UNIVERSITY HOSPITALS OF MORECAMBEBAY NHS TRUST

TRUST BOARD MEETING

To be held on 16 June 2010Agenda No: 2

Report of: / Patrick McGahon-Director of Service and Commercial Development
Paper Prepared by: / Jo Borthwick, Head of Business Planning
Date of Paper: / 10 June 2010
Subject: / Board Self Certification of Governance Robustness
Care Quality Commission
Standards: / Outcomes 15, 16, 22-28
Assurance Framework Link: / Strategic Objective – All
Auditors Local Evaluation
(ALE) Link:
Background Papers: / Self certification 22 April 2009
Item Considered at Earlier Committees
(pls detail mtgs): / Not Applicable
Patient & Public Involvement: / Not Applicable
In case of query, please contact: / Jo Borthwick ext.46686
Purpose of Paper:
Part of the Foundation Trust application process, undertaken by Monitor, requires the Board to self-certify that it has robust governance arrangements in place. This report reviews the elements of the Trust’s governance arrangements as required by the Monitor Guide to Applicants, November 2008 sections 5.3.2.2, 5.3.2.3 and Appendix B12.
This report confirms the Trust has robust arrangements in place. The Board is asked to review and comment upon the report before approving a final self certification for the Trust’s governance arrangements.
The Board is asked to:
  1. REVIEW and COMMENT on the draft self-certification of the robustness of the Trust’s governance regime.
  2. APPROVE the self certification within this report prior to submission to Monitor
  3. APPROVE the actions identified in section 2 of this report.

  1. Background

1.1 The joint Department of Health and Monitor document “Applying for NHS Foundation Trust status: Guide to Applicants”, November 2008 asks two key questions about the robustness of the Trust’s governance arrangements:

Q1 Does the Trust Board believe that the Trust has the organisational capacity necessary to deliver the Business Plan? (section 5.3.2.2)

Q2 How is the applicant performing against existing targets and national core standards? (5.3.2.3)

1.2Appendix B12 of the guide provides a summary of the key elements of the self-certification requirement covering:

  1. Clinical quality
  2. Service performance
  3. Other risk management processes and
  4. Board roles, structures and capacity

The report identifies the assurances that relate to each area and any actions required to further enhance robustness.

1.3This self-certification must be formally approved/ adopted at a Board Meeting.

2. Board self-Certification Statements

2.1 Appendix B12 of the guide outlines the four areas for self-certification and includes the key questions under each area. The tables below reproduce the four areas and associated questions with comments, assurances and further actions planned.

2.2 Table 2.1 covers the area of clinical quality.

1

Table 2.1 Clinical Quality – Clinical Quality
Question 1- The Board is satisfied that, to the best of its knowledge and using its own processes (supported by the Care Quality Commission (HCC) metrics it chooses to adopt) its aspiration to be an NHS Foundation trust has and will keep in place effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.
Comments / Assurances / Further Actions Planned
Care Quality Commission Registration
The Trust has implemented the following:
  1. Integrated performance report to monitor national targets
  1. Clinical Quality and Safety Committee focusing on clinical indicators
  1. Utilisation of CHKS clinical benchmarking
  1. National patient surveys
  1. Advancing Quality
  1. Patient Environment Action Teams
  1. Board to Ward Assurance Arrangements for Infection Control and Prevention
  1. Patient Safety First
  1. Nursing and Midwifery Strategy
  1. Nursing practice reviews
/
  • The Trust received registration without conditions with the Care Quality Commission from 1 April 2010
  • Integrated performance reports (Board and FPSCs October 2008 onwards)
  • Clinical Quality and Safety Committee-
10 December 2008 (onwards)
Bi-monthly meetings (December 2009 onwards)
  • CHKS key performance indicators in place
  • Inpatient Survey 2009 (Board, 26 May 2010)
  • Outpatients Survey 2009
(CQSC, 14 April 2010)
  • Results for 2009/10 reported by SHA (published June 2010) showing performance achieved including £0.2m in incentive funding secured
  • PEAT visit feedback reported via Quality Accounts 2009/10 (Board, 9 June 2010)
  • Board to Ward Board reports:
18 March 2009
22 July 2009
18 November 2009
20 January 2010
24 March 2010
26 May 2010
  • HCAI KPI Dashboard (Infection and Prevention sub-committee – from October 2008 onwards)
  • Board Report
26 November 2008
  • Prototype Ward to Board Assurance Report
May 2010
  • Strategy launched July 2010 (Board, 22 July 2010)
  • Nursing care practice reviews
a)Elderly RLI (reported to Clinical Quality and Safety Committee, 11 February 2009)
b)Orthopaedics RLI (Patient experience Sub Committee, 5 May 2010)
  • Nursing Quality Assessment Tool (NQAT) piloted at FGH August 2009
/
  • Targeted action plans in place
  • CQUIN improvement metric for 2010/11
  • Advancing Quality indicators included within CQUIN for 2010/11
  • Roll out of Productive Ward dashboard GURU Ongoing with target to complete by June 2010
  • Considering Board Performance Reporting at Board Workshop 30 June 2010
  • Roll out to all sites from March 2010

Question 2- The Board is satisfied that, to the best of its knowledge and using its own processes, plans in place are sufficient to ensure ongoing compliance with the Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections (“The Hygiene Code”)
Comments / Assurances / Further Actions Planned
Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections (“The Hygiene Code”) -
Actions completed from Code of Hygiene inspection and Trust has submitted evidence to lead inspector. Trust was licensed unconditionally for HCAIs by the Care Quality Commission from April 2009. /
  • HCC inspection in August2008, reported in December 2008
  • January 2009 Board paper detailing action plan to address issues relating to sub duties 2 and 4.
  • March 2009 evidence against action plan submitted to lead inspector ( in advance of June 2009 target date that was given)
  • September 2009 Board Paper – reducing HCAIs in England
  • Board to Ward Assurance KPIs
/
  • Modernisation of Infection Prevention Team – review of roles , responsibilities and operational function (Ongoing)

2.3 Table 2.2 covers the area of service performance.

Table 2.2 Service Performance
Question 3- The Board is satisfied that the plans in place are sufficient to ensure ongoing compliance with all existing targets (after the application of thresholds) and national core standards and a commitment to comply with all known targets going forward
Comments / Assurances / Further Actions Planned
  • The key issues are:
  1. Compliance with all existing targets after application of the thresholds. The Trust has performed well during 2009/10. Three areas of concern identified during the year:
a) A&E 4 hour target- delivered 98.06% for year
b) Thrombolysis Call to needle time –delivered 59.72% against a target of 68%
c) 18 weeks non-admitted patients /
  • Care Quality Commission rating of “fair” for services in 2008/09
  • Forecast rating of “good” for 2009/10
  • Integrated Performance reports to:Board and FPSC (October 2008 onwards)
  • A&E reports:
iExternal Review Emergency Care Intensive Support Team Report - FPSC 16 December 2009
iHMT 3 February 2010
iiHMT 7 April 2010
  • Thrombolysis call to needle time action plan (May 2009)
  • Standard met in all specialities with the exception of neurosurgery in March and Quarter 4
/
  • Agreed actions as part NHS North Lancashire Unscheduled Care Group – progress reported at May 2010 meeting
  • Further work required with NWAS to improve performance (monthly meetings)
  • Responsibility for Neurosurgery transferred to Lancashire Teaching Hospitals on 11 May 2010

2. National Core Standards – Trust has always reported compliance based upon assurance process /
  • 2008/09
Summary of top 3 at risk to each Board, quarterly progress reports (June/Sept/Dec 2008),Board paper on reporting requirements (January2009), draft declaration to CQSC ( February2009), Audit Committee and Board ( March 2009) FPSC( April 2009),Chief Executives Group self assessment summary (9 February2009).
Internal audit reports for domain (6 August 2008) c9(May 2008),c2(March 2008),c7e(November2008),c24(February2009),systems and process for declaration(March2009).
  • 2009/10
Internal Audit reports for Records Management; Waste Management; Medicines Management; Patients Needs; Privacy & Confidentiality; Declaration Process (May 2009)
Summary report and update (FPSC, 5 November 2009)
Draft mid-year declaration (Board, 18 November 2009)
Care Quality Commission Registration Requirements and updates (FPSC, December 2009, CQSC December 2009, April 2010, Board January 2010, March 2010)
3. Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections (“The Hygiene Code”) -Actions completed from Code of Hygiene inspection and submitted evidence to lead inspector. Trust was licensed unconditionally for HCAIs by the CQC from April 2009. /
  • January 2009 Board paper detailing action plan to address issues identified for sub duties 2 and 4.
  • March 2009 evidence against action plan submitted to lead inspector ( in advance of June 09 target date that was given)
  • Unannounced CQC inspection Jan 2010 – no breaches, 1 recommendation
  • Trust delivered 2009/10 targets for MRSA and CDifficile

Table 2.3 covers the area of other risk management processes

Table 2.3 Other Risk Management Processes
Question 4- Issues and concerns raised by external audit and external assessment groups (including reports for NHS Litigation Authority assessments) have been addressed and resolved. Where any issues or concerns are outstanding, the board is confident that there are appropriate action plans in place to address the issues in a timely manner
Comments / Assurances / Further Actions Planned
The Board and sub-committees review reports from external bodies on a regular basis and engage in direct dialogue where appropriate. The Board is assured there are no significant issues or concerns from external bodies /
  • Annual Audit Letter, Audit Commission October 2009
  • Head of Internal Audit Opinion, Audit Committee June 2010
  • Business Case process – CPCC action plan agreed with update reported (audit Committee, 21 April 2010)

Question 5- All recommendations to the board from the audit committee are implemented in a timely and robust manner and to the satisfaction of the body concerned
Comments / Assurances / Further Actions Planned
Internal audit recommendations are followed up at each audit committee meeting via a tracking system. External audits are followed up in the annual audit letter. In addition the committee has its own action tracking system. /
  • Audit Committee reports
10 June 2009
17 June 2009
30 September 2009
9 December 2009
25 February 2010
21 April 2010
Question 6- The necessary planning performance management and risk management processes are in place to deliver the business plan.
Comments / Assurances / Further Actions Planned
The Trust has robust processes in place to ensure delivery of the business plan including:
1)Planning – Long term strategy is reviewed internally (Board Development sessions)
2)Performance Management –
The key areas of Trust progress include:
  1. Business Plan 2009/10 utilises the Trust’s strategic objectives that are translated into targets for monitoring purposes
  1. Integrated performance report monitors progress against key national financial and operational targets
  1. Performance management process is clearly defined and includes an escalation process if corrective action is required
3) Risk Management-
  1. The Trust Board developed its Risk Assurance Framework 2009/10 to identify principal risks. It has consistently reviewed the top risks during the year and reappraised them in April 2010 (FPSC)
  1. At the operational level each Division has a risk register to monitor an effective system of control
  1. External review of risk management systems providing assurance (CNST/NHSLA)
  1. Contingency plans are in place for business continuity and emergency planning
/
  • Board Development sessions
25-26 June 2008 (Developing the clinical strategy)
23 July 2008 (Clinical strategy update)
6 August 2008 (LTFM)
10 September 2008 (Service Development strategy)
18 March 2009 (Building Partnerships)
12-13 January 2010 (The Future Environment – Quality/People/Money)
  • Business Plan 2009/10 and 2010/11 (Board, March 2009 and 2010)
  • Business Plan 2008/09 quarterly monitoring
23 July 2008
22 October 2008
11 February 2008
20 May 2009
24 June 2009
5 November 2009
  • Internal Audit Report on Business Planning Process 2009/10 – significant Assurance (June 2010)
  • Integrated Performance reports 2009/10 monitored on a monthly basis by:
Board
20 May 2009
22 July 2009
23 September 2009
18 November 2009
20 January 2009
24 March 2010
26 May 2010
FPSC
22 April 2009
24 June 2009
5 November 2009
16 December 2009
10 February 2010
28 April 2010
  • Performance Management Arrangements (Integrated Business Plan, Appendix 25, May 2010)
  • Assurance Framework 2009/10 (Board, May 2009)
  • Top 10 risks monitoring reports (Board- 20 May 2009, 22 July 2009, 23 September 2009, 18 November 2009, 24 March 2010, 28 April 2010 (FPSC)
  • Board review of top risks
  • 18 November 2009
  • Workshop (Board, November 2009)
  • Top11 risks paper (FPSC, December 2009)
  • Divisional risk reports developed in year and reviewed by Integrated Risk Sub Committee
  • NHSLA Level 2 compliance, September 2009
  • CNST Maternity services Level 2, April 2008
  • Trust business continuity plan (Board, June 2008)
  • Informatics related business continuity plans (2010)
  • Major Incident Plan (RLI) approved by Emergency Preparedness Business Contingency meeting- 25 March 2009
/
  • Strategic direction shared with Shadow Council of Governors sub-committee March 2010. Workshop planned Summer 2010
  • Assessment at level 2 new standards (February 2011)

Question 7- A statement if Internal Control (“SIC”) is in place and the aspirant NHS foundation trust is complaint with the risk management and assurance framework required that support the SIC pursuant to most up to date guidance from HM Treasury (
Comments / Assurances / Further Actions Planned
The Trust’s Statement of Internal Control is approved by the Trust Board and is supported by the Head of Internal Audit Opinion /
  • Audit Committee 09 June 2010
/
  • No outstanding actions from the 08/09 SIC.

Question 8- All key risks to compliance with their Authorisation have been identified and addressed
Comments / Assurances / Further Actions Planned
The Assurance Framework 2010/11was approved at the FPSC, 28 April 2010 /
  • Assurance Framework 2010/11 (FPSC, April 2010)
  • Top 10 risks monitoring reports (Board- 20 May 2009, 22 July 2009, 23 September 2009, 18 November 2009, 24 March 2010, 28 April 2010 (FPSC)
  • Board review of top risks
  • 18 November 2009
  • Workshop (Board, November 2009)
  • Top11 risks paper (FPSC, December 2009)
/
  • Assurance Framework to be reviewed by FPSC “post election2 to ensure it is “fit for purpose”

2.5 Table 2.4 covers the areas of Board roles, structures and capacity.

Table 2.4 Board roles, structures and capacity
Question 9- The board maintains its register of interests, and can specifically confirm that there are no material conflicts of interests in the board
Comments / Assurances / Further Actions Planned
The Board has robust procedures in place to ensure conflicts of interest are identified and how they are to be managed /
  • Revised Standing Orders, Standing Financial Instructionsand Scheme of Delegation approved by FPSC 16 December 2009
  • Board commitment to Nolan principles re-affirmed October 2008
  • Register of Directors interests – latest date reviewed and notified to Board 24 March 2010

Question 10- The board is satisfied that all directors are appropriately qualified to discharge their functions effectively, including setting strategy, monitoring and managing performance, and ensuring management capacity and capability.
Comments / Assurances / Further Actions Planned
  • Yes, based upon the knowledge, skills and experience of the overall management team
  • Chief Executive- performance against outline job description (Appendix B14 of Guide):
a)Strategy –The Trust has a clear strategy as outlined in the IBP with robust risk management to support its implementation
b)HR – Effective HR Department in place with continued improvement in staff survey results for 2009
c)Operations- Trust has implemented revised performance management, has a track record of delivery of key targets and effective governance in this area
d)Communications and Relationships- Improved communications approach now in place with dedicated Communications Team. Stakeholder analysis in draft outlining key issues and management process. Robust arrangements in place with PCTs, OSCs and other key groups. /
  • Executive and Associate Directors qualifications and experience (IBP Appendix 17 May 2010)
  • Strategy – IBP Chapter 5, May 2010
  • Executive to Executive meetings with PCTs (monthly)
  • Executive directors attendance at QIPP regional and local summits (on-going)
  • Revised Staff side structure covering:
1)Collaborative Working Groups (Divisional) – Bi-monthly
2)Joint Working Group (Trust wide) – Monthly (policies)
3)Joint Negotiation and Consultative Committee (Trust wide)- Bi Monthly (strategy)
4)Local Negotiating Committee (Trust wide) – Bi-monthly (strategy and policy)operational from April 2008.
  • Board Integrated Performance Report (October 2008 onwards)
  • Revised Performance Management Framework
  • Cumbria Health and Well Being Scrutiny Committee
  • Acute Medical Services in Morecambe Bay Task Group (attended quarterly)
  • Trust attends the following locality groups on an on-going basis:
Furness Strategic Partnership
South Lakeland Strategic Partnership
  • Shadow Council of Governors includes members of Partner Organisations (2009)
/
  • HR – Staff Survey, 2009 reporting to Board 26 May 2010

2. Director of Finance
a)Financial strategy, management and risk- current Director of Finance has developed a financial strategy with the Board that has eliminated the Trust’s historic debt and clearly outlined the way forward for the next 5 years. Trust has a clear budget setting and control process in place. Annual accounts delivered to national timescales
b)Payroll – Trust has moved to national Electronic staff Record (ESR) system (date) and directly controls its own payroll staff
c)Investment appraisal/ commercial opportunities and risk – Annual capital programme managed via capital Group and reported to the Board in Finance report
d)Raising of debt/ other finance
e)Cashflow management
f)PR/ Communications on aspects of finance issues
g)Financial responsibilities and issues - FT related- Revised reporting in place reflecting Monitor’s financial governance requirements
h)Financial system developed – The Trust has a robust financial system (oracle) and is developing new business reporting systems
i)Managing of financial arrangements
j)Provision of staff training – Finance and other
k)Stringent liquidity controls Trust has effective cashflow forecasting and liquidity monitoring process in place. /
  • Long-Term Financial Model (LTFM) in IBP (May 2010)
  • Letter from NWSHA Director of Finance confirming Trust no longer in turnaround (July 2008)
  • ALE Scores for 2009/10 = 4 forecast.
  • Budget paper to Board (24 March 2010)
  • Board/ FPSC Financial reports (on-going)
  • Audit Committee- Accounts reviewed and recommended for adoption by Trust Board June 2010.
  • All payroll Internal Audit reports in 2009/10 showed significant assurance (limited on one small area – portering)
  • Fixed Assets internal audit report (March 2009 = significant assurance)
  • Internal Audit report on Capital Programme Monitoring 2009/10 – Significant Assurance
  • Board approval of capital programme 2010/11 (24 March, 2010)
  • Capital Group (monthly)
  • Monthly report of progress against capital plans included in Integrated Performance Report – Board and FPSC October – 2008 onwards
  • Working capital –Proposals from banks currently being negotiated (June 2010)
  • Board reports include cashflow projections (December 2008 onwards)
  • Team briefings (monthly)/Weekly News include details of financial performance
  • Report on Fitness for Purpose undertaken by Robson Rhodes (June 2007). Final report reviewed by Audit Committee (November 2007)
  • Internal audit reports on key financial systems in 2009/10:
  • Capital Programme Monitoring
  • Cash Management (draft)
  • Receivables and Credit Control
  • NHS Overseas Visitors
  • Patients Property (2 reports)
  • General ledger Controls
  • Board Reporting
  • Payroll (5 reports)
  • Risk Management Policy
  • Charitable Funds
  • Governance Structures
  • NHS North Lancashire contracts 2010/11 signed-off by June 2010
  • Finance – Senior staff have attended a range of courses with specific consultancy support for FT around the LTFM. Department also has staff in training for CCAB qualifications.
  • Other – Board development sessions used for NEDs. Senior managers have dedicated briefing sessions (e.g. 5 May 2010)
  • Board financial reports include cashflow forecasts (December 2008 onwards)
/
  • NHS Cumbria contract 2010/11 negotiations on-going (June 2010)