring progress 

against each as detailed in the report. 

Members discussed the current monitoring arrangements in place from Ward to Board for a 

number of the key indicators detailed and agreed that, as appropriate detailed monitoring 

arrangements were in place within the corporate reporting framework, a quarterly update 

should be received by way of an exception report to the Board and the Executive 

Management Board. 

RESOLVED: Members received the report and approved the proposed monitoring 

arrangements. The initial quarterly monitoring report will be presented 

at the next Trust Board meeting. 

TB/2012/138 END OF LIFE CARE STRATEGY 

Mrs Wissett introduced the report outlining the refreshed end of life strategy which is 

designed to improve the choices of the patients on end of life care pathways in line with the 

National Cancer Strategy. Members noted that the strategy had wider implications than 

cancer services and was being promoted in partnership with other organisations across 

Pennine Lancashire. 

Members discussed the recommendations contained within the report, particularly with 

regard to the work of the Palliative Care Partnership Board and the End of Life Care Steering 

Group. Members endorsed the recommendations of the report. 

RESOLVED: Members received the report and endorsed the actions for delivering 

improved end of life care to patients, carers and families. 

TB/2012/139 INTEGRATED PERFORMANCE REPORT 

a) Quality & Safety 

Mrs Wissett advised members that with regards to the Monitor Compliance Framework, the 

Trust was currently rated amber/green and was expected to achieve green status towards 

the later part of the year. With regards to the Department of Health Operating Framework, 

the Trust is categorised as “achieving”. 

Members noted that the patient satisfaction scoring was consistently above target at 97% 

and went on to discuss how this fluctuated across divisions according to the patient’s 

perception of their involvement in their own care. Complaints were noted to have reduced 

this month against the numbers for June. 

Members received and noted the exception reports provided in relation to C Difficile rates 

and pneumonia mortality and Mrs Schram advised members of the continuing work being 

undertaken on a case by case basis to investigate mortality and ensure the dissemination of 

learning across the organisation. 

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Mrs Bertenshaw added that with regards to the 18 weeks target, the Trust is seeing a good 

performance on the aggregate indicator but there continues to be an escalating demand in 

some areas which will impact on performance and is being discussed with Commissioners. 

Members further noted that in relation to general surgery and orthopaedics there was 

ongoing work being undertaken to recruit additional medics to ensure the Trust is able to 

meet demand in these specialties. 

b) Finance 

Mr Wood presented the financial element of the report advising members that there are no 

issues with compliance for the period up to the end of August and the Trust remains on 

target to achieve a financial risk rating of 3 for the year end. Members noted the current 

monthly position was a £300k surplus which is consistent with the financial plan. Mr Wood 

confirmed that CIP delivery remained within acceptable limits and drew members’ attention 

to the recent receipt of £3m aged debt as discussed at the previous meeting. In response to 

Mr Hill’s query Mr Wood outlined the work being undertaken across the finance function to 

reduce the timescales of outstanding invoices with a view to getting them paid in a timely 

manner. 

c) Human Resources 

Mr Brandwood advised members that the current sickness/absence levels remain high, 

however, since the papers for the meeting were issued he had received the figures for 

August which shows that the average had fallen to 4% which is the best month so far this 

financial year. Members noted that the Community Division was now being actively 

supported to implement the Sickness Absence Policy with an initial audit being undertaken 

of compliance.Members noted the improved rate of completion of non-consultant staff 

appraisals, from 40% to 61%. 

Mr Brandwood referred members to the exception report provided in relation to temporary 

staff spend and the actions being taken to mitigate and recover the position. 

RESOLVED: Members received the report and noted the actions. Members approved 

the actions being taken to recover areas of under performance. 

TB/2012/140 FOUNDATION TRUST UPDATE 

Mr Hodgson presented his report reminding members of the discussions held at the recent 

Board Away Day in relation to the likely progress and timing of the application from this 

stage. Mr Brearley added that he had received some positive comments from the Strategic 

Health Authority following the recent Board to Board meeting where it had been commented 

that we are quite clearly a clinically led organisation. It was agreed that the full feedback 

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from the SHA Board to Board meeting will be shared on the return of the Chairman. Mr Hill 

commended all staff on the work that had been undertaken to ensure success to this stage 

of the application. 


TB/2012/141 AUDIT COMMITTEE ANNUAL REPORT 

Mrs Murphy presented this report in the absence of Mrs Sedgley, advising members that the 

report detailed the work of the Audit Committee over the course of the year in complying with 

the Terms of Reference and Work Plan set by the Trust Board on an annual basis. Members 

noted that the Committee had completed the work plan and had met the requirements set 

out in the Trust’s Risk Management Strategy and Plan. Members noted the declarations of 

the Committee members at the conclusion of their report in relation to the work they had 

undertaken and the appointment of Grant Thornton as external auditor for the current 

financial year. Members noted and approved the proposed work plan for the Committee for 

the current financial year and particularly commended the Local Counter Fraud Specialist on 

the work he had undertaken across the organisation. 

RESOLVED: Members received the report and approved the Annual Work Plan. 

TB/2012/142 ANNUAL AUDIT LETTER 

Mr Wood presented the Annual Audit Letter received from the Audit Commission which 

outlined the work of the Commission during the course of the year. Mr Wood provided 

members with further assurance on the work undertaken to further minimise the small 

number and value of coding errors and members noted the conclusion that the Trust had 

performed well in the year in a challenging financial environment and that the Audit 

Commission was of the view that the Trust had made good progress towards achieving 

Foundation Trust authorisation. 

RESOLVED: Members received and noted the Annual Audit Letter. 

TB/2012/143 REPORTS OF SUB COMMITTEES 

Members received the reports of the Trust Board sub committees noting that all items 

identified for escalation had been received and considered by the Trust Board. 


TB/2012/144 ANY OTHER BUSINESS 

No further items of business were presented. 

TB/2012/145 TIME & DATE OF NEXT MEETING 

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The next meeting will take place at 14:00 on 31 st October 2012, Trust Headquarters, Royal 

Blackburn Hospital 

RESOLVED: That publicity will be prejudicial to the public interest by reason of the 

confidential nature of the business to be transacted and that the public 

should be excluded. 

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PART ONE 

Meeting Date: 

Report Purpose: Agenda Item: 4 

31 st October 2012 For Decision 

Performance Monitoring √ 

For Information □ 




Hazel Harding 

Report Title: 

Action Matrix 

Company Secretary Chairman 


Committee 

Date 



N/A 

Yes 

No 





Commitments: 


N/A 

N/A 





• To maintain & improve patient experience 

& outcomes through achievement of the 

key indicators/ objectives outlined in the 

Trust’s Quality Account 

• To invest in & develop our workforce & 

improve staff engagement & satisfaction 

levels 


with the CQC & be licensed to provide 

services without conditions 


deliver a cost improvement programme of 

5% 




• To continually promote equality & diversity 

at every level within the organisation 

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V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(4) Action Matrix.docx



Identified: 






Outcomes: 



















communities 







The outstanding actions are appended 

Members are requested to receive updates on 

outstanding actions and agree further actions 

as appropriate 

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Minute No Action By When Agenda Item 

TB/2012/132 Previous Minutes Minutes to be amended FM Immediately Oral Report 

TB/2012/137 Annual Plan Strategic 

Themes 

First quarterly report to be presented MH Immediately Agenda Item 8 

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PART ONE 

Meeting Date: 


31 st October 2012 For Decision 






Mark Brearley 

Report Title: 

Chief Executives Report 

Company Secretary Chief Executive 


Committee 

Date 



No 

Implications For Partners: As detailed in the report 



Development and maintenance of partnerships that 

support the Trust’s business. 

Related to Strategic Objectives 


• To improve patient experience by putting 

quality at the heart of everything we do 


through innovation, pathway reform and the 


• To invest in and develop our workforce, 

and improve staff engagement and 

satisfaction levels 

• To continually promote equality and 

diversity at every level within the 

organisation 


with the CQC and therefore be licensed to 

provide services without conditions 


internal and external stakeholders to 

reduce health inequalities, improve public 

health and reduce cost across the health 

economy 

• To improve the Trust’s liquidity position and 

deliver the required efficiencies 

Legal Implications Identified: None identified 

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V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(7) CEO Report.docx


Identified: 






Outcomes: 


















communities 







A summary of national, regional, health 

economy and internal developments is 

provided for information 

Members are asked to receive the report and 

note the contents. 

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National Updates 

Sherwood Forest Hospitals 

Monitor intervened at Sherwood Forest Hospitals NHS Foundation Trust on 21 st September 

when that organisation was found to be in significant breach of it Terms of Authorisation. An 

interim Chair and Chief Executive have been appointed and the Care Quality Commission 

(CQC) is to carry out an urgent inspection into breast cancer screening, pathology and 

clinical governance at the Trust. A number of other reviews including reviews of Board and 

quality governance have also been ordered by Monitor. 

Hospital Food 

New standards setting out what patients should expect from NHS hospital food have been 

announced by the Health Secretary. The principles covering quality, nutritional content and 

choice will be assessed by patients and assessments are expected to commence in April 

2013. The Trust will work to continue to improve provision in line with the principles. 

Health Watch England 

The new national, statutory consumer champion for health and social care in England was 

launched on 1 st October. The organisation aims to ensure that the public’s voice is heard at 

a national level. 

Ensuring Fair and Transparent Pricing 

The Department of Health (DoH) launched a consultation on 5 th October seeking views on 

which providers should be able to formally object to the way Monitor will calculate prices for 

NHS services from April 2014 and at what level of objection would Monitor have to 

reconsider or refer its pricing calculations to the Competition Commission. Further details of 

the consultation are available on the DoH website. 

Local Updates 

North West Air Ambulance 

The North West Air Ambulance charity a shop in the main entrance of the Royal Blackburn 

Hospital was officially opened on 9 th October. The charity would be delighted both to accept 

donations and volunteers for help in undertaking fund raising activities from staff and 

members of the public. 

Staff Recognition 

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Many congratulations to Gillian Baird and Elaine Abbott who began working as cadets in 

1972 and have now been working at the Trust for 40 years each. 

The diabetic eye screening service has been commended and been place second in the 

prestigious NHS Quality in Care for Diabetes Awards 2012 in the category ‘Best Early 

Detection and Prevention Initiative Category’. 

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PART ONE 

Meeting Date: 


31 st October 2012 For Decision □ 


For Information 

Report Submitted By: 

David Kirkham, Service 

Development Manager 

Report Approved By: 

Martin Hodgson, Director of 

Service Development 

Report Title: 

Strategic Development 

Plan 2012-13 

Date Considered By Divisional Board Chair Declaration of 

Divisional Board/ 

Reason Not 

Approval: 

N/A 


No 

Considered By 

Divisional Board: 

N/A 


None identified. 

Related to key risks identified on 1.4, 1.5, 1.9, 1.91, 1.11, 1.12 

Assurance Framework & 

Consequences: 

Related to Corporate Commitments: • Improved patient experience by putting 

quality at the centre of everything we do 

• Delivery of national standards and targets 

• Improved productivity 

• Improved efficiency 

• Invest in and develop our workforce 

Legal Implications Identified: None identified. 

Data Protection Implications None specific. 

Identified: 

Diversity and Equality Implications 

Identified: 

All embracing Equality Impact Assessment (EIA) 

required linked to PCT led health economy EIA 











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V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(8) Strategic Objectives.docx


Outcomes: 








communities 







The trust’s five year Strategic Development Plan 

2012-13 outlines progress against all of the key 

strategic developments identified in the trust’s 

Divisional Business Plans 2011/12 (for 2012/13 to 

2016/17) on a quarterly basis. 

The Board is asked to receive and note the 

contents of the report 

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1. Introduction 

We have developed our five year (2012-2017) Integrated Business Plan through an iterative 

process in which we have used our Divisional Business Plans as the foundation i.e. there is 

coherence between the Divisional and Corporate service plans. 

The trust’s Strategic Development Plan outlines progress against all of the key strategic 

developments identified in the trust’s Divisional Business Plans. As discussed and agreed at 

the September EMB and Board this will be monitored on a quarterly basis, and also at the 

monthly Divisional performance meetings. 

McKinsey, in their external assessment of our Board Governance Assurance Framework, 

emphasised the importance of: 

i. Delivery against the Trust’s key milestones (to be reported upon on a quarterly 

basis); 

ii. Engagement with internal and external stakeholders over our strategy and strategic 

plans; and 

iii. The Board ‘reflecting on the effectiveness of the strategic monitoring process and 

being comfortable with holding the organisation to account against delivery of the 

five-year strategy’. 

This report addresses these issues/ recommendations. 

2. Current Position 

Milestones identified in the first year (2012/13) of the trust’s five year Strategic Development 

Plan is attached at appendix 1. It sets out all of the key strategic developments by division, 

identifies the divisional lead and outlines key timelines with associated commentary by 

divisions. 

The status of this report has been ratified by the business managers and/ or divisional 

general managers within each division and exception reports, due to their commercial 

sensitivity are provided to Board members in Part 2. 

In summary there are 88 Service Developments currently identified across the divisions, 23 

of which require business cases due for completion in 2012/13. Of these 8 have been 

approved, 13 are in progress and 2 are awaiting decisions from Commissioners. 

There are a number of on-going developments in Community Division which will assist in 

progressing the care closer to home agenda, preventing avoidable hospital admissions and 

facilitation of earlier discharge to reduce the length of stay in hospital. A number of these 

projects have been agreed and funded through reablement monies from commissioners and 

are in the process of being implemented, and will become operational in October/November. 

Other developments are in progress through redesign and realignment of existing services to 

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meet the care close to home agenda and progressing accordingly. No further business 

cases are required at this point in time. 

As stated earlier in this report, progress against all of the key strategic developments will be 

continually updated and will be formally reviewed at the divisional performance meetings 

from November. Divisions are expected to use their own performance management, 

reporting and communication processes. Progress against the Strategic Development Plan 

will be updated and submitted to Executive Management Board and the Board on a quarterly 

basis. 

3. Conclusion 

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

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Strategic Development Plan 2012/13 – 2016/17 

Surgery and Anaesthetic Services 

Produce Business Case for approval at EMB (20th Consultant) 

Q.1 Q.2 Q.3 Q.4 

Business Case Full Implementation 

Lead Status Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Required? (Y/N) Date 

Contract Team 

Involvement 

Required? (Y/N) 

Code of 

Conduct 

Needed? 

(Y/N) 

1 

2 

3 

Repatriation and Expansion of Orthopaedic Elective Activity 

Development of 

a Vascular 

Centre 

Reconfiguration of 

Medical Oncology 

Service 

4 Increase in ENT elective activity 

market share 

5 AQP Direct Access Adult Hearing 

Service Tender 

6 Increasing percentage of laparoscopic 

surgery across all specialties where 

clinically appropriate 

7 Increased day case rates especially 

where best practice tariffs apply 

Produce Business Case for approval at EMB (21st Consultant) 

Phase 1: Repatriation: Year 1 2012/13 (PYE – repatriation of 

activity in Quarter 4 only) 

Recruit 21st Consultant with Upper Limb interest & identify 

admin support 

21st Consultant to commence operating 

Extension of pharmacy opening hours to ensure active 

discharge 

Phase 2 – Expansion of Market Share: Year 2 2013/14 (FYE 

– repatriation of activity) 

Review year end position with regard to activity, capacity, DoH 

targets, case mix, human resources, theatre and OPD utilisation 

and introduce further stretch target 

Ensure PCT/GP Clusters engaged 

Consider introducing patient surveys to understand why pts 

choose to go 'elsewhere' 

Implement dedicated Middle Grade lists for ‘simple’ surgery 

Introduce dedicated LA lists 

Consider inpatient to day case procedures 

Secure HSDU & domestic services provision 

Review and cost required additional input from Physio 

Review and cost required additional input from OT 

Review and cost required additional input from Radiology 

Review and cost required additional input from Pharmacy 

Years 3-5 2014/15 – 2016/17 

Retain 25% year on year of work currently going to the 

Independent Sector 

Review year end position with regard to activity, capacity, DOH 

targets, case mix, human resources, theatre, bed base and 

OPD utilisation and introduce further stretch target 

Hold stakeholder event 

Market Services 

Ensure appropriate skill mix in place 

Specialist Centres notified 

Agreement made on population split between the two 

interventional centres in South Cumbria 

Workforce arrangements initiated for partnering organisation 

and development of a Vascular ward 

Phase 1 - Activity from screening referred to Trust plus nonelective 

in patient arterial surgery 

Phase 2 - 100% in patient arterial surgery transferred 

Implementation steering group established 

Finalise job plans for oncologists 

Recruit additional nurse specialist 

Gain Royal College approval for job plans 

Advertise consultant posts (3 posts initially) 

Discussions with LTH regarding on-going/additional support 

during recruitment and SLA renegotiation as appropriate 

Other infrastructure arrangements put in place 

Nurse specialist post commences 

Consultant posts commence 

Further recruitment to 4th consultant post 

Carry out market analysis 

Carry out demand and capacity review 

Cath Taylor 

Victoria Bateman 

Deborah Loftus 

Y 2014/15 

Y Y 

Recruit specialty doctor (to reduce OPD waiting times) Leigh Hudson 

Submit tender Y N 

Mobilisation plan from PCT prior to contract award and service 

commencement Leigh Hudson 

N 

3 x General Surgeons currently training in laparoscopic 

techniques for colorectal procedures Judith Salaman 

N 

All HPB surgeons undertake laparoscopic surgery Robert Watson 

N 

Integrated Laparoscopic Theatre Equipment being procured 

through PCT funding Robert Salaman 

Y 

N 

Review of current practice for Lap Chole and Hernia. Audit 

underway to identify pathway issues Amareen Kausar 

Ensure all day case work is undertaken at BGH and not RBH. Robert Watson/Victoria 

Review of pooling arrangements Bateman 

Y 

Y 

Q.1 2013/14 

2013/14 

TBC 

8 Continued expansion of enhanced 

recovery pathways 

Cath Taylor




Contract Team 

Involvement 


Code of 

Conduct 

Needed? 

(Y/N) 

9 

NWSCG Bariatric Surgery Tender 

10 

11 

Develop Emergency Surgery Service 

Consultant recruitment to General 

Surgery with an interest in emergency 

surgery 

Submit tender 

Recruit additional emergency surgeons x 2 to complete the 

surgeon of the day rota 

Increase the number of patients discharged from STU 

Reduce LOS on the Emergency Wards 

Reduce Emergency Care pathway by working with radiology to 

look at slots for investigation 

Recruit Advanced Practitioner roles for STU Robert Watson 

Advertise consultant posts 

Shortlist and interview 

Offer position 

Consultant starts posts 

Recruit trainee nurse endoscopists 

Undertake capacity and demand modelling 

Robert Watson/Victoria 

Bateman N N 

Robert Watson/Victoria 

Bateman 

Y 

Y 

Y 

N 

N 

N 

N 

N 

N 

N 

N 

12 

13 

Continued development of Endoscopy 

Services 

Continue development of Breast 

Service 

14 Bid for 2nd Floor UCC and recruitment 

of 2 ophthalmology Consultants 

Improve the utilisation of existing lists by implementing nurse led 

consent, changing bowel prep to movicol and work with 

scheduling to improve patient booking 

Implement an improved validation process in place for repeat 

procedures 

Achieve 6 week JAG target on-going 

With medicine review capacity required and how this will be 

met. ?Consultant/staff grade Endoscopist. Victoria Bateman 

Implement the new follow up protocol for cancer patients Julie Iddon 

Expand reconstruction procedures offered. Link with PCT to 

agree strattice and lipomodelling approval Victoria Bateman 

Julie Iddon/Hillary 

Develop Advanced Practitioner Role Wallbank 

Increase day case rates Julie Iddon 

Submit UCC bid 

Business case for additional posts Leigh Hudson 

Y 

Y 

N 

Y 

15 

Transfer of chronic ophthalmology 

conditions into community e.g low 

visual aids, stable glaucoma, ocular 

hypertension Go live Leigh Hudson N Y Y 

16 

Consultant recruitment to urology 

Cath Taylor 

17 Development of laser prostatectomy Cath Taylor 

18 

Continued development of urology 

cancer surgery 

Medicine 

19 

Redesign of 

Rehabilitation and 

Reablement Services 

Implementation of Blackburn with Darwen Tender 

East Lancashire redesign proposals developed and agreed with 

commissioners 

Establish implementation work streams 

Community and pathway enablers implemented 

Reduction of further beds in line with community service 

implementation 

Social care beds decommissioned from current providers 

Social care beds recommissioned at Pendle Community 

Hospital 

Cath Taylor 

Cath Gregson 

20 

21 

22 

Orthogeriatrics 

Development of an 

Integrated Urgent 

Care Model 

BwD Inpatient Sub Acute 

Rehabilitation 

Phase 1 pilot 

Design of subsequent phases of project 

Decommission 10 Beds 

Agree new process for patient transfer 

Service commencement of 10 new Community based beds 

Complete Business Case for Orthogeriatrician 

identify funding 

Business Case approved 

Final approval of Job Plan by RCP 

Funding identified through reablement monies 

Approval of Business Case 

Beverley Eaves 

Cath Gregson 

Cath Gregson 

Y 

Y


23 

Fracture Liaison Service 

24 

Botox Service at rakehead 

25 

Enhanced Neuropsychology Service 

Lead Status Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 

Business Case 

Mar-13 Required? (Y/N) 

Full Implementation 

Date 

Recruitment of 2 fracture liaison nurses 

Recruitment of 4PAs of Orthogeriatrician 

Revise Clinical Pathways 

Establish database 

Commence Implementation stage 

Service commencement Cath Gregson 

Y 

2013/14 

Business Case produced and approved 

Service Commencement Cath Gregson 

Y 

2013/14 

Business case approved by DMB 

Internal funding identified 

50% external funding from Commissioners Cath Gregson 

Y 

Contract Team 

Involvement 


Y 

Code of 

Conduct 

Needed? 

(Y/N) 

26 

Integration of Rheumatology, Chronic 

Pain and MSK services 

Gabrielle Heseldon/ 

Joint education plan Chris Payne 

27 Dermatology Business Case to appoint a 6th Dermatologist Gabrielle Heseldon Y 

28 

Implementation of Primary PCI Service Rita Briggs 2015/16 

Business case approved 

29 

Implementation of ICD Service 

30 

Implementation of rotablation 

Mobilisation meetings held with Clinical Transformation Board 

Training completed 

Service Commencement 

Working paper approved by DMB 

Contract arrangements agreed with Commissioners 


Rita Briggs 

Rita Briggs 

Y 

31 Implementation CT Angiography Business Case produced and approved Rita Briggs Y 2013/14 

32 

OOH GI bleed service 

33 

Provide safe and effective NIV 

34 

Integrated COPD and LTOT 

Working paper approved by DMB 

Redesign of Consultant Job Plans 

Service Commencement Rita Briggs 

Identify safe nursing levels 

Identify funding 

Recruit nursing staff 

Work with ITU / MAU to plan actions Rita Briggs 

Implement the COPD pathway redesign 

RAC to be fully operational Now with Community 

PA to be allocated to RAC Division 

35 Consultant led Sleep services Business case for a consultant to be produced and approved Rita Briggs Y 

36 Implementation of Endobronchial 

Ultrasoundservices (EBUS) 

37 

Enhanced pleural services - 

Thoracoscopy 

38 

Develop Nutrition services 

39 

Improve Endoscopy access 

Family Care 

Identify source of £100k funding for additional equipment Rita Briggs 

PA allocation to pleural services 

Thoracoscopy to be obtained 

Operational guidance to be developed Rita Briggs 

Business case produced and approved 

Recruit nurse specialist Rita Briggs 

Recruit to gastro post 

Recruit to nurse endo post Rita Briggs 

Y 

40 

41 

Increase in Market 

Share for Obstetric 

Activity 

Develop LWNC as a centre for 

laparoscopic surgery / Development of 

a Tertiary Laparoscopic Surgery 

centre 

Gynaecology: Hysteroscopy & 

42 

Cystoscopy - Out of theatres and into 

43 

Fertility / Develop satellite IVF 

services 

Develop Business Case for recruitment of additional midwives 

and support staff to incorporate impact on NICU 

Develop Marketing Plan, website and social media tools 

Recruit to additional posts 

Continuous evaluation of service provided both qualitative and 

quantitative analysis 

Identification of a laparoscopic lead 

Establishment of a Trust wide laparoscopic users group 

Scope options for establishing TLH 

Full Business Plan developed for implementation of 

laparoscopic service / centre 

Outline business case considered at DMB 

Full business case considered at EMB given Trust wide 

implications and investment necessary 

Implementation / action plan in place 

Agreement with theatres r/e funding 

Formulation of implementation plan 

Visit to Leeds and Bradford 

Review of standard operating procedures for Leeds and Clinical 

Pathways 

Formulate and agree standard operating procedures and new 

clinical pathways for ELHT 

Vanessa Hollings/ Simon 

Hill 

Vanessa Hollings/ Simon 

Hill 

Debbie Mawson 

Debbie Mawson 

Y 

Y




Contract Team 

Involvement 


Code of 

Conduct 

Needed? 

(Y/N) 

44 

45 

Development of a dedicated children’s 

unit at BGH 

Bid to EMB 

Project Initiation 

Develop integrated management arrangements and supporting 

infrastructure for new Directorate 

Identify key clinical pathways to review across the 3 sub- 

Directorates so that services are streamlined across the whole. 

Complete ‘show and tell’ sessions between 3 areas and identify 

key areas on which integration can benefit service quality, cost 

Catherine Vozzolo 

Y 

Y 

Integrated service for children and 

young people 

46 Develop Paediatric Oncology Shared 

Care Unit (POSCU) level 1 services 

Bid r/e Integrated Pathway 

Clinical pathways review 

Admin pathways review 

Complete business case for POSCU level 1 services 

Seek approval from ELHT and Cancer Network 

Confirm /complete estates plans to support business case 



N 

Y 

N 

Y 

47 

Develop Paeds haematology services 

Complete business case 

Seek approval from relevant boards 

Confirm /complete action plans to instigate service 

Y 

2013/14 

Y 

Y 

Review services and identify key business opportunities 

48 

Develop Paeds nephrology services 

49 

Develop Paeds CF services 

Complete business case and seek approval at relevant boards 

Action plan to instigate service 

Confirm contractual arrangements 






Y 

Y 

2013/14 

2013/14 

Y 

Y 

Y 

Y 

50 

53 

Paediatric shared care services with 

Adult Tertiary services: 

Diabetes 

Haematology 

Endocrinology 

Cardiology 

Rheumatology 

51 

Develop 16+ ADHD service 

52 

Develop Looked after children service 

54 Develop the complex and ventilated 

children’s services 

To redesign and develop the 

infrastructure supporting community 

55 

and neurodevelopmental paeds 

(electronic medical records, 

56 Achievement of Paeds Diabetes Best 

Practice Tariff/ Pathway 

57 

Develop single day Autistic spectrum 

disorder (ASD) assessment 

Child-Adult Transition services review 

Complete business case (ELCAS Consultant) and seek 

approval 

Complete actions necessary to set up service 




Review SLA/ service provision with commissioners and agree 

new service specification 

LAC lead establishment and service spec in place 

Review update LAC in ELCAS/ CNP 

Initiate service contract 




Business case and action plan to establish electronic medical 

records in CNP 

Redesign of appointments and admin system within CNP 

Business case to EMB 

Recruit Psychologist 


Improved transition policies 

Agreed transition with commissioners 

Expansion of service to fill gaps 

Improved safeguarding of vulnerable adults 









Y 

Y 

N 

Y 

2013/14 

N 

N 

N 

Y 

N 

Y 

Y 

2013/14 

Y 

N 

N 

Y 

Y 

2013/14 

2013/14 

N 

Y 

N 

Y 

58 Develop Paeds Allergy service Business case to DMB Catherine Vozzolo Y Y Y 

59 

Diagnostics and Clinical Support 

60 

Paeds IM&T Strategy/infrastructure 

(electronic records, mobile working) 

athology Service 

Reconfiguration 

(PACE) 

IM&T Strategy 

Operational delivery plan Catherine Vozzolo 

MOU between the three trusts agreed via trust boards 

Project Manager appointed 

Launch event 

Completion of detailed scoping of project options 

Exploit joint procurement opportunities 

Referred away tests brought back in-house 

Consolidate some esoteric or specialised non-urgent testing to a 

common site 

Y 

N 

N


Pa 

R 

Code of 

Lead Status Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 

Business Case 

Mar-13 Required? (Y/N) 

Full Implementation 

Date 

Contract Team 

Involvement 


Conduct 

Needed? 

(Y/N) 

Option appraisal and business case presented to each Trust 

Board Gill Rose 

Y 2013/14 

N N 

61 

Potential expansion of Point of Care 

Testing 

Community Cardiovascular Risk Checks 

Jeff Cottam/ Kath 

Brownbill N N N 

62 PACs Upgrade Go live Jeff Cottam N N N 

63 BGH Centralisation of radiology 

booking 

Undertake feasibility study to centralise Radiology Booking in 

the Outpatient Booking Centre 

Transfer of Radiology booking to Booking Centre Jeff Cottam 

Beds identified 

N 2013/14 

N 

N 

64 

Develop day case angio and non 

vascular intervention 

65 Roll out • Radiology 

Ordercomms to GP Practices 

Case for extended hours working 

66 

arrangements 

Nurse Recruitment Jeff Cottam 

Secure additional recurrent funding 

Recruitment 

Jeff Cottam 

Gill Rose 

67 

Therapies input into Reablement Tracey McGlone 

Pilot EDM for well babies 

Agree Business Case for roll out to all specialties 

68 

Implement EDM in paediatrics 

Electronic Document Management Roll out EDM to other specialties Rosemary Duckworth Y 

2016/17 

69 Electronic Prescribing and Medicines 

Administration (ePMA) 

Community Services 

NHS EL Community Non-cancerous 

70 

Lymphoedema Service Tender 

NHS East Lancashire Primary Medical 

71 

Care GP Services 

Submit tender 

Contract award and service commencement 

Neil Fletcher 

Val Sibson 

Submit tender Val Sibson 

N 

72 Community Response Team in ED Val Sibson Poss 

73 

Community Hospital Utilisation Val Sibson N 

74 

Discharge facilitation Val Sibson N 

75 

Musculoskeletal services Val Sibson N 

Chronic Obstructive Pulmonary 

76 

Disease (COPD) Val Sibson N 

77 

Development of the Virtual Ward Val Sibson N 

78 Ambulatory Diabetes care Val Sibson N 

79 Integration of specialist community 

services with acute services e.g. 

pulmonary rehab and oxygen services 

Val Sibson 

Catriona Logan/ Gill 

Integration of Rheumatology services and MSK Rose N N 

80 

Integration of community and acute 

therapy services e.g. Rheumatology, 

MSK, Chronic Pain etc. 

Integration of Chronic Pain service and MSK 

Catriona Logan/ Gill 

Rose 

N 

81 Develop intermediate care and 

rehabilitation services Val Sibson N N 

82 Develop Pan Lancashire model for 

Community equipment Services Val Sibson N N




Contract Team 

Involvement 


Code of 

Conduct 

Needed? 

(Y/N) 

83 

Rossendale Pilot Val Sibson 

Review treatment room services to 

align to primary care work 

Staff Consultation Val Sibson 

N 

2013/14 N 

Integrated wound care services to 

84 support enhanced care of long term 

wounds Val Sibson N N 

Develop diagnostic Doppler service 

85 

for ambulatory DVT care 

Val Sibson 

86 

Develop links with Lancashire Care 

Foundation Trust and the AQuA 

network to support the implementation 

of services that provide care for those 

with dementia working with colleagues 

from the Medical Division Val Sibson N N 

Build on the recent reorganisation of 

87 

locality based community nursing 

teams to incorporate therapy and 

specialist services Val Sibson N N 

88 

Support the development of the ‘end 

of life’ pathway Val Sibson N N 

Notes: 

Developments identified in Divisional Business Plans 2011/12 (for 2012/13 to 2016/17). 

Where timelines and/ or future full implementation dates are not shown, Implementation timetables have yet to be agreed. 

Trust Main Service Developments highlighted in Bold 

as at 18th October 2012 

Status Key 

Performing well/achieving milestones 

Within tolerance 

Behind plan / action required

Meeting Date: 



Divisional General 

Managers 


PART ONE 


For Decision 




Report Title: 

Val Bertenshaw 

Winter Plan 2012/13 

Director of Operations 


Committee 

N/A 

Date 



Yes 

No 




Related to Strategic Objectives 


ELHT Plan will form part of the Health Economy 

response for Winter 

AF602, AF067, AF100 

• To improve patient experience by putting 

quality at the heart of everything we do 


through innovation, pathway reform and the 


• To invest in and develop our workforce, 

and improve staff engagement and 

satisfaction levels 

• To continually promote equality and 

diversity at every level within the 

organisation 


with the CQC and therefore be licensed to 

provide services without conditions 


internal and external stakeholders to 

reduce health inequalities, improve public 

health and reduce cost across the health 

economy 

Page 1 of 57 



V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(9) Winter Plan 12 13.docx



Identified: 






Outcomes: 



• To improve the Trust’s liquidity position and 

deliver the required efficiencies 

N/A 

N/A 

N/A 












communities 







The plan provides an overview of the key East 

Lancashire Hospitals NHS Trust (ELHT) 

policies, procedures and Divisional Operations 

Plans necessary to ensure that winter demand 

and capacity pressures are managed 

effectively. 

The aim of the plan is to ensure that all staff 

are aware of what information and guidance is 

available to support them in coping with 

periods of high demand, enabling a coordinated 

approach to maintaining patient flow 

and positive clinical outcomes 

Page 2 of 57 






Members are asked to approve the plan and 

note the risks 

Page 3 of 57 




WINTER PLAN 2012/13 

Introduction 

The plan provides an overview of the key East Lancashire Hospitals NHS Trust (ELHT) 

policies, procedures and Divisional Operations Plans necessary to ensure that winter 

demand and capacity pressures are managed effectively. 

The aim of the plan is to ensure that all staff are aware of what information and guidance is 

available to support them in coping with periods of high demand, enabling a co-ordinated 

approach to maintaining patient flow and positive clinical outcomes. 

Methodology 

The document has been contributed to by all the Divisions. The methodology and format 

follow best practice guidance from NHS North and the document complies with the 

Assurance Checklist attached an appendix in the plan. It also includes the learning from last 

winter following the internal review led by the Chief Executive. The document has been 

shared with stakeholders and will form part of an overall health economy plan. 

Demand and Capacity 

The plan is based on a forecasted increase in activity of 5% on 2011/12 and provides for an 

additional 57 beds: 

B6 

– extra capacity of 5 beds. 

C3 

- extra capacity of 5 beds. 

D5 (CDS) – 13 beds (cohort ward.) 

D1 

- additional 10 beds. 

Ward 23 (BGH) – 24 beds. 

Total 57 

The modelling does identify that on occasions 57 beds will be insufficient. At such times, 

additional non-elective capacity will be made available by flexing elective capacity where 

possible, without impacting on 18 weeks and cancer targets and stepping appropriate 

patients down into additional nursing home beds that have been purchased by 

commissioners. 

Changes based on the learning from 2011/12. 

1. Recruitment to key roles commenced much earlier. 

2. Procurement of medical equipment to support additional capacity commenced much 

earlier. 

Page 4 of 57 




3. The introduction of the Senior Clinician On-Call Role into the Escalation process to 

ensure senior clinical overview of flow management. 

4. More robust staff vaccination plan given the 70% target which has been set this year. 

5. A cold weather i.e. snow, ice, etc plan has been included to reflect the operational 

response by the Orthopaedic directorate. 

6. More use of the alternative to admission pathways available from the Community 

division. 

7. Discharge Facilitation Team now work 7 days a week. 

Key Risks 

The overarching risk concerning our ability to manage increased demand is captured on the 

Assurance Framework. Risks within this are as follow: 

1. Recruitment to key medical and nursing roles. 

2. Impact of Flu on staff availability. 

3. Higher than predicted demand resulting in an inability to maintain flow thereby 

impacting on patient experience and achievement of the 4 hour target. 

4. Increased cancellation of elective work thereby impacting on 18 weeks. 

5. Increased costs that are not covered by income due to the impact of the 30% cap on 

the NEL baseline. 

6. Completion of Estates alterations. 

Recommendations 

Members are asked to approve the plan and note the risks. 

Page 5 of 57 




East Lancashire Hospitals NHS Trust 

Winter Resilience Plan 2012/13 

Version 4.1 

(updated October 2012) 

Page 6 of 57 




CONTENTS 

Section Description Page 

1 INTRODUCTION 3 

2 

3 

NHS NORTH WEST - RESILIENCE TRIGGERS 

(Including Winter Planning) 

EAST LANCASHIRE HEALTH ECONOMY 

PLANNING 

4 ELHT METHODOLOGY 9 

5 KEY FACTORS 10 

6 ELHT ESCALATION PLAN 11 

7 

8 

NON-ELECTIVE MEDICAL ACTIVITY FORECAST 

2012 / 13 

NON-ELECTIVE SURGICAL ACTIVITY 

FORECAST 2012/2013 

9 MEDICINE – OPERATIONAL PLAN 24 

10 

SURGERY AND ANAESTHETIC SERVICES – 

OPERATIONAL PLAN 

11 FAMILY CARE – OPERATIONAL PLAN 35 

12 

13 

DIAGNOSTIC AND TREATMENT SERVICES – 


COMMUNITY SERVICES DIVISION – 


14 FACILITIES 44 

15 REPORTING 45 

16 PANDEMIC INFLUENZA 46 

17 COMMUNICATIONS 48 

18 RISKS 49 

19 CONCLUSIONS 50 

20 ADDITIONAL READING 51 

4 

7 

13 

19 

33 

38 

40 

Page 7 of 57 




1. INTRODUCTION 

The plan provides an overview of the key East Lancashire Hospitals NHS Trust (ELHT) 

policies, procedures and Divisional Operational Plans necessary to ensure that winter 

demand and capacity pressures are managed effectively. 

The aim of the plan is to ensure that all staff are aware of what information and guidance is 

available to support them in coping with periods of high demand, enabling a co-ordinated 

approach to maintaining patient flow and positive clinical outcomes. 

The plan utilises Trust polices and procedures, Regional and National guidance and Care 

Quality Commission Standards. 

For the purpose of this plan the winter season is defined as the beginning of November 2012 

to the end of March 2013, when higher than normal levels of emergency medical 

attendances / admissions are expected. 

It is also recognised that this is a holiday period (Christmas and New Year) when normal 

services are reduced. 

The plan has been reviewed by all Divisions and will be measured against the NHS North 

West Assurance checklist. 

Page 8 of 57 




2. NHS NORTH WEST - RESILIENCE TRIGGERS (Including Winter Planning) 

Level One (within Trust) 

Description - Trusts manage their own pressures within normal parameters. Liaison 

between providers and commissioners should be the norm and this will ensure that all local 

stakeholders are aware of current pressures and ready to respond appropriately to any 

peaks and troughs in demand. This level may typically be + 15% of urgent activity, this could 

be across the organisation or just one key area. 

Escalation Trigger point – If individual Trust resources cannot / are consistently struggling 

to meet demand (+ 15%) then the affected trust should liaise with its commissioners to 

implement a Health Tactical Coordinating Group (HTCG) at Health *Economy level. This 

group may be chaired by the affected Acute Trust but must contain an executive level input 

from the lead commissioning organisation and partner agencies such as Social Care. 

*The Health economy should consist of all the local health providers, including Social Care 

partners this group should be the same one who met and produced the winter plan. 

(Planning Group) At Level 2 it becomes the Health Tactical Coordinating Group for the 

purposes of Command and Control 

Level Two (Local Health Economy) 

Description – Health economies manage their own pressures within their agreed planning 

frameworks. Joint working between providers and commissioners is expected on a daily 

basis – led by the Commissioner Executive Director (Cluster PCT/GPC). Liaison with the 

Lead PCT / Local Health Emergency Preparedness Communities (LHEPC) is expected to 

ensure that all stakeholders are sharing the same information and preparation can be made 

to facilitate escalation to level three if required. 

Escalation Trigger Point – If health economy resources cannot meet the demand and all 

the appropriate steps have been taken such as deployment of additional resources, 

accelerated hospital discharge and cancellation of elective workload - then the lead 

commissioning organisation (Cluster PCT/GPC) should liaise with the Lead PCT/LHEPC to 

implement a Health Strategic Coordinating Group (HSCG) at the agreed geographical level. 

Page 9 of 57 




This group should be chaired by the Lead PCT/On Call Strategic Commander (Health) but 

must contain an Executive Level delegate from each commissioner/organisation. The 

commissioning bodies shall be responsible for liaison across their health economy in respect 

of any outputs from the Strategic Meetings through the respective Health Tactical 

Coordinating Groups. 

Level Three (Cluster Wide Health Economy) 

Description – The Lead PCT / LHEPC will coordinate the agreed geographical health 

economy through the Health Strategic Coordinating Group having regard to mutual aid and 

agreeing generic decisions across the conurbation. Commissioners manage the pressures 

within their health economy through their Tactical Coordinating Groups and feed into the 

Lead PCT/LHEPC on a daily basis. If part of a multi-agency response, then the Lead 

PCT/LHEPC will also attend the Local Resilience Forums SCG and feed into that process. 

Escalation Trigger point – If Lead PCT/LHEPC NHS resources and joint working cannot 

meet the demand OR the NHS SHA/CB declare a Level Four response - then the Lead PCT 

/ LHEPC will liaise with the NHS SHA/CB to implement a Sector Health (Regional) 

Coordinating Group. This group will be chaired by a Director of the NHS SHA/CB but must 

contain the Chair(s) from the Health Strategic Coordinating Group(s) (HSCG) 

Level Four (Sector (Regional) Health Economy) 

Description – The NHS SHA/CB manage the pressures within their (Region) Sector through 

the Sector Health (Regional) Coordinating Group. The SHCG will coordinate the Sector 

health economies through the Lead PCTs/LHEPCs having regard to (Regional) Sector 

decisions across the affected geographic area. If part of a multi-agency response then the 

Lead PCT/LHEPC will also attend the Local SCG and feed into that process with (Regional) 

Sector NHS SHA/CB attending any requisite wider geographical groups if established. 

Escalation Trigger point – If over the geographical area managed NHS resources cannot 

meet the demand then the (Regional) Sector NHS SHA/CB will liaise with the National 

Page 10 of 57 




NHS/NHS CB to request national / international input / resources. The NHS/ NHS CB input 

will be fed back to the (Regional) Sector by an Executive Director of the NHS/NHS CB. 

Level Five (National Health Service) 

Description – The demand is such that only a nationally coordinated response is 

appropriate, this may be concluded following escalation through the various stages above 

OR fed down the chain as in Swine Flu. In either scenario the top-down input will be 

managed within Cluster PCTs via the Lead PCT/LHEPC and Sector Health Strategic 

Coordinating Group(s). 

Page 11 of 57 




3. EAST LANCASHIRE HEALTH ECONOMY PLANNING 

Joint preparation is the foundation to successful management of the extra demands placed 

on the health economy over the winter period to ensure appropriate levels of performance 

are maintained. Members of the health economy (shown below) have engaged in the 

winter planning process and have met on several occasions to contribute to a jointly owned 

resilience plan. 

• East Lancashire Hospitals NHS Trust 

• Blackburn with Darwen NHS Teaching Care Trust Plus 

• NHS East Lancashire Primary Care Trust 

• Social Services (BwD and Lancashire County Council 

• North West Ambulance Service 

The Plan is currently in development and will be circulated to the SHA and wider once 

finalised. 

PCT Escalation Levels 

An example of what the PCT escalation tactics might look like following recent discussions: 

Escalation Level 1 – extra 24 (inc 12 step down) beds 

The planned expansion of Clitheroe Community Hospital to re-open Hodder ward was 

considered financially unviable. 

A nurse led ward is planned for the BGH site – but will be run via the Community Division 

utilising developing pathways around ED deflection and the Virtual Ward. 

Escalation Level 2 – extra 15 beds 

• Social Services departments temporarily redeploy staff from prevention to discharge 

+ 5. There will be no Community social work staff supporting people remaining in the 

community as per Escalation Level 1. 

• Net result + 15 

Page 12 of 57 




Escalation Level 3 – extra 15 beds 

• The community Division will temporarily deploy community staff to pull patients 

(working with Clinicians) from wards + 10 

• Community Assessors to patrol the wards, identifying patients appropriate for 

discharge + 5 

• Net result + 15 

In addition an ELHT Discharge Facilitator will work closely with Commissioning Leads to 

agree the follow: 

• There is a standard definition of a DTOC and this has been agreed with PCT and 

Provider. 

• Performance standards for each part of the discharge pathway 

• Reporting arrangements in place for each standard 

• Escalation measures 

Health Economy Discharge tele-conferences currently take place three times a week and will 

continue throughout the winter period. 

A review of rehabilitation services is taking place as part of the financial challenge work 

being undertaken by NHS BwD. 

Page 13 of 57 




4. ELHT METHODOLOGY 

In formulating the ELHT response to winter pressures, the Trust has referred to the 

supporting documents and the following sources of information. 

a) Primary Data 

In preparing its operational response the Trust has taken account of the opinions of 

Trust and Health Economy professionals, in addition to lessons learned from 

previous years and past and current health economy organisational winter plans. 

b) Secondary Data 

In order to identify activity trends for the forthcoming winter period, the Trust has 

reviewed the medical and surgical admissions, conversion and discharge rates for 

the 2011 / 12 winter period and Regional and National commentary and guidance 

regarding best practice. 

Page 14 of 57 




5. KEY FACTORS and Risks 

A review of previous winter plans and audits of operational issues encountered has 

highlighted the following as key factors in winter planning and these issues have been taken 

into account by the Divisions when producing their operational plans. 

• Operational preparedness (demand and capacity planning, staffing, equipment, 

consumables, medicine management). 

• Discharge planning (community team support, out of hours primary care 

arrangement, North West Ambulance Service provision, Social Services support). 

• Critical Care and Paediatric capacity. 

• Infection Control requirements. 

• The need for clear internal and external communication mechanisms. 

• The need for clear and robust internal department plans for the Christmas and New 

Year holidays. 

• Ambulance handovers. 

• Vaccination programme. 

Key Risks 

The overarching risk concerning our ability to manage increased demand is captured on the 

Assurance Framework. Risks within this are as follow: 

7. Recruitment to key medical and nursing roles. 

8. Impact of Flu on staff availability. 

9. Higher than predicted demand resulting in an inability to maintain flow thereby 

impacting on patient experience and achievement of the 4 hour target. 

10. Increased cancellation of elective work thereby impacting on 18 weeks. 

11. Increased costs that are not covered by income due to the impact of the 30% cap on 

the NEL baseline. 

12. Completion of Estates alterations. 

Page 15 of 57 




6. ELHT ESCALATION PLAN 

The Bed Management Team (Chair, Senior Manager, Medial Representative, Matron, 

Surgical Representative, Matron, Business Manager, Bed Facilitator and Senior Clinician of 

the day), are the custodians of the escalation process and are responsible for all the 

technical details relating to: 

• The calculation of trigger points (in liaison with clinical staff) 

• The institution of status levels (in liaison with Senior Manager on Call / Duty Matron). 

• The communication of status levels during the health economy teleconference 

• The maintenance of processes and procedures. 

In order to provide robust operational management, the daily bed meeting will be chaired by 

the Director of Operations or a Divisional General Manager. The floor of the Emergency 

Department will have an Operations Manager in place each working day (Monday to Friday) 

and a Business Manager or Matron will coordinate bed availability at ward level as follows; 

Each morning the Bed Facilitator’s will establish each hospital site’s status by predicting the 

future bed state position over the next 24 hours utilising: 

• Historical performance data 

• Current actual position 

• Clinical judgement 

STATUS LEVEL PRESSURES TYPE OF ACTIONS 

GREEN Normal Routine proactive bed management. 

YELLOW 

AMBER 

RED 

Higher than Normal 

High 

Extreme 

Highlighting problems and making 

contingency plans in case pressures 

continues. 

Deployment of increasing scales of 

counter-measures to decrease short 

term demand and increase short term 

capacity. 

Large scale interventions to increase 

capacity and decrease demand, 

including regional load sharing, this 

may include the establishment of a 

cross divisional forum chaired by 

Medical Director, Director of 

Operations “Red Leader”. 

Page 16 of 57 




BLACK 

Internal Major Incident 

Declared 

In all cases where RBH Emergency 

Department is closed or faces 

imminent closure the internal major 

incident plan must be initiated. 

Although the alert status of the Royal Blackburn Hospital and Burnley General Hospital may 

vary, the Trust’s overall status will be equal to the highest level site. The status of all acute 

hospitals with the Lancashire and Cumbria sector will be considered when weighing up the scale 

of support that can be offered. This approach maximises access to patient services for East 

Lancashire patients whilst increasing the resources available to support neighbours in an 

efficient and co-ordinated manner. At times of extreme bed pressures or unmanageable access 

problems ELHT will contact neighbouring Trusts to secure assistance where possible. ELHT will 

also offer support to neighbouring Trust if they are able. 

At red level, there maybe a requirement to establish an internal was divisional forum “Red 

Leader” to ensure divisional plans are being adhered to and/or to rule on any cross divisional 

disputes. This will be chaired by Medical Director and Director of Operations or their nominated 

deputies. It will also advise on the active deployment of medical staff across divisions, if 

required. 

General capacity and resource issues must be escalated and decisions made in accordance 

with ELHT/C069 Escalation Plan. All staff should also be aware of and, where necessary, refer 

to following policies which accompany the ELHT/C069 Escalation Plan: 

• Policy for Moving Patients from the Emergency Department to appropriate speciality: 

ELHT/CO036 

Page 17 of 57 




7. NON-ELECTIVE MEDICAL ACTIVITY FORECAST 2012 / 13 

The non-elective forecast shown in the graphs and tables below from 29 October 2012 to 31 

March 2013 is based on the following: 

- an average of the last 4 years activity for this period reveals a percentage 

increase of 24.3% (approximately 6% per year increase) 

- Anecdotally the view is that the winter of 2010/11 was worse in terms of 

number of patients admitted due to the pandemic flu outbreak. However, 

analysis has revealed that the previous year 2009/10 was in fact worse. 

- Therefore, based on this information, we have forecast an increase in activity 

of 1 standard deviation from 2011/12 

The base line acute bed numbers for the Medical Division are considered as being 441 (which 

excludes MAU, all Pendle beds and associated length of stay and also excludes existing 

escalation beds in the system as shown in bed configuration table below). 

Based on retrospective data the forecast below indicates the weeks throughout the winter period 

in which medical admissions are expected to exceed discharges within the Trust. 

Page 18 of 57 




A breakdown of the forecast below shows the predicted admissions and discharges. When 

calculated with the average length of stay of the relevant week from 2011-12 then gives the 

number of beds required on any particular day throughout the Winter period. 

Compared against the number of Acute beds including Winter Pressure Beds (441 + 24 = 501 – 

see Bed Configuration) the Addition Esc Beds Required column shows the number of additional 

beds outside the Medical Division that is required on each particular day. 

Predictive Admissions 374 

a b c d e f g h 

Week Date Day 

Predictive 

Daily 

Average 

(2008-12) 

Predictive 

Daily 

Average + 

StdDev 

(2008-12) 

2011-12 

Respective 

Week 

Average 

LoS 

Req 

Beds 

(b*c) 

Available 

Acute 

Beds 

(Exc 

PCH/RH) 

Deficit 

of 

Beds 

(d-e) 

Escalation 

Beds 

Allocated 

Additional 

Escalation 

Beds 

Required 

(f-g) 

31 29/10/2012 Monday 34 43 

293 441 0 12 

31 30/10/2012 Tuesday 53 61 416 441 0 12 

31 31/10/2012 Wednesday 46 57 389 441 0 12 

31 01/11/2012 Thursday 43 49 6.83 334 441 0 12 

31 02/11/2012 Friday 50 51 348 441 0 12 

31 03/11/2012 Saturday 58 66 450 441 9 12 

31 04/11/2012 Sunday 45 51 348 441 0 12 

32 05/11/2012 Monday 34 43 

273 441 0 12 

32 06/11/2012 Tuesday 57 65 413 441 0 12 

32 07/11/2012 Wednesday 51 60 382 441 0 12 

32 08/11/2012 Thursday 46 51 6.37 324 441 0 12 

32 09/11/2012 Friday 50 55 350 441 0 12 

32 10/11/2012 Saturday 59 66 420 441 0 12 

32 11/11/2012 Sunday 45 55 350 441 0 12 

33 12/11/2012 Monday 32 37 

238 441 0 12 

33 13/11/2012 Tuesday 52 58 374 441 0 12 

33 14/11/2012 Wednesday 44 49 316 441 0 12 

33 15/11/2012 Thursday 63 71 6.46 458 441 17 12 5 

33 16/11/2012 Friday 66 75 484 441 43 12 31 

33 17/11/2012 Saturday 47 52 335 441 0 12 

33 18/11/2012 Sunday 36 39 251 441 0 12 

34 19/11/2012 Monday 40 46 

380 441 0 12 

34 20/11/2012 Tuesday 60 68 561 441 120 12 108 

34 21/11/2012 Wednesday 66 72 595 441 154 12 142 

34 22/11/2012 Thursday 51 61 8.26 504 441 63 12 51 

34 23/11/2012 Friday 45 54 446 441 5 12 

34 24/11/2012 Saturday 48 51 421 441 0 12 

34 25/11/2012 Sunday 41 47 388 441 0 12 

35 26/11/2012 Monday 42 56 

369 441 0 12 

35 27/11/2012 Tuesday 45 52 6.59 342 441 0 12 

35 28/11/2012 Wednesday 45 47 309 441 0 12 

Page 19 of 57 




35 29/11/2012 Thursday 56 61 402 441 0 12 

35 30/11/2012 Friday 64 68 448 441 7 12 

35 01/12/2012 Saturday 65 72 474 441 33 12 21 

35 02/12/2012 Sunday 33 42 276 441 0 12 

36 03/12/2012 Monday 35 40 

274 441 0 12 

36 04/12/2012 Tuesday 57 59 405 441 0 12 

36 05/12/2012 Wednesday 58 65 446 441 5 12 

36 06/12/2012 Thursday 52 57 6.87 391 441 0 12 

36 07/12/2012 Friday 47 57 391 441 0 12 

36 08/12/2012 Saturday 48 57 391 441 0 12 

36 09/12/2012 Sunday 34 44 302 441 0 12 

37 10/12/2012 Monday 36 43 

330 441 0 12 

37 11/12/2012 Tuesday 58 60 461 441 20 12 8 

37 12/12/2012 Wednesday 61 68 523 441 82 12 70 

37 13/12/2012 Thursday 67 74 7.70 569 441 128 12 116 

37 14/12/2012 Friday 64 67 515 441 74 12 62 

37 15/12/2012 Saturday 66 72 554 441 113 12 101 

37 16/12/2012 Sunday 54 57 438 441 0 12 

38 17/12/2012 Monday 47 53 

397 441 0 12 

38 18/12/2012 Tuesday 50 57 427 441 0 12 

38 19/12/2012 Wednesday 57 62 465 441 24 12 12 

38 20/12/2012 Thursday 58 63 7.51 472 441 31 12 19 

38 21/12/2012 Friday 64 71 532 441 91 12 79 

38 22/12/2012 Saturday 54 63 472 441 31 12 19 

38 23/12/2012 Sunday 36 48 360 441 0 12 

39 24/12/2012 Monday 31 37 

248 441 0 12 

39 25/12/2012 Tuesday 65 69 462 441 21 12 9 

39 26/12/2012 Wednesday 66 81 543 441 102 12 90 

39 27/12/2012 Thursday 43 56 6.70 375 441 0 12 

39 28/12/2012 Friday 37 58 388 441 0 12 

39 29/12/2012 Saturday 49 57 382 441 0 12 

39 30/12/2012 Sunday 44 47 315 441 0 12 

40 31/12/2012 Monday 47 56 

383 441 0 12 

40 01/01/2013 Tuesday 48 56 383 441 0 12 

40 02/01/2013 Wednesday 53 60 410 441 0 12 

40 03/01/2013 Thursday 55 69 6.84 472 441 31 12 19 

40 04/01/2013 Friday 37 50 342 441 0 12 

40 05/01/2013 Saturday 60 64 438 441 0 12 

40 06/01/2013 Sunday 51 61 417 441 0 12 

41 07/01/2013 Monday 42 50 

348 441 0 12 

41 08/01/2013 Tuesday 53 59 410 441 0 12 

41 09/01/2013 Wednesday 43 46 320 441 0 12 

41 10/01/2013 Thursday 61 65 6.97 452 441 11 12 

41 11/01/2013 Friday 55 65 452 441 11 12 

41 12/01/2013 Saturday 62 69 480 441 39 12 27 

41 13/01/2013 Sunday 35 45 313 441 0 12 

42 14/01/2013 Monday 26 34 

228 441 0 12 

42 15/01/2013 Tuesday 62 76 511 441 70 12 58 

6.73 

42 16/01/2013 Wednesday 35 40 269 441 0 12 

42 17/01/2013 Thursday 48 55 369 441 0 12 

Page 20 of 57 




42 18/01/2013 Friday 48 57 383 441 0 12 

42 19/01/2013 Saturday 59 60 403 441 0 12 

42 20/01/2013 Sunday 44 50 336 441 0 12 

43 21/01/2013 Monday 42 56 

396 441 0 12 

43 22/01/2013 Tuesday 48 55 389 441 0 12 

43 23/01/2013 Wednesday 47 53 375 441 0 12 

43 24/01/2013 Thursday 41 49 7.08 346 441 0 12 

43 25/01/2013 Friday 46 56 396 441 0 12 

43 26/01/2013 Saturday 41 47 332 441 0 12 

43 27/01/2013 Sunday 31 41 290 441 0 12 

44 28/01/2013 Monday 31 45 

351 441 0 12 

44 29/01/2013 Tuesday 37 43 335 441 0 12 

44 30/01/2013 Wednesday 53 63 492 441 51 12 39 

44 31/01/2013 Thursday 43 47 7.81 367 441 0 12 

44 01/02/2013 Friday 47 59 460 441 19 12 7 

44 02/02/2013 Saturday 43 59 460 441 19 12 7 

44 03/02/2013 Sunday 22 34 265 441 0 12 

45 04/02/2013 Monday 24 31 

241 441 0 12 

45 05/02/2013 Tuesday 49 65 505 441 64 12 52 

45 06/02/2013 Wednesday 34 41 319 441 0 12 

45 07/02/2013 Thursday 56 64 7.78 498 441 57 12 45 

45 08/02/2013 Friday 55 61 474 441 33 12 21 

45 09/02/2013 Saturday 54 61 474 441 33 12 21 

45 10/02/2013 Sunday 47 50 389 441 0 12 

46 11/02/2013 Monday 39 42 

279 441 0 12 

46 12/02/2013 Tuesday 58 65 432 441 0 12 

46 13/02/2013 Wednesday 51 60 398 441 0 12 

46 14/02/2013 Thursday 60 68 6.65 451 441 10 12 

46 15/02/2013 Friday 62 81 538 441 97 12 85 

46 16/02/2013 Saturday 45 59 392 441 0 12 

46 17/02/2013 Sunday 41 54 358 441 0 12 

47 18/02/2013 Monday 39 53 

330 441 0 12 

47 19/02/2013 Tuesday 49 63 392 441 0 12 

47 20/02/2013 Wednesday 50 63 392 441 0 12 

47 21/02/2013 Thursday 47 64 6.23 398 441 0 12 

47 22/02/2013 Friday 49 62 386 441 0 12 

47 23/02/2013 Saturday 46 56 348 441 0 12 

47 24/02/2013 Sunday 26 36 224 441 0 12 

48 25/02/2013 Monday 29 36 

261 441 0 12 

48 26/02/2013 Tuesday 49 51 370 441 0 12 

48 27/02/2013 Wednesday 60 68 493 441 52 12 40 

48 28/02/2013 Thursday 47 52 7.26 377 441 0 12 

48 01/03/2013 Friday 50 56 406 441 0 12 

48 02/03/2013 Saturday 64 70 508 441 67 12 55 

48 03/03/2013 Sunday 35 49 355 441 0 12 

49 04/03/2013 Monday 38 50 

282 441 0 12 

49 05/03/2013 Tuesday 46 60 338 441 0 12 

49 06/03/2013 Wednesday 49 60 5.64 338 441 0 12 

49 07/03/2013 Thursday 41 44 248 441 0 12 

49 08/03/2013 Friday 60 64 361 441 0 12 

Page 21 of 57 




49 09/03/2013 Saturday 56 59 333 441 0 12 

49 10/03/2013 Sunday 33 37 208 441 0 12 

50 11/03/2013 Monday 38 51 

363 441 0 12 

50 12/03/2013 Tuesday 46 57 406 441 0 12 

50 13/03/2013 Wednesday 56 65 463 441 22 12 10 

50 14/03/2013 Thursday 42 50 7.13 356 441 0 12 

50 15/03/2013 Friday 44 53 378 441 0 12 

50 16/03/2013 Saturday 49 52 370 441 0 12 

50 17/03/2013 Sunday 50 61 435 441 0 12 

51 18/03/2013 Monday 35 44 

314 441 0 12 

51 19/03/2013 Tuesday 50 60 429 441 0 12 

51 20/03/2013 Wednesday 44 58 415 441 0 12 

51 21/03/2013 Thursday 52 61 7.16 436 441 0 12 

51 22/03/2013 Friday 48 62 443 441 2 12 

51 23/03/2013 Saturday 40 53 379 441 0 12 

51 24/03/2013 Sunday 26 33 236 441 0 12 

52 25/03/2013 Monday 34 51 

371 441 0 12 

52 26/03/2013 Tuesday 38 46 335 441 0 12 

52 27/03/2013 Wednesday 51 62 452 441 11 12 

52 28/03/2013 Thursday 42 52 7.29 379 441 0 12 

52 29/03/2013 Friday 54 68 495 441 54 12 42 

52 30/03/2013 Saturday 51 60 437 441 0 12 

52 31/03/2013 Sunday 41 53 386 441 0 12 

The model is the method by which the Trust will predict and manage the demand for emergency 

beds on a daily basis to enable the Trust to manage its patient flow proactively rather than 

reactively throughout the period. 

The key shows that from the beginning of November 2012 through to the end of March 2013. 

There are occasions when demand exceeds capacity which will be mitigated by a combination 

of:- 

− Reduction in Elective work 

− Transfer of Elective work to Burnley General Hospital 

− Use of the Nurse Led Ward at Burnley General Hospital 

− Use of the Nursing Homes beds commissioned by the CCGs. 

− Impact of Admissions Avoidance schemes provided by the Community division. 

Medical Division Bed Configuration 

MEDICAL BEDS USED WINTER 2012 

Ward 

Ward Name 

Acute 

Beds 

Additional 

Beds/Bays 

Escalation 

Beds 

Rehab 

Beds 

TOTAL 

BEDS 

MAU Medical Assessment Unit 36 36 36 

Page 22 of 57 




ASU Acute Stroke Unit 22 22 

B4 Older People 24 24 

B6 Older People 20 5 25 

B8 Older People 25 25 

B18 Cardiology 26 26 

C1 Gastroenterology 19 19 

C3 Gastroenterology 23 5 28 

C6 Respiratory 25 25 

C8 Respiratory in Bi-pap 20 20 

C10 Older People 22 22 

CCU Coronary Care Unit 10 10 

441 

D1 Gastroenterology 14 10 24 

D1 to "CDS" 13 13 

WD16 Elective Admissions 24 24 

C2 Fast Flow 18 3 21 

C4 Fast Flow 18 3 21 

D3 Older People 20 6 26 

C7 Respiratory 22 22 

C9 Older People 22 22 

C11 Gastroenterology 22 22 

WD23 Community Ward 24 24 24 

HARTLEY Sub-Acute Specialist Rehab 24 24 

MARSDEN Rehabilitation Stroke Unit 24 24 

REEDYFORD Sub-Acute Specialist Rehab 24 24 

91 

RAKEHEAD Complex Specialist Neuro Rehab 19 19 

TOTAL 432 57 12 91 592 

Areas are also being created for winter pressures within wards B6, C3 and D1 and CDS. 

This will result in the following being available from the dates shown below; 

B6 – extra capacity of 5 beds, availability to be confirmed 

C3 – extra capacity of 5 beds, availability to be confirmed 

D5 (CDS) – end of October 2012, creating 13 cohort ward for MRSA 

D1 – end of October, will become a general ward providing an additional 10 beds 

Ward 23 (BGH) – 24 beds, availability to be confirmed 

This will provide an additional 57 beds. 

The plan depends on a high level of bed occupancy; the breakdown of which is shown below: 

Length of Stay, occupancy and revised capacity requirements 

Winter Period - 29th October 2012 - 31st March 2013 (154days) 

Expected Days in Average Modelled Bed Numbers 

Page 23 of 57 




Admissions Period LoS Based on Occupancy 

(2011-12) 

85% 90% 95% 100% 

Predictive Average

8. NON-ELECTIVE SURGICAL ACTIVITY FORECAST 2012/2013 

Calculations, using a similar methodology have also been made for Surgery. 

Predictive Admissions 374 

a b c d e f g h 

Week Date Day 

Predictive 

Daily 

Average 

(2008-12) 

Predictive 

Daily 

Average + 

StdDev 

(2008-12) 

2011-12 

Respective 

Week 

Average 

LoS 

Req 

Beds 

(b*c) 

Available 

Acute 

Beds 

(Exc 

PCH/RH) 

Deficit 

of 

Beds 

(d-e) 

Escalation 

Beds 

Allocated 

Additional 

Escalation 

Beds 

Required 

(f-g) 

31 29/10/2012 Monday 21 22 

170 174 0 0 

31 30/10/2012 Tuesday 28 30 232 174 58 0 58 

31 31/10/2012 Wednesday 32 36 279 174 105 0 105 

31 01/11/2012 Thursday 26 29 7.76 221 174 47 0 47 

31 02/11/2012 Friday 23 25 190 174 16 0 16 

31 03/11/2012 Saturday 30 32 248 174 74 0 74 

31 04/11/2012 Sunday 21 23 174 174 0 0 

32 05/11/2012 Monday 29 31 

198 174 24 0 24 

32 06/11/2012 Tuesday 29 31 198 174 24 0 24 

32 07/11/2012 Wednesday 31 33 215 174 41 0 41 

32 08/11/2012 Thursday 28 30 6.52 195 174 21 0 21 

32 09/11/2012 Friday 30 33 212 174 38 0 38 

32 10/11/2012 Saturday 32 33 215 174 41 0 41 

32 11/11/2012 Sunday 25 27 176 174 2 0 2 

33 12/11/2012 Monday 18 20 

127 174 0 0 

33 13/11/2012 Tuesday 32 34 217 174 43 0 43 

33 14/11/2012 Wednesday 18 22 137 174 0 0 

33 15/11/2012 Thursday 19 22 6.39 140 174 0 0 

33 16/11/2012 Friday 28 32 201 174 27 0 27 

33 17/11/2012 Saturday 32 35 220 174 46 0 46 

33 18/11/2012 Sunday 20 22 137 174 0 0 

34 19/11/2012 Monday 20 23 

132 174 0 0 

34 20/11/2012 Tuesday 22 24 141 174 0 0 

34 21/11/2012 Wednesday 24 26 153 174 0 0 

34 22/11/2012 Thursday 24 26 5.89 153 174 0 0 

34 23/11/2012 Friday 23 25 147 174 0 0 

34 24/11/2012 Saturday 23 25 144 174 0 0 

34 25/11/2012 Sunday 19 22 129 174 0 0 

35 26/11/2012 Monday 19 21 

160 174 0 0 

35 27/11/2012 Tuesday 28 30 235 174 61 0 61 

35 28/11/2012 Wednesday 28 31 7.85 239 174 65 0 65 

35 29/11/2012 Thursday 26 27 208 174 34 0 34 

35 30/11/2012 Friday 26 29 223 174 49 0 49 

Page 25 of 57 




35 01/12/2012 Saturday 22 26 204 174 30 0 30 

35 02/12/2012 Sunday 33 36 282 174 108 0 108 

36 03/12/2012 Monday 13 17 

99 174 0 0 

36 04/12/2012 Tuesday 26 29 172 174 0 0 

36 05/12/2012 Wednesday 31 35 211 174 37 0 37 

36 06/12/2012 Thursday 37 39 6.04 235 174 61 0 61 

36 07/12/2012 Friday 25 30 178 174 4 0 4 

36 08/12/2012 Saturday 44 46 278 174 104 0 104 

36 09/12/2012 Sunday 25 27 163 174 0 0 

37 10/12/2012 Monday 29 32 

163 174 0 0 

37 11/12/2012 Tuesday 26 26 134 174 0 0 

37 12/12/2012 Wednesday 21 23 116 174 0 0 

37 13/12/2012 Thursday 22 24 5.18 121 174 0 0 

37 14/12/2012 Friday 23 25 129 174 0 0 

37 15/12/2012 Saturday 16 17 88 174 0 0 

37 16/12/2012 Sunday 23 26 134 174 0 0 

38 17/12/2012 Monday 15 20 

88 174 0 0 

38 18/12/2012 Tuesday 25 26 117 174 0 0 

38 19/12/2012 Wednesday 24 26 117 174 0 0 

38 20/12/2012 Thursday 20 21 4.51 94 174 0 0 

38 21/12/2012 Friday 27 29 130 174 0 0 

38 22/12/2012 Saturday 26 28 126 174 0 0 

38 23/12/2012 Sunday 26 32 144 174 0 0 

39 24/12/2012 Monday 18 21 

126 174 0 0 

39 25/12/2012 Tuesday 23 25 150 174 0 0 

39 26/12/2012 Wednesday 31 34 202 174 28 0 28 

39 27/12/2012 Thursday 25 27 6.04 163 174 0 0 

39 28/12/2012 Friday 17 18 108 174 0 0 

39 29/12/2012 Saturday 18 21 126 174 0 0 

39 30/12/2012 Sunday 24 27 160 174 0 0 

40 31/12/2012 Monday 18 18 

102 174 0 0 

40 01/01/2013 Tuesday 25 28 156 174 0 0 

40 02/01/2013 Wednesday 35 37 210 174 36 0 36 

40 03/01/2013 Thursday 17 19 5.69 108 174 0 0 

40 04/01/2013 Friday 30 33 187 174 13 0 13 

40 05/01/2013 Saturday 34 38 216 174 42 0 42 

40 06/01/2013 Sunday 34 36 204 174 30 0 30 

41 07/01/2013 Monday 24 25 

150 174 0 0 

41 08/01/2013 Tuesday 31 35 208 174 34 0 34 

41 09/01/2013 Wednesday 34 35 208 174 34 0 34 

41 10/01/2013 Thursday 24 26 6.04 153 174 0 0 

41 11/01/2013 Friday 21 23 138 174 0 0 

41 12/01/2013 Saturday 21 23 138 174 0 0 

41 13/01/2013 Sunday 19 22 129 174 0 0 

42 14/01/2013 Monday 22 25 

154 174 0 0 

42 15/01/2013 Tuesday 22 24 6.17 148 174 0 0 

42 16/01/2013 Wednesday 25 28 169 174 0 0 

Page 26 of 57 




42 17/01/2013 Thursday 25 29 175 174 1 0 1 

42 18/01/2013 Friday 25 28 169 174 0 0 

42 19/01/2013 Saturday 24 25 154 174 0 0 

42 20/01/2013 Sunday 18 20 120 174 0 0 

43 21/01/2013 Monday 24 25 

159 174 0 0 

43 22/01/2013 Tuesday 17 19 118 174 0 0 

43 23/01/2013 Wednesday 28 31 194 174 20 0 20 

43 24/01/2013 Thursday 24 25 6.39 156 174 0 0 

43 25/01/2013 Friday 22 23 146 174 0 0 

43 26/01/2013 Saturday 24 27 169 174 0 0 

43 27/01/2013 Sunday 18 19 121 174 0 0 

44 28/01/2013 Monday 23 25 

158 174 0 0 

44 29/01/2013 Tuesday 24 24 151 174 0 0 

44 30/01/2013 Wednesday 27 29 180 174 6 0 6 

44 31/01/2013 Thursday 26 28 6.33 177 174 3 0 3 

44 01/02/2013 Friday 21 22 136 174 0 0 

44 02/02/2013 Saturday 19 20 126 174 0 0 

44 03/02/2013 Sunday 20 25 155 174 0 0 

45 04/02/2013 Monday 17 19 

112 174 0 0 

45 05/02/2013 Tuesday 27 30 182 174 8 0 8 

45 06/02/2013 Wednesday 26 27 161 174 0 0 

45 07/02/2013 Thursday 21 25 6.08 148 174 0 0 

45 08/02/2013 Friday 25 25 152 174 0 0 

45 09/02/2013 Saturday 24 26 158 174 0 0 

45 10/02/2013 Sunday 20 23 136 174 0 0 

46 11/02/2013 Monday 22 24 

101 174 0 0 

46 12/02/2013 Tuesday 28 30 128 174 0 0 

46 13/02/2013 Wednesday 23 26 112 174 0 0 

46 14/02/2013 Thursday 23 24 4.34 104 174 0 0 

46 15/02/2013 Friday 23 25 106 174 0 0 

46 16/02/2013 Saturday 19 21 88 174 0 0 

46 17/02/2013 Sunday 25 27 117 174 0 0 

47 18/02/2013 Monday 17 19 

95 174 0 0 

47 19/02/2013 Tuesday 26 28 138 174 0 0 

47 20/02/2013 Wednesday 27 29 145 174 0 0 

47 21/02/2013 Thursday 27 29 5.02 143 174 0 0 

47 22/02/2013 Friday 29 32 160 174 0 0 

47 23/02/2013 Saturday 28 30 148 174 0 0 

47 24/02/2013 Sunday 24 27 135 174 0 0 

48 25/02/2013 Monday 29 30 

160 174 0 0 

48 26/02/2013 Tuesday 33 35 184 174 10 0 10 

48 27/02/2013 Wednesday 18 21 112 174 0 0 

48 28/02/2013 Thursday 29 32 5.35 171 174 0 0 

48 01/03/2013 Friday 20 23 123 174 0 0 

48 02/03/2013 Saturday 31 32 168 174 0 0 

48 03/03/2013 Sunday 21 23 120 174 0 0 

49 04/03/2013 Monday 27 29 5.75 166 174 0 0 

Page 27 of 57 




49 05/03/2013 Tuesday 35 37 212 174 38 0 38 

49 06/03/2013 Wednesday 29 31 175 174 1 0 1 

49 07/03/2013 Thursday 28 30 172 174 0 0 

49 08/03/2013 Friday 29 32 183 174 9 0 9 

49 09/03/2013 Saturday 36 38 218 174 44 0 44 

49 10/03/2013 Sunday 20 22 123 174 0 0 

50 11/03/2013 Monday 17 20 

118 174 0 0 

50 12/03/2013 Tuesday 23 25 145 174 0 0 

50 13/03/2013 Wednesday 29 31 183 174 9 0 9 

50 14/03/2013 Thursday 26 30 5.93 175 174 1 0 1 

50 15/03/2013 Friday 16 18 106 174 0 0 

50 16/03/2013 Saturday 20 21 121 174 0 0 

50 17/03/2013 Sunday 21 24 142 174 0 0 

51 18/03/2013 Monday 11 14 

76 174 0 0 

51 19/03/2013 Tuesday 13 15 82 174 0 0 

51 20/03/2013 Wednesday 25 27 153 174 0 0 

51 21/03/2013 Thursday 17 20 5.68 110 174 0 0 

51 22/03/2013 Friday 26 30 167 174 0 0 

51 23/03/2013 Saturday 32 35 196 174 22 0 22 

51 24/03/2013 Sunday 23 25 139 174 0 0 

52 25/03/2013 Monday 24 26 

161 174 0 0 

52 26/03/2013 Tuesday 26 30 186 174 12 0 12 

52 27/03/2013 Wednesday 12 14 85 174 0 0 

52 28/03/2013 Thursday 21 22 6.34 136 174 0 0 

52 29/03/2013 Friday 22 23 145 174 0 0 

52 30/03/2013 Saturday 27 30 190 174 16 0 16 

52 31/03/2013 Sunday 17 21 129 174 0 0 

Bed Configuration Bed Configuration - RBH 

Ward 

Ward Name 

SURGICAL BEDS USED WINTER 2012 

Acute 

Beds 

Additional 

Beds/Bays 

Escalation 

Beds 

Rehab 

Beds 

BG15 Orthopaedic 28 28 

STU Surgery 13 13 

B14 Special Surgery 24 24 

B22 Orthopaedics - HIP Fracture 23 23 

B24 Orthopaedics - general trauma 23 23 

BG6 Ophthalmology 0 0 

BHDU High Dependency 0 0 

BSDY Day Case Surgery 0 0 

C14 Surgery 34 34 

C18 Surgery 36 36 

C22 Urology / vascular 34 34 

CRIC Intensive Care 0 0 

TOTAL 

BEDS 

41 

174 

Page 28 of 57 




DCUR Day Case Surgery 0 0 

END Endoscopy 0 0 

OMFS Max Facs day unit unit 0 0 

POCU Critical Care 0 0 

ROSE Endoscopy 0 0 

SADU Surgical Admiss & Discharge 0 0 

UROC Urology Clinic 0 0 

BUIU UROL. INVESTIGATIONS UNIT 0 0 

TOTAL 215 0 0 0 215 

The model is the method by which the Trust will predict and manage the demand for emergency 

beds on a daily basis to enable the Trust to manage its patient flow proactively rather than 

reactively throughout the period. 

Co-ordination of Operational Escalation plans for the Trust is via 

the Daily Bed Meetings, these will take place 09:30 / 13:00 / 16:00 

and if required 18:00 

Page 29 of 57 




9. MEDICINE – OPERATIONAL PLAN 

Normal activity 

• All wards with predicted discharges will accept one patient from MAU commencing at 10 

am or when the pressure of admissions is exceeding capacity in MAU. 

• The identification of these patients will be the responsibility of the consultant in charge of 

MAU and Senior Nurse in charge of MAU only. 

• Once this escalation is triggered the Consultant in charge of MAU will be notified and a 

registrar will be sent to ED to facilitate assessment of relevant patients. 

• The Acute Physician who commences duties at 1 pm will liaise with the nominated 

Manager of the day for Medicine following the 1pm bed meeting. 

• After discussions at the 1pm bed meeting it may be deemed appropriate to ask the oncall 

Consultant of the day to attend MAU as a matter of urgency to assist with 

assessments of patients or to visit wards to facilitate additional discharges. 

Winter Period Patient Flow Maintenance 

The Medical Division have agreed the following measures to maintain patient flow, and 

maximise clinical and managerial input into the medical wards during the winter period. 

• Daily consultant ward rounds 

• A fully compliant rota for Medical Assessment Unit, the wards, Emergency Department 

and Urgent Care Centres during the holiday period, with daily ward rounds at the 

weekends, between Christmas and New Year and for the duration of the winter period. 

• A separate rota has been devised by the Clinical Director for MAU to cope in the event of 

escalation into extra Medical beds. 

Page 30 of 57 




• Medical Staff Operational plan for escalation wards / outliers 

• Clear rota for managers and matrons over the holiday period and beyond with clear bed 

management and Out of Hours cover. 

• Additional diagnostic sessions to include MR, CT and echo-cardiology services between 

Christmas and New Year and a general emphasis in preventing delayed discharges. 

• Full discharge coordination between Christmas and New Year and at the weekends 

throughout the winter period. 

• PCT have agreed to accept patients into nursing homes prior to formal assessments 

taking place to prevent delayed discharges. This should be initiated via the discharge 

team to individual PCTs 

• Health Economy plan includes spot purchasing of nursing home beds in times of 

extreme pressure. 

Escalation Triggers 

The division has also agreed to refer to the following trigger points when considering 

opening escalation areas, and will inform the bed facilitation team when these trigger points 

have been reached to aide decision making as part of the ELHT/C069 Escalation Plan: 

Delayed handover of patient from NWAS in ED or on MAU this maybe described as the 

following: 

Page 31 of 57 




NON ELECTIVE ADMISSION POLICY FOR THE MANAGEMENT OF PATIENTS FROM 

HANDOVER BY NWAS TO ARRIVING ON WARD 

ACTION CARD 1 

Emergency Department 

Under normal circumstances – below 8 attendances per hour 

The Emergency Department has a total capacity of 26 bays. At times in which ambulance arrivals are 

in a steady state the following should be adhered to:- 

1. Where possible attempt to keep the Emergency Department below or around 20 patients in 

the department. 

2. Or secondly try to keep the patient in the department out of the red status on the CRIS board, 

which indicates that the patient has been in the department for less than 3 hours. 

ACTION CARD 2 

Under pressure – above 8 attendances per hour on an on going basis 

1. The ED coordinator to remind medical staff of impending pressure the department is under. 

2. Coordinator/Consultant in charge to assess all patients in the department with a view to 

convert pre-empt to confirm or discharge. 

3. It should be the aim of the department to process all patients within 3½ hours. 

ACTION CARD 3 

Under significant pressure – Ambulance screen (HAS) shows above 10 patients due to arrive shortly 

1. The action indicated above should be implemented and MAU should be contacted to move a 

corresponding number of patients or more to wards with immediate effect. 

2. The Bed Manager/Duty Manager should liaise with the ED co-ordinator, consultant in charge 

of ED, the MAU co-ordinator and the MAU consultant in charge, following discussion with the 

on call Senior Clinician to ensure that these processes are managed with patients at the 

centre of care with their interests as a priority. 

3. In the event of ambulance queues within ED, trolleys should be made available for NWAS 

staff to off load and additional nursing staff should be provided to manage these patients, this 

should be discussed with the Duty Matron who should consider redeployment from other 

areas. 

a) When patients are queuing in ED move some of these queuing patients (clinical 

unassessed) directly to ward areas following discussion with specialties. 

For example, children who are queuing with an ambulance crew for a cubicle to become 

available can be accepted and seen directly by paeds on COAU. 

Page 32 of 57 




Patients re-attending by ambulance who have been discharged that day, are clinically stable 

can be moved back to the discharging ward area or fast flow rather than queue in ED for a 

cubicle following discussion with specialty. The main reason for re-attends is often lack of 

support services being initiated prior to discharge or inability to manage at home. 

b) Patients awaiting other services, rapid assessment team, accessing intermediate 

care beds or transport home should be moved directly to fast flow areas and should not wait 

until patient in 4 th hour of attendance to do so. This will free up capacity for incoming 

vehicles. (Sometimes the ED requires a little longer than 4 hours to manage this one). 

Medical Staffing Actions 

It would beneficial in these circumstances if the Emergency Department could be assisted, by 

sending speciality junior doctors for example Medical/Surgical Junior Doctors from ward areas 

to assist with clerking and assessment. This should be arranged through discussion with the 

Duty Director and Senior Clinician On Call and where possible should be flagged up in 

advance of the problem occurring which can be predicated by assessing the ambulance HAS 

screens. 

ACTION CARD 4 

Medical Assessment Unit 

The function of Medical Assessment Unit is to assess and treat medically unwell patients, then to 

discharge with possible follow up or admit for further investigation and care. The target length of stay 

is 12 hours. 

The main source of patients is the Emergency Department and GP direct referrals. 

Under normal circumstances 

It is essential that eleven patients are moved every morning from MAU to the Medical Wards. This 

means that patients are placed in either empty beds, or an early discharge is facilitated by 11am, or a 

patient is sat out in the identified seating area, in extreme circumstances an additional trolley in 

placed on wards. 

1. Patients should be moved from MAU continuously throughout the day and night and match 

the activity in ED and GP referrals. 

2. Attempts to run with in excess of 5 empty beds is desirable at all times 

ACTION CARD 5 

Under pressure – more than 10 patients expected and full unit 

1. The MAU consultant and co-ordinator to identify patients for transfer to wards and these 

patients should be sent immediately. (Such patients may not have all paperwork regarding 

assessment completed.) 

2. Sufficient patients should be identified and moved to accommodate those from ED and GP 

direct admissions. 

3. Portering services should be contacted with a view to assisting rapid movement from MAU by 

increasing the complement for approximately 1 hour. 

Page 33 of 57 




ACTION CARD 6 

Under extreme pressure – more than 15 patients expected and full unit 

Follow as above with the following addition:- 

1. If no beds are available on wards, implement the surge plan, which is 1 additional patient per 

ward with supervision on these wards by matron/duty matrons. There must be an assessment 

of the appropriateness of these patients prior to moving by the co-ordinator in the MAU and 

senior clinician staff. 

2. Senior management should consider escalation in conjunction with Senior Clinical Team on 

call including on call senior clinician. 


Following discussions with the Duty Director and Senior Clinical On Call consideration should 

be given to asking the On Call Physician to attend the MAU to assist the Acute Physician with 

senior assessments. It should be noted that these clinicians are on call from 08.00 AM until 

08.00 AM the following day. It should also be noted that the Acute Physicians are not 

considered to be on call and are shifted. 

ACTION CARD 7 

Urgent Care Centres 

The normal capacity is between 20-30 patients. The service provided is for minor injuries and illness. 

Under extreme pressure – up to 40 patients 

1. The consultant in charge in combination with Duty Manager and Senior Clinician on call to 

decide when to implement rapid assessment and triage. It may be feasible to redeploy staff 

from ED or the other Urgent Care Centre, or ask patients to attend their own GP’s if feasible. 

2. Look at capacity at other Urgent Care Centre or minor injury unit and advice patients to attend 

these sites. 

3. In the event of an unwell patient attending the Burnley Urgent Care Centre, staff in the ED to 

be notified and the Senior Consultant to distribute staff accordingly. 

4. Any patient waiting in patient admission should be transferred to appropriate inpatient bed or 

transferred to ED as space allows if inpatient is bed not available. 

5. Patients awaiting transport home should be moved to fast flow areas directly and not wait in 

UCC. (this will free up valuable cubicles within UCC) 


At times of extreme pressure the department should be assessed for the number of minor 

injury patients, if above 20 or it is deemed that quick assessment of these patients will 

alleviate pressure the Orthopaedic Registrar should be contacted following discussion with 

the Duty Director and Senior Clinician On Call. The plan is for the Orthopaedic Registrar to 

work within the Urgent Care Centre reviewing and assessing the minor injury patients. It 

should be noted that many of these patients will not have been reviewed or accepted by the 

Orthopaedic Directorate. 

Page 34 of 57 




At handover you must receive the following information: - 

- How many breaches in last 24 hrs 

- How many of them since midnight 

- What are the main causes 

- What has been done to minimise these 

- Was the plan from the bed meeting/weekend plan followed if not why not 

- Who have any problems been escalated to i.e. Specialty Consultant on call, Senior Clinician 

on call, Director on call 

- Has the on call log been completed 

- If there have been breaches handover should be to someone in Medicine the following day by 

phone or to the next on call manager if at a weekend 

Specific Wards Triggers 

Trigger 

Actions 

C8 (Respiratory Bi-Pap Patients) 

6 patients already on Bi-Pap with no 

immediately signs of a reduction in this 

support for existing number of patients 

1. Respiratory nursing team to assess 3 

x day the status of patients and their 

response on bi-pap 

2. Medical team to review all patients to 

ensure individual treatment plans are 

current and forward planning. 

3. Respiratory MDT to escalate to Senior 

Management potential shortfall within the 

service over the next 24 hour period 

4. Senior Managers to assess 

equipment level & arrange for hiring 

appropriate equipment 

5. Staffing levels to be assessed within 

respiratory wards and re-deployment 

from existing areas 

6. Respiratory Assessment to increase 

their capacity of appropriate patients to 

allow increased nursing input for bi-pap 

patients from respiratory wards 

7. Review situation every 12 hours until 

down to x patients on Bi-Pap 

Page 35 of 57 




Escalation Staffing: Medical Division 

Nurse Staffing 

The Division of Medicine has commenced a recruitment drive during July/August 2012 to 

increase that compliment of all Medical wards to 1.12 nurses per bed across the whole of the 

base compliment of beds, additional winter resilience beds and the additional 24 Nurse Led 

beds at Burnley General. 

Medics Staffing 

Dr N Roberts will be developing a plan to allocate both consultants and Junior Medical Staff 

to these Medical areas. The principle in which this will work is published on the trust intranet 

and works on the basis that the consultant on call takes patients under their care who are 

admitted to escalation areas and the Juniors are actively deployed to the relevant ward area 

– as per medical director’s escalation plan. 

It should be noted that recruitment for additional Junior medical staff for C9, C11 and C7 will 

commence in August/September 2012. 

Surge Plan 

Medical Division Surge Plan 

Please see Action Cards above. 

Surge Plan: Wards Action 

Ward Area Ward Name Action 

Page 36 of 57 




ASU (B2) Acute Stroke Unit 

Not included in Surge Plan, but may have to 

review patients for step-down / early transfer to 

Rehabilitation / Community 

B4 Elderly Care Identify patients for sit-out and step-down 

Hartley 

Will have to review patients for step-down and 

prepare to accept patients from Acute Trust 

Marsden 



Rakehead 

Not included in Surge Plan 

Reedyford 



B6 Elderly Care Identify patients for sit-out and step-down 

B8 Medicine Identify patients for sit-out and step-down 

MAU 

Medical 

Assessment Unit 

C2 

Identify patients for sit-out and step-down 

C4 


CCU 


review patients for step-down 

B18 


review patients for step-down and prepare to 

accept patients from CCU 

C10 

C6 


C8 


C7 


C1 


C9 


C11 


C3 


D1 


PAU - Ward 16 



CDS 

Not included due to Infection Control area 

D3 


If the above is unsuccessful and there is prolonged congestion within the Emergency 

department (see Trigger table below), the Trust Surge Plan would be implemented. 

Page 37 of 57 




Trust Surge Plan 

‘Red Leader’ group chaired 

This will be co-ordinated by the Director of Operations and Medical Director or their named 

deputies and would be implemented when: 

The following triggers continue for over 4 consecutive hours with no obvious improvement: 

Trigger 

Actions 

> 25 patients in ED Move medics from MAU to ED and backfill MAU 

> 2 hour wait in ED for initial assessment 

follows: 

> 40 patients in Blackburn Urgent Care Centre - 2 registrars from wards 

> congestion within MAU 

- 2 FY1’S from wards 

>20 patients waiting to be assessed 

>20 patients waiting to come in 

- Explore the situation relating to 

specialty bed availability and utilise as 

required 

- Cancel routine operations for the 

following day 

- Following cancellation of surgery, 

mobilise medics to assist with managing 

patients in ED / MAU / Medical Wards 

including Escalation wards 

- Consider reducing / cancelling 

outpatient clinics to release medical staff 

to assist in the above 

Page 38 of 57 




10. SURGERY AND ANAESTHETIC SERVICES – OPERATIONAL PLAN 

The Surgery and Anaesthetic Services Division has further refined the way in which it 

ensures all patients are reviewed on a timely basis. Senior Medical Staff ward rounds take 

place on a daily basis for all surgical areas and for those patients who are being cared for in 

escalation areas. 

The introduction of the Surgical Triage Unit has improved the emergency pathway for nonelective 

patients leading to a reduction in length of stay for acute surgical patients. 

The pathway for Orthopaedic trauma patients has also improved with the introduction of the 

Orthopaedic Trauma Team. The Team co-ordinate the flow of patients from the wards to 

theatre ensuring theatre sessions are utilised effectively and the patient does not experience 

any unnecessary delays. In addition an orthopaedic referral can be seen in Fracture Clinic to 

support ED and UCC in times of extreme pressures. 

The Division will significantly reduce elective activity in Christmas Eve and the 2 working 

days between Christmas and New Year. (27 and 28, December 2011). The Division will 

close ward 15 at BGH (elective orthopaedics) and B14 at RBH. Emergency 

ENT/Maxillofacial will be accommodated on C22. The treatment room on B14 will remain 

functional throughout this period. Nursing, medical, administrative staffing levels will be 

reduced accordingly in line with the reduced workload. 

Outside of the Christmas period, Surgery will escalate into B14 and C22 at weekends and 

SDCU or endoscopy (RBH) if required during the weekdays and if pressure is extreme. 

However prior to escalation into SDCU, consideration will be given to cancel elective 

surgery. This will be done in consultation with the relevant Consultant, Clinical Director and 

Business Manager. 

In addition steps will be taken to move as much elective surgical activity to the BGH site and 

to transfer post-operative orthopaedic cases to ward 15 at BGH. In case of long term 

pressure consideration will be given to opening the day unit at BGH as an inpatient facility to 

ensure the continuation of surgical activity, 

Page 39 of 57 




Severe Weather Conditions: Trauma and Orthopaedic Response 

In extreme circumstances i.e. extreme adverse weather conditions with corresponding 

increased trauma activity, the Emergency Directorate and the Orthopaedic Directorate will 

instigate a contingency plan. 

The On Call ED Consultant and 1 st and 2 nd On Call Trauma and Orthopaedic Consultants of 

the day, along with the ED and Orthopaedic Directorate Managers and Matrons will take a 

leading role in determining the action to be taken. 

If the number of patient attendees results in added pressure on the ED/Urgent Care 

Departments the 1 st On Call Trauma and Orthopaedic Consultant will either make themself 

available to assist with patient flow or ask a Senior SpR to attend and assist. This may 

involve the cancellation of other clinical activity. 

Any Gaps in ED Staffing should be highlighted early to the Chair of the bed meeting / 

Manager On Call and Senior Clinician On call. The Trauma Co-ordinators will be alerted to 

the increased pressures and will take a leading role in the allocation of suitable inpatient 

facilities. They will, where possible, prioritise ‘pull through’ those patients presenting with 

fractured neck of femur. 

Page 40 of 57 




11. FAMILY CARE – OPERATIONAL PLAN 

The Division of Family Care will implement the operational measures outlined below in 

response to the anticipated increased demand over the winter period. 

It should be noted that all aspects of the plan are predicated by the expectation that 

increased pressure on the Royal Blackburn site does not force the unexpected/unplanned 

transfer of patients from other specialities to beds within the Lancashire Women & Newborn 

Centre. 

Obstetrics, Gynaecology & Sexual Health. 

The Directorate proposes the following key interventions in response to the expected peaks 

in demand: 

Obstetrics 

• Business intelligence indicates that the maternity service will experience an increase 

in births from November 2011 - January 2012. A workforce plan to ensure adequate 

cover for this surge in activity has been presented to and supported by the DMB in 

July 2011and is reviewed regularly as further business intelligence is known & 

experience of services reconfigured under MPN Service Model A is gained. 

Gynaecology 

• It is planned to go ahead with business as usual over the winter period (including the 

2 weeks covered by the Christmas bank holidays).Lists will only be cancelled for the 

acknowledged bank holidays and the activity plan reflects this. It is anticipated that by 

December breast care will be accommodated on the gynaecology ward and this will 

keep bed occupancy at optimum levels. 

Sexual Health 

• Business as usual apart from the bank holidays. 

There are however, external factors which will impact on the above plan as detailed: 

a. Bed shortages on the RBH site leading to inappropriate transfer of re-habilitated 

patients to the acute Gynae beds. 

Page 41 of 57 




. Protracted adverse weather conditions leading to cancellation of lists/activity due 

to unavailability of nursing/medical staff. 

c. Flu pandemic 

d. Inability to implement the workforce plan due to recruitment difficulties. 

e. The effect of the reconfiguration of the Manchester Making It Better campaign 

within Maternity services which will lead to a further increase in the births. A 

business case to reflect the activity and needs is currently in progress. 

Paediatrics & NICU 

The Directorate of Paediatrics are in the unique position of having no available options to 

increase bed or COAU capacity in response to increased demand. In addition staff from 

other areas cannot be safely redeployed from other specialities. 

As a result key interventions focus on increasing flow, the use of community services to 

support early discharge and increased staffing and senior support by to smooth out peaks in 

demand by the transfer/divert of staff to areas of most demand & the use of Bank and 

agency staff during periods of unanticipated demand. 

In addition the following key interventions are in place/planned: 

• Ward rounds/ reviews are in place three times a day, with focus on discharge early in 

the day. 

• Advanced nurse practitioners are working in ED/UCCs/COAU to prevent admissions 

where clinically appropriate. 

• Close liaison with Tertiary centres for discharge/transfer are in place to ensure 

discharges or admissions are not delayed. 

• Increased senior presence on the COAU at times of peak demand so that children 

are reviewed at a senior level early in their non-elective pathway. 

• Staffing, referrals and patients are diverted, as per escalation procedures, between 

sites to ensure that capacity meets demand. 

• The escalation protocol has been reviewed for CMIU, to ensure processes are in 

place to manage cross-site demand. 

• Senior level support to the COAU/ward has been increased for the winter period, with 

an additional middle grade rota for non-elective services for the winter period. 

Page 42 of 57 




The escalation plan for Paediatrics lays out 4 key status levels: Green, Yellow, Amber and 

Red. Formal escalation actions begin at status yellow. Please refer to escalation procedure 

for key actions at each status level. 

Peaks in demand are first experienced in the COAU. Historically emergency paediatric 

demand is quiet in the mornings and builds to a peak in late afternoon / evening period. The 

paediatric department will flex up staffing to respond e.g. more frequent consultant ward 

rounds, extra staffing including use of advanced paediatric nurse practitioners on COAU. 

The intention is to have an early senior opinion on presenting patients to safely discharge 

children home without unnecessary delay 

There is a fully compliant rota for CMIU, COAU and the inpatient unit. There will be 2 

consultants and a team of middle and junior grade doctors on for emergencies each day and 

2 consultant’s on-call through the night covering: 

• CMIU BGH (6 beds) Opening Hrs 10.00-20.00 (Mon-Fri) & 12.00-20.00 (Sat- 

Sun/B Hols) 

• COAU RBH 24/7 (14 beds) 

• ED RBH 24/7 

• Inpatient Unit RBH 24/7 (50 beds plus 3 HDU beds) 

• Child Protection (inpatient & outpatient) 

Neonatology will respond to any increased demand as per tried and tested escalation policy. 

CAMHS 

It is not anticipated that demand for CAMHS will significantly increase during the winter 

period nor will the expected higher than normal levels of emergency medical attendances / 

admissions impact on the service. 

Page 43 of 57 




12. DIAGNOSTIC AND TREATMENT SERVICES – OPERATIONAL PLAN 

The planned provision of diagnostic and treatment services over the Christmas and New 

Year period 2012-2013 will be shared in detail through our final Christmas plan (Monday 17 

December 2012 to Sunday 6 January 2013), which will be circulated in early December. 

A summary plan for each service is given below, but these will be refined after further 

discussions with stakeholders, as any major changes in activity are likely to affect the DCS 

services, and joint planning will be needed. The priority for DCS will be to provide a flexible 

and responsive service in line with fluctuating demand in order to ensure that patient safety, 

best clinical practice and ‘flow’ is fully supported over the winter period. 

INPUT TO BED MANAGEMENT MEETINGS 

As of 5th November 2012 there will be a representative from DCS at each of the daily bed 

meetings (Monday to Friday). Their role will be to act as a point of contact for any DCS 

issues regarding flow, and to progress chase across the whole of DCS where any potential 

‘flowstoppers’ are identified. This will enable DCS to undertake root cause analysis of 

delays; to work proactively to ensure pathways are improved and to develop systems for 

‘pulling’ and prioritising caseload to support flow where this is clinically feasible. This will 

also be a reactive role promoting rapid response to prevent delays wherever possible. 

PHARMACY 

Pharmacy, as in previous years, will respond to the needs of the Trust in ensuring a 

satisfactory flow of patients. Recruitment is underway for additional pharmacists and a 

pharmacy technician to support wards C7, C9 and C11. Resources to further cover the 

proposed escalation wards will be from within the current pharmacy teams. However, if 

recruitment is unsuccessful prioritisation will be to escalation areas but this will lead to a 

reduction in both pharmacist and technician cover to other areas. In order to support flow 

over this period it would be extremely helpful to have timely and accurate recording/report of 

patients for discharge. This will allow us to focus the resources on the relevant 

areas/patients rather than wait for discharges to be written. Discussions are currently 

ongoing regarding input required for the proposed nurse led ward at BGH. 

RADIOLOGY 

• Weekly monitoring at scheduling meetings will identify shift in demand early. 

Page 44 of 57 




• Shift of workload internally from less impacted areas where possible. 

• Use of capacity lists to keep on top of reporting. 

• Outsourcing of MRI and US scanning to “In-Health” (under contract). (It is unlikely 

this will be required). 

• Outsourcing of reporting to “Medica” (under contract) 

• Creation of the following additional sessions where possible (including extending the 

working day in CT & US) 

CT 2 

MRI 1 

Ultrasound 2 

Plain Film 

1 

Nuclear Medicine 

1 

PATHOLOGY 

Any increase in demand will be absorbed within the current arrangements, through flexible 

working. 

THERAPIES 

Occupational Therapy and Physiotherapy staff will working together through a change 

process in Medicine, Surgery and Orthopaedics to develop an integrated therapy inpatient 

team. This involves realigning processes and paperwork to ensure high quality efficient care, 

prioritising and deploying staff to match capacity with demand on a daily basis, removing 

bottlenecks, avoiding duplication and waste .This will have a positive effect on flow and 

discharge throughout the bed base. As part of this process a review and increase in existing 

provision of physiotherapy and occupational therapy support at weekends is being 

undertaken to assist flow and discharge. 

Outpatient and Community Physiotherapy; Dietetics and Orthotics services are also under 

review and provision will be increased to enable prioritisation of winter demand as required. 

Page 45 of 57 




13. COMMUNITY SERVICES DIVISION – OPERATIONAL PLAN 

This plan provides an overview of the community division response to East Lancashire 

Hospitals NHS Trust winter resilience plan for 2012/2013. 

The aim of the plan is to ensure that all community staff are aware of the requirements of the 

division in service delivery during winter pressures. The winter season has been defined as 

the beginning of November 2012 to the end of March 2013 when higher than normal 

attendances/admissions are expected. Adverse weather in previous years during these 

months has impacted on community division service delivery particularly in domiciliary 

services. It is also recognised that the impact of the holiday period has caused a reduction in 

normal services. 

In order to plan for winter pressures key areas have been planned which have been termed 

as definite and potential schemes and outline actual and potential actions to support the 

division in winter pressures planning. In addition to these contingency plans to ensure 

essential services are in place have been identified. In order to progress these areas further 

an action plan has been developed to ensure this plan can be implemented 

Definite Schemes 

• Last year we created 3 escalation beds on Pendle ward at Clitheroe, increasing the 

total bed stock at CCH from 30 to 33. These beds have remained open. 

• New roles in admissions avoidance have been developed following consultation with 

staff. These posts are based around an infrastructure of integrated locality teams. 

The focus of these roles will be to prevent avoidable hospital admissions, reduce 

readmissions and re-attenders and work closely with staff in secondary care to 

secure timely discharge and enable people to receive care closer to home. They are 

based within RBH and also out in the Community. They identify patients who have 

readmitted within 30 days and patients with multiple readmissions within 12 months. 

They also attend ward rounds in order to sign post and inform the consultants if 

services can be provided in a community setting. They facilitate an early discharge 

and when patients are then discharged home they follow them up and will put in a 

plan of care working with the virtual ward. 

Page 46 of 57 




The admission avoidance staff and discharge facilitation team work together to 

reduce duplication and ensure integrated working and in reach into the wards to 

achieve transfer home once intervention in secondary care is no longer required. 

The staff will be working a 7 day week providing in reach to wards and their role is 

evolving to provide support for patients where it is needed. 

The Virtual Ward is now available across Burnley, Pendle, Rossendale, and 

Hyndburn. Referrals can be made during hours of 8-30 – 4pm at this moment in 

time. The Integrated Community Nursing Team will care for the patients 24 hours. . 

It is well established now with a ‘hub’ providing a base for the staff and referrals 

made. Evaluation of the virtual ward project has indicated positive outcomes in 

relation to supporting complex patients in community settings in prevention of 

hospital admissions which will be relevant during winter pressures. Advanced Nurse 

Practitioners attend in a responsive nature to enable patients to be cared for at home 

instead of the hospital setting 

• A community triage team will be available within the ED to identify patients that could 

potentially be nursed within the virtual ward or other appropriate community settings. 

This will be a multi disciplinary team including social services that will work with all 

East Lancashire patients to enable support to be given in the Emergency Department 

by signposting patients to the most appropriate setting and providing care in the 

community by wrapping services around the patient. There will also be a Community 

Response Unit located close to the ED which will be used by the Community Triage 

team to facilitate a more timely discharge for patients who are medically stable and 

able to be cared for in the Virtual Ward. 

• The Community Division now have an Integrated Community Team, consisting of 

different skill mixes that work on a locality basis to support the Virtual Ward and 

patients in the community. 

• From November 2012 all community nurses will be within an integrated locality team, 

providing case management and further coordinated care which includes therapies. 

• Community staff within the division will be directed to support essential core services 

to meet winter pressure demands. Services have been categorised into essential, 

core and non essential for this purpose 

• Direction has been agreed from all services to allow staff limited holiday leave during 

the winter season. 

Page 47 of 57 




• Immunisation for influenza prevention will be offered to all staff working within 

community division and staff will be actively encouraged to take up the offer of 

immunisation via additional staff clinics. 

• The oxygen providers have given assurances that they have plans to provide extra 

support for the distribution of oxygen supplies over the winter period 

• The Macmillan team would be able to help / support the Integrated Community Team 

by undertaking some visits e.g. syringe drivers. 

• There are also Independent prescribers within the team, who could be directed to the 

front end if required to ensure any palliative care patients were turned around quickly 

or avoid being admitted via ED / MAU 

• There is now a Respiratory Assessment Centre who will see patients with respiratory 

problems admitted either via ED or from home via the GP. They will keep the 

patients for a short period of time with a Consultant oversight and hopefully stabilise 

them to allow them to come home with close observations by the Virtual Ward or 

Integrated Community Teams. 

• Additional resource has been put into CHC assessment processes to be managed 

within DFT. 

Potential Schemes 

• Further educational sessions focussing on appropriate discharge planning for 

medical and nursing staff could be delivered in acute divisional settings with input 

from community division. Additional information highlighting roles of therapists, 

equipment provision and pathways for care can be cascaded via nursing and 

midwifery forums to facilitate more effective earlier discharges from hospitals. 

• Further work with social services could be initiated to enable support for admissions 

avoidance via in reach work and advanced practitioners increasing or restarting 

packages of care. 

• The Podiatry Service has staff on site at RBH in the Diabetes Unit who could 

expedite discharges to Community Services following appropriate liaison and 

communication of discharge plan of patient. 

• A nurse led ward is proposed to be open on Ward 23 over the winter at BGH site – 

plans are underway but have still not been confirmed as yet. Within this ward 12 

beds will be used for step down beds and 12 will be for patients admitted through ED 

that can be cared for on this ward – the types of patients will be LTC patients that 

Page 48 of 57 




have exacerbated, elderly frail that have deteriorated, etc. These patients will be 

coordinated with the Community Response Unit. If the ward is unable to open, 

further resources will be provided to provide extra support for patients to be nursed in 

the community. 

• Negotiations are underway with commissioners to agree direct access to step down 

beds for appropriate patients with particular reference to CHC assessment 

processes. 

• Need to support education for medical staff to indicate that patients are medically 

stable, no longer require acute care and are fit for discharge in order to support safe 

discharge processes. 

Community Division staff have access to a 4 wheel drive vehicle which may be used by 

domiciliary care staff. Only staff who have received awareness training to use the 4 wheel 

drive may use this vehicle. 

Contingency Planning for winter pressures 

The priorities below outline the actions to be taken in community division services due to 

winter pressures: 

Priority level 1- inpatient beds at Clitheroe and Accrington Community Hospitals 

If the impact of winter pressures affects the capacity of the inpatient facility within the 

Community Hospitals the focus is to ensure all wards remain open and all available beds 

can be utilised. In the event of reduced staffing levels affecting this service the hospital 

manager will utilise staff from other community services. 

Priority level 2- Essential Services affected by winter pressures 

Reduced capacity within any of the essential services due to winter pressures must be 

supported by managers by accessing staff from non essential services to support care 

delivery during the affected period. 

Page 49 of 57 




14. FACILITIES 

The Trust has two 4 wheel drive vehicles that are available for use during adverse weather 

conditions. These vehicles are only driven by qualified transport staff. 

The Logistics Department would need prior warning to facilitate the 4 wheel drive service – 

this would coincide with weather warnings. 

Page 50 of 57 




15. REPORTING 

Bed Meetings take place three or four times daily (depending on pressures). Daily Internal 

SITREP reports are circulated. 

Teleconference calls health economy wide will take place regularly, frequency will be 

determined depending on status declared. 

Page 51 of 57 




16. PANDEMIC INFLUENZA 

Although as of September 2012 there is no longer an immediate threat from pandemic 

influenza, the dangers associated with H1N1virus still remains prevalent, and therefore the 

risks to our patients and staff remains. 

Working in conjunction with the Department of Health (DH) and the NHS, ELHT remains 

vigilant to the unpredictability of influenza and has developed plans to be in a position to 

deal with such an event occurring. 

The Trust has a duty of care and a responsibility to have localised plans in place. The Chief 

Medical Officer (NHS North of England) recently distributed guidance on the seasonal 

influenza vaccination programme for 2012/13. Based on the work undertaken last year, an 

increased target to vaccinate 70% of frontline health workers has been set. 

With this in mind ELHT has put in place a dedicated Influenza Vaccination Team which is 

overseen by the Influenza Task and Finish Group. An action plan has been developed 

which includes a programme of events to deliver the vaccination roll out to our staff and our 

patients that fall into the ‘at risk category’. 

These plans have been developed in conjunction with NHS North of England’s guidance and 

their six key elements which the Trusts influenza programme has been based and designed 

around. We have also used the following documents during the design stage of our plans. 

• NHS North West Strategic Health Authority Pandemic Influenza Plan 

• DH Seasonal Flu Plan Winter 2012 / 13 

The Trust Influenza Plan has been updated to reflect the most current influenza guidance 

and built into the plans is the capacity to order additional vaccines if there is a surge in 

demand. 

In the event of a pandemic or a local increase in influenza related cases the ELHT Trust 

Surge Management Plan will be referred to. The DH and the Health Protection Agency 

(HPA) monitor the spread and outbreaks of pandemic influenza both worldwide and 

Page 52 of 57 




nationally. Close scrutiny and monitoring of influenza has been observed over that past year 

due to the Olympics and European Football Championships. 

The strategic management of the influenza programme will be overseen by the Emergency 

Preparedness Group (EPG). EPG will monitor progress of the action plan and will allow 

escalation of potential issues should they arise, and provide feedback to the Trust Board for 

assurance purposes. 

Page 53 of 57 




17. COMMUNICATIONS 

All communications will be handled via the ELHT Communications team in co-operation with 

other health economy communication leads during normal working hours. 

Out of hours all external communication requests should be directed to the senior manager 

on-call. The Director on-call who will ultimately decide what information is released out of 

hours on the advice of the senior manager on-call, or Silver Command (Flu Escalation 

Group) in the event of a ‘Major Incident’ being declared. 

ELHT will participate in the NHS North West wide Choose Well campaign. 

Page 54 of 57 




18. RISKS 

Potential risks compromising the integrity of this plan include: 

• Higher than forecasted number of medical or surgical attendances and admissions 

• Delayed discharges due to reduced Social care 

• Impact on delivery of national targets 

• High levels of staff sickness 

• The unavailability of the necessary medical and nursing staff 

• Higher than nationally predicated levels of influenza 

• Outbreaks of MRSA, C.Diff and Noro virus 

• Increased lengths of stay 

• Lower than anticipated primary care/ GP out of hours provision 

• Lack of ambulance provision 

• Lower than anticipated community team provision 

• Lower than anticipated social services provision 

• Loss of income 

Risk assessments and mitigation plans will be signed off by Divisional Management Boards 

for consideration by the Executive Management Team. 

Page 55 of 57 




19. CONCLUSION 

East Lancashire Hospitals NHS Trust has robust plans in place for managing demand and 

increasing capacity during periods of peak activity throughout the winter season. 

Underpinning these plans are clear procedures and trigger points when contingency plans 

should be implemented, all of which are based on national and regional guidance and best 

practice. 

This plan will be measured against the NHS North West Assurance checklist. 

Page 56 of 57 




20. ADDITIONAL READING 

Additional supporting documents on East Lancashire Hospitals NHS Trust intranet include: 

- East Lancashire Hospitals NHS Trust Surge Management Plan Version 5.0 

- East Lancashire Hospitals NHS Trust Pandemic Influenza Plan Version 3.0 

http://elancs.intranet/ep/Docs/ELHT%20Pandemic%20Influenza%20Plan%20- 

%20V3.pdf 

- East Lancashire Hospitals NHS Trust Major Incident Plan Version 3.0 

http://elancs.intranet/ep/Docs/MAJOR%20INCIDENT%20PLAN%20- 

%20VERSION%203%20-%20MARCH%202011.pdf 

Page 57 of 57 





PART ONE 

Meeting Date: 


31 st October 2012 For Decision □ 

Performance Monitoring 



Governance 

Finance 

Information and HR 


Lynn Wissett 

Deputy Chief Executive 

Report Title: 

Integrated Performance & 

Patient Safety and Quality 

Report 

Departments 


Committee 

Date 



NA 

Yes No 

Implications For Partners: Contractual performance and reputation 

Related to key risks identified on • Position against key indicators 


contained within the NHS Operating 

Framework, Monitor Compliance 

Framework, Quality Schedule 

(including CQUIN) and Standard Acute 

Trust contract. 

Related to Corporate • Improved patient experience by putting 

Commitments: 

quality at the centre of everything we 

do. 

• Delivery of all national standards and 

targets. 

• Improved productivity. 

• Improved efficiency. 

Legal Implications Identified: Contractual implications 

Data Protection Implications None identified 

Identified: 

Diversity and Equality None identified 




• A comprehensive service available to 

all 

Page 1 of 2 



V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(10) Integrated Performance Report.docx


Outcomes: 





• Aspiring to highest standards of 

excellence & professionalism 








communities 





The Integrated Performance Report details the 

Trust’s latest operational performance against 

all key indicators by way of dashboards. The 

dashboards are accompanied by exception 

reports highlighting key achievements and 

areas of focus. 

To acknowledge the improvements, note the 

exceptions and seek assurance that 

appropriate actions are being progressed 

where improvements are required. 

Page 2 of 2 



V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(10) Integrated Performance Report.docx

Assessment against Monitor Compliance Framework 2012/13 

Governance Risk Rating 

Area Measure Definition 

How Performance will be Judged 

Safety 

MRSA bacteraemia 

If not in best performing quartile, at least in line with 

DoH objective targets set. If no target, sustain existing 3 1 Quarterly 

1 Q1 

1 Q2 

0 0 0 

performance. 

2 YTD 

HCAI measure (MRSA & CDI) 

6 Q1 

Safety CDI 

Meeting the C Diff objective 43 1 Quarterly 11 Q2 

1 0 0 

17 YTD 

Threshold 

(no 

rounding) 

Weighting 

Monitoring 

Period 

Performance 

Quarter 2 

Quarter 2 

Quarter 3 

Forecast 

Rolling 4 

Quarter 

Forecast 

Quality 

Quality 

Quality 

Quality 

Quality 

Quality 

Quality 

Quality 

Patient 

Experience 

Patient 

Experience 

Patient 

Experience 

Cancer 2 week wait from referral to date 

seen either: 

Cancer 62 day wait for first treatment 

comprising either: 

All Cancers: 31 day wait from diagnosis to 

first treatment 

All cancers: 31 day wait for second or 

subsequent treatment comprising either: 

Referral to Treatment waiting times 



Percentage of patients seen within two 

weeks of an urgent GP referral for 

suspected cancer 

Percentage of patients seen within two 

weeks of an urgent referral for breast 

symptoms where cancer is not initially 

suspected 

Percentage of patients receiving first 

definitive treatment for cancer within 62- 

days of an urgent GP referral for 




days of referral from and NHS Cancer 

Screening Service 


definitive treatment within 31 days of 

decision to treat 

Percentage of patients receiving 

subsequent treatment for cancer within 

31-days where that treatment is Surgery 



31-days where that treatment is an Anti- 

Cancer Drug Regime 



31-days where that treatment is a 

Radiotherapy Treatment Course 

Percentage of patients treated within 18 

weeks - 

Admitted Pathways 

Percentage of patients treated within 18 

weeks - Non-Admitted Pathways 

Percentage of patients on an ongoing 

pathway waiting less than 18 weeks 

Failure against any threshold will represent failure of 

the target 


the target 


the target 


the target 


the target 


the target 


the target 


the target 

While performance is measured on an aggregate basis 

NHS FT's are required to meet the threshold on a 

monthly basis - failure in any month represents failure 

for the quarter. 









93% Quarterly 

0.5 

93% Quarterly 

85% Quarterly 

1 

90% Quarterly 

Jul/Aug 

96% 0.5 Quarterly 0 0 0 

97.05% 

94% Quarterly 

98% 1 Quarterly 

Jul/Aug 

95.51% 

Jul/Aug 

96.69% 

Jul/Aug 

89.75% 

Jul/Aug 

97.73% 

Jul/Aug 

97.4% 

Jul/Aug 

100% 

94% Quarterly n/a 

n/a n/a n/a 

90% 1 Quarterly 93.9% 

0 0 0 


0 0 0 


0 0 0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Quality A & E Total time spent in A & E 

%age of patients waiting less than 4 hours >95% 1 Quarterly 95.97% 

0 0 0 

Effectiveness 

Data completeness: Community Services 

Data completeness, using CIDS 

definition, across 7 fields 

Failure against any field within the data set will incur a 

score of 0.5 

50% 0.5 Quarterly All >50% 

0 0 0 

Patient 

Experience 

Self certification against compliance with 

requirements regarding access to 

healthcare for people with a learning 

disability 

` 

Meet the 6 criteria for meeting the needs of people with 

learning disability, based on recommendations set out 

in Healthcare for All (2008) 

n/a 0.5 Quarterly 0 0 0 

Service Performance 

Score 

Key: 

Governance Risk Rating 

=1 =2 =4 Red 

Maximum 

weighted 

score 

10 1 0 0 

Governance Risk Rating : Amber/Green Green Green

Department of Health - Operating Framework: Acute Trusts Service Performance 2012/13 

Thresholds 

Performance Indicator 

Numerator Denominator Performing 

Underperforming 

Weighting 

for PF 

Data 

frequency 

Monthly/QTD/YTD 

Performance 

September 

2012 

ELHT Score 

ELHT 

Weighted 

Score 

Total time in A&E - 95% of patients 

should be seen within four hours 

The number of patients spending four hours or less 

in all types of A&E department 

The total number of patients attending all types of A&E 

department 

95% 94% 1 Weekly QTD 95.62% 3 3.0 

MRSA 

Actual number of MRSA Planned number of MRSA 0 >1SD* 1 Monthly YTD 2 3 3.0 

C Diff 

Actual number of C Diff cases Planned number of C Diff 0 >1SD 1 Monthly YTD 17 3 3.0 

RTT - admitted - 90% in 18 weeks 

RTT - non-admitted - 95% in 18 weeks 

RTT - incomplete 92% in 18 weeks 

RTT delivery in all specialties 

Diagnostic Test Waiting Times 

Total number of completed admitted pathways 

where the patient waited 18 weeks or less 

Total number of completed non-admitted 

pathways where the patient waited 18 weeks or 

less 

Total number of incomplete pathways where the 

patient waited 18 weeks or less 

Number of treatment functions where standards 

are not delivered (admitted, non-admitted and 

incomplete pathways) 

The number of patients waiting 6 weeks or more 

for a diagnostic test (15 key diagnostic tests) at the 

end of the period 

Total number of completed admitted pathways 90% 85% 1 Monthly Month Actual 93.2% 3 3.0 

Total number of completed non-admitted pathways 95% 90% 1 Monthly Month Actual 99.0% 3 3.0 

The total number of incomplete pathways at end of the period 92% 87% 1 Monthly Month Actual 96.3% 3 3.0 

0 >20 1 Monthly Month Actual 0 3 3.0 

The total number of patients waiting at the end of the period

Performance Indicator 


definitive treatment within one month 

(31-days) of a cancer diagnosis 

(measured from ‘date of decision to 

treat’) 

Numerator Denominator Performing 

Number of patients receiving first definitive 

treatment for cancer within 31 days of receiving a 

diagnosis (decision to treat) within a given period 

for all cancers (ICD-10 C00 to C97 and D05) 

Total number of patients receiving first definitive treatment for 

cancer within a given period for all cancers (ICD-10 C00 to C97 and 

D05) 

Thresholds 

Underperforming 

Weighting 

for PF 

Data 

frequency 

96% 91% 0.25 Monthly 

Monthly/QTD/YTD 

Month Actual 

August 

Performance 

September 

2012 

ELHT Score 

ELHT 

Weighted 

Score 

96.60% 3 0.8 

Proportion of patients waiting no more 

than 31 days for second or subsequent 

cancer treatment (radiotherapy 

treatments) 

Number of patients receiving subsequent/adjuvant 

radiotherapy treatment within a maximum waiting 

time of 31-days during a given period, including 

patients with recurrent cancer. 

Total number of patients receiving subsequent/adjuvant 

radiotherapy treatment within a given period, including patients 

with recurrent cancer. 

94% 89% n/a Monthly 

Month Actual 

August 

Not applicable 

Not 

applicable 

Not 

applicable 

62-Day Wait for First Treatment 

Following Referral from an NHS Cancer 

Screening Service 

All Cancer Two Month Urgent Referral 

to Treatment Wait 

Delayed transfers of care 


treatment for cancer within 62-days following 

referral from an NHS Cancer Screening Service 

during a given period (covers any cancer ICD-10 

C00 to C97 and D05) 


treatment for cancer within 62-days following an 

urgent GP (GDP or GMP) referral for suspected 

cancer within a given period, for all cancers (ICD-10 

C00 to C97 and D05) 

The average number of acute and non-acute 

patients (aged 18 and over) per day whose transfer 

of care was delayed during the quarter. The 

average number of delayed transfers of care is 

calculated by dividing the total number of delayed 

days during the quarter by the number of days in 

the quarter. 


cancer following referral from an NHS Cancer Screening Service 

within a given period (covers any cancer ICD-10 C00 to C97 and 

D05) 


cancer following an urgent GP (GDP or GMP) referral for suspected 

cancer within a given period, for all cancers (ICD-10 C00 to C97 and 

D05) 

The average number of occupied beds per day. The average 

number of occupied bed days is calculated by dividing the total 

number of occupied bed days (consultant-led and non-consultantled 

bed days) during the quarter by the number of days in the 

quarter. 

90% 85% 0.50 Monthly 

85% 80% 0.50 Monthly 

Month Actual 

August 

Month Actual 

August 

100.00% 3 1.5 

88.10% 3 1.5 

3.5% 5.0% 1 Quarterly Quarter Actual 1.30% 3 3.0 

Mixed Sex Accommodation Breaches 

The number of MSA breaches for the reporting 

month in question 

The number of Finished Consultant Episodes (FCEs) that finished in 

the month, regardless of when they started. 

0.0% 0.5% 1 Monthly Month Actual 0 3 3.0 

VTE Risk Assessment 

Number of adult inpatient admissions reported as 

having had a VTE risk assessment on admission to 

hospital using the clinical criteria of the national 

tool (including those risk assessed using a cohort 

approach in line with published guidance). 

Number of adults who were admitted as inpatients (includes day 

cases, maternity and transfers; both elective and non-elective 

admissions) 

90.0% 80.0% 1 Quarterly Quarter Actual 94.43% 3 3.0 

Sum of weights 

13.75 54 41.3 

Scoring values 

Underperforming: 

Performance under review: 

Performing: 

0 

2 

3 

Overall performance score threshold Underperforming if less than 2.1 

Performance under review if between 2.1 and 2.4 

ELHT position based on 

current performance* 

3.00 

* Performance calculation - weighted score divided by sum of applicable weights

Patient Safety and Experience 

Mortality Dashboard 

Safety Thermometer 

Indicator 

HSMR 

SHMI 

Observed deaths as index of the 

national rate 

Expected deaths as index of the 

national rate 

Palliative care as index of the 

national rate 

Comorbidity as index of the 

national rate 

Top 10 mortality diagnos is groups 

(all diagnos es) 

Rolling 12 month - ranked by 

highest volume of deaths in 

period 

By admis sion 

(all diagnos es) 

Mortality Alerts 

(HSMR/Diagnos is /Procedures) 

Rolling 12 month period 

56 diagnos is groups 

All diagnos is 

Rolling I2 

April 2011/ 

Q1 12/13 Q2 12/13 2012/13 

Months 

March 2012 

(Aug 11 to 

(post-rebase) 

(April-June) (July) YTD 

July 12) 

102.8 100.1 96 105.6 98.5 

97.7 - 108 95.1-105.2 86.3-106.5 88.1-125.5 90 - 107.6 

113 

n/a 

(2011/12) 

(100 = average) 99 

96 97 

(100 = average) 92 

93 93 

Pneumonia 

Acute Cerebro vascular disease 

Congestive heart failure non 

hypertensive 

COPD 

Acute MI 

Acute and unspecified renal 

failure 

Septicaemia 

Fracture neck of femur 

Gastrointes tinal haemorrage 

Urinary Tract Infections 

Elective Admis sions 

Emergency Admissions 

Red 

Green 

April 2010/ 

March 11 

108 

(102.9-113.4) 

113 

57 

108 

112 

100.4-124.5 

103.9 

87.8-122 

103.3 

82.8-127.3 

117.9 

95.8-143.5 

108.6 

83.1-139.6 

109.4 

77.8 - 149.6 

101.9 

77.9-130.9 

93.9 

68.6-125.3 

88.3 

64.4-118.1 

102 

73.5-137.8 

79.1 

56.5-107.7 

109.4 

104.6-114.4 

68 69 

107 107 

112.8 118.3 136 97.8 125.9 

101-125.6 106.3-131.2 110.9-165.1 61.3-148.1 104.6-150.2 

110.3 110.4 84.3 130 96.7 

93-129.8 94.1-128.3 58.4-117.9 75.7-208.1 72.2-126.8 

103.7 108.4 109 94.2 111.8 

82.2-129.1 86.6-134.1 67.4-166.6 34.4-205.1 74.8-160.5 

93.2 84.2 67.2 55.5 61.2 

73.2-117.0 65.4-106.8 36.7-112.8 11.2- 162.2 35 -99.4 

99.8 82.7 98 103.7 102.4 

77.5-126.5 62.5-107.5 59-153.1 20.8-302.9 64.9-153.7 

105.7 91 77.3 56.1 73.4 

77.1-141.4 66.8-121 39.9-135.1 6.3-202.4 40.1-123.1 

117.8 99.2 84.6 52.1 77.5 

90.3-151 72.6-132.4 38.6-160.6 5.9-188.2 38.6-138.6 

101.2 108.4 91.7 205.7 125.3 

72.9-136.8 78.7-145.5 39.5-180.6 88.6-405.2 71.6-203.5 

104 106.5 124.4 71.2 111.6 

74.9-140.5 76.8-144 62-222.6 8.0 - 257.1 59.4-190.8 

93.5 86.8 116.6 86.6 106.8 

67.1 - 126.9 61.1-119.6 58.1-208.7 23.3-221.7 59.7-176.1 

86.3 86.6 76.6 42.4 67 

61-118.4 61.6-118.4 34.9-145.4 4.8-153.1 33.4-119.8 

103.7 101.4 97.6 108.1 100.2 

99-108.6 96.8-106.2 88.7-107.3 91.9-126.3 92.3-108.6 

6 

9 

Complaints 

Patient Experience Surveys 

September 2012 Totals Overall Dignity Information Involvement Quality 

No. % % % % % 

Trust 991 93% 97% 93% 96% 93% 

Medicine 233 96% 99% 92% 96% 99% 

Surgery 220 92% 94% 92% 96% 93% 

Family care 244 91% 97% 93% 95% 87% 

Community 153 94% 99% 95% 95% 98% 

Diagnostic and Clinical 141 95% 98% 96% 99% 95% 

Key 0%-79% 80%-89% 90%-100%

Performance Escalation 

HCAI Measure 

Standard September Q2 Year to Date Forecast 

Monitor - meet quarterly trajectory 

Meeting the C. Difficile Objective 4 11 17 A 

DoH - meet cumulative trajectory 

What is driving the reported underperformance? 

What actions are being taken to improve performance? 

Monitor and the Department of Health use different methodology to 

measure performance against the C. Difficile objective. 

The Department of Health Operating Framework measure specifies 

that to be assessed as underperforming, Trusts would need to be >1 

standard deviation of the cumulative year to date trajectory. As at 

September, performance remains within the cumulative trajectory of 

18 at 17 cases and as such, will be judged as performing. 

There is increased monitoring of high impact interventions and an increased presence of the Infection Control team on wards. Root cause analysis is undertaken on each case and lessons learned. 

In addition the following actions are being reinforced:- 

- staff reminded to hand wash with soap and water rather than gel. 

- regular cleaning of furniture. 

- bioquelling of areas if increased incidence continues. 

- bioquelling of areas throughout the update programme will continue. 

Monitor measure performance on a quarterly basis against the 

trajectory for the month and quarter. The month trajectory for 

September was 3 cases with a reported incidence of 4. Quarter 2 

performance 11 cases against a quarter trajectory of 7. 

Going forward the trajectory for Quarter 3 is 13 cases. 

The Infection Control Team ensure that individual action plans are in place at ward level to address issues and where increased incidence is noted, wards are kept under special monitoring measures until 

they have been 100% incident free for 3 consecutive weeks. 

Expected date to meet standard: October 2012 

Lead Director 

L Wissett 

Patient Safety and Experience - Mortality 

Standard 

April 2011 to March 2012 

2012/13 Forecast 

SHMI National average 100 

113 - above expected Not available R 



The SHMI has been reported as higher than expected for 2011/12 at 

113 whereas HSMR is within expected range at 102.8. 

In order to help further understand the variance between the two measures, an independent expert analysis into the reported SHMI has been commissioned from Dr Foster Intelligence and the report is 

awaited. 

The main difference between to the 2 measures are: 

- SHMI monitors in and out of hospital deaths for up to 30 days 

following discharge. 

Repeated queries have been submitted to the Information Centre as regards the rationale to make no adjustment for deprivation - given the demographics of our local population it is likely this will impact 

negatively on the reported SHMI. 

In response to receiving this query from many other Trusts the Information Centre are to release further detailed information regarding deprivation levels alongside the SHMI figure at the end of October. 

- SHMI measures all diagnoses groups against the 56 diagnosis 

groups in HSMR. 

- SHMI makes no adjustment for palliative care or deprivation. 

- SHMI has only 1 year national benchmark data, HSMR uses 10 

years of data. 

Expected date to meet standard: April 2013 

Lead Director 

C Schram

£000 

£000 

£000 

Net Surplus / (Deficit) Plan Actual Variance ------------ In-month ----------- ---------- Year to date ---------- 

YTD Prior Prior Yr 

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

1.5 

1.0 

0.5 

0.0 

-0.5 

Current CIP Performance 

£m £m £m Plan Actual Variance Plan Actual Variance Actual Month Movement Closing 

Cumulative 2.0 2.1 0.1 £m £m £m £m £m £m £m £m £m £m 

In Month 0.3 0.3 0.0 Income 

Patient care revenue 30.3 30.9 0.6 183.5 186.0 2.5 

Other operating income 1.8 1.7 (0.1) 10.6 10.7 0.0 

Total Assets 293.2 296.9 (3.7) 285.7 

Annual Annual YTD YTD YTD 

Plan Best Case Target Achieved Variance 

£000 £000 £000 £000 £000 

Current Month 16,208 14,992 7,229 7,230 1 

3,000 

2,500 

2,000 

1,500 

1,000 

500 

East Lancashire Hospitals NHS Trust: Financial Overview as at 30 September 2012 

Overall Income & Expenditure Position Summary of Financial Position Summary Balance Sheet 

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

0 

Cumulative Actual 

Cumulative Variance 

Forecast 

Expenditure 

Pay (21.2) (21.4) (0.2) (127.2) (126.7) 0.5 Total Liabilities (170.3) (174.5) 4.2 (162.9) 

Non-Pay & Reserves (8.4) (8.7) (0.3) (51.8) (54.8) (3.0) 

Total Assets Employed 122.9 122.4 0.5 122.8 

EBITDA 2.6 2.6 (0.0) 15.1 15.2 0.1 

PDC/Depreciation/Interest (2.0) (2.0) 0.0 (11.9) (11.9) 0.0 

Surplus/(Deficit) 0.5 0.6 0.0 3.2 3.3 0.1 

Financed by: 

(Impairments)/reversals 0.0 0.0 0.0 (3.0) (3.0) 0.0 

Surplus/(Deficit) 0.5 0.6 0.0 0.2 0.3 0.1 Taxpayers Equity 122.9 122.4 0.5 122.8 

Non-IFRIC12 Impairments 0.0 0.0 0.0 4.0 4.0 0.0 

IFRIC12 and donated assets (0.2) (0.2) (0.0) (2.2) (2.3) (0.0) 

Breakeven Performance 0.3 0.3 (0.0) 1.9 2.1 0.1 

CIP Performance 

£m 

Total Trust Savings Target Planned 

18.0 

16.0 

14.0 

12.0 

10.0 

8.0 

6.0 

4.0 

Financial Risk Ratings 

2.0 

I&E Surplus 

0.0 

Margin 


NOTE: The liquity ratio assumes a working capital facility of £29.8m representing 

approx. 30 days of operating expenditure. This would need to be arranged as part of 

the FT application process. 

Bridge Analysis - Income variance Bridge Analysis - Pay Expenditure variance Bridge Analysis - Non-Pay Expenditure variance 

0 

(100) 

(200) 

(300) 

(400) 

(500) 

(600) 

(700) 

(800) 

(900) 

(1,000) 

Progressing 

Actioned 

Plan 

3,500 

3,000 

2,500 

2,000 

1,500 

1,000 

500 

0 

YTD 

Overall 

Liquid Ratio 

EBITDA Margin 

5 

4 

3 

2 

1 

0 

EBITDA % 

Achieved 

Net return after 

financing

Oct-11 

Nov-11 

Dec-11 

Jan-12 

Feb-12 

Mar-12 

Apr-12 

May-12 

Jun-12 

Jul-12 

Aug-12 

Sep-12 

£m 

18 

16 

14 

12 

10 

8 

6 

4 

2 

Capital Expenditure 

- 


Revised 

Plan 

0.05 0.20 0.47 0.94 1.58 2.02 2.99 4.48 6.98 9.35 11.92 15.63 

Actual 0.04 0.24 0.54 1.10 1.34 1.70 

East Lancashire Hospitals NHS Trust: Financing Overview as at 30 September 2012 

£m 

45 

35 

25 

15 

5 

(5) 

(15) 

(25) 

(35) 

(45) 

Working Capital 

Axis Title 

Creditors Cash Debtors Stock Total 

Better Payment Practice Code 

Aged Debt Analysis 

100% 

98% 

Non-NHS Payables 

100% 

98% 

NHS Payables 

£000 

Total Gross Debtors >30 days 

31 - 60 61 - 90 

96% 

96% 

4,000 

91 - 365 1 Year+ 

94% 

92% 

90% 

% Invoices paid within target 

(number) 

% Invoices paid within target 

(value) 

94% 

92% 

90% 

% Invoices paid within 

target (number) 

% Invoices paid within 

target (value) 

3,500 

3,000 

2,500 

2,000 

Performance Actual Actual 

Target % 

September 

2012 

YTD 

Non NHS - No. of invoices 95.0% 95.9% 97.0% Meeting target 

Non NHS - Value of invoices 95.0% 97.4% 97.3% Meeting target 

NHS - No. of invoices 95.0% 98.2% 96.9% Meeting target 

NHS - Value of invoices 95.0% 99.9% 99.2% Meeting target 

Comments 

1,500 

1,000 

500 

0 

Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 

Performance Actual Actual Performance 

Target Days September Prior Mth 

Target 

2012 

Capital Absorption Rate 3.50% 

Payable Days 45.0 56.0 59.8 Meeting target External Financing Limit (EFL)* £2,681k 

Receivable Days (Gross Debt) 15.0 6.4 5.6 Meeting target Capital Resource Limit (CRL)* £13,639k 

Statutory Financial Duties 

*These are annual targets reported at Month 12 

. The Trust is on plan to achieve its Statutory 

Financial Duties

Financial Risk Rating 

Financial 

Criteria 

Weight (%) 

Metric to be scored 

Rating Categories Quarter 2 

5 4 3 2 1 

Quarter 3 

Forecast 

Rolling 4 

Quarter 

Forecast 

Achievement of Plan 

10 

EBITDA achieved (% of plan) 100 85 70 50

Human Resources Indicators 

No. 

Indicator 

2011/12 

Performance 

Regulator 

2012/13 

Threshold 

Apr-12 

May-12 

Jun-12 

Quarter 1 

Jul-12 

Aug-12 

Sep-12 

Quarter 2 

Oct-12 

Nov-12 

Dec-12 

Quarter 3 

Forecast 

Jan-13 

Feb-13 

Mar-13 

Quarter 4 

YTD 

Notes 

1 Staff in post 

6,100 HR 5,935 6,101 6,093 6,076 6,090 

6,133 6,047 N/A 6,047 

2 Sickness absence rate (single month) 

4.19% HR 3.75% 4.01% 4.11% 4.04% 4.05% 

4.31% 4.00% Risk 4.09% 

3 Staff turnover (12 month period FTE) 

8.67% HR 9% 8.76% 9.09% 9.09% 8.98% 

10.15% 8.97% Achieve 8.97% 

4 AFC staff appraisals completed in last 12 months 

58.09% HR 90% 82.00% 82.00% 82.00% 82.00% 

82.00% 82.00% Risk 82.00% 

5 Medical staff appraisals completed in last 12 months (Consultant/ M&D Staff) 

88% 83.00% 82.00% 83.00% 82.67% 

87.00% 86.00% Achieve 86.00% 

HR 

95% 

41.00% 41.00% 41.00% 39.00% 40.33% 

61.00% 57.00% Risk 57.00% 

ESR Medical& Dental Appraisal Rate 26.25% 

Taken from "Employment Services KPI Report" 

6 Temporary staff spend (month) 

£780,521 HR

Performance Escalation 

Human Resources 

Indicator 

number 

August 

Quarter 

Year to 

Date 

Forecast 

Medical Staff Appraisals Completed in last 12 months (Non Consultants) 5 57% 57% 57% 

90% 


The underperformance is driven, in the main, by the capacity of the AMD's 

and Clinical Directors to undertake the work and the priority they attach to 

it. 

Appraisal is not always carried out by the line manager and there have 

been issues with the number of trained appraisers available to do this 

work. 

Underperformance is also driven by the continuing fall out of valid 

appraisals from the 12 month window 


A training programme for appraisers is now in progress. Appraisal 

is a key part of the revalidation process for doctors and its importance 

is being stressed at all levels 

Failure to participate in the appraisal process will result in pay 

progression being withheld. 

A dedicated resource has been identified within the Medical Education 

Department to monitor completion. 

NON CONSULTANT 

APPRAISALS 

Medicine 

Division 

Surgery 

Division 

Family 

Care 

Division 

D & T 

Service 

Division 

Return 

Rate 

12 Months 

Jan-12 20% 49% 59% 67% 47% 48% 

Feb-12 39% 54% 72% 76% 56% 54% 

Mar-12 23% 44% 61% 64% 41% 48% 

Apr-12 16% 64% 33% 100% 41% 47% 

May-12 16% 55% 41% 100% 41% 47% 

Jun-12 16% 52% 38% 100% 39% 45% 

Jul-12 32% 79% 55% 100% 61% 66% 

Aug-12 36% 56% 62% N/A 57% 63% 

Expected date to meet standard: October 2012 

Return 

Rate 

15 Months 

Lead Director: 

Ian Brandwood


PART ONE 

Meeting Date: 


31 st October 2012 For Decision 




Peter Weller 


Lynn Wissett 

Report Title: 

Assurance Framework 

Associate Director of Deputy Chief Executive and Update 

Patient Safety & Chief Nurse 

Governance 


Committee 

Date 



NA 

Yes No 

Implications For Partners: Failure to fulfil contractual obligations to 

commissioners. 



Impacts on all Risks on the Framework - Risk that 

organisation does not manage risks which result in 

not achieving strategic objectives leading to failure to 

reach FT status and be a sustainable organisation 

for the future. 

Related to Corporate All corporate objectives and aims and all CQC 

Commitments: 

Registration requirements 


Legal Implications Identified: None identified 

Data Protection Implications None identified 

Identified: 

Diversity and Equality None identified 










• Working in partnership across organisational 

Page 1 of 12 



V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(11) Assurance Framework.doc


Outcomes: 



boundaries 




communities 







The Assurance Framework is the main tool by 

which the Trust Board monitors the principal 

risks to the organisation in relation to achieving 

the strategic objectives. 

The framework maps the organisation’s 

objectives to principal and subordinate risks, 

controls and assurances. 

The complete Assurance Framework has been 

reviewed against the CQC and Monitor 

compliance and regulatory requirements and 

board foresight of other risks. This has been 

mapped to the Integrated Business Plan and 

the framework is updated as further insight is 

provided as the Integrated Business Plan is 

progressed. 

This paper highlights where previously reported 

risks have been revised. 

This paper highlights the changes to the 

framework, top scoring risks (15 and above) 

Actions and assurances in place or planned to 

mitigate these risks are shown and the paper 

identifies the Target risk score and review 

timescale. 

The top 5 risks as cited in the Integrated 

Business Plan are identified and the Assurance 

Framework risk have been mapped to these. 

Page 2 of 12 






Members are asked to approve the revisions to 

the assurance framework based on Board 

insight on performance and foresight of 

potential and current risks in relation to 

achieving the strategic objectives and note the 

actions, controls and assurances in place to 

mitigate these risks which are directly mapped 

to the 5 Key risks as cited in the IBP. 

Page 3 of 12 




1. Background 

1.1 The current Assurance Framework was approved by Trust Board in March 

2012. Trust Board members, Directors, their deputies, clinical leaders and 

senior managers within the organisation were instrumental in identifying the key 

principal risks related to the organisation delivering its objectives. It is an 

iterative framework populated with risks associated with compliance framework 

and corporate objectives. Board foresight and insight into organisational 

performance inform the risk monitoring process. Risks are identified and as 

actions are taken by the operational management of the organisation the 

mitigating factors are reviewed continuously alongside the current risk score. 

Risks from Divisional and Corporate Directorate Business plans have been 

systematically reviewed to ensure the framework reflects these. 

1.2 The key risks have been mapped across the framework and risks have been 

rated in accordance with the Trust scoring matrix. Examples of mitigation, 

positive assurances and controls are highlighted with the framework, as are 

areas where further controls and assurances are required. 

2. Review of risks and changes to the framework 

The Trust key risks are identified in the Integrated Business plan 2012 – 

2017, and listed below. All risks identified on the assurance framework are 

mapped to these key risks, prefixed with the key risk number and have an 

identified lead director. The mitigations for the constituent risks are detailed in 

the individual risks on the Assurance framework. 

The identified 5 key risk as referred to in the Integrated Business Plan are:- 

1. Failure to deliver essential standards of quality and safety including 

failure to reduce and manage Health Care Acquired infections. 

(Overall score 15) 

2. Failure to delivery and deploy an effective information and intelligence 

strategy. (Overall Score 10) 

3. Development and maintenance of partnerships that support the 

Trust’s business (Overall Score 10) 

4. The benefits of Transforming Community Services transaction are not 

realised and failure to maintain a patient centred and commercially 

focussed organisation (Overall score 15) 

5. Delivery of the estates strategy fails to enable delivery of the Trust’s 

objectives (Overall Score 9) 

Page 4 of 12 




Each Lead Director has reviewed the Framework for their risks and 

amendments to scores have been made following review of the Assurance 

Framework risks in light of current reported performance or outcomes and 

year end impact assessment to date: 

Since the previous report to Board no new risks have been added to the 

assurance framework. No risk scores have been increased. 

The following risk scores have been decreased 

• 3-AF94 - Failure to negotiate and agree contracts with commissioning 

bodies reduced from 10 to 5 based on the current reported position. 

• 4-AF100 – Failure to manage unplanned changes in patient flows 

including unplanned growth in Urgent Care reduction from 15 – 10 

based on the current reported position 

• 4-AF107 – Failure to Maintain Cash flow reduced from 10 to 5 based 

on current reported performance. 

• 4-AF109 -. Failure to manage PFI contract reduced from 10 to 5 

based on current contractual position. 

• 5-AF112 – Failure to manage readmissions reduced from 20 to 10 

based on current reported position 

• 3-AF114 – Failure to have in place and implement a long term change 

programme realising efficiency and work force change reduction from 

20 to 15 based on current reported position. 

The risk 1-AF92 has been removed at the request of the Director of Finance 

from the Assurance Framework as this risk relates to payment of a supplier, 

and has been incorporated in to 1-AF91 - Failure to meet regulation and 

registration requirements in relation to suitability of management. 

. 

The tables appended to this paper identify those risks currently scoring 15 or 

above, with a summary of actions taken to monitor mitigations of the risk and 

anticipated target score. 

3 Conclusion/Recommendations 

3.1 The current Assurance Framework was approved by Board in March 2012. 

This framework continues to highlights the controls and assurances in place 

against the current principal risks and mitigations where further actions are 

Page 5 of 12 




equired to reduce the risk. Implementations of the actions will influence the 

impact on non-delivery of the strategic objectives. Assurance is provided that 

the principal risks are aligned to the Foundation Trust trajectory and 

Foundation Trust Pipeline and Integrated Business Plan. 

3.2 Risk Treatment Plans are in place against the risks identified and are 

continuously monitored to ensure actions take place to reduce risk. 

3.3 Divisions are continuously reviewing the Service Delivery risks associated 

with the Integrated Business Plan and these are mapped to the framework as 

they progress through Divisional Boards. 

3.4 Members are asked to approve the revisions to the assurance framework 

based on the Board insight into performance and foresight of potential and 

current risks in relation to achieving the strategic objectives and note the 

actions, controls and assurances in place to mitigate these risks. 

Page 6 of 12 




Risks currently scoring 25 on the Assurance Framework 

None 

Risks currently scoring 20 on the Assurance Framework 

Key 

risk 

Risk 

No 

Risk 

Current 

Risk 

Score 

1 AF57 Referral to Treatment waiting times 20 

Mitigations, Actions & Assurance processes 

• Established reporting arrangements are providing reports for constituent 

targets key deliverables - Performance monitoring through to Board 

reporting, and contractual obligations and contract monitoring 

• Issue specific Local Implementation Teams are addressing operational 

requirements and have constituent action plans in place to address 

requirements 

• Network reports and activity performance reports monitor these and 

ensure remedial action as needed 

• Commissioner & Strategic Health Authority (SHA) monitoring and 

reporting Trust Information 

• Performance Summary - Breach report and analysis and SITREPs 

ensure early alerts and action is taken as needed 

Target 

Risk Score 

10 

Page 7 of 12 




Risks currently scoring 15 – 16 on the assurance framework 

Key 

risk 

Risk 

No 

Risk 

Current 

Risk 

Score 


• Sickness absence policy in place and is being assertively lead and 

Target Risk 

Score 

4 AF080 

Failure to reduce the level of staff 

sickness absence 

16 

managed by HR/OD through Divisions. Establishment of Health and Wellbeing 

Board with constituent action plan. Monitoring and reporting to 

Divisional Boards and Exec Board through HR dashboards and included 

8 

in integrated performance monitoring and reporting. 

1 AF001 

4 AF003 

4 

AF005 

Failure to maintain quality patient 

experience by achieving all Care Quality 

commission standards and targets 

Failure to realise the benefits of the 

inherent MPN service models 

Capacity in partner organisations to 

develop effective systems to 

accommodate Trust’s activity and 

impact of this on patient experience e.g. 

prevention of admission , accommodate 

effective discharge to reduce length of 

stay and numbers of delayed transfers 

of care 

15 

15 

15 

• Strategic and operational infrastructure is in place, TCS transaction 

completed with transformation programme in place. 

• Enabling plans in place to support the vision and journey towards FT 

status. FT Steering group with Executive reporting to Trust Board and 

constituent action plan reporting through to SHA and Department of 

Health (DH). 

• MPN Service Models are integrated into the operational infrastructure and 

direction and have outcome and performance indicators aligned and 

monitoring mechanisms in place with corporate goals for corporate teams 

which have been set and communicated. 

• Constituent work streams across the organisation are in place via sub 

committees and Divisional boards’ organisational work streams are in 

place to address the requirements. 

10 

10 

10 

Page 8 of 12 




Key 

risk 

Risk 

No 

1 AF14 

Risk 

Maintaining business continuity and 

emergency preparedness and 

responding to seasonal pressures 

Current 

Risk 

Score 

15 


• Established reporting and escalation arrangements in place Emergency 

preparedness group within the trust and across the Health economy 

• Discussion with Commissioners agreed seasonal plan 

4 AF28 

• NHSLA steering group undertaking focused review of work streams to 

ensure compliance to 2012 standards 

Failure to maintain the requirements of 15 

NHSLA Acute Standards Level 3 

• Routine progress reporting and escalation of issues through to Quality 

10 

and Safety Board and Governance Committee 

1 AF26 

Failure to understand, analyse and 

15 

reduce mortality rates 


10 

Failure to have a safety culture of 


1 AF34 

openness learning and challenge and 


15 

understand the impact from national 


10 

1 AF39 

learning 

MRSA bacteraemia 15 


requirements 

10 

1 AF40 C Difficile infection 15 


10 



1 AF48 

• Commissioner & SHA monitoring and reporting Trust Information 


15 

days of an urgent GP referral for 

• Performance Summary - Breach report and analysis and SITREPs 

10 



1 AF58 Admitted (95 th centile) 15 10 

Target Risk 

Score 

10 

Page 9 of 12 




Key 

risk 

Risk 

No 

1 AF062 

3 AF093 

Risk 

Unplanned re-attendance rate - 

Unplanned re-attendance at A&E within 

7 days of original attendance (including 

if referred back by another health 

professional) 

Failure to ensure that the Trust meets 

mandatory financial targets and delivers 

value for money services 

Current 

Risk 

Score 

AF097 Failure to deliver agreed activity plan 15 


Target Risk 

Score 

15 10 

15 

• Trust Board , Audit Committee, Executive Management Board, - review 

progress reports against plan, Budgetary control over activity , allocation, 

provisions and reserves, Monthly budget statements 

• CIP meetings with executive leadership 

• Partnership working - efficiency review. 

• Finance team works to a number of detailed reporting timetables. External 

key data returns. Internally work to a detailed final accounts timetable 

agreed with External Audit. 

• Finance Programme established and implemented to achieve financial 

balance. 

• Performance Framework monitored Executive Management Board 

• Divisional Performance Monthly meeting schedule 

• Executive Management Board receive reports from Divisional Boards who 

have business plans in place with remedial action taken as necessary. 

Integrated Performance management framework is integral to the 

operational and strategic assurance infrastructure 

15 

10 

Page 10 of 12 




Key 

risk 

Risk 

No 

Risk 

Current 

Risk 

Score 


Target Risk 

Score 

2 AF103 

4 AF105 

Failure to be proactive in dealing with 

Financial pressures and constraints 

Failure to meet CIP thus affecting Trust 

performance - Failure to ensure CIPS 

projects are managed within project 

plans and timescales agreed and 

failure to monitor variance from CIPS 

with timely remedial action-Failure to 

have mitigations in place for nondelivery 

or slippage in CIPs 

15 

15 

• Trust Board , Audit Committee, Executive Management Board, - review 

progress reports against plan, Budgetary control over activity , allocation, 

provisions and reserves, Monthly budget statements 


• Partnership working – efficiency review. 

• Finance team works to a number of detailed reporting timetables. External 

key data returns. Internally work to a detailed final accounts timetable 

agreed with External Audit. 

• Finance Programme established and implemented to achieve financial 

balance- 



• Proactive Finance plan in place with Divisional Management boards 

• Executive Management Board receives and reviews escalation of issues 

15 

15 

• FT project plan in place which is overseen by an Executive lead FT 

4 AF110 

Failure to achieve Foundation Trust (FT) 

trajectory, milestones and FT Status: 

15 

steering group - all constituent requirements are considered and aligned 

to SHA performance management requirements and DH reporting 

10 

requirements 

Page 11 of 12 




Key 

risk 

Risk 

No 

Risk 

Current 

Risk 

Score 



Target Risk 

Score 




Failure to manage readmissions - 


4 AF112 

impact on income as a result of 

operating framework requirements 

20 

requirements 



• Commissioner & SHA monitoring and reporting Trust Information 

• Performance Summary - 

Breach report and analysis and SITREPs 


• Trust Board , Audit Committee, Executive Management Board, review 

4 AF114 

Failure to have in place and implement a 

long term change programme realising 

efficiency and workforce change 

20 

progress reports against business plan 


• Partnership working - efficiency review. 


10 


Page 12 of 12 




East Lancashire Hospitals NHS Trust 

Assurance Framework 

2012 - 13 

Version as at 25th September 2012

East Lancashire Hospitals NHS Trust Assurance Framework 2012/13 as at September 2012 

Minimum Board Update Frequency 

Key risk 

Risk Number 

Classification 

Principal Risk (PR) and 

Subordinate Risks (SR) 

Date risk added / transferred to AF 

Link to CQC Registration 

requirement 

Key Controls (Actions and 

Mitigations) 

Assurances on controls (Evidence) 

Positive Assurances (Good 

performance) 

Details frequency of 

board update 

Key risk reference 

Gaps in Assurances (Areas for 

Improvement) 

Gaps in Control (Corrective Action) 

Date for corrective action to be 

complete 

Previous Risk Score (LxI) 

Current Risk Score (LxI) 

Tactical Lead (TL) Director 

Lead (DL) 

Accountable Committee 

Within a Devolved Assurance 

Framework to Division / Directorate 

Ref for 

the risk 

Which 

area of 

activity. 

Finance, 

HR etc and 

which 

Strategic 

Objective 

Describes the risks against what the Trust must 

do in a term that reflects DH Guidance for 

Principal Risks (Areas shaded grey reflect CQC 

Registration and outcome requirements) 

Date risk 

added to 

the AF 

Lists the 

CQC 

regulation 

Describes the action the Trust and its partners are taking to 

and outcome 

achieve the Trust must do and to prevent the risk being realised 

that this 

principal risk 

relates to 

Lists the evidence trails that will demonstrate this risk 

is under control i.e. SHA returns, Internal Audit 

Reports, Performance Data 

Provides details relating to performance 

when this performance is meeting targets / 

standards 

Provides details when this performance is 

NOT meeting targets / standards 

Details of corrective action 

that has been agreed but has 

yet to be put into place to 

ensure control 

Risk score 

Date for 

when last 

action to be 

reported to 

complete 

the Board 

Current 

Risk Score 

Name of lead person 

responsible for 

overseeing actions (key 

controls or Gaps in 

Controls) Name of 

Director Lead for this 

principal risk 

Committee who 

oversees the 

management of this 

principal risk on behalf 

of the Board 

Whether this principal risk has 

been devolved to front line staff 

and is being managed via an 

devolved framework 

Key Strategic Objectives and Corporate Commitments: 

1. To improve patient experience by putting quality at the heart of everything we do 

2. To develop services of the highest quality through innovation, pathway reform and the implementation of best practice 

3. To invest in and develop our workforce, and improve staff engagement and satisfaction levels 

4. To continually promote equality and diversity at every level within the organisation 

5. To maintain all regulatory requirements with the CQC and therefore be licensed to provide services without conditions 

6. To further develop clinical services with key internal and external stakeholders to reduce health inequalities, improve public health and reduce cost across the health economy 

7. To improve the Trust’s liquidity position and deliver the required efficiencies 

3 months 1 AF001 Trustwide 

Failure to maintain quality patient experience by 

achieving all Care Quality Commission standards 

and targets 

Revised 

April 2012 

Trustwide 

Impacts on all 

Strategic and operational infrastructure is in place with Quality, Patient 

Safety as a driving force with enabling plans in place to support the 

vision and journey towards FT status . Patient Experiences indicators 

and monitoring mechanisms in place with Corporate Goals for 

Corporate Teams which have been set and communicated . 

Constituent work streams across the organisation are in place via sub 

committees and Divisional boards' organisational work streams are in 

place to address the requirements. 

Trust Board leadership - Board Sub Committees - EMB, , 

Audit & Governance Committees, Quality & Safety Board 

QSB with Divisional arrangements reporting to these fora. 

Internal Audit reports, External Audit reports, Performance 

Monitoring by commissioners and SHA, External validation 

reports. Assurance & Governance Processes contribute to 

the key controls and assurances against the compliance 

framework for the organisation. 

Management structure with accountability 

arrangements through a scheme of delegation 

covering both corporate and clinical divisions - 

Performance and assurance reports to Board 

and its subcommittees demonstrate assurance 

and action taken where issues are identified or 

performance and quality is not within an 

acceptable range. 

Consistent implementation of plans at a 

Divisional Level are continuously being 

monitored and inform the Trust Performance 

and Quality and Safety Profiles. TCS 

workstreams are embedded into the 

infrastructure and included in reporting 

arrangements. 

No additional controls 

identified as needed 

Mar13 

(Monthly) 

15 15 

DL : Chief Executive & 

Executive team 

Trust Board & Trust 

Board Sub Committees 

Yes - Constituent elements are 

devolved through scheme of 

delegation 


Failure to meet CQC registration requirements 

relating to respecting and involving people who use 

services 

Revised 

April 2012 

Reg 17 

Outcome 1 

Constituent risks are included in all the below and are identified throughout the framework and incorporated. 



Mar13 

(Monthly) 

5 5 







delegation 


Failure to realise the benefits of the inherent MPN 

service models 

Revised 

April 2012 

Trustwide 


Strategic and operational infrastructure is in place, TCS transaction 

completed with transformation programme in place. Enabling plans in 

place to support the vision and journey towards FT status . MPN 

Service Models are integrated into the operational infrastructure and 


monitoring mechanisms in place with Corporate Goals for Corporate 

Teams which have been set and communicated . Constituent work 

streams across the organisation are in place via sub committees and 

Divisional boards' organisational work streams are in place to address 

the requirements. 


with Divisional arrangements and infrastructure reporting 

to these fora. Performance Monitoring internally and 

reporting to commissioners through contractual 

obligations and to SHA, External validation reports. 

Performance Monitoring , Assurance & Governance 

Processes contribute to the key controls and assurances 

against the compliance framework for the organisation. 

Management Structure with accountability 

arrangements in place and feeding into Trust 

systems. -Divisional Boards effectively 

overseeing delivery and agreed plans in place. 

The Inclusion of MPN service model realisation 

in strategic objectives and decisions of partner 

organisations and recognition of the impact on 

Trust strategic direction by partners decisions - 

joined up strategic approach across health 

economy - IBP to include strategy direction and 

vision 

No ELHT Gaps identified - 

Facilitate continuous 

engagement through the Board 

to Boards, Local Implementation 

teams and Health economy 

cross cutting groups 

Mar13 

(Monthly) 

15 15 

DL : Chief Executive 

TL Dir of Service 

Development 

Executive Management 

Board 



delegation 


Failure to realise the benefits of the Transforming 

Community Services transaction - Failure to 

maintain and develop further relationship with 

partner organisations/referrers. Systems processes Revised 

and working practices may be inconsistent with April 2012 

organisational direction and alignment of the 

Community Division within the Divisional structure 

of the organisation. 

Trustwide 




















Management Structure with accountability 

arrangements in place and feeding into Trust 

systems. -Divisional Boards effectively 

overseeing delivery and agreed plans in place. 

The Inclusion of TCS and IBP benefits 

realisation in strategic objectives and decisions 

of partner organisations and recognition of the 

impact on Trust strategic direction by partners 

decisions - joined up strategic approach 

across health economy - 



engagement and transition 

through the Board to Boards, 

Local Implementation teams and 

Health economy cross cutting 

groups - 

Mar13 

(Monthly) 12 12 


TL Dir of Service 

Development 

Executive Management 

Board 



delegation 


Capacity in partner organisations to develop 

effective systems to accommodate Trust's activity 

and impact of this on patient experience e.g. 

prevention of admission , accommodate effective 

discharge to reduce length of stay and numbers of 

delayed transfers of care 

Revised 

April 2012 

Trustwide 




















Board to Board activity - Management 

Structure with accountability arrangements in 

place and feeding into Trust systems. Contract 

monitoring meetings and feedback 

Inclusion of MPN and IBP realisation and impact 

upon ELHT Trust needed in strategic objectives 

of partner organisations and continuous 

reinforcement of joint up strategic approach 

across the health economy. MPN programme 

benefits realisation and governance 

arrangements to be continuously owned by all 

agencies. - Not an ELHT led process 

Non identified - Implementation 

and engagement programmes in 

place - Third Party Impact 

Mar13 

(Monthly) 

15 15 


TL : Dir Of Operations 



delegation 


Failure to fully engage with Patient and Public 

Involvement Agenda - LINks , Membership and 

Scrutiny organisations 

Revised 

April 2012 

Outcome 1, 4, 

6, 7, 16 

Systems are in place to give the intelligence and assurance to 

understand factors influencing the Trust’s reputation , objectives and 

service delivery : Quality & Governance Frameworks, Matrons 

responsibility for Patient Experience, Divisional Board Structures, , 

Patient Involvement in service development, service redesign, PALS 

service, Approved Complaints policy. Equality strategy. Executive 

Management Board and Board subcommittees examine & reports key 

agendas. Governance Committee, Quality & Safety Board QSB and 

constituent sub groups, Divisional Boards Membership strategy 

progression - 

Internal Audit reports, External accreditation reports , 

Minutes of Governance Committee, Quality & Safety Board 

QSB and constituent sub groups, Divisional Boards, 

PEAT Assessment, LINks , External accreditation Patient 

Survey Findings, Practice review programme, Matrons 

Standards, Ward Quality Framework ,Essence of Care 

programme. Quality Strategy implementation 

Internal Audit reports for specific commissioned 

workstream assurance External accreditation 

reports , Minutes of Governance Committee, 

Quality & Safety Board QSB and constituent sub 

groups minutes, Divisional Board minutes, , 

PEAT Assessment, LINKS, Membership 

feedback and engagement , External 

accreditation Patient Survey Findings, Practice 

Review programme. 

Embedding of staff understanding of Patient 

Experience and involvement/ engagement 

agenda at Divisional Board level and service 

level during transitional change - Embedding 

and ownership of agenda at Divisional level. 

Non identified - Implementation 

and engagement programmes in 

place 

Mar13 

(Monthly) 

8 8 

DL ; Director of Clinical 

Care & Governance 

EMB & Governance 

Committee 

Yes 

3 months 4 AF007 

Finance 

and 

Planning 

and 

Operations - 

Trust wide 

Failure to have in place a Trust wide system to 

market and promote ELHT clinicians and services & 

Failure to meet the marketing code of practice for 

NHS funded services & thus become a provider of 

choice 

Revised 

April 2012 

Trustwide 


Strategic and operational infrastructure is in place to ensure Business 

planning feeding into Integrated Business Planning process. Service 

Development team - Marketing plans and market intelligence 

monitoring in place - progress reported through Divisional Boards 

/Executive Management Board. Marketing strategy to June Board 

Market intelligence reports at Divisional level. Service 

Development reports and performance management data 

and information. Director of Public Health engaged in 

development of Chap 4 IBP. Marketing plan developed in 

Family Division. 

Market analysis completed - Information pack; 

Increased awareness of marketing 

activity reports & Monthly performance by 

responsibilities within Divisions to be embedded 

specialty by share of choice - Marketing strategy 

at Business Manager level. 

outlined in Business plan 

Non Identified 

Mar13 

(Monthly) 

10 10 

DL : Director of Service 

Development 

EMB 

Yes 



OD - Trust 

wide 

Failure to ensure corporate communications 

strategy is in place and failure to manage reputation 

risk with the public and media 

Failure to embed the Single Equality Scheme 

Revised 

April 2012 

Revised 

April 2012 

Trustwide 


Trustwide 


Communications team and strategy in place with emphasis on proactive 

media and wider stakeholder engagement. 

Single Equality Scheme, Performance reporting framework, Equality 

Act 2010, Equal opportunity monitoring, Diversity & Equality Training, 

Approved PPI Strategy/Action plan, Patient experience Framework , 

Governance Framework, 

Lead Matrons ( Patient Experience) , Divisional Board Structures, 

Patient Involvement in service development, service redesign, 

Approved Complaints policy. PALS Service and Patient Experience 

monitoring mechanisms 

Regular updates to Executive Communications Meeting. 

EMB and Non Executive Directors. 

LINKs , Overview and Scrutiny Committee, Quality & 

Safety Board QSB, Governance Committee, Divisional 

Boards, Patient Surveys, CQC SHA & Governance 

reviews, PEAT visits, PEAT Group with Audit findings and 

action plan responses 

Transformational Change agenda and programme in 

place. Work streams on transformational change. 

Organisational Development programme in place. 

Performance scrutiny KSF Core Dimension 6, PDR 

process 

Positive media coverage and stakeholder 

feedback. Media handling arrangements 

demonstrable 

Single Equality Scheme, Equality Impact 

Assessments, DDA assessments and 

compliance reports, audit findings and 

remedial action, PEAT Meeting minutes. KSF 

and PDR progress reports. Delivery of D & E 

Training. E&D Monitoring via HR Scorecard 

Non identified 

To strengthen the assurance Divisional teams 

give to Divisional Boards. To demonstrate fully 

developed action plans in response to Equality 

Impact Assessments & KSF core dimension 

training - Equality and Diversity Manager 

progressing organisational development plan. 



Mar13 

(Monthly) 

10 10 

Mar13 

(Monthly) 

10 10 

DL ; Deputy CEO 

/Director of Clinical Care 

& Governance 

DL : Director of Human 

Resources and OD 

EMB 

EMB 

Yes 

Yes 

3 months 1 AF010 CC & G - 

Trust wide 

Failure to respond to findings from Patient Survey 

and for these to inform improvement specifically 

focus on Privacy and Dignity 

Revised 

April 2012 

Trustwide 


Systems are in place to give the intelligence and assurance to factors 

influencing the Trust’s response to the Patient Survey requirements: 

Quality and Governance Framework are in place, Clear leadership 

from Nursing and Midwifery leaders forum demonstrable- Matrons 



service, Approved Complaints policy. Diversity and Equality strategy. 

Executive Management Board examines & reports key agendas. 

Governance Committee, Quality & Safety Board QSB and constituent 

sub groups, Divisional Boards Membership strategy progression - 

Reports to Nursing & Midwifery leaders forum, Quality & 

Safety Board QSB, Governance Committee , Trust Board 

quality reports , reports outlining Patient Survey and 

patient experience reviews findings and implementation of 

action plan in response to this across the organisation 

Patient centeredness featuring in workforce and 

service planning discussions and decisions. 

Patient & Staff Surveys and their report findings 

and benchmark of survey findings- use of 

Patient experience trackers and patient 

experience indicators and measures 

Divisional ownership and embedding of 

programme and engagement of medical staff in 

response to patient surveys and patient 

experience findings and action plans are being 

continuously implemented and monitored- 


Mar13 

(Monthly) 

5 5 



Governance (Quality & 

Safety Board QSB) 

Yes 

Page 1 of 7



Trust wide 

Failure to ensure and meet CQC regulatory 

requirements relating to consent to care and 

treatment 

Revised 

April 2012 

Reg 18 

Outcome 2 

There is a systematic approach to Consent for care and treatment - 

policies and procedures across the Trust which reflects DH 

requirements, the clinical audit programme systematically monitors 

adherence to these - augmented by processes for informed consent 

and mental capacity assessments and implementation of Deprivation 

of Liberty assessments and requirements. ELHT Safeguarding Board 

systematically addresses requirements and oversees Deprivation of 

Liberty and Mental Capacity Act requirements 

Reports / Minutes to Patient Safety Group Quality & Safety 

Board QSB, Trust safeguarding Board , Governance 

Committee , minutes of which go through reporting 

channels to Trust Board outlining compliance findings and 

implementation of action plan in response to this across 

the organisation - Mental capacity Act monitoring and 

DOLS by ELHT safeguarding Board 

Systematic audit reports show strengthened 

compliance in reports to Patient Safety Group 

and Quality & Safety Board QSB 

Divisional ownership and embedding of consent 

by medical staff in response to clinical audit 

findings - action plan implementation 


Mar13 

(Monthly) 

10 10 

DL - Director of Clinical 

Care & Governance & 

Medical Director 



Yes 


Trust wide 


relating to care and welfare of people who use 

services 

Revised 

April 2012 

Reg 9 

Outcome 4 

Systems and processes are in place to give the intelligence and 

assurance to understand whether care and welfare of patients is being 

maintained - constituent national targets and priorities , quality 

Reports / Minutes to Patient Safety Group Quality & Safety 

framework : Quality and Risk Profile is systematically monitored and 

Board QSB, EMB Governance , Trust Board outlining 

reported upon and directorate level QRPs are in place and fed back to 

compliance findings and implementation of action plan in 

a service level . Approved Quality Strategy/Action plan, LINKs Patient 

response to this across the organisation in respect of 

Experience Framework, Quality & Governance Frameworks, Clinical 

constituent agenda and relevant quality and performance 

accountability and leadership. Patient Experience, Divisional Board 

standards 

Structures, Board and Sub committees, Executive Management 

Board examines & reports key agendas. Governance Committee, 

Quality & Safety Board QSB and constituent sub groups, 

Quality & Risk profile analysis. Internal Audit 

reports for specific commissioned workstreams. 

Assurance External accreditation reports , 

Minutes of Governance Committee, Quality & 

Safety Board QSB and constituent sub groups 

minutes, Divisional Board minutes, EMB and 

performance reports PEAT Assessment, 

LINKS, Membership feedback and engagement 

, External accreditation Patient Survey Findings, 

Practice Review programme. Leadership 

walkrounds and monitoring centrally of 

Directorate Quality & Risk Profiles feeding into 

Divisional Boards and QSB. 

Continuous implementation of action plans 

arising in specific reports, audits and ongoing 

performance developments 


Mar13 

(Monthly) 10 10 






Yes 


Trust wide 

Failure to respond to findings from Patient Survey 

and for these to inform improvement 

Revised 

April 2012 

Trustwide 


Systems are in place to give the intelligence and assurance to factors 

influencing the Trust’s response to the Patient Survey requirements: 

Approved Patient Experience, Governance Framework, Matrons 






sub groups, Divisional Boards Membership strategy progression - As 

a requirement of CQUIN is included in the Quality Accounts and 

reported upon systematically through this process 

Quality Account, Quality Account and Quality contract 

monitoring reports. Reports to Quality & Safety Board 

QSB, Governance , Trust Board outlining Patient Survey 

review findings and implementation of action plan in 

response to this across the organisation 



Patient & Staff Survey report findings and 

benchmark of survey findings 



response to patient survey findings action plan- 


Mar13 

(Monthly) 

10 10 





Yes 

3 months 1 AF014 Trust wide - 

Maintaining business continuity and emergency 

preparedness and responding to seasonal 

pressures 

Revised 

April 2012 

Trustwide 


Executive Lead structure in place - Emergency Preparedness 

Infrastructure established with reporting arrangements into Quality & 

Safety Board QSB and EMB reporting National Regional and local 

infrastructure. Alignment of Community services arrangements with 

ELHT arrangements took place prior to TCS implementation 

Minutes and Reports from Emergency preparedness and 

Business Continuity Group ( chaired by an Executive 

Director) to Quality & Safety Board QSB, Minutes f which 

go to Governance Committee , Trust Board outlining 

Emergency preparedness compliance and implementation 

of action plan in response to this across the organisation 

Action plan progress reports and achievement 

of constituent agendas- 

Divisional business Continuity plans need to be 

combined to reflect revised process and 

systems introduced nationally in response to 

ongoing developments - Business Continuity as 

a result of TCS transfer – Particularly linked to 

corporate & clinical policy alignment. 

No Gaps in Control identified 

Mar13 

(Monthly) 

15 15 

DL: Director of 

Operations 

EMB and Quality & 

Safety Board QSB 

Yes 



relating to nutritional needs 

Revised 

April 2012 

Reg 14 

Outcome 5 

Assessment Tool and established standards in place - Nursing and 

Midwifery leaders forum, Nutritional sub group , PSG Quality & Safety 

Board QSB demonstrate leadership of setting and monitoring 

compliance requirements and standards across the organisation in 

respect of constituent agenda and relevant quality and performance 

standards 

Reports / Minutes to Nursing and Midwifery leaders forum, 

nutritional sub group , PSG Quality & Safety Board QSB, 

outlining compliance findings and implementation of action 

plan in response to this across the organisation in respect 

of constituent agenda and relevant quality and 

performance standards . Audit programme systematically 

progressed 

Clinical Audit reports for specific commissioned 


reports , , Quality & Safety Board QSB , Nursing 

and Midwifery leaders forum and constituent 

sub groups minutes, Divisional Board minutes, 

EMB and quality reports PEAT Assessment, 

LINKS, patient/relative feedback and 

engagement , External accreditation Patient 

Survey Findings, Practice Review programme 


arising in specific reports, audits 


Mar13 

(Monthly) 

10 10 





Yes 



relating to cooperating with other providers 

Revised 

April 2012 

Reg 24 

Outcome 6 

Strategic Plans in place with enabling plans in place to support the 

vision and journey towards FT status and clinical partnerships . Care 

Pathways / Clinical Networks , Contract opportunities indicators and 


Teams set. and communicated . Constituent work streams across the 

organisation via sub committees and divisional boards' organisational 

work streams are in place to address the requirements. 

Trust Board leadership - Board Sub Committees - EMB, 

EMB, Audit & Governance Committees, Quality & Safety 

Board QSB, Internal Audit reports, External Audit reports, 

Performance Monitoring by commissioners and SHA, 

External validation reports. Assurance & Governance 

Processes 

Reports from Network meetings and clinical 

pathways groups, Reports and minutes of 

constituent work streams 


arising in specific reports, audits 


Mar13 

(Monthly) 

5 5 





Yes 


Failure to implement the Quality Contract , CQUIN 

and Advancing Quality Initiative and its constituent 

parts of Patient Recorded Outcome Measures 

(PROMS ) and Patient Experience 

Revised 

April 2012 

Trustwide 


Constituent elements of Quality contract are included within 

Performance , Governance and Assurance workstreams - Advancing 

Quality Initiative programme initiated and progressed commencing - 

Constituent work streams with AQ reporting through Quality & Safety 

Board QSB, Governance Committee EMB and to Trust Board Monitor 

through EMB and Contracting processes - CQUIn element of quality 

contract 

Meeting minutes from monitoring committees - Quality & 

Safety Board QSB and Multi organisation and functional 

approach to advancing quality. Quality Performance 

meeting notes and minutes with commissioners 

demonstrate contract monitoring- Quality accounts and 

quality performance reports 

Quality accounts and reports show performance 

against indicators and markers and reported 

upon transparently 

No gaps in assurance identified 


Mar13 

(Monthly) 

10 10 

DL: Director of Clinical 


EMB 

Yes : Care Stream activity 

3 months 1 AF018 Trust wide 

Failure to maintain & improve patient and carer 

experience (thus reputation) 

Revised 

April 2012 

Outcome 1, 4, 

6, 7, 16 - 

impacts on all 

Systems in place to give the intelligence and assurance to understand 

factors influencing the Trust’s reputation: Approved Patient Experience 

monitoring, LINKs Quality and , Governance Framework, Matrons 







Systematically included in Quality account and quality account and 

quality contract monitoring 







programme. Quality Strategy implementation , Quality 

contract delivery and quality contract monitoring 

internal Audit reports for specific commissioned 








Review programme., Ward Level performance 

framework for care indicators 

Embedding of staff understanding of Patient 

Experience and Patient Experience agenda at 

Divisional Board level and service level during 

transitional change. Embedding and ownership 

of agenda at Divisional level. Programme 

identifies and actions constituent parts Quality 

Framework and strategy to be embedded in all 

directorates and monitored through directorate 

quality and risk profiling. 


Mar13 

(Monthly) 

10 10 

DL : Director of Clinical 


Audit & Governance 

Committees 

Yes 



relating to assessing and monitoring the quality of 

service provision 

Revised 

April 2012 

Reg 10 

Outcome 16 

Systems in place to give the intelligence and assurance to understand 

factors influencing the Trust’s reputation: Approved Patient Experience 

monitoring, LINKs Quality and , Governance Framework, Matrons 







Systematically included in Quality account and quality account and 

quality contract monitoring 







programme. Quality Strategy implementation , Quality 

contract delivery and quality contract monitoring 

internal Audit reports for specific commissioned 








Review programme., Ward Level performance 

framework for care indicators 



Mar13 

(Monthly) 

5 5 





Yes 



relating to complaints management and processes 

Revised 

April 2012 

Reg 19 

Outcome 17 

Systems in place to reflect national complaints regulations and 

requirements and to give the intelligence and assurance to understand 

Trusts complaints performance and handling: Approved Complaints 

policy and /Action plan following complaints audits, LINKs Patient 

experience Framework, Governance Framework inform these, 

Clinical accountability and leadership. Divisional Board Structures, 

Board and Sub committees, Governance Committee, Quality & Safety 

Board QSB and constituent sub groups examine reports key agendas 

themes and lessons learned ,- 

Governance Unit reports, External accreditation reports , 



Patient Survey Findings, Practice review programme, 

Matrons Standards, Ward Quality Framework Quality 

Strategy implementation and reports and quality account 

Audit reports show compliance against action 

plan and systematic programme to further 

strengthen in place - Compliance against key 

complaints indicators and learning from 

complaints standards 

Further strengthen adherence to at Divisional 

Level to responding to complaints within 

timescales ensuring the widespread learning 

and actioning as a result of complaints 


Mar13 

(Monthly) 

10 10 

DL : Director of Clinical 



Committees 

Yes 



relating to Records 

Revised 

April 2012 

Reg 20 

Outcome 21 

Systems in place to reflect national records regulations and 

requirements and to give the intelligence and assurance to understand Lead Executive Director, Heath records dept, Health 

Trusts performance and handling against these: Approved records records committee , Information Governance Steering 

policy and /Action plan following audits, Governance Framework Group, Governance Unit reports, External accreditation 

inform these, Clinical accountability and leadership. Health records reports , Minutes of Governance Committee and its sub 

Committee reporting to, Governance Committee via Quality & Safety committee, Quality & Safety Board QSB and constituent 

Board QSB and constituent sub groups examine reports key agendas sub groups, Divisional Boards, Patient Survey Findings, 

themes and lessons learned ,Information Governance & toolkit in Practice review programme, Matrons Standards, Ward 

place against key requirements and monitoring through Information Quality Framework Quality Strategy implementation and 

Governance Steering Group reporting through to IM & T Board and reports and quality account 

Quality & Safety Board. 

Audit reports show strong compliance against 

action plan and systematic programme to 

further strengthen in place - 

Further strengthen adherence to professional 

record keeping standards - ensure the action 

plan following integration of TCS and 

Information Governance action plan post TCS is 

implemented. 


Mar13 

(Monthly) 

10 10 

DL = Director of 

Operations 


Committees 

Yes 


Failure to meet the Information Governance 

requirements and the consequential impact on 

patient care and safety and have an Information 

Governance assurance framework in place 

Revised 

April 2012 

Reg 20 

Outcome 21 

Monitoring mechanisms in place Information Governance 

Infrastructure and policies, Governance Committee, Quality & Safety 

Board QSB, Information Governance Group outlined in Trust Risk 

Management Plan and supporting policies - systematic reporting, and 

monitoring of incidents associated with information governance 

organisational intelligence for divisions to act upon - 

Information Governance group minutes and reports to 

Quality & Safety Board QSB including DH/SHA return and 

subsequent Trust work plan for information Governance 



Divisional and Directorate leaderships and 

ownership and of the information governance 

agenda. 

Strengthen Divisional and 

Directorate engagement into 

Information Governance work 

stream and reporting to 

Divisional Boards 

Mar13 

(Monthly) 

10 10 

DL = Director of Finance 

Information and Planning 



Yes 

Page 2 of 7


Failure to meet regulation and registration 


requirements in relation to quality and management - Revised 

Trust wide - 

specifically - statement of purpose, notification of April 2012 

deaths and incidents 

Regs 12, 

16.17,18 

Outcomes 15, 

18,19,20. 

Established process and system in place to meet reporting 

requirements via notification , StEIS and uploads to NRLS - Incident 

which are reported meeting the SUI criteria are investigated using 

RCA methodology - reported to Executive leads for Clinical Care and 

Governance and Medical Director - all SUIs require action plan which 

are systematically monitored in Divisions and Governance Unit for 

action plan progression prior to closure - themes risk assessed and 

included in aggregation of learning from incidents - Vulnerable Adult 

alert process in place and reports to internal Safeguarding Board - 

reporting of Deprivation of Liberty incidents systematically in place 

through a defined process to CQC. 

Quality & Safety Board QSB, Governance Committee, 

Divisional Boards, Patient Safety Group , SHA & 

Governance reviews, e measured through NRLS 

Benchmarking reports and reports for the to StEIS and 

HM Coroner purposes of monitoring harm from incidents 

Vulnerable Adult alert process in place and reports to 

internal Safeguarding Board - reporting of Deprivation of 

Liberty incidents systematically in place through a defined 

process to CQC. 

Compliance with indicators and regulatory 

requirements demonstrable , systematic audit 

reports show strengthened compliance in 

reports to PSG and Quality & Safety Board QSB 



Mar13 

(Monthly) 

5 5 






Yes 



Failure to have in place a system to report , 

investigate and monitor incidents and Serious 

Untoward incidents 

Failure to reduce the level of harm associated with 

healthcare delivered in the Trust 

Revised 

April 2012 

Revised 

April 2012 

Outcomes 

1,2,4,5,6,7,8,9 

,10,11,12,13,1 

4,16,17,20 

Outcomes 

1,2,4,5,6,7,8,9 

,10,11,12,13,1 

4,16,17,20 

Trust Board Part 2 minutes & Governance Committee 

Established SUI process and system in place reporting to Trust Board - minutes, Divisional reports to Quality & Safety Board QSB 

Incident which are reported meeting the SUI criteria are investigated and Divisional SQTs and Boards - Quarterly Divisional 

using RCA methodology - reported to Executive leads for Clinical Care Governance reports to Quality & Safety Board QSB and 

and Governance and Medical Director - all SUIs require action plan PSG papers and discussion - action plans for each 

which are systematically monitored in Divisions and Governance Unit constituent SUI demonstrating action taken. Included in 

for action plan progression prior to closure - themes risk assessed Quality Contract and Quality contract monitoring - adverse 

and included in aggregation of learning from incidents 

incident rate and harm outcomes included in quality 

Strategic Plans in place with Quality, Patient Safety as driving forces 

with enabling plans in place underpinned by Clinical engagement . 

Safety indicators and monitoring mechanisms in place with Corporate 

Goals for Corporate Teams set. and communicated . Constituent work 

streams across the organisation via sub committees and divisional 

boards' organisational work streams are in place to address the 

requirements. - Governance Infrastructure, Governance Committee, 

Quality & Safety Board QSB, Patient safety Committee as outlined in 

Trust Risk Management Plan and supporting policies. Trust 

participates in national and regional safety collaborative and these are 

included within quality contract and CQUIN requirements. 

account publication 

Quality & Safety Board QSB, Governance Committee, 

Divisional Boards, Patient Safety Group , SHA & 

Governance reviews, PEAT visits, PEAT Group with Audit 

findings and action plan responses 

Transformational Change agenda and programme in 

place. Work streams on transformational change. 

Organisational Development programme in place. 

Performance scrutiny KSF Core Dimension 6, PDR 

process - these will be measured through NRLS 

Benchmarking reports and RIDDOR reports for the 

purposes of monitoring harm from incidents - quality 

contract and CQUIN indicators include specific 

requirements related to harm reduction which are 

systematically reported upon and included in the quality 

account 

April 2009 provided positive assurance - 

Internal; audit report provided positive 

assurance NHSLA assessment of the process 

remains extant 

Systematic reports received are informing harm 

reduction and providing organisational 

intelligence regarding this - 

Consistent implementation of process and 

systems in place within timescales at Divisional 

and directorate level 


No Gaps identified 


Mar13 

(Monthly) 

5 5 

Mar13 

(Monthly) 

10 10 











Yes 

Yes 


Failure to understand, analyse and reduce mortality 

rates 

Revised 

April 2012 

Outcomes Mortality rates monitored systematically through Performance reports 

1,2,4,5,6,7,8,9 to Board via EMB and Governance committee and Quality & Safety 

,10,11,12,13,1 Board QSB - participation in collaborative initiatives with other 

4,16,17,20 organisations , transparent reporting through the Quality account 

Mortality reports and actions and minutes of corporate and 

divisional governance fora and Board s in response to 

mortality rates 

Mortality rates in specialties below peer and 

evidence of analysis and divisional response 

when variance identified 

Divisional ownership and systematic monitoring 

and reporting to divisional boards to be 

systematically progressed and monitored and 

embedding of programme and engagement of 

medical staff in programme of analysis and 

reduction 

No Gaps in control identified - 

Mar13 

(Monthly) 

15 15 






Yes 


Failure to have in place the required data capture to 

sustain patient pathways and inform organisational 

intelligence regarding to risks to patients 

Revised 

April 2012 

Outcomes Systems for capturing data in place - PAS, clinical coding and 

1,2,4,5,6,7,8,9 informatics function informing Dr Foster and other data source e.g. 

,10,11,12,13,1 DATIX - supported through an informatics structure with operating 

4,16,17,20 procedures 

Reports identifying analysis of data capture 

Systematic reports received are informing 

patient pathways and providing organisational 

intelligence regarding this - e.g. DR FOSTER 

Ongoing action to improve data quality and 

coding To audit and understand the quality of 

the data informing clinical coding from the 

clinical source 


Mar13 

(Monthly) 

5 5 






Yes 


Failure to maintain the requirements of NHSLA 

Acute Standards Level 3 

Revised 

April 2012 

Outcomes Quality & Safety Board QSB has ensured all 50 criterion from the 5 

1,2,4,5,6,7,8,9 standards s are in the Trust risk management plan and have in place 

,10,11,12,13,1 mechanism to audit and monitor the 50 criterion reporting to 

4,16,17,20 Governance Committee 

Reports to Governance committee systematic reports 

from constituent work streams to Quality & Safety Board 

QSB and sub committees 

Quality & Safety Board QSB receiving 

continuous reporting against the constituent 

standards at Level 3 and variances against 

Level 3 requirements understood and action 

taken 

Revised standards for 2012/13 launched 

January 2012 - Gap analysis currently underway 

against revised requirements 

Revised standards for 2012/13 

launched January 2012 - Gap 

analysis currently underway 


Mar13 

(Monthly) 

15 15 






Yes 


Failure to maintain the requirements of NHSLA 

CNST Maternity Requirements 

Revised 

April 2012 

Outcomes Quality & Safety Board QSB has ensured all 50 criterion from the 5 

1,2,4,5,6,7,8,9 standards s are in the Family Care Divisional Boards responsibility 

,10,11,12,13,1 and have in place mechanism to audit and monitor the 50 criterion 

4,16,17,20 reporting to Quality & Safety Board QSB 

Reports to Family Care Divisional Management Board 

Governance committee systematic reports from 

constituent work streams to Quality & Safety Board QSB 

and sub committees 

Level 2 standards extant and progression of 

revised standards being coordinated within the 

division of Family Care - Compliance awarded 

in February 2011 - extant until 2014. 


programme - Divisional and corporate 

requirement to collate continuous evidence 

against requirements not consistently being met 

Revised standards for 2012/13 

launched January 2012 - Gap 

analysis currently underway 


Mar13 

(Monthly) 

10 10 






Yes 


Failure to implement and roll out the Patient Safety 

Express Initiative 

Revised 

April 2012 

Outcomes 

1,2,4,5,6,7,8,9 

,10,11,12,13,1 

4,16,17,20 

Strategic Plans in place with Quality, Patient Safety as driving forces 

with enabling plans in place underpinned by Clinical engagement . 

Safety indicators and monitoring mechanisms in place with Corporate 

Goals for Corporate Teams set. and communicated . Constituent work 

streams across the organisation via sub committees and divisional 


requirements. - Governance Infrastructure, Governance Committee, 

Quality & Safety Board QSB, Patient safety Committee as outlined in 

Trust Risk Management Plan and supporting policies 

Reports to Patient Safety Committee and Quality & Safety 

Board QSB and upward reporting to Governance 

committee - introduction of Quality accounts and reporting 

enables reporting against key milestones and indicators 

systematically 

Upload and inputting to Patient Safety First 

extranet has commenced to enable 

benchmarking - reports to PSG and Quality & 

Safety Board QSB against key milestones and 

packages with actions in place to address 

remedial action 



programme 


Mar13 

(Monthly) 

5 5 






Yes 


Failure to systematically learn from incidents 

complaints and Claims and patient experience thus 

failing to improve and address patient safety 

Revised 

April 2012 

Safety indicators and monitoring mechanisms in place . Constituent 

work streams across the organisation via sub committees and 

Outcomes divisional boards' organisational work streams are in place to address 

1,2,4,5,6,7,8,9 the requirements. - Governance Infrastructure, Governance 

,10,11,12,13,1 Committee, Quality & Safety Board QSB, Patient safety Committee as 

4,16,17,20 outlined in Trust Risk Management Plan and supporting policies - 

systematic reporting , analysis and aggregation for Incidents , PALS , 

Complaints and Claims and Patient Experience 

CQC declaration process, Governance Committee , 

Board reports, Quality & Safety Board QSB minutes, 

Patient Safety Group minutes and reports, submissions to 

National Patient Safety First campaign , submissions to 

National Patient Safety Agency Internal Audit reports 

against CQC standards . NHSLA accreditation process 


of constituent agendas- Assurances from 

internal audit provided in past quarter and 

remain extant 



programme 


Mar13 

(Monthly) 

10 10 






Yes 



Failure to have a clinical audit and clinical 

effectiveness programme in place 

Failure to have a programme to respond to Central 

Alerts Strategic Alert Bulletins and NPSA 

requirements 

Revised 

April 2012 

Revised 

April 2012 

Clinical Audit and Clinical Effectiveness programme across the 

Outcomes organisation via sub committees and divisional boards' organisational 

1,2,4,5,6,7,8,9 work streams are in place to address the requirements. - Governance 

,10,11,12,13,1 Infrastructure, Governance Committee, Quality & Safety Board QSB, 

4,16,17,20 Patient safety Committee as outlined in Trust Risk Management Plan 

and supporting policies - systematic reporting , 

monitoring mechanisms in place via sub committees and divisional 

Outcomes boards' organisational work streams are in place to address the 

1,2,4,5,6,7,8,9 requirements. - Governance Infrastructure, Governance Committee, 

,10,11,12,13,1 Quality & Safety Board QSB, Patient safety Committee as outlined in 

4,16,17,20 Trust Risk Management Plan and supporting policies - systematic 

reporting, and monitoring 



Patient Safety Group minutes and reports, Internal Audit 

reports against CQC standards . NHSLA accreditation 

process - Clinical Audit and NICE reports systematically 

produced with minutes of supporting committees 

Quality & Safety Board QSB minutes , Corporate risk 

register , Patient Safety Groups and Divisional 

Governance forums reporting to Divisional Boards 




remain extant 





programme 


ownership and of alerts related to specific 

specialties and engagement of medical staff in 

programme 

Directorate clinical audits are not 

systematically feeding into 

Directorate/ Divisional 

Governance mechanisms to be 

monitored against 

recommendations - Divisional 

Boards to ensure this is 

addressed 


Mar13 ( 

Monthly) 

5 5 

Mar13 ( 

Monthly) 

5 5 











Yes 

Yes 


Failure to have a Safety culture of openness , 

learning and challenge and understand the impact 

from national learning e.g. Francis report 

Revised 

April 2012 

Safety indicators and monitoring mechanisms in place . Constituent 

work streams across the organisation via sub committees and 

Outcomes divisional boards' organisational work streams are in place to address 

1,2,4,5,6,7,8,9 the requirements. - Governance Infrastructure, Governance 

,10,11,12,13,1 Committee, Quality & Safety Board QSB, Patient safety Committee as 

4,16,17,20 outlined in Trust Risk Management Plan and supporting policies - 

systematic reporting , analysis and aggregation for Incidents , PALS , 

Complaints and Claims and Patient Experience 



Patient Safety Group minutes and reports, submissions to 

National Patient Safety First campaign , submissions to 

National Patient Safety Agency Internal Audit reports 

against CQC standards . NHSLA accreditation process 




remain extant 

Divisional ownership and challenges at 

Divisional Boards to Directorates require 

strengthening embedding of programme and 

engagement of medical staff in programme 


Mar13 ( 

Monthly) 

15 15 






Yes 



relating to management of medicines requirements 

Revised 

April 2012 

Outcomes 

1,2,4,5,6,7,8,9 

,10,11,12,13,1 

4,16,17,20 

Monitoring mechanisms in place via sub committees and divisional 


requirements. - Governance Infrastructure reporting to Governance 

Committee from Quality & Safety Board QSB, Patient Safety 

Committee as outlined in Trust Risk Management Plan and supporting 

policies - systematic reporting, and monitoring - Medicines 

Management Performance Group chaired by Medical Director 

Medicines Management Board , Quality & Safety Board 

QSB minutes , Corporate risk register , Patient Safety 

Groups and Divisional Governance forums reporting to 

Divisional Boards - Drug and Therapeutics committee 

minutes and medicines management performance group 

minutes 


of constituent agendas- Audit reports and 

systematic reporting to identified committees 


ownership and of the management of 

medicines to be consistently implemented 


Mar13 ( 

Monthly) 

10 10 





Yes 



relating to Safeguarding people who use services 

from abuse - Adults & Children 

Revised 

April 2012 

Reg 11 

Outcome 7 

ELHT Safeguarding Board report to Trust Board with designated 

Executive Director , constituent policies and procedures in place 

meeting the legislative requirements - designated individuals and 

infrastructure for Safeguarding Children and Adults in place 

Annual report to Trust Boards and minutes of ELHT 

safeguarding Board to Quality & Safety Board QSB - 

constituent action plan implementation monitored through 

to SHA and commissioning PCTs and implementation 

Safeguarding Adults system and reporting 

process in place - increased usage 

demonstrated. , Safeguarding Children 

declaration published and on website - 

Safeguarding adult declarations , internal 

clinical audit reports and findings 


ownership and requires consistent 

implementation 


Mar13 ( 

Monthly) 

10 10 





Yes 


Failure to achieve all national targets, operating 

framework requirements and MONITOR 

compliance framework requirements specifically: 

Revised 

April 2012 


specifically Management structure with established accountability arrangements 

Outcomes through a scheme of delegation covering both corporate and clinical 

1,2,4,5,6,7,8,9 divisions -Performance Framework- Executive Management Board - 

,10,11,12,13,1 Performance meeting schedule 

4,16,17,20 

Established reporting arrangements providing reports for constituent targets key deliverables - Executive Management Board Audit & Governance 

Committees - Reports from external bodies, Internal & External Audit reports, CQC focused inspection programme, SHA & Commissioner performance 

monitoring. Issue specific Local Implementation Teams, Network reports and activity 



Mar13 ( 

Monthly) 

10 10 

DL ; Director of 

Operations 

EMB reporting to Trust 

Board 

Yes 

Page 3 of 7


3 months 1 AF038 Trust wide - HCAI measure (MRSA & CDI) 

3 months 1 AF039 Trust wide - MRSA bacteraemia 

3 months 1 AF040 Trust wide - CDIFICILE 

3 months 1 AF041 Trust wide - MSSA 

3 months 1 AF042 Trust wide - E Coli 


Failure to meet the MRSA screening requirements 

for patients prior to admission to hospital 


referral for suspected cancer 

Revised 

April 2012 

10 10 

Revised 

Trust Infection Control Strategies and work plan- Accountability and 

April 2012 Established reporting arrangements providing reports for 

15 15 

reporting arrangements with performance monitoring by DH, PCT, 

Revised Outcomes 

constituent deliverables of Infection Control agenda - 

SHA and CQC - Infection Control Assurance Framework aligns to 

Embedding of personal responsibilities - need to No Gaps in control identified - 

April 2012 1,2,4,5,6,7,8,9 

Board reports, Audit & Governance Committees reports Action plan progress reports and achievement 

Mar13 ( 15 15 

Health and Social Care Act requirement - requirements included 

ascertain MSSA and ECOLI level benchmark constituent action plans on track 

Revised ,10,11,12,13,1 

DH Action plan and SHA Monitoring - Internal Audit of constituent agendas- 

Monthly) 

within Quality contract and monitored by commissioners through 

and baseline 

re Infection Control 

April 2012 4,16,17,20 

against CQC Stds. Positive feedback from DH and SHA 

10 10 

quality contract monitoring processes - public reporting through 

Revised 

visit 

Integrated Board Performance report and Quality Accounts 

April 2012 

10 10 

Revised 

April 2012 

Cancer 2 week wait from referral to date seen Revised 


either: 


Percentage of patients seen within two weeks of an Revised 

Trust wide - 

urgent GP referral for suspected cancer 

Percentage of patients seen within two weeks of an 

Revised 

3 months 1 AF046 Trust wide - urgent referral for breast symptoms where cancer is 

not initially suspected 


Cancer 62 day wait for first treatment 

Trust wide - 

comprising either: 

Percentage of patients receiving first definitive 

Revised 

treatment for cancer within 62-days of an urgent GP 




treatment for cancer within 62-days of referral from 

and NHS Cancer Screening Service 


treatment for cancer within 62-days of a consultant 

decision to upgrade their priority status 

Outcomes 

1,2,4,5,6,7,8,9 MRSA Screening policy outlines process an intent underpinned by 

,10,11,12,13,1 Saving Lives Programme 

4,16,17,20 

Established reporting arrangements providing reports for 

constituent deliverables of the MRSA screening agenda - 

Board reports and reports to EMB /EMB , Action plan and 

SHA Monitoring - I 

Action plan progress reports 

Embedding of process and systems introduced 

No Gaps in control identified - 

action plans on track -since 31st 

December we need to be 

screening all patients, including 

emergencies. 

Mar13 ( 

Monthly) 

10 10 

April 2012 

10 10 

Established reporting arrangements providing reports for constituent 

Outcomes 

April 2012 targets key deliverables - Performance monitoring through to Board 

10 10 

Issue specific Local Implementation Teams, Network reports and 

April 2012 4,16,17,20 

10 10 

Revised 

April 2012 

10 10 

April 2012 Established reporting arrangements providing reports for constituent 

15 15 

Revised 

1,2,4,5,6,7,8,9 

Identified in Performance 

Mar13 ( 

April 2012 Issue specific Local Implementation Teams, Network reports and Identified in Performance dashboard and report 

Identified in Performance dashboard and report Identified in Performance dashboard and report 

10 10 

Revised 

1,2,4,5,6,7,8,9 

reporting, and contractual obligations and contract monitoring - 

,10,11,12,13,1 

Outcomes 

,10,11,12,13,1 

4,16,17,20 

activity performance reports - Commissioner & SHA monitoring and 




reporting Trust Information - Performance Summary - Breach 

Identified in Performance dashboard and report 




dashboard and report 


Report. data returns. SITREPs. 

April 2012 

10 10 

Mar13 ( 

Monthly) 

Monthly) 

Medical Director - and 

the Director of Infection 

Prevention and Control. 

DL: Medical Director , 

Director of Infection , 

Prevention and Control 


Operations 


Operations 


Board 

Quality & Safety Board 

QSB , Governance 

Committee and EMB 


Board 


Board 

Yes 

Yes 

Yes 

Yes 


All Cancers: 31 day wait from diagnosis to first 

treatment 

Revised 

April 2012 

10 10 



treatment within one month of a cancer diagnosis 

Revised 

April 2012 



Outcomes 


1,2,4,5,6,7,8,9 


,10,11,12,13,1 


4,16,17,20 


Report. data returns. SITREPs 





Mar13 ( 

Monthly) 

10 10 


Operations 


Board 

Yes 

All cancers: 31 day wait for second or 



treatment is Surgery 

subsequent treatment comprising either: 

10 10 

Percentage of patients receiving subsequent 

treatment for cancer within 31-days where that 


3 months 1 AF055 Trust wide - treatment for cancer within 31-days where that 

treatment is an Anti-Cancer Drug Regime 



treatment for cancer within 31-days where that 

treatment is a Radiotherapy Treatment Course 

Revised 


April 2012 

10 10 

Revised 

Issue specific Local Implementation Teams, Network reports and Identified in Performance dashboard and report 


April 2012 ,10,11,12,13,1 

dashboard and report Monthly) 5 5 

Revised 


April 2012 

5 5 

Revised 

Outcomes 

1,2,4,5,6,7,8,9 

4,16,17,20 






3 months 1 AF057 Trust wide - Referral to Treatment waiting times 


April 2012 

20 20 


Revised Outcomes 

3 months 1 AF058 Trust wide - Admitted (95th percentile) 


April 2012 1,2,4,5,6,7,8,9 

Identified in Performance Mar13 ( 15 15 



Revised ,10,11,12,13,1 

dashboard and report Monthly) 

3 months 1 AF059 Trust wide - Non-admitted (95th percentile) 


April 2012 4,16,17,20 

10 10 


Revised 

3 months 1 AF060 Trust wide - Incomplete Patients (95th percentile) 


April 2012 

10 10 

3 months 1 AF061 Trust wide - A&E Quality Indicators 10 10 

Mar13 ( 


Operations 


Operations 


Board 


Board 

Yes 

Yes 


Unplanned re-attendance rate - Unplanned reattendance 

at A&E within 7 days of original 

attendance (including if referred back by another 

health professional) 

Revised 

April 2012 

15 15 

Revised 

Outcomes 



3 months 1 AF064 Trust wide - Total time in Emergency Department 


April 2012 1,2,4,5,6,7,8,9 

Identified in Performance Mar13 ( 10 10 



Revised ,10,11,12,13,1 

dashboard and report Monthly) 

3 months 1 AF065 Trust wide - Left department without being seen rate 


April 2012 4,16,17,20 

10 10 


Revised 

3 months 1 AF066 Trust wide - Time to initial assessment - 95th centile 


April 2012 

10 10 

3 months 1 AF067 Trust wide - Time to treatment in department - median 

Revised 

April 2012 

10 10 

3 months 1 AF068 Trust wide - Stroke indicator 10 10 


Operations 


Board 

Yes 

3 months 1 AF069 Trust wide - Stroke Indicator 

Revised 

April 2012 



Outcomes 


1,2,4,5,6,7,8,9 


,10,11,12,13,1 


4,16,17,20 







Mar13 ( 

Monthly) 

10 10 


Operations 


Board 

Yes 

3 months 1 AF070 Trust wide - Minimising delayed transfers of care 10 10 


Number of non-acute patients (aged 18 & over) 

whose transfer of care was delayed 

vs number of non-acute patients who were admitted 

to the trust each week 

Revised 

April 2012 



Outcomes 


1,2,4,5,6,7,8,9 


,10,11,12,13,1 


4,16,17,20 



Identified in Performance dashboard and report Identified in Performance dashboard and report Identified in Performance dashboard and report 



Mar13 ( 

Monthly) 

5 5 


Operations 


Board 

Yes 


Failure to meet CQC registration requirements Revised 

relating to maintain cleanliness and infection control April 2012 

Reg 12 

Outcome 8 

Infection control accountability and assurance structures in place and aligned to Trust Assurance and Governance mechanisms - Director of Infection Prevention and Control in place - detailed Infection Control assurance 

framework and plan reflecting constituent component parts of the act - specific risks outlined below 


Mar13 ( 

Monthly) 

10 10 







Yes 


Failure to comply with the Health and Social Act 

2008 requirements of the Care Quality Commission 

(CQC) and failure to register with CQC in relation to 

Infection prevention and control - ( Maintaining an 

Infection Control Assurance Framework) 

Revised 

April 2012 

Reg 12 

Outcome 8 

Infection control accountability and assurance structures in place and 

aligned to Trust Assurance and Governance mechanisms - Director of 

Infection Prevention and Control in place - detailed Infection Control 

assurance framework and plan reflecting constituent component parts 

of the act 

Board Sub Committees - EMB, EMB, Audit & Governance 

Committees, Quality & Safety Board QSB, Internal Audit 

reports, External Audit reports, Performance Monitoring by 

commissioners and SHA, External validation reports. 

Assurance & Governance Processes - Benchmarking 

Performance trajectory, infection control audit 

and monitoring reports - Saving Lives Delivery 

team reports and Infection Control Committee 

reports - 

Assurance framework for Infection control 

systematically monitors detailed constituent 

parts 


Mar13 ( 

Monthly) 

10 10 







Yes - Devolved Service Quality 

and Governance arrangements 

and performance framework 


Operational 

Divisions 

and Corp 

Directorate 

Trust wide 


relating to maintaining safety and suitability of 

premises - Failure to ensure care is provided in 

environments that promote patient and staff 

wellbeing and respect for patients needs and 

preferences in that they are designed for the 

effective and safe delivery of treatment, care or a 

specific function . They provide as much privacy as 

possible and are maintained and cleaned to 

optimise health outcomes for patients 

Revised 

April 2012 

Reg 15 

Outcome 10 

Strategic Partnership developments with PCTs and Local Authorities, 

Trust Business Plan, Site Utilisation Group , Executive Management 

Board Nurse Leaders Forum , Quality & Safety Board QSB, Patient 

Safety Group, Practice Review Survey programme , H & S 

programme, Estates strategy and reporting to EMB, DSSA declaration 

and monitoring to Board, Patient Experience Trackers systematically 

inform patient experience monitoring 

Internal Audit reports, PEAT reports and validation, Patient 

Survey, Staff survey, Patient Experience reports, 

Feedback from PALS, Complaints and Claims , Feedback 

from Patient Experience tracker - , Quality & Safety Board 

QSB reports Practice Review observation of care. 

Feedback from Estates strategy and reporting to EMB, 

DSSA declaration and monitoring to Board Patient 

Experience Trackers systematically inform patient 

experience monitoring H & S committee monitor 

adherence with H & S requirements 

estates strategy , Internal Audit reports, PEAT 

reports and validation, Patient Survey, Staff 

survey, LINks reports, Care Environment & 

Amenities group minutes, Quality & Safety 

Board QSB reports Practice Review observation 

of care, Membership reports, PCT 

commissioner's reports , OSC reports, Public 

declaration re DSSA, H & S committee minutes 

The Estates Strategy has focused on the 

reconfiguration of the built estates environment . 

The estates environment reconfiguration 

purposefully focused on the assurance that the 

wards and departmental areas were fit for re 

provision of services across sites and patient 

occupation standards. Focus now on ongoing 

investment in built environment 


Mar13 ( 

Monthly) 10 10 

DL : Director of Finance 

TL : Associate Director of 

Estates and Facilities 




Yes 

Page 4 of 7



Operational 

Divisions 

and Corp 

Directorate 

Trust wide 

3 months 5 AF076 Finance/ 

Estates 





Operational 

Divisions 

Trust wide 

HR & OD - 

Trust wide 

HR & OD - 

Trust wide 

HR & OD - 

Trust wide 


relating to maintaining safety and suitability of 

equipment 

Failure to transform the Estate and supporting 

infrastructure and implementation of Estates 

strategy /site utilisation 


relating to staffing requirements 


relating to workers 


relating to supporting workers requirements 

Revised 

April 2012 

Revised 

April 2012 

Revised 

April 2012 

Revised 

April 2012 

Revised 

April 2012 

Revised 

Failure to reduce the level of staff sickness absence 

April 2012 

Reg 16 

Outcome 11 

Reg 15 

Outcome 10 

Reg 9 

Outcome 4 

Reg 22 

Outcome 13 

Reg 21 

Outcome 12 

Reg 23 

Outcome 14 


specifically 

outcome 12, 

13,14 

Medical Devices work programme, training programme and audit 

programme and PFI systematic contract monitoring 

Estates Strategy , Estates work stream. Site Utilisation Group EMB, 

and DMBs 

Monitoring mechanisms in place via divisional boards reporting to 

EMB Governance Infrastructure, Governance Committee, Quality & 

Safety Board QSB, Patient safety Committee as outlined in Trust Risk 

Management Plan and supporting policies - systematic reporting, and 

monitoring of incidents associated with staffing providing 

organisational intelligence for divisions to act upon - Reviews of 

staffing using agreed methodology - systematic monitoring of medical 

workforce and EWTD, workforce planning and HR dashboard 

monitors key indicators 

Internal Audit reports, PEAT reports and validation, Patient 

Survey, Staff survey, Patient Experience reports, 

Feedback from PALS, Complaints and Claims , Feedback 

from Patient Experience tracker - , Quality & Safety Board 

QSB reports Practice Review observation of care. 

Feedback from Estates strategy and reporting to EMB, 

DSSA declaration and monitoring to Board Patient 

Experience Trackers systematically inform patient 

experience monitoring. H & S committee monitor 

adherence with requirements 

Estates Strategy - Estates cross cutting work stream 

reports. Site Utilisation Committee minutes and reports, 

EMB, EMB minutes and reports - 

EMB ,DMBs and Minutes of Trust Board sub committees 

with responsibilities. HR dashboard , Corporate risk 

register , Quality & Safety Board QSB Patient Safety 

Groups and Divisional Governance forums and Divisional 

Board minutes -Incident analysis and complaints 

responses and action plan - recruitment and retention 

initiatives and actions by specific divisions to recruit staff - 

Constituent risks identified below - assurance markers for each of the identified elements of the CQC requirements outlined 

New sickness absence policy introduced. EAP introduced. 

Establishment of Health and well-being working party. Monitoring and 

reporting to Divisional Boards and Exec Board. 

Monthly monitoring at all DMBs and through to Board 

through delegated performance monitoring structures 

Medical Devices Management process , Estates 

strategy , Internal Audit reports, PEAT reports 

and validation, Patient Survey, Staff survey, 

LINks reports, Care Environment & Amenities 

group minutes, Quality & Safety Board QSB 

reports Practice Review observation of care, 

Membership reports, PCT commissioner's 

reports , OSC reports, Public declaration re 

DSSA, H & S committee minutes 

Estates Strategy in place reported to Trust 

Board with updates reported to EMB 

HR dashboards reports show integrated 

reporting of key indicators, Quality and Safety 

reports show monitoring of key indicators and 

remedial action as necessary , Divisional 

Business plans and monitoring show integration 

with staffing issues and requirements. 

Introduction of Fast Physio. OH Review and 

relaunch including review of management 

referral pathways. Development of Well Being 

Strategy. Divisional and organisational 

monitoring in place. 


ownership and of the management of 

equipment to be consistently implemented 



ownership and of the staffing and workforce 

agenda 

Audits identify inconsistent implementation of 

sickness absence policy. 






Mar13 ( 

Monthly) 

10 10 

Mar13 ( 

Monthly) 

9 9 

Mar13 ( 

Monthly) 

10 10 

Mar13 ( 

Monthly) 

10 10 

Mar13 ( 

Monthly) 

10 10 

No Gaps in Control identified 16 16 


TL : Associate Director of 

Estates and Facilities 

DL: Director of Finance , 

Information & Capital 

TL : Director of Estates & 

Director of Service 

Development 












EMB 

EMB 

EMB and Governance 

(Quality & Safety Board 

QSB) 



QSB) 

Exec Board 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 


HR OD - 

Trust wide 

Failure to engage managers, staff and clinicians in 

the PDR/PDP/appraisal process and to ensure that 

PDR & PDP are outcome focussed and aligned to 

patient care 

Revised 

April 2012 


specifically 

outcome 12, 

13,14 

Revalidation working Group for medical staff. Revision of PDP 

process and paperwork for AfC Staff. Development of robust 

monitoring systems for medical and non-medical appraisal. 

Simplification of KSF dimensions and evidence 

Reports to Quality & Safety Board QSB, and EMB on 

behalf of EMB and Governance outlining PDR/PDP and 

appraisal uptake and extent to alignment to patient care - 

KSF and Job planning elements included in frameworks 

adopted by the Trust to ensure continued patient focus 



Patient & Staff Survey report findings and 

benchmark of survey findings. Working group to 

manage the implementation of medical 

revalidation. Training Needs Analysis derived 

from PDR process to be reported upon. 

Introduction of electronic 360 degree appraisal 

for medical staff 

Further development of monitoring system 

required and consideration for on-line appraisal 

system for non medical staff. Line managers 

engagement 

Analysis of training needs from 

PDR process 2010/11 

determined and Analysed - 

Mar13 ( 

Monthly) 

6 6 





QSB) 

Yes 


HR & OD - 

Trust wide 

Failure to achieve and communicate the benefits 

afforded by Staff engagement initiatives 

Revised 

April 2012 


specifically 

outcome 12, 

13,14 

Staff LINKS forum established. Development of Divisional action plans 

following staff survey. Working towards IIP accreditation. 

Development of Divisional OD plans. Review of induction 

Controls aligned to OD strategy and monitored through 

DMBs and Executive Management Team 

STAR Awards, ICO Newsletter, 

Cultural change needs ownership and 

embedding across the Trust to strengthen the 

opportunities afforded by the Staff engagement 

initiatives 

No Gaps identified 4 4 

DL: Director of HR and 

OD 

EMB 

Yes 


HR & OD - 

Trust wide 

Failure to monitor staff satisfaction and failure to act 

upon the monitoring results 

Revised 

April 2012 


specifically 

outcome 12, 

13,14 

OD strategy in place incorporates staff survey as measurement 

methodology - internal programme in place for staff survey to ensure 

responsiveness to staff other than on an annual basis 

HR DMB Monitoring of performance and Staff Survey 

reports and action plan and subsequent reporting to Exec 

Board. Also considered by Health and Well-being group 

and local DMBs. 

Team briefings , corporate communications 

,Leadership Programmes, Management 

development programmes - workforce 

initiatives in EMB reports - Mandatory training 

and training reports 



opportunities afforded by the Staff Survey 

findings 

Need to continue impetus of 

cultural change- needs 

ownership and embedding 

Divisions- to strengthen the 

assurance Divisional teams give 

to Divisional Boards 

12 12 


OD 

Exec Board 

Yes 


HR & OD - 

Trust wide 

Failure to communicate and embed the 

organisations values and expected culture 

Revised 

April 2012 


specifically 

outcome 12, 

13,14 

Objectives set for organisation with clear leadership framework from 

the Trust Board - CEO briefing mechanism and communications 

function in place -Business plan and OD strategy in place 

incorporates leadership and skill development of workforce , 

competencies as, role redesign and succession planning , promoting 

wellbeing of staff. People strategy in place, Staff engagement strategy 

in place, leadership strategy incorporating management development 

and performance management in place.KSFProcess Core 

Dimensions. Workforce strategy in place linked into Business plan 

Exec Board Monitoring of performance and Staff Survey 

reports and action plan and subsequent reporting to the 

Board 

Team briefings , corporate communications 

,Leadership Programmes, Management 






opportunities afforded by the staff partnership 

and engagement initiatives in place 







Mar13 ( 

Monthly) 

10 10 


OD 

Exec Board 

Yes 


HR & OD - 

Trust wide 

Failure to implement the Organisational 

Development Strategy 

Revised 

April 2012 


specifically 

outcome 12, 

13,14 

Objectives set for organisation with clear leadership framework from 

the Trust Board - CEO briefing mechanism and communications 

function in place -Business plan and OD strategy in place 

incorporates leadership and skill development of workforce , 

competencies as, role redesign and succession planning , promoting 

wellbeing of staff. People strategy in place, Staff engagement strategy 

in place, leadership strategy incorporating management development 

and performance management in place.KSFProcess Core 

Dimensions. Workforce strategy in place linked into Business plan 

EMB Monitoring of performance and delivery of Change 

agenda, , External Accreditation (NHSLA, CQC, ), Patient 

Survey reports, Staff Survey reports, Royal College 

accreditation processes. University accreditation as an 

education provider Board workforce reports, management 

capability reports - reports to EMB against leadership 

developments . Staff Survey reports. , management 

development programme - , 

Leadership Programmes, Management 





embedding within Divisions- to strengthen the 

assurance Divisional teams give to Divisional 

Boards 







12 12 


OD 

EMB 

Yes 



HR & OD - 

Trust wide 

HR & OD - 

Trust wide 

Failure to understand organisations workforce 

requirements 

Failure to manage poor performance and 

improvement of the workforce 

Revised 

April 2012 

Revised 

April 2012 


specifically 

outcome 12, 

13,14 


specifically 

outcome 12, 

13,14 

Divisional Workforce plans linked to Business and Financial plans. 

Divisional Board accountabilities 

Message of the Day - Team Brief Communication process , 

Appraisals PDR/PDPs- Agreed process and policies- Consultants/Non 

Consultant Staff Grade policy and Personal Development policy, Line 

management responsibilities within organisational framework, 

Induction and Mandatory training, JNCC Quality & Safety Board QSB & 

Governance committee. KSF Monitoring process links for PDR & PDP. 

Divisional Board accountabilities EMB, EMB , CPG responsibilities 

and actions. 

Monitoring of performance and delivery against plans by 

Divisional Management Boards and EMB. 









Workforce Planning Toolkit. Development of HR 

scorecard to produce workforce intelligence 




and training reports. Revision of Managing 

Performance Policy for AfC staff and 

introduction of monitoring system 

Needs ownership and embedding within 

Divisions- to strengthen the assurance 

Divisional teams give to Divisional Boards 




Boards 












Mar13 ( 

Monthly) 

10 10 

8 8 


OD 


OD 

MPN Programme Board Yes 

EMB 

Yes 


HR & OD - 

Trust wide 

Failure to align planning mechanisms between 

service needs and learning of staff 

Revised 

April 2012 


specifically 

outcome 12, 

13,14 

KSF Framework, PDR process, job planning and appraisal Devolved 

systems Business and workforce planning processes, JNCC, JLNC 

Governance Framework. System for informing education 

commissioning linked to divisional workforce plans 

Staff Survey, Educational accreditation 

Staff Survey, Educational accreditation response, Practice response, Practice Reviews, Transformational 

Reviews, Transformational Change demonstrated - annual Change demonstrated - training commissioned 

Training reports 

and uptake. Response to national consultation 

on education commissioning 

To strengthen assurance Divisional teams give 

to divisional Boards based on improved 

workforce planning. 

To strengthen assurance 

Divisional teams give to 

divisional Boards based on 

improved workforce planning 

10 10 


OD 

EMB 

Yes 


HR & OD - 

Trust wide 

Failure to manage the competing demands as a 

provider of education and a provider of services - 

Conflicting demands on staff regarding service 

delivery and achieving targets against availability for 

teaching 

Revised 

April 2012 


specifically 

outcome 12, 

13,14 

KSF Framework, PDR process, job planning and appraisal Devolved 

systems Business planning processes, JNCC, Governance 

Framework- Educational contractual obligations set out in SLAs and 

contracts 

Staff Survey, Educational accreditation response, Practice 

Reviews, Transformational Change demonstrated - annual 

Training reports - Deanery reports and PMETB outcome 

levels - performance against contracts with educational 

providers and establishments 

Staff Survey, Educational accreditation 

response, Practice Reviews, Transformational 

Change demonstrated - training commissioned 

and uptake 

To strengthen assurance Divisional teams give 

to divisional Boards - systematic reporting of 

performance against PMETB requirements 

To strengthen assurance 

Divisional teams give to 

divisional Boards 

Mar13 ( 

Monthly 

12 12 


OD 

EMB 

Yes 


HR & OD - 

Trust wide Failure to recruit and retain staff Revised 

April 2012 


specifically 

outcome 12, 

13,14 

Divisional Board accountabilities 

Message of the Day - Team Brief Communication process , 

Appraisals PDR/PDPs- Agreed process and policies- Consultants/Non 

Consultant Staff Grade policy and Personal Development policy, Line 

management responsibilities within organisational framework, 

Induction and Mandatory training, JNCC Quality & Safety Board QSB & 

Governance committee. KSF Monitoring process links for PDR & PDP. 

Divisional Board accountabilities EMB, EMB , CPG responsibilities 

and actions. Efficient systems and processes supported by leadership 

and engagement 
















Boards 







Mar13 ( 

Monthly) 

12 12 


OD 

EMB 

Yes 


Trustwide- 

Clinical 

Care & 

Govern 

Failure to meet regulation and registration 

requirements in relation to Suitability of 

Management - specifically requirements where the 

service provider is an individual or partnership, 

requirements where the service provider is a body 

other than a partnership, requirements relating to 

registered managers , registered person training , 

notification of absence , notification of changes . 

Failure to comply with CQC Fees requirements 

Revised 

April 2012 

Regs 

4,5,6,7,13,14, 

15 ,19 

Outcomes 3, 

22,23,24,25,2 

7,28 

Governance Unit systematically monitors the requirements and 

provides assurance through to Governance Committee , direct 

nominated persons to ensure that the registered person status is met 

and that notification associated with changes and absence of 

designated persons is met via Governance Unit 

Governance Unit systematically monitors the requirements 

and provides assurance through to Governance 

Committee , direct nominated persons to ensure that the 

registered person status is met and that notification 

associated with changes and absence of designated 

persons is met via Governance Unit 

Application to and registration with CQC 

confirmed for regulated sites and activities 

No gaps in assurance identified No Gaps identified 5 5 



Governance 

Yes 

Page 5 of 7



Finance 

and 

Planning 

Failure to ensure that the Trust meets mandatory 

financial targets and delivers value for money 

services 

Revised 

April 2012 


specific Reg 

13 Outcome 

26 

Trust Board , Audit Committees, Executive Management Board, EMB, 

plan - progress reports against, Budgetary control over activity , 

allocation, provisions and reserves, Monthly budget statements, 

Divisional accountants/ analysts, Partnership working - efficiency 

review. Finance team works to a number of detailed reporting 

timetables. External key data returns. Internally work to a detailed final 

accounts timetable agreed with External Audit. Finance Programme 

established and implemented to achieve financial balance- CIP 

meetings with executive leadership 

Audit & Governance Committees Minutes, Executive 

Management Board Minutes, Reports to Trust Board, 

Internal Audit Reports, External Audit reports , SHA & 

Commissioner Performance Management Reports. 

Board reports demonstrating progress against 

objectives and financial plans, Divisional 

Reports finance & Performance Meetings 

- CIP meetings Reporting programme is 

implemented- Board and Executive action in 

line with finance reports to EMB to receive 

additional assurances - Executive team 

specialing each area of issue through 

performance management infrastructure 

No gaps in assurance identified No Gaps identified 15 15 

DL : Director of Finance, 

Planning ... 

EMB 

Yes 


Finance 

and 

Planning 

and 

Operations 

Failure to negotiate and agree contracts with 

commissioning bodies - Failure to maintain 

contracts ( Impact of 3rd party decisions) 

Revised 

April 2012 


Contract review and monitoring meetings - Trust Board , Audit and 

Governance Committees, Executive Management Board, EMB, plan - 

progress reports against, 

Executive Management Board Minutes, Reports to Trust 

Board, Commissioner and trust contract sign off 

Board reports and sub committee 

demonstrating progress against contract , 

Contract now agreed and operational 

Ongoing Health Economy Contract discussions 

and monitoring of contract requirements 

No Gaps identified - impact of 

commissioning intentions is a 

third party risk that is 

continuously monitored. 

Mar13 ( 

Monthly) 

10 5 


and Director of Service 

Development 

EMB 

Yes 


Finance 

and 

Planning 

Failure to have an integrated business plan in 

place which considers opportunities for service 

developments ( thus business) attracting new 

patients 

Revised 

April 2012 


Management structure with established accountability arrangements 

through a scheme of delegation covering both corporate and clinical 

divisions -Performance Framework- Executive Management Board - 

Governance Committee - Performance meeting schedule, corporate 

planning days and remedial - contracting process and engagement 

with commissioners including Board to Boards and clinical networks 

resulting in Business plan made up of constituent directorate and 

divisional business plans - Directorate and Divisional Business Plan 

core template introduced for 2011/12 

Divisional 5 year clinical strategies, Business plan, , 

Service Delivery Models - Membership strategy - reports 

on Business plan to EMB, FT Engagement Group and 

CEO oversight group, Clinical network meetings and 

outcomes , contract meetings and outcomes informed by 

business unit actions and plans 

Divisional and directorate business plans and 

strategies and contracts aligned and mapped 

to commissioning intent. Draft now complete 

and reviewed by Board 

Commissioning intentions from commissioners 

are not articulated in longer term visions 

Ongoing dialogue and clinician 

involvement across health 

economy 

5 5 


Development 

EMB 

Yes 


Finance 

and 

Planning 

Failure to ensure predictions and future 

commissioning intent inform ELHT business and 

service planning 

Revised 

April 2012 


Management structure with established accountability arrangements 

through a scheme of delegation covering both corporate and clinical 

divisions -Performance Framework- Executive Management Board - 

Governance Committee - Performance meeting schedule and 

remedial - contracting process and engagement with commissioners 

including Board to Boards and clinical networks resulting in Business 

plan made up of constituent directorate and divisional business plans 

Business plan, , Service Delivery Models - Membership 

strategy - reports on Business plan to EMB, Clinical 

network meetings and outcomes , contract meetings and 

outcomes 

Divisional and directorate business plans and 

strategies and contracts aligned and mapped 

to commissioning intent 

Commissioning intentions from commissioners 

are not articulated in longer term visions, 

however Divisional 5 year strategy work should 

now reflect the prioritised list of intentions 

Ongoing dialogue with 

commissioners to establish long 

term commissioning intentions 

has resulted in an agreed 

prioritised list of high level 

intentions 

Mar13 ( 

Monthly) 

9 9 


Development 

EMB 

Yes 

3 months 2 

B- 

AF097 Operations Failure to deliver agreed activity plan Revised 

April 2012 


Trust Board , Audit and Governance Committees, Executive 

Management Board, EMB, plan, Divisional Boards and Directorate 

reports- Integrated Performance management framework is integral to 

the operational and strategic assurance infrastructures 

Reports to performance meeting , Divisional Boards EMB 

and TB 

Monthly information pack; Divisional 

Performance Meetings - Reports to EMB - 

Management of activity being embedded within 

Divisions 

Plan to be managed and embedded at 

Divisional Level further embedding with 

workforce plans and long term financial model 

Board 

Business managers to have 

ownership and management of 

plan and Business plan at 

Divisional level 

Mar13 ( 

Monthly) 

15 15 

DL : Director of 

Operations 

EMB 

Yes 


Finance 

and 

Planning 

and 

Operations 

Failure to have systems in place to monitor 

performance against agree activity plan 

Revised 

April 2012 



Management Board, EMB, plan, Divisional Boards and Directorate 

reports- Contract review meeting process 

Reports to weekly performance meeting , Divisional 

Boards EMB and TB - contract review meeting process 

Monthly information pack; Divisional 

Performance Meetings - Reports to EMB - 

Management of activity being embedded within 

Divisions 

Plan to be managed and embedded at 

Divisional Level further embedding with 

workforce plans and long term financial model 

Board and Executive action in line with finance 

reports to EMB to receive additional assurances 

- Executive team specialing each area of issue 

Business managers to have 

ownership and management of 

plan and Business plan at 

Divisional level 

Mar13 ( 

Monthly) 

5 5 DL : Director of Finance EMB Yes 

3 months 4 AF099 Finance & 

Planning 

Finance 

and 

3 months 4 AF100 Planning 

and 

Operations 


Finance 

and 

Planning 

and 

Operations 

Failure to have a Fraud Management programme in 

place 

Failure to manage unplanned changes in patient 

flows including unplanned growth in Urgent Care 

Failure to have available high quality financial and 

activity information and for this to systematically 

inform service activity and developments - failure to 

develop information processes and systems 

Revised 

April 2012 

Revised 

April 2012 

Revised 

April 2012 




Trust Board , Audit Committee, Policies Procedures , Fraud 

awareness plan and systems 

Systems in place to give early alert to changes in flow - Information 

analysists - Reporting to Executive - EMB monthly monitoring - 

Performance packs and Information analysis from Trust Information 

functions 










Reports to Audit Committee - Returns to Counter Fraud 

services 

Systems in place to give early alert to changes in flow - 

Information analysists - Reporting to Executive - EMB 

monthly monitoring - Performance packs and Information 

analysis from Trust Information functions 

Reports to Audit Committee - Returns to 

Counter Fraud services 

Marketing linkage to activity monitoring through 

Divisional business plans and information 

analysis on a continual basis 

Established Trust Information Function in place. 

Divisional Information packs are produced monthly and 

Information pack and Divisional Information 

Divisional Information Analysts are in place. Benchmarking 

analysists in place. Benchmarking data 

data has been introduced into the performance reports 

introduced within performance reports 


Uncertainty as to future commissioned model 

Divisions need to further embed and align 

financial, workforce and activity predictions at a 

service management level with service 

modelling 



Divisions need to further embed 

and align financial, workforce 

and activity predictions at a 

service management level with 

service modelling 

Mar13 ( 

Monthly) 

5 5 DL : Director of Finance EMB Yes 

Mar13 ( 

Monthly) 

15 10 

Mar13 ( 

Monthly) 

10 10 


Development 


Planning ... 

EMB 

EMB 

Yes 

Yes 



Finance 

and 

Planning 

and 

Operations 

Finance 

and 

Planning 

and 

Operations 

Failure to maintain and further develop relationships 

with Commissioners and failure to respond to 

revised commissioning arrangements 

Failure to be proactive in dealing with Financial 

pressures and constraints 

Revised 

April 2012 

Revised 

April 2012 



Board to Board meetings with PCTs - Clinical engagement - GP 

commissioning - Marketing strategy 










Marketing and engagement demonstrated 

Trust Board , Audit Committees, Executive Management 

Board, EMB, plan - progress reports against, Budgetary 

control over activity , allocation, provisions and reserves, 

Monthly budget statements, Divisional accountants/ 

analysts, Partnership working - efficiency review. Finance 

team works to a number of detailed reporting timetables. 

External key data returns. Internally work to a detailed final 

accounts timetable agreed with External Audit. Finance 

Programme established and implemented to achieve 

financial balance- CIP meetings with executive 

leadership 

Engagement with PCT and Commissioners and 

sign up to Business plan 

Organisation transformation underway - 

evidence that actions are in hand - 





Mar13 ( 

Monthly) 

10 10 

Mar13 ( 

Monthly) 

15 15 


Planning ... 


Planning ... 

EMB 

EMB 

Yes 

Yes 




Finance 

and 

Planning 

and 

Operations 

Finance 

and 

Planning 

and 

Operations 

Finance 

and 

Planning 

Failure to meet in year CIP thus affecting Trust 

performance - Failure to ensure CIPS projects are 

managed within project plans and timescales 

agreed and failure to monitor variance from CIPS 

with timely remedial action-Failure to have 

mitigations in place for non delivery or slippage in 

CIPs 

Failure to ensure quality and safety of services 

when determining CIP programmes 

Failure to maintain cash flow 

Revised 

April 2012 

Revised 

April 2012 

Revised 

April 2012 




As above - CIP monitoring processes in place - each CIP has project 

charter and monitoring in place 

As above - CIP monitoring processes in place - each CIP has project 

charter and monitoring in place with requirement to appraise impact 

on service and risk assessment 










Budget sign off and budget reporting incorporating 

budget reporting incorporating agreement to 

agreement to CIP targets can be evidenced - CIP reporting 

CIP targets can be evidenced 

and monitoring 

Project charters for each CIP with risk appraisal at an 

operational level 

Trust Board , Audit Committees, Executive Management 

Board, EMB, plan - progress reports against, Budgetary 

control over activity , allocation, provisions and reserves, 

Monthly budget statements, Divisional accountants/ 

analysts, Partnership working - efficiency review. Finance 

team works to a number of detailed reporting timetables. 

External key data returns. Internally work to a detailed final 

accounts timetable agreed with External Audit. Finance 

Programme established and implemented to achieve 

financial balance- CIP meetings with executive 

leadership 

Overarching programme management to CIP 

programme can be demonstrated - individual 

risk appraisals can be demonstrated with 

discussions at DMB & /or EMB 

Delivery of financial plan, strengthening balance 

sheet controls 

Divisions actively being managed to deliver CIP 

Programme Board and Executive action tin line 

with finance reports to EMB to receive additional 

assurances - Executive team specialing each 

area of issue 

Divisions must demonstrate consistent 

application of Divisional Board risk assessment 

to each CIP for quality and safety 

Divisions must demonstrate consistent 

application of Divisional Board risk assessment 

to each CIP for quality and safety - contract 

negotiation needs finalising 



Divisions have not identified 

alternatives if CIP programme 

cannot be delivered or slippage - 

contract negotiation needs 

finalising and agreeing 

Mar13 ( 

Monthly) 

15 15 


Planning ... 

Mar13 ( 

Monthly) 

10 10 DL All Directors EMB Yes 

Mar13 ( 

Monthly) 

10 5 


Planning ... 

EMB 

EMB 

Yes 

Yes 


Finance 

and 

Planning 

Failure to provide on going high quality accurate 

financial advice and leadership to the organisation 

to the organisation 

Revised 

April 2012 











Monthly budgetary and balance sheet reporting can be 

evidenced . 

Expenditure reporting processes. 

Continuous provision of accurate financial data - 

process to enable service line reporting - 


Mar13 ( 

Monthly) 

5 5 


Planning ... 

EMB 

Yes 


Finance 

and 

Planning 

Failure to manage PFI contract 

Revised 

April 2012 


- Reg 15 , 16 

Outcome 10 , 

11 

PFI Contract Monitoring process in place against key performance 

indicators and monitoring infrastructure . 

PFI Contract Monitoring process in place against key 

performance indicators and monitoring infrastructure . 

PFI Contract Management Function in place 

with reporting arrangements through to 

performance monitoring system 

Effective contract management needs to be 

further embedded 


Mar13 ( 

Monthly) 

10 5 


Planning ... 

EMB 

Yes 

Page 6 of 7




Finance 

and 

Planning 

and 

Operations 

Finance 

and 

planning 



Finance 

and 

Planning 

and 

Operations 

Failure to achieve FT trajectory , milestones and FT 

Status and FT Covenants requirement 

Revised 

April 2012 

Failure to deliver robust and meaningful LTFM to 

Revised 

the timetable as required by the tripartite agreement 

April 2012 

between the SHA/DH/ELHT 

Failure to manage readmissions - impact on 

income as a result of operating framework 

requirements 

Failure to inform and engage with changes to 

commissioning bodies and process and impact of 

third party decisions in light off NHS reforms - 

Revised 

April 2012 

Revised 

April 2012 

impacts on all 




FT project plan in place which is overseen by FT Engagement Group 

and CEO oversight group - all constituent requirements are 

considered and aligned to SHA performance management 

requirements and DH reporting requirements 

Discussion and project plan through FT Engagement Group and CEO 

oversight group. Cascade requirements to Divisions through Business 

Planning forums and routine divisional business meetings to ensure 

FT requirements are embedded in the system and way of working. 

Ensure that timetable for routine refresh of the model is understood so 

that all divisions and departments contribute required metrics and 

datasets eg workforce, estates, activity, divisional CIPs etc in a timely 

manner. 

Systems in place to give early alert to readmission information- 

Information analysists - Reporting to Executive - EMB monitoring - 

Performance packs and Information analysis from Trust Information 

functions Audit and monitoring to provide evidence for agreement of 

local exclusions to minimise income risk and the TCS pathway 

redesign opportunity will enable work to progress for preventable 

readmissions 


Management Board, EMB, progress reports against, strategic 

decisions and direction 

FT project plan in place which is overseen by FT 

Engagement Group and CEO oversight group - all 

constituent requirements are considered and aligned to 

SHA performance management requirements 

External reporting to SHA in line with agreed formal 

trajectory. Routine reporting and performance monitoring 

to EMB and Trust Board. Regular reporting to FT 

Engagement Group and CEO oversight group and 

associated workstreams. 

Systems in place to give early alert to - Information 

analysists - Reporting to Executive - EMB monthly 

monitoring - Performance packs and Information analysis 

from Trust Information functions 

Executive Management Board Minutes, Reports to Trust 

Board, Commissioner and trust discussions 

FT action plan outturn reports and production of 

required outputs to SHA within timescales 

Divisional, directorate and board understanding 

of the LTFM and ownership of the associated 

strategy. 

Monitoring activity through Divisional business 

on a continual basis 


demonstrating progress against strategic 

direction 


Strengthen engagement and understanding at 

all levels and ensure routine updates at Board 

and Divisional meetings. 

Provide evidence for agreement of local 

exclusions to minimise income risk and the TCS 

pathway redesign opportunity for the 

preventable ones. 

Ongoing Health Economy discussions and 

monitoring of strategic decisions 


Strengthen engagement and 

understanding at all levels and 

ensure routine updates at Board 




engagement and transition 

through the Board to Boards, 

Local Implementation teams and 

Health economy cross cutting 

groups - 

No Gaps identified - impact of 

commissioning intentions is a 

third party risk that is 

continuously monitored. 

Mar13 ( 

Monthly) 

15 15 

Mar13 ( 

Monthly) 

10 10 

Mar13 ( 

Monthly) 

20 10 

Mar13 ( 

Monthly) 

10 10 



DL : Director of 

Operations 


Planning .. And Director 

of Service Development 


Planning .. And Director 

of Operations. 

EMB 

Trust Board, EMB 

EMB 

EMB 

No 

yes 

Yes 

Yes 


Finance 

and 

Planning 

and 

Operations 

Failure to have in place and implement a long term 

change programme realising efficiency and 

workforce change 

01-Jun-12 


Clinically lead operational management structure with established 

accountability arrangements through a scheme of delegation covering 

both corporate and clinical divisions -Performance and HR/ OD 

Frameworks- Executive Management Board - Governance Committee Executive Management Board Minutes, Reports to Trust 

- Performance meeting schedule, corporate planning days and Board, Commissioner and trust discussions 

remedial - contracting process and engagement with commissioners 

including Board to Boards and clinical networks resulting in Business 

plan made up of constituent directorate and divisional business plans - 


demonstrating progress against strategic 

direction 

Strengthen engagement and understanding at 

all levels and ensure routine updates at Board 


Strengthen engagement and 

understanding at all levels and 

ensure routine updates at Board 


Mar13 ( 

Monthly) 

20 15 


Planning .and all 

Directors 

EMB 

Yes 

Page 7 of 7

Risk Score Matrix 

Look at the scale for Likelihood of Occurrence and identify a score that best relates to the work area 

Then look at the Most likely Impact/Consequences scale and identify a score that best relates to the work area 

Multiply the Likelihood of Occurrence Score by the Most Likely Impact/Consequence Score 

Insert your decision into the relevant section of the Assurance Framework 

Most likely Impact/Consequences 

Likelihood of 

None Minor Moderate Major Catastrophic 

occurrence/ recurrence 

1 2 3 4 5 

Almost 

5 5 10 15 20 25 

certain 

Likely 4 4 8 12 16 20 

Possible 3 3 6 9 12 15 

Unlikely 2 2 4 6 8 10 

Rare 1 1 2 3 4 5 

Level of Risk 

Low Risk 

Moderate 

Risk 

Significant 

Risk 

Extreme Risk

Meeting Date: 


Report Submitted By: 

Nicola Tamanis, 

Associate Director of 


Date Considered By 

Divisional Board/ 

Reason Not 

Considered By 

Divisional Board: 

N/A 



PART ONE 

Report Purpose: 

For Decision 

Performance Monitoring 

For Information 


Assurance Framework & 

Consequences: 


Commitments: 



Identified: 





□ 

Report Approved By: 

Martin Hodgson, Director of 


Divisional Board Chair 

Approval: 

N/A 

□ 


1.4, 1.5, 1.9, 1.91, 1.11, 1.12 

Agenda Item: 12 

Report Title: 

FT Progress Report 


Confidentiality 

Required: 

No 

• Improved patient experience by putting 

quality at the centre of everything we do 

• Delivery of national standards and targets 

• Improved productivity 

• Improved efficiency 

• Invest in and develop our workforce 


None specific. 

All embracing Equality Impact Assessment (EIA) 

required linked to PCT led health economy EIA 







Page 1 of 6 



V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(12) FT Progress Report.docx


Outcomes: 










communities 







This paper sets out the latest position in 

relation to the progress of the Trust’s 

application for Foundation Trust status, 

including the identified inherent risks. 

Trust Board is asked to note the update 

provided. 

Page 2 of 6 




1. Introduction 

The purpose of this report is to update members on the progress of our Foundation Trust Application. 

The verbal feedback from the Strategic Health Authority (SHA) Board to Board was shared and 

considered at the Board Development Day on 25 th September. Formal feedback has also now been 

received from the SHA. The SHA Provider Development Board formally approved the recommendation 

to support our application through to the Department of Health (DH) phase at their meeting on the 27 th 

September 2012. The inherent risks for the organisation in the FT application process have been 

specifically included in the paper for further discussion. 

2. Performance against the Compliance Framework 

MRSA 

No cases of MRSA were identified in September maintaining the year to date total of two cases against a 

year to date trajectory of two and a full year trajectory of three. Given the full year trajectory of just three 

cases this continues to be a risk. 

Clostridium Difficile 

Four cases of post 3 day C. Difficile were identified in September against an in month target of three, 

bringing the year to date total to seventeen against a year to date trajectory of eighteen and a full year 

trajectory of forty three. 

18 Weeks 

As at September 2012 no treatment functions are failing 18 week standards (total of admitted/nonadmitted/on-going). 

3. Single Operating Model (SOM) – Part 2 

Part 2 of the SOM requires submission of a monthly reporting template, which requires Boards to self 

certify compliance against a number of key criteria, and therefore operate in a manaer akin to the Board 

of a Foundation Trust. 

4. Integrated Business Plan (IBP) 

A ‘redacted’ version of the final IBP has been produced and shared with our commissioners. A draft 

Summary IBP is being developed, which will be used to share the highlights of the IBP with our staff and 

the wider public to raise awareness of our Foundation Trust application in addition to supporting the 

recruitment of members and Governors. 

Page 6 of 6 




5. Progress to date 

5.1 Governors and membership 

A draft election timetable has been produced which ensures all our Governors are elected/appointed in 

advance of our earliest authorisation date of 1 April 2013. Governor awareness sessions are currently 

being arranged. Draft documents in relation to Governors and the Election Process will be discussed in 

the Part 2 meeting. 

Although projected membership numbers remain in a healthy position, with circa 10,800 public members 

and 6,500 staff members, we would like to grow the public membership numbers to circa 12,000 public 

members by April 2013. A number of initiatives will be used to grow the membership, facilitated by a 

membership officer who started on the 11 th October 2012. 

Staff engagement sessions continue to be delivered across the Trust. 

5.2 Third Party Assurance Process 

Action plans for all three elements of the assurance process; Quality Governance, Board Governance 

and Historical Due Diligence have been developed, disseminated appropriately and were considered at 

the recent Board Development Day. Delivery will be managed through the relevant governance systems 

and structures. 

6. Department of Health Phase 

As stated in the introduction to this paper we have entered the second phase of the Foundation Trust 

assessment, for which the DH remains responsible (see the timeline below). We will be one of the last 

aspirant foundation trusts to follow this route to authorisation. Responsibility for the foundation trust 

pipeline will transfer to the National Trust Development Authority (NTDA) on the 1 November 2012. As a 

result the NTDA are taking an interest in our application and are involved in assessing the quality 

aspects of our submission. 

The DH phase generally lasts between 4 and 12 weeks and is fundamentally a desktop exercise where 

we are required to respond to questions about our application from the DH. The SHA remains our point 

of contact and the questions are sent via the Provider Development Unit at the SHA. The first set of 

questions, which were focussed on the financial aspects of our application, have been received to which 

we have responded. We are expecting to receive at least one further set of questions covering the 

governance aspects of our application. We have been informed that the Applications Committee at which 

our application will be considered is due to take place on the 27 th November 2012. 

The key activities over the next three months are highlighted in the timeline below: 

Page 6 of 6 




7. Key Risks 

The feedback from the Provider Development Unit (PDU) /SHA cluster remains positive and we now 

have a national Green rating from the Department of Health. There remain however a number of 

inherent risks which have been considered and built into the existing Risk Assurance Framework. These 

have been recently reviewed and scored and are collectively reflected in Chapter 7 of the IBP. Specific 

risks worth capturing at this juncture are: 

- within the context of a very difficult economic environment nationally, and particularly in the public 

sector, the identification of underpinning CIP schemes, in detail for the next three financial years 

and indicative for a further two. The PDU have indicated that the development of robust CIPs 

including quality impact assessments and underpinning workforce plans should be the top priority 

for the Trust. Continued significant progress has been made by Divisions since the last report, 

culminating in the Divisional presentations to the Board at our recent development day, but there 

is still work to do before we reach the Monitor assessment phase 

- similarly how we plan for financial risks, supporting contingency plans and hence develop our 

mitigations against the ‘downside’ case – this planning continues to progress but requires further 

development 

- ensuring continued Commissioner support for our service development plans, working 

collaboratively and productively on recently received commissioning intentions (especially with 

developing Clinical Commissioning Groups) including jointly agreed activity plans and also 

Page 6 of 6 




obtaining good contract settlements for the next few years within the prevailing environment of 

austerity 

- delivering effective communication, and thereby ensuring ‘ownership’ of our plans to both our 

staff and also all relevant external stakeholders, which will also influence how well we deliver our 

membership strategy 

- continued good delivery against all key service, performance and quality indicators, with potential 

further (albeit reduced risk of) industrial action in respect of the proposed pension reforms 

- continued effective management of the action plans arising from the third party assurance 

process 

8. Conclusion 

Members are asked to note the contents of this report, acknowledge the excellent progress made in the 

last month, understand the inherent process over the next few months and receive assurance that 

collectively we continue to address the underpinning workstreams and inherent risks identified. 

Page 6 of 6 




Meeting Date: 

30 th October 2012 



Company Secretary 


PART ONE 


For Decision □ 


For Information 


Report Title: 

Hazel Harding 

Reports of 

Chairman 

Subcommittees 


Committee 

N/A 





Commitments: 




Date 


No 

As identified in the reports 






• To maintain & improve patient experience & 

outcomes through achievement of the key 

indicators/ objectives outlined in the Trust’s 

Quality Account 

• To invest in & develop our workforce & improve 

staff engagement & satisfaction levels 

• To maintain all regulatory requirements with the 

CQC & be licensed to provide services without 

conditions 


deliver a cost improvement programme of 5% 




• To continually promote equality & diversity at 

every level within the organisation 


Page 1 of 8 



V:\Management Meeting Records\TRUST BOARD\2012\MEETING PREP\Part 1\(13) Sub Committee Report.docx


Identified: 






Outcomes: 









• Aspiring to highest standards of excellence & 

professionalism 

• Reflecting needs and preferences of patients & 

families 

• Working in partnership across organisational 

boundaries 



• Accountable to public, patients & communities 







A summary of the discussions and discussions 

of the Board’s sub-committees is presented for 

members. 

Members are asked to receive the report 

noting the contents, the assurances provided 

and the activities of the Board’s subcommittees. 

Page 2 of 8 




Sub Committee 

Foundation Trust Programme Board 

Date of Meeting 10 th October 2012 

Chair 

Martin Hill 

Recommendation 

For 

For Discussion For Information x 

Approval 

Attendance Excellent x Acceptable Not Quorate 

Agenda Fit for Purpose Yes x No 

and Terms of Reference 

Key Elements of the Meeting 

• Three month timeline 

• Exception report 

• Elections and Governors 

Top Risks Identified During the Meeting 

• Delivery of the Foundation Trust Application timeline and actions 

The Committee Considered 

• Three month timeline 

Members received and discussed the update to the three month timeline noting the 

interface between the Department of Health and the NTDA and how this was likely to 

impact on our FT trajectory. Members noted potential dates for the DoH to consider the 

FT application and the role of the NTDA in relation to the quality aspects of the 

application. 

• Exception report 

Members noted the arrangements agreed for the reporting of actions against the external 

assessment action plan and confirmed that a summary IBP was being prepared. Mr 

Wood gave an update on the progress of the change management process and the need 

to continue to develop efficiency programmes for the new financial year and that 

scenario planning would be undertaken with the Board as soon as possible. 

• Elections and Governors 

Members received a progress report against the Governor election work stream and 

noted that a full proposal would be presented to the Board for consideration. 

Items for Escalation 

None 

Action Required from Receiving Committee: 

To receive the report 

Page 3 of 8 




Sub Committee 

Charitable Funds Committee 

Date of Meeting 17 th October 2012 

Chair 

George Boyer 


For 

For Discussion For Information √ 

Approval 

Attendance Excellent √ Acceptable Not Quorate 

Agenda Fit for Purpose Yes √ No 



• Fund Performance Report 

• Fund Investment Report 

• Long Service and Retirement Report 

• Albert Birtwistle Endowment Fund Update 

• Transfer of Community Funds 

• Charitable Funds Annual Accounts and Annual Report 

• Applications for Use of Funds 

• Statutory, Best Practice Update 

• Chronic Funds Update 

• Communications Group Update 

• Any Other Business 


• Development and maintenance of partnerships that support the Trust 


• Action Matrix 

Work will be undertaken to see if the hospital cup competition can be re-instated 

linking membership and volunteers and a report will be presented in one year. Legal 

advice will be sought on the state of the chronic pain fund following which further 

contact will be made with donors. 

• Fund Performance Report 

Members noted changes in fund balances with fund movements and the receipt of a 

legacy of £244K for general radiology funds. Members agreed changes to the format 

of the report. A report on the future use of the Victoria Nurses fund will be provided 

to the next committee. 

• Investment Performance Report 

Page 4 of 8 




Members noted that investment returns were likely to outstrip the agreed 

benchmarks at the end of the year. 

• Long Service & Retirements 

Members agreed a cross divisional pro-rata levy to meet the anticipated cost of 

awards in year. 

• Albert Birtwistle Endowment 

Members noted the Charities Commission had granted approval to expend the 

permanent endowment and that the total would now be transferred to the general 

purpose fund with funds to be expended at Burnley General Hospital where possible. 

• Transfer of Community Funds 

Members noted the transfer of funds under the TCS arrangements. It was agreed 

these will be merged with the current ELHT portfolio and managed together under 

the current Ethical Investment Strategy. Further rationalisation will be undertaken as 

appropriate. 

• Charitable Funds Annual Accounts and Annual Report 

Members noted that the Audit Commission had provided a clear assessment of the 

accounting arrangements and recommended some presentational changes to the 

report prior to its submission to Trust Board. 

• Fund Raising Activities Report 

Members approved the applications to fundraise and sought verification that the 

Voluntary Services Manager provided thank you letters to fundraisers. 

• Applications to Fundraise. 

Members declined making a grant to the NHS Retirement Fellowship as it did not 

benefit current staff or patients but offered the use of accommodation as an 

alternative. 

• Statutory and Best Practice Update 

Members received an information report on recent statutory and best practice 

developments. 

• Communications Group Update 

Members requested a report for the next meeting on what the Communications 

Department could offer in the way of supporting fundraising activities. 

• Any Other Business 

Members noted the review of fund manager arrangements to strengthen governance 

processes and to publicise funds available. Members discussed further staff 

representation on the committee 

Page 5 of 8 





Annual Report and Annual Accounts for Charitable Funds – November Trust Board 


To receive the report and note the contents. 

Page 6 of 8 




Sub Committee 

Business Forum 

Date of Meeting 19 th September 2012 

Chair 


Hazel Harding 

For 

Approval 

For Discussion For Information X 

Attendance Excellent X Acceptable Not Quorate 

Agenda Fit for Purpose 



• Quality and Patient Experience 

• Performance Dashboards 

• Finance 

• HR 

Yes X No 


• Failure to deliver essential standards of quality and safety 

• Failure to reduce and manage Health Care Acquired infections 

• Failure to deliver and develop an effective information and intelligence strategy 

• Development & maintenance of partnerships 

• Delivery of the estates strategy 


• Quality and Patient Experience Report 

Members received and discussed a case study on a pneumonia patient considering the 

learning and actions being put in place. Members discussed the prevalence of some 

community acquired infections and public health issues. Members noted mortality rates 

and ongoing research 

• Performance Dashboards 

Members noted current performance dashboards in relation to finance, HR and 

operational issues. Exception reports were received and discussed and improved 

performance was noted in a number of operational areas. In relation to finance members 

noted an improvement in the phasing of CIP and that Divisions were aware of the need 

to ensure recurrent provision of CIP programmes and particularly noted the improvement 

in the aged debt position. 

In relation to HR there was some concern over Sickness Absence performance but 

members noted divisions were being provided with appropriate support and discussed 

Personal Development Review rates. An exception report was received and discussed 

Page 7 of 8 




on non consultant medical staff appraisal and members noted the actions being 

implemented to recover this position. 


None 


To receive and note this report 

Page 8 of 8

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