1/2 COUNCIL OF GOVERNORS 16 March 2016 5.30pm – 7pm Board Room, Aintree Lodge AGENDA d = document v = verbal p = presentation No Item Reference Preliminary Business - Chairman 5.30 1. Apologies for Absence To note the apologies CG15-16/043 (v) 2. Declarations of Interest To receive declarations of interest in agenda items and/or any changes to the register of governors’ declarations of interest pursuant to Standing Orders CG15-16/044 (v) 3. Minutes from the last meeting (9 December 2015) To approve the minutes from the last meeting and discuss any matters arising CG15-16/045 (d) Where are we going as an Organisation? 5.35 4. Strategic Update Chairman/Chief Executive To note the update CG15-16/046 (v) How are we performing? 5.50 5. Finance & Performance – Key Issues & Assurance Received Chair of the F&P Committee CG15-16/047 (p) How are we treating our patients? 6.00 6. Quality & Safety - Key Issues & Assurance Received Chair of the Q&S Committee CG15-16/048 (p) How do we run ourselves? What do others think? 6.10 7. Report from Audit Committee Chair of Audit Committee CG15-16/049 (p) 6.20 8. Governor Activity To note CG15-16/050 (v) 6.35 9. Reports of Governor Committee Chairs: Membership Committee (2 February 2016) Quality of Care Committee (11 February 2016) To discuss the key issues, approve any recommendations and note the reports CG15-16/051 (d) Council of Governors' Meeting Agenda - 16 March 2016 Page 1 of 31
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COUNCIL OF GOVERNORS - Aintree University Hospital · Ref Minute Preliminary Business CG15-16/031 Apologies for Absence The apologies were noted as above. CG15-16/032 Declarations
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1/2
COUNCIL OF GOVERNORS 16 March 2016 5.30pm – 7pm
Board Room, Aintree Lodge
AGENDA
d = document v = verbal p = presentation
No Item Reference
Preliminary Business - Chairman
5.30 1. Apologies for Absence
To note the apologies
CG15-16/043 (v)
2. Declarations of Interest
To receive declarations of interest in agenda items and/or any changes to the register of governors’ declarations of interest pursuant to Standing Orders
CG15-16/044 (v)
3. Minutes from the last meeting (9 December 2015)
To approve the minutes from the last meeting and discuss any matters arising
To discuss the key issues, approve any recommendations and note the reports
CG15-16/051 (d)
Cou
ncil
of G
over
nors
' Mee
ting
Age
nda
- 16
Mar
ch 2
016
Page 1 of 31
Aintree University Hospital NHS Foundation Trust
Agenda: Council of Governors’ Meeting 16 March 2016 2/2
6.45 10. Terms of Reference for Governor Committee
Quality of Care Committee
To approve the terms of reference for the Committee
CG15-16/052 (d)
Other items for Governors to be aware of
6.50 11. Council of Governors’ Forward Plan 2016/17
To approve
CG15-16/053 (d)
Concluding Business
6.55 12. Any Other Business
Chairman
CG15-16/054 (v)
13. Date and Time of Next Meeting:
Wednesday 15 June 2016 at 12.30pm
Council of Governors – Objectives 2015/16
To further develop skills and knowledge base in order to collectively understand and constructively challenge and support the quality of care agenda provided by the Trust
To improve communication and engagement with members of the Trust in line with the membership strategy objectives
To monitor the performance of the Board of Directors through holding the Non-Executive Directors individually and collectively to account
To deliver its statutory duties in line with regulatory requirements
Page 2 of 31
1/6
Council of Governors
Wednesday 9 December 2015 12.30pm
Board Room Aintree Lodge
DRAFT MINUTES
Present: Neil Goodwin - Chairman
Pamela Peel - Lead Governor
Sharon Bird - Public Governor
Mike Booth - Public Governor
Mike Bowker - Public Governor
Tony Byrne - Public Governor
Gerry Hill - Public Governor
John Johnson - Public Governor
Tony Kneebone - Pubic Governor
Brian Lawless - Public Governor
Julie Naybour - Public Governor
Stephen Thornhill - Public Governor
Rosemary Urion - Public Governor
Lorraine Heaton - Staff Governor (AHPs)
Andrew Swift - Staff Governor (Medical)
John Wilding - Appointed Governor (University of Liverpool)
In Attendance: Steve Warburton - Acting Chief Executive
Joanne Clague - Non-Executive Director
Steve Evans - Medical Director
Nicola Firth - Director of Nursing & Quality
Michael Games - Corporate Governance Manager
Sue Green - Director of People and Corporate Affairs
Ian Jones - Acting Director of Finance & Business Services
Caroline Keating - Associate Director of Corporate Governance/Board
Secretary
Colin Maloney - Non-Executive Director
Kevan Ryan - Non-Executive Director
Angie Smithson - Chief Operating Officer
Nicola Allen - Corporate Governance Officer
Elaine Carter - Member of the Public
Apologies: Tracey Barnes - Public Governor
Rose Milnes - Public Governor
Helen Frankland - Staff Governor (Nursing)
Paul Cummins - Appointed Governor (Sefton Council)
Barbara Hunter-Douglas - Appointed Governor (Edge Hill University)
Kerry McManus - Staff Governor (Other)
Juliet Herzog - Non-Executive Director
Tim Johnston - Non-Executive Director
Paul Fitzpatrick - Director of Estates & Facilities
3. C
G15
-16/
045
- M
inut
es o
f the
Las
t Mee
ting
(9 D
ecem
ber
2015
)
Page 3 of 31
Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors Meeting 9 December 2015 2/6
Ref Minute
Preliminary Business
CG15-16/031 Apologies for Absence
The apologies were noted as above.
CG15-16/032 Declarations of Interest
There were no declarations of interest.
CG15-16/033 Minutes from the last meeting (14 October 2015)
The minutes from the previous meetings were approved as an accurate record.
The Chairman advised that the Council of Governors had met in Private Session prior to
the commencement of this meeting to approve the following recommendations of the
Nominations Committee:
The appointment of Steve Warburton as Chief Executive of the Trust
The re-appointment of Tim Johnston as a Non-Executive Director of the Trust for a
three year term of office with effect from 1 January 2016
The appointment of Joanne Clague as a Non-Executive Director the Trust with the
commencement of her three year term of office remaining as 1 April 2015.
Where are we going as an Organisation?
CG15-16/034 Strategic Update
The Chief Executive advised the meeting of the following matters:
Partnerships: A Board to Board meeting with the Royal Liverpool & Broadgreen
University Hospitals NHS Trust (RLBUHT) had taken place on 16 October 2015 at
which the clinicians of both Trusts presented the case for merger of acute adult
services across Liverpool. The Aintree Board considered the joint strategic options
appraisal (JSOA) that had been prepared by the Joint Clinical Advisory Group at its
Board meeting in October 2015 and fully endorsed the recommendations included in
the paper. The Trust issued a communication to its staff in this regard. The JSOA
was also considered by the RLBUHT Board in November 2015 and they issued a
communication to their staff. In addition, the Chief Executives of Aintree and
RLBUHT presented on joint working at the Mayor’s Health Summit which was well
received. A further meeting of the Joint Strategic Leadership Group was scheduled
for 11 December 2015 to agree next steps.
Liverpool Health Community Services: it is understood that the Trust
Development Authority (TDA) was to lead on the tender process for community
services with Lots being issued for tender during December 2015 and January 2016.
The Trust would be giving consideration to bidding for the most appropriate services
that would complement its current service delivery either on a sole basis or in
conjunction with another health care provider.
Comprehensive Spending Review: NHS England had negotiated with the
Treasury for advanced funding into the NHS for 2016/17 but this would mean that
future years would see lower levels of growth. The reason for the advancement was
to bring about stability and redressing financial balance. In addition, there was
Page 4 of 31
Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors Meeting 9 December 2015 3/6
Ref Minute
acknowledgement that the 4% efficiency targets would be extremely difficult to meet
year on year and so it was anticipated that next year the efficiency target would be
reset at 2%.
The Council of Governors requested clarification on the following matters:
How will the discussions on joint working with RLBUHT continue to be
funded? Support has been provided on project costs by the Liverpool Clinical
Commissioning Group and it was hoped that this would continue to be the case going
forward.
Following the meeting of the JSLG on 11 December would there be a joint
statement issued? It was the intention to issue a joint statement once agreement
had been reached on the next steps and the formal wording of the communication
agreed by the two organisations.
The Council noted the update.
How are we performing?
CG15-16/035 Finance & Performance – Report on Key Issues & Assurance Received
David Fillingham (Non-Executive Director), Chair of the Finance & Performance
Committee, gave a presentation covering the key issues, challenges and achievements
for October/November 2015. Particular mention was made of the deteriorating
performance in A&E and the establishment of weekly conference calls to update the
Board on progress against actions identified. The scrutiny of the Trust’s challenging
financial position was also a major factor in the Committee’s deliberations with particular
emphasis on progress against the achievement of the Cost Improvement Programme.
The Committee had received presentations from the Medicine and Clinical Support
Services Divisions on the key challenges and actions in place to improve performance.
Clarification was sought on the position in relation to the closure of intermediate beds in
Sefton and it was explained that there was no intention by Sefton to replace these beds
and that they were spot purchasing beds where they were needed. The Trust was
further impacted by those patients remaining in hospital whilst the family liaise with the
local authority on finding an appropriate care home. The Trust had launched an initiative
to assess people within their homes where appropriate and established a step down
facility for medically optimised patients to alleviate the pressure within the hospital. The
Trust was doing all it could to improve its processes internally but it often required the
intervention and co-operation of other providers to complement the discharge process
undertaken by the Trust.
The Council noted the presentation.
How are we treating our patients?
CG15-16/036 Quality & Safety – Report on Key Issues & Assurance Received
Colin Maloney (Non-Executive Director), Member of the Quality & Safety Committee,
gave a presentation covering the purpose of the Committee, its key challenges and
specific items presented during October/November 2015. Specific mention was made of
3. C
G15
-16/
045
- M
inut
es o
f the
Las
t Mee
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(9 D
ecem
ber
2015
)
Page 5 of 31
Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors Meeting 9 December 2015 4/6
Ref Minute
the Committee’s review of serious incidents and the challenges and concerns raised to
receive assurance that appropriate lessons had been learned, recommendations and
actions identified and acted upon to mitigate future incidents occurring; the examination
of performance of the Trust’s infection prevention and control programme; examples of
emerging risks brought to the Committee’s attention (Ophthalmology and Results to
Action) and the monitoring of progress.
Clarification was sought on how governors can be assured that the information provided
to the Committee was correct. It was explained that it was the responsibility of the Non-
Executive Directors to challenge the data presented and triangulate it with other sources
to determine its accuracy. In addition, Director Walkrounds provided an opportunity to
validate the information provided in the reports. The point was made that the deep dives
and presentations from other staff members allowed the Committee the chance to
challenge and verify the content.
Reference was also made to the quality and safety of medical patients in surgical wards
and it was explained that some wards had mixed specialities because there were
patients with co-morbidities. A weekly meeting of harm reviews all incidents but there
had been no incidences relating to medical patients in surgical wards.
The Council noted the presentation.
How do we run ourselves? What do others think?
CG15-16/037 Report from Audit Committee
Jo Clague (Non-Executive Director), Member of the Audit Committee, gave a
presentation covering the role of the Committee, its key items and challenges and the
progress and achievements/progress made. Reference was made to the deep dive
undertaken on the Board Assurance Framework (BAF) with particular mention made of
the praise received on the content, format and clarity of the BAF but with
acknowledgement that further work was required on its linkages to the operational risk
register and the management of all risks scoring above 15. The Committee also dealt
with the report from NHS Protect and the actions identified to improve compliance.
Reference was made to the Trust’s ‘satisfactory’ rating for Information Governance, the
improvement in compliance arising from ward spot checks and the positive rating
received by the Trust for its accurate annual reference cost returns following a national
audit.
The Council noted the presentation.
CG15-16/038 Reports of Governor Committee Chairs
Membership Committee – 3 November 2015
Pam Peel, Chair of the Committee, referred to the report and advised that revisions had
been made to the content of the Governor Toolkit and it had been the intention to discuss
the matter at the Informal Governors’ meeting on 2 December but there was insufficient
time to do so. The Committee would continue to take the matter forward but would
require the support of the Communications Team to assist Governors.
Page 6 of 31
Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors Meeting 9 December 2015 5/6
Ref Minute
The Council noted the report.
Quality of Care Committee – 12 November 2015
Mike Booth, Chair of the Committee, referred to the report and advised that there had
been a healthy debate as part of the presentation on Outpatients on waiting in clinics and
how delays were communicated to patients. In addition, the Committee had welcomed
the changes being made to system in Pharmacy to improve service delivery. The
Committee had also been heartened by the improvements in mortality needs but
acknowledged that Governors may need further training in this area to enhance their
understanding.
The Council noted the report.
Nominations Committee – 7 December 2015
Neil Goodwin, Chair of the Committee advised that the recommendations from the
Committee had been approved by the Council in Private Session and reported at the
beginning of the this meeting.
CG15-16/039 Terms of Reference for Governor Committees
The Council of Governors reviewed the revised terms of reference for each of the
Governor Committees and approved them accordingly.
Other items for Governors to be aware of
CG15-16/040
Draft Minutes of the Annual Members’ Meeting – 30 September 2015
The draft minutes of the Annual Members’ Meeting held on 30 September 2015 were
noted by the Council.
CG15-16/041 Governor Activity
The Lead Governor advised that she had been honoured to attend the two Award
Ceremonies held in November 2015 and particularly mentioned the Trust’s recognition at
the HSJ Awards after being shortlisted in five categories. She also mentioned that she
had been in contact with the Fazakerley Health & Wellbeing Forum and planned to
attend a meeting in January 2016. She highlighted that this links with the membership
strategy in regard to forging links between Governors and the local community through
these types of bodies.
Mention was also made by other governors of their involvement in the Fracture Clinic,
Nutrition & Hydration Collaborative and the Leadership & Management event.
The Council noted the update.
Concluding Business
CG15-16/042 Any Other Business
The Associate Director of Corporate Governance/Board Secretary advised that a
3. C
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(9 D
ecem
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2015
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Page 7 of 31
Aintree University Hospital NHS Foundation Trust
Minutes: Council of Governors Meeting 9 December 2015 6/6
Ref Minute
process had been put in place for dealing with letters from members of the public in
regard to the Trust’s discussions with RLBUHT. Any letters received by the Trust or a
Governor would be forwarded to her and acknowledged and responded to by the Chief
Executive through Trust Communications to ensure there was a consistent message
being given. The Council noted the process.
The Lead Governor provided her congratulations on behalf of the Council to Steve
Warburton on his appointment as Chief Executive.
Date and Time of Next Meeting:
Wednesday 16 March 2016 in the Board Room Aintree Lodge at 5.30pm.
The meeting closed at 2.05pm Chair’s Signature: Date:
Page 8 of 31
Fin
an
ce &
Pe
rfo
rman
ce (
F&
P)
Co
mm
itte
e
Ke
y Is
su
es,
Ch
all
en
ge
s &
Ac
hie
vem
en
ts
Mo
nth
8 t
o M
on
th 1
0
201
5/1
6
Da
vid
Fill
ingh
am
No
n-E
xe
cutive D
irecto
r/ D
ep
uty
Cha
irm
an
5. C
G15
-16/
047
- F
inan
ce &
Per
form
ance
- K
ey Is
sues
& A
ssur
ance
Rec
eive
d
Page 9 of 31
Pro
gre
ss
/Ach
iev
em
en
ts
P
ati
en
t S
afe
ty T
he
rmo
me
ter
•C
on
sis
ten
tly a
bo
ve
th
e n
atio
na
l m
ed
ian
sco
re.
R
ed
uc
tio
n in
SH
MI
•F
urt
he
r im
pro
ve
me
nt; T
rust b
ette
r th
an
na
tio
na
l a
ve
rag
e.
P
ati
en
t E
xp
eri
en
ce
•O
ve
r 9
8%
of in
pa
tie
nts
wo
uld
re
co
mm
en
d A
intr
ee
.
R
efe
rra
l To
Tre
atm
en
t
•Ta
rge
t b
ein
g m
et o
n a
co
nsta
nt b
asis
.
R
ed
uc
tio
n in
Ou
tpa
tie
nt
Ca
nc
ella
tio
ns
•D
ow
nw
ard
tre
nd
in
ca
nce
llatio
n n
um
be
rs c
on
tin
ue
d.
C
-Dif
fic
ile p
erf
orm
an
ce
•C
ase
s w
ith
in c
on
tra
cte
d a
nd
in
tern
al tr
aje
cto
ry.
Page 10 of 31
Ke
y C
ha
llen
ges
D
iag
no
sti
c A
ccess -
Q3 m
issed; Q
4 p
erf
orm
ance a
t risk
C
an
cer
62
-day –
Capacity issues (
Janua
ry)
caused p
erf
orm
ance d
ip. F
eb &
Marc
h
impro
vem
ent
not
enough t
o d
eliv
er
Q4 t
arg
et
S
tro
ke –
Perf
orm
ance n
ot
recovere
d a
s e
xpecte
d,
with f
low
issues h
avin
g n
egative
impact on d
irect ad
mis
sio
n o
f patients
to s
troke w
ard
C
QU
INs -
Perf
orm
ance p
ositiv
e; som
e r
isk o
n d
eliv
ery
of
sm
all
num
be
r of
targ
ets
M
RS
A –
1 c
ase r
eport
ed
D
ela
yed
Tra
nsfe
rs o
f C
are
/ R
ead
y f
or
Dis
ch
arg
e –
continuin
g incre
ase in n
um
ber
of patients
“re
ady f
or
dis
charg
e”
(once m
edic
ally
fit).
O
n-g
oin
g w
ork
with S
ocia
l
Serv
ices, C
om
munity T
rust
and C
om
mis
sio
ners
to a
ddre
ss.
F
inan
cia
l p
erf
orm
an
ce:
•Im
pro
vem
ent
in d
eficit a
gain
st pla
n, but
continuin
g c
ost pre
ssure
s f
rom
medic
al and
nurs
e s
taffin
g,
(agency)
and d
eliv
ery
of
CIP
•In
com
e fro
m u
rgent
care
path
way r
ecovere
d,
but
applic
ation o
f P
bR
rule
s b
y
Com
mis
sio
ners
rem
ain
a c
halle
nge in p
ath
way r
edesig
n
•C
om
mis
sio
ners
to im
pose fin
es for
non
-deliv
ery
of A
ED
targ
ets
(4 h
rs a
nd a
mbula
nce
turn
aro
und),
despite im
pact
of
syste
m w
ide issues o
n t
arg
et
deliv
ery
.
5. C
G15
-16/
047
- F
inan
ce &
Per
form
ance
- K
ey Is
sues
& A
ssur
ance
Rec
eive
d
Page 11 of 31
AE
D
A
&E
perf
orm
an
ce –
Continued p
oor
perf
orm
ance t
hro
ugh J
anuary
. Q
4 w
ill
not be m
et.
D
irect
dis
cussio
ns w
ith M
onitor
on im
pro
vem
ent
have t
aken
pla
ce.
Em
erg
en
cy &
Acu
te C
are
Pla
n:
•D
evelo
p s
et of princip
les a
s f
ram
ew
ork
for
imple
menta
tion t
o d
evelo
p
one v
isio
n/
model of care
for
the T
rust
•U
nderp
innin
g t
hese a
re c
lear
clin
ical path
wa
ys a
nd p
roto
cols
with
measura
ble
perf
orm
ance m
etr
ics
•E
arly S
enio
r R
evie
w a
cro
ss a
ll te
am
s
•Im
pro
ved c
om
munic
ation t
o facili
tate
co-o
rdin
ation (
board
huddle
s)
•O
ne ‘M
edic
al Take’ w
ith c
lear
role
s a
nd functions
•P
rote
cte
d A
ssessm
ent
Capacity in A
&E
and A
ssessm
ent
units
•C
lear
patient
flow
rule
s in a
nd o
ut
of hours
Page 12 of 31
AE
D –
Go
ve
rnan
ce S
tru
ctu
re
5. C
G15
-16/
047
- F
inan
ce &
Per
form
ance
- K
ey Is
sues
& A
ssur
ance
Rec
eive
d
Page 13 of 31
P
resen
tati
on
s f
rom
Div
isio
ns
•S
urg
ery
(M
8):
-U
nderp
erf
orm
ance o
n e
lective a
nd d
ay c
ase w
ork
(C
IP/p
roductivity p
lan)
-A
dm
in s
taffin
g o
vers
pend tackle
d thro
ugh c
hanges in w
ork
ing m
eth
ods
-A
nnu
al Leave P
olic
y s
till
a c
halle
nge (
adhere
nce to 6
week n
otice p
eriod)
-Im
ple
me
nta
tio
n o
f E
lectr
onic
Bo
okin
g T
oo
l fo
r T
he
atr
es (
eB
oT
) w
ith
in
sele
cte
d s
pecia
ltie
s p
roduced p
ositiv
e r
esults. O
n-g
oin
g w
ork
to r
oll
this
ou
t
•M
ed
icin
e (
M9):
-A
ED
perf
orm
ance -
inte
rim
support
appoin
ted t
o s
upport
form
ula
tion &
imple
menta
tion o
f com
pre
hensiv
e a
ction p
lan a
cro
ss the w
hole
syste
m
-Length
of sta
y incre
asin
g, dela
ys in d
ischarg
ing
medic
ally
fit a
key issue
-F
inancia
l positio
n d
ete
riora
ted.
CIP
pla
ns for
bed
clo
sure
s n
ot
imple
menta
ble
. M
edic
al agency s
pend t
o m
ain
tain
serv
ice d
eliv
ery
co
ntin
ue
d
•C
lin
ical S
up
po
rt S
erv
ice
s (
M10):
-F
inancia
l positio
n p
ositiv
e; expecte
d t
o c
om
e in a
t bala
nce for
the y
ear
-R
isk a
round r
adio
logis
t re
sig
natio
ns w
ith p
ote
ntial im
pact on p
erf
orm
ance.
Ke
y A
reas
Co
vere
d
Page 14 of 31
2015/1
6 C
ap
ital
pro
gra
mm
e
P
rogre
ss r
eport
on t
he c
apital pro
gra
mm
e f
or
the y
ear.
Som
e s
lippage o
n the
pro
gra
mm
e,
princip
ally
rela
ting to t
he U
CA
T p
roje
ct.
1
2-H
ou
r B
reach
Rep
ort
C
onsid
er
reasons b
ehin
d the b
reach
and lessons learn
t.
F
inan
cia
l P
lan
nin
g U
pd
ate
an
d 2
016/1
7 B
ud
gets
- A
ppro
ved
Ke
y A
reas
Co
vere
d
£m
Incom
e
319.8
Expenditure
342.5
(22.7
)
CIP
7.0
Fin
an
cia
l g
ap
(1
5.7
)
ST
F a
llocation
9.5
Com
mis
sio
ner
support
required
7.4
Co
ntr
ol to
tal
1.2
5. C
G15
-16/
047
- F
inan
ce &
Per
form
ance
- K
ey Is
sues
& A
ssur
ance
Rec
eive
d
Page 15 of 31
FIN
AN
CE
S &
AC
TIV
ITY
1. Im
pro
ve
me
nt in
co
sts
vs p
lan
re
fle
cts
no
n-r
ecu
rre
nt re
lea
se
fro
m r
ese
rve
s / b
ala
nce
sh
ee
t a
s m
itig
atio
n a
ga
inst C
IP
sh
ort
fall
an
d c
ost p
ressu
res. D
ete
rio
ratio
n in
in
co
me
po
sitio
n r
efle
cts
im
pa
ct o
f u
rge
nt ca
re f
low
issu
es o
n e
lective
ca
se
loa
d.
Page 16 of 31
AC
CE
SS
TA
RG
ET
S
5. C
G15
-16/
047
- F
inan
ce &
Per
form
ance
- K
ey Is
sues
& A
ssur
ance
Rec
eive
d
Page 17 of 31
CL
INIC
AL
IN
DIC
AT
OR
S
Page 18 of 31
Qu
ality
& S
afe
ty C
om
mit
tee
Ke
y Is
su
es :
De
c-F
eb
201
5/1
6
Ju
liet H
erz
og
, N
on
-Executive
Dire
cto
r
6. C
G15
-16/
048
- Q
ualit
y &
Saf
ety
- K
ey Is
sues
& A
ssur
ance
Rec
eive
d
Page 19 of 31
Ke
y C
ha
lle
ng
es
Serio
us Incid
ents
•A
ll in
cid
en
t re
po
rts r
evie
we
d,
hig
hlig
htin
g le
arn
ing
, th
em
es,
co
nce
rns
O
ph
tha
lmolo
gy R
isk r
epo
rt
•S
tan
din
g a
ge
nd
a ite
m a
nd
re
ma
ins o
n t
he
Tru
st
risk r
eg
iste
r
In
fectio
n P
reven
tio
n &
Co
ntr
ol
•E
xce
ptio
n r
ep
ort
s,
actio
n p
lan
s, p
rog
ress t
racke
d
•C
Difficile
be
low
na
tio
na
l tr
aje
cto
ry b
ut
ab
ove
in
tern
al str
etc
h
targ
et.
12
ca
se
s s
ucce
ssfu
lly a
pp
ea
led
, 5
ca
se
s p
en
din
g.
To
tal n
um
be
rs le
ss th
an
at
this
po
int
last ye
ar.
Page 20 of 31
Sp
ec
ific
Ite
m P
res
en
tati
on
s
A
ss
au
lts
De
ep
Div
e
•F
ocus o
n t
rain
ing a
nd s
afe
ty.
Mo
nitori
ng in p
lace
C
om
pla
ints
Deep
Div
e (
Pati
en
t A
dvic
e &
Co
mp
lain
ts T
eam
– P
AC
T)
•F
ocus o
n k
ey p
oin
ts in d
ealin
g w
ith c
om
pla
ints
:
•p
utt
ing
th
ing
s r
igh
t
•access
•pro
cess
•re
sponse
L
ap
aro
tom
y A
ud
it
•P
rocess im
pro
vem
ent
pla
n
Q
uality
of
Pati
en
t C
are
in
AE
D
•O
ve
rvie
w o
f in
cid
en
ts b
y s
eve
rity
with
in t
he
A&
E D
ep
art
me
nt.
•D
espite p
oor
perf
orm
ance a
gain
st A
&E
4 h
our
access s
tand
ard
, evid
en
ce
sugge
sts
th
at
qualit
y o
f care
pro
vid
ed
to p
atients
has n
ot
suffere
d.
6. C
G15
-16/
048
- Q
ualit
y &
Saf
ety
- K
ey Is
sues
& A
ssur
ance
Rec
eive
d
Page 21 of 31
Pro
gre
ss o
n Q
ua
lity
& S
afe
ty O
bje
cti
ve
s
T
he C
om
mitte
e r
egu
larly r
ece
ive
s r
epo
rts r
ela
ting
to
qua
lity &
safe
ty o
bje
ctives. In
this
tim
e p
eriod, th
e
follo
win
g w
ere
rece
ive
d:
•A
intr
ee
Qu
alit
y I
mp
rove
me
nt
Pro
gra
mm
e U
pd
ate
s
•C
orp
ora
te R
isk R
ep
ort
Q2
•P
ractice
, Im
pro
ve
me
nt
& L
esso
ns L
ea
rne
d Q
3
•Q
ua
lity S
tra
teg
y Y
ea
r 2
Q3
re
po
rt
•A
AA
Q3
re
po
rt
•W
ork
forc
e Q
3 r
ep
ort
•M
ort
alit
y r
ep
ort
•S
afe
Nu
rse
Sta
ffin
g r
ep
ort
Page 22 of 31
Au
dit
Co
mm
itte
e
Ke
y Is
su
es,
Ch
all
en
ge
s &
Ac
hie
vem
en
ts
Mo
nth
8 t
o M
on
th 1
0
201
5/1
6
Tim
Joh
nsto
n, N
ED
Chair
7. C
G15
-16/
049
- R
epor
t fro
m A
udit
Com
mitt
ee
Page 23 of 31
C
lin
ical A
ud
it P
erf
orm
an
ce R
evie
w
•aim
an
d d
efin
itio
n o
f clin
ica
l audits
•overv
iew
of
pla
nnin
g, pro
cess, re
port
ing a
nd m
onitoring u
ndert
aken
•2
01
4/1
5 p
erf
orm
an
ce
an
d p
erf
orm
an
ce
to d
ate
20
15
/16
, in
clu
din
g d
eta
ils o
f
cancelle
d a
nd
ab
an
do
ne
d p
roje
cts
du
rin
g 2
01
5/1
6
•overv
iew
of
NIC
E m
ain
tenance o
f com
plia
nce
•develo
pm
en
tal w
ork
bein
g u
ndert
aken inclu
din
g im
ple
menta
tion o
f a C
linic
al A
udit
Manag
em
ent
Syste
m (
CA
MS
)
Assura
nce
receiv
ed that
robust
govern
ance p
roce
ss in p
lace for
pro
ject
cancella
tion/a
bando
nm
ent w
ith e
scala
tion to C
linic
al S
tan
dard
s M
anag
er,
and to
Medic
al D
irecto
r fo
r appro
val if a
ppro
priate
, w
ith C
linic
al E
ffectiveness E
xecutive L
ed
Gro
up a
dvis
ed o
n 6
-month
ly b
asis
.
Ke
y A
rea
s C
ov
ere
d
Page 24 of 31
Ke
y C
ha
lle
ng
es
In
form
ati
on
Go
vern
an
ce B
reach
Rep
ort
– E
nd
osco
py :
•in
cid
ent (r
eport
ed D
ecem
ber
2015)
arisin
g fro
m r
ecent
use o
f a s
yste
m p
urc
ha
sed
prior
to t
he T
rust’s r
evis
ed p
rocure
men
t pro
cesses b
ein
g in p
lace
•valid
ation identified 1
9 p
atient
record
s a
ffecte
d,
with 1
patient
requirin
g a
repeat
pro
ced
ure
•is
sue e
scala
ted im
media
tely
to T
rust
SIR
O,
pro
vid
ing a
ssura
nce
that
pro
cesses
were
bein
g a
dhere
d t
o
•re
vie
w o
f all
Tru
st
syste
ms u
nderw
ay w
ith a
ll depart
ments
required t
o c
onfirm
no
softw
are
in u
se that
was n
ot
recogn
ised o
r support
ed b
y t
he T
rust
•supplie
rs to
investigate
robustn
ess o
f syste
m.
Wid
er
revie
w t
o b
e c
om
ple
ted a
s p
art
of
the o
n-g
oin
g investigation to identify
oth
er
pote
ntial gaps o
r syste
m issues.
Revie
w o
f perf
orm
ance m
anag
em
ent
of
thir
d p
art
y s
upplie
rs to b
e a
dded t
o t
he
inte
rnal audit p
lan
. 7. C
G15
-16/
049
- R
epor
t fro
m A
udit
Com
mitt
ee
Page 25 of 31
In
tern
al A
ud
it (
RS
M)
Pro
gre
ss R
ep
ort
•m
onitoring o
f C
ost
Impro
vem
ent
Schem
es
•IT
Dis
aste
r R
ecovery
•re
usable
Medic
al D
evic
es M
ain
tenance
•sic
kness A
bsence M
anag
em
ent
In
tern
al A
ud
it 2
016/1
7 S
trate
gy
Indic
ative
str
ate
gy
app
roved
a
nd
pro
vid
ed
to
Q
ualit
y
&
Safe
ty
Co
mm
itte
e
for
com
ment
L
ocal C
ou
nte
r F
rau
d S
erv
ice
Manag
em
ent
actions
from
N
HS
P
rote
ct
qualit
y
assessm
ent
report
ag
reed
w
ith
imple
menta
tion
follo
wed
up
un
de
r th
e 2
01
6/1
7 w
ork
pla
n
L
osses a
nd
Co
mp
en
sati
on
s R
ep
ort
•in
cre
ase in n
on
-clin
ical cla
ims
•susta
ined r
eduction in ‘sharp
s’ i
ncid
ents
Ke
y Ite
ms
Page 26 of 31
1/1
Membership Committee Report
Report to Council of Governors
Date 16 March 2016
Committee Name Membership Committee
Date of Committee Meeting 2 February 2016
Chair’s Name & Title Pam Peel, Lead Governor
Summary of Meeting
The Committee received a presentation on the development of the new Trust website which provided
an overview of the progress made, the design, improved content and features to be made available.
The Committee discussed the proposed extranet feature and how this would work alongside existing
systems, being mindful of the need to maintain openness and transparency. The Committee was
advised that further engagement was to take place with stakeholders, including Governors, to
develop the proposed features.
The Committee received an update on the progress being made against the Membership Strategy
Implementation Plan and was advised that all actions remained on track. The Committee requested
that the Communications Team consider the objectives for year 2 and provide an update for the next
meeting.
The Committee reviewed the proposals for the Focus On events for 2016 and agreed that the topics
be Carers, Discharge/Leaving Hospital and Stroke.
A lengthy discussion took place on Governor involvement in membership engagement. Particular
emphasis was placed on the potential to hold a World Café style event so that Governors can
explore their role and expectations in engaging with members and what can be provided from the
Trust by way of support. Consideration was to be given to holding a World Café event for Governors
to be facilitated by Organisation & Development.
The Committee approved the revised FT Membership Form
Recommendation
The Council of Governors is asked to note the report.
9. C
G15
-16/
051
- R
epor
ts o
f Gov
erno
r C
omm
ittee
Cha
irs -
Mem
bers
hip
Com
mitt
ee 2
Feb
ruar
y 20
16
Page 27 of 31
1/1
Quality of Care Committee Report
Report to Council of Governors
Date 16 March 2016
Committee Name Quality of Care Committee
Date of Committee Meeting 11 February 2016
Chair’s Name& Title Mike Booth
Summary of Meeting
A presentation was provided on Patient Experience – current position and future plans which
included an overview of the key priorities of the Quality Strategy 2014/17 with particular emphasis on
care providing a positive experience. Details were also provided of the results of the National
Inpatient Survey 2014 and the improvements made during 2015 together with an overview of the
outputs from the Friends & Family Test (FFT) and details of where feedback is received from. The
Committee was informed that the patient experience team had submitted an application for the
Patient Experience Network National Awards (PENNA) and had been shortlisted for the awards
ceremony on 2 March 2016. In addition, application had been made for the NHS England Friends
and Family Test awards but details of shortlisting were still awaited. The presentation also provided
an overview of the shared improvements dashboard established within the Trust to track progress.
Work was also being undertaken on the flexible visiting project with two wards identified as pilots and
the development of a Visitors Charter to set out expectations of visitors and staff. An overview was
also provided of the key priorities for 2016/17.
The Committee was presented with the report on the Aintree Assessment and Accreditation
Framework Q3 2015/16 and advised that the framework had been in place for over a year and
provided management with a tool for assessing nursing and ward standards against detailed criteria.
An overview was provided of the ward assessments undertaken in Q3 with nine being undertaken of
which two wards had received Aintree Champions Excellence (ACE), three wards were rated Green,
two Amber and two Red. It was explained that the two Red rated wards had been assessed under
the framework for the first time and robust action plans had been put in place although nothing
significant had come to light during the assessments. The Committee was further advised that it was
the intention to roll out the assessment to outpatients during Q4 and that the criteria was being
updated to improve the standards.
The Committee also discussed the Trust current mortality rates using the Standard Hospital
Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) methodologies.
The Committee was advised that the Trust’s SHMI had reduced further to its lowest position of 99.9,
consolidating the Trust’s position and ensuring the Trust was no longer considered an outlier. It was
also highlighted that the HSMR remained below expected and that the Trust’s crude mortality rate
continued to show a downward trend.
The Committee reviewed its Forward Plan 2016/17 and noted that the quality priorities would be
determined once the review of the Quality Strategy objectives for 2016/17 had been concluded.
The Committee undertook its annual review of its terms of reference and noted the proposed
revisions to the attendees to include Deputies. It was agreed to recommend their approval to the
Council of Governors.
Recommendation
The Council of Governors is asked to note the report.
9. C
G15
-16/
051
- R
epor
ts o
f Gov
erno
r C
omm
ittee
Cha
irs -
Qua
lity
of C
are
Com
mitt
ee 1
1 F
ebru
ary
2016
Page 28 of 31
Quality of Care Committee: Terms of Reference February 2016 1/2
Quality of Care Committee
TERMS OF REFERENCE
Authority
1. The Quality of Care (QoC) Committee is authorised by the Council of Governors (CoG) and will
be Governor-led.
Purpose
2. To act as a focal point for work involving the care and safety of patients and to enable Governors
to become better informed on issues of concern to members and the public.
Membership
3. The QoC will be comprised of seven Governors.
4. The Chair of the Committee will be elected by the QoC Committee on an annual basis.
5. The Director of Nursing & Quality and the Medical Director or their respective deputies will be in
attendance. Other members of the Executive Team will be asked to attend as appropriate
6. Membership of the Committee will be reviewed annually at the first meeting of the Council of
Governors after the Annual Members Meeting. Governors will be invited to express an interest in
membership of the Committee prior to that meeting of the Council of Governors.
7. Vacancies will be filled by open self nomination and election by the Council of Governors if
necessary for the appropriate term.
8. All Governors will be welcome to attend meetings of the Committee although voting rights will be
restricted to the seven formal Governor members.
Quorum
9. A quorum shall be four members of the Committee.
10. Any decisions reached at an inquorate meeting shall be referred to the next quorate meeting for
approval.
Requirements of Membership
11. It is essential that all members participate in the meetings and punctuality must be observed.
12. The Chair will ensure that the key issues identified are highlighted as appropriate to the HMB
and/or lead executive director/manager as required.
10. C
G15
-16/
052
- T
erm
s of
Ref
eren
ce fo
r G
over
nor
Com
mitt
ee -
Qua
lity
of C
are
Com
mitt
ee
Page 29 of 31
Aintree University Hospital NHS Foundation Trust
Quality of Care Committee: Terms of Reference February 2016 2/2
Duties
13. In order to fulfil its role, the duties of the Committee will be:
To understand, support and be engaged with the Trust’s Quality Strategy
To receive reports on progress towards achieving the quality priorities, namely:
o care that is safe
o care that is clinically effective
o care that provides a positive experience for patients and their families
To receive and comment on indicators on safety, clinical effectiveness and patient
experience, in line with the national direction on quality. At present, these include:
Healthcare Associated Infections (HCAI), Mortality, Cleanliness and Patient Satisfaction. As
further indicators are developed or more detailed work is necessary, Governors may be
asked to contribute to additional working groups.
To review the results of patient satisfaction surveys, both national and local and to
understand the impact on patient care
To comment on the Trust’s declaration(s) to the Care Quality Commission on compliance with
its registration on behalf of the Council of Governors
Reporting
14. The Chair of the Committee will report on the proceedings of each meeting to the next meeting of
the Council of Governors.
15. Minutes of the Committee meetings will be provided to the Council of Governors on request.
Administration of Meetings
16. The Committee/Group will meet quarterly. The duration of each meeting shall be approximately
1.5 hours with the schedule of meetings agreed at the initial CoG meeting following the Annual
Members’ meeting.
17. The FT Secretary will make arrangements to ensure that the Committee is supported
administratively. Duties in this respect will include preparation of agendas and taking minutes of
the meeting.
18. Agendas and papers will be circulated at least 4 working days (or 3 working days plus a
weekend) in advance of the meeting.
19. Minutes will be circulated to Group members as soon as is reasonably practicable.
Review
20. The Terms of Reference shall be reviewed annually (next review date: February 2017) and
submitted to the Council of Governors for approval following a review by the QoC of its