COUNCIL OF GOVERNORS’ MEETING PRESENTATION PACK TUESDAY, 17TH JULY 2018 AT 1.30 PM Lecture Theatre Two (2), Education and Research Centre, Wythenshawe Hospital
WELCOME TO THE COUNCIL OF GOVERNORS Tuesday, 17 th July 2018
Assurance & Risk MIKE DEEGAN Chief Executive Officer Manchester University NHS Foundation Trust
Assurance & Risk The Risk Management & Assurance Process: • High Level risks are those risks scoring 15 or above on the Trust Risk Register. These are derived from each of the Hospital/MCS risk registers • Full review undertaken at Group Risk Management Committee; mitigating actions agreed and reported to the Audit Committee and Board of Directors • All High Level risks are linked to the Board Assurance Framework which is reviewed by the Audit Committee, Board of Directors & Scrutiny Committees
Assurance & Risk Assessment of the anticipated length of time the risk will remain on the risk register at a high level: S Short term: 0-6 months M Medium term: 7-18months L Long term: 19 months + RAG rating on progress: Red Amber Green Delay in Progress being Good progress implementation of made on being made on mitigating action – mitigating actions – action plan or unknown timescale. anticipated that anticipated that More assurance risk will be high level risk will needed that planned mitigated in the be reduced in the action will fully projected planned timescale. mitigate the risk in an timescale but acceptable timescale. more assurance needed.
Current High Level Risks – Scored 15 or above Current Risk Term Status on Risk Status Short, Medium, 16/05/18 (17/07/18) Long A (20) A (20) Timely Access to Emergency Services – M Failure to deliver the 4 hour wait standard A (16) A (16) RMCH Urgent Care & Emergency M Care Capacity A (20) A (15) SMH Obstetric Capacity M G (16) G (16) Delivery of the 6 weeks wait diagnostics target S A (16) R (20) Group delivery of the RTT 18 weeks standard L A (16) A (16) Timely access to Cancer Services (Delivery of M the 62 day standard) Council of Governors’ Meeting – 17 th July 2018
Current High Level Risks – Scored 15 or above Risk Term Current Status on Short, Risk Status 16/05/18 Medium, (17/07/18) Long A (15) A (15) Compliance with Regulations – Electrical M G (15) G (15) Compliance with Regulations – Fire Stopping M G (16) G (16) Central Site Management of Patient Records M A (16) A (16) Clinical Quality of Health Records L A (15) A (15) Cyber Security L A (20) A (20) Compound risk relating to the proposed L acquisition of NMGH Council of Governors’ Meeting – 17 th July 2018
Current High Level Risks – Scored 15 or above Risk Term Current Status on Short, Risk Status 16/05/18 Medium, (17/07/18) Long A (16) A (16) Communications of diagnostic test L & screening results A (16) A (16) Adult Congenital Heart Services M R (20) R (20) Financial Sustainability L G (16) G (16) Regulatory (CQC) Compliance Evidence M A (16) A (16) Appraisal Compliance M G (15) G (15) Critical Care Monitoring Station (RMCH) S Council of Governors’ Meeting – 17 th July 2018
Assurance & Risk QUESTIONS ?
Continuing to Shine Preparing for a CQC Inspection Sarah Corcoran, Director of Clinical Governance
Assessment Types…. CQC Comprehensive Assessment Use of Well-led Resources
The Regulations Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 5: Fit and proper persons: directors These regulations are part of the fundamental standards of care Regulation 9: Person-centred care Regulation 10: Dignity and respect Regulation 11: Need for consent Regulation 12: Safe care and treatment Regulation 13: Safeguarding service users from abuse and improper treatment Regulation 14: Meeting nutritional and hydration needs Regulation 15: Premises and equipment Regulation 16: Receiving and acting on complaints Regulation 17: Good governance Regulation 18: Staffing Regulation 19: Fit and proper persons employed Regulation 20: Duty of candour
Registered Activities These are the activities (what it is we do) registered with the CQC that we undertake in our various premises and helps them understand what type of organisation we are. They include activities such as: • Treatment of disease, disorder or injury • Assessment or medical treatment for persons detained under the Mental Health Act 1983 • Surgical procedures • Diagnostic and screening procedures
Acute core services Urgent and emergency services Medical care (including older people’s care) Surgery Critical care Maternity Services for children and young people End of life care Outpatients Core Services Acute specialist core services Neonatal services Transition services Mental Health Care in Acute Trusts Community core services Community health services for adults Community health services for children, young people and families Community health inpatient services Community end of life care Mental Health Child and Adolescent Mental Health Wards Specialist community mental health services for children and young people
Additional Services Acute Gynaecology Diagnostic imaging Rehabilitation Spinal injuries Community health Community dentistry Sexual health services Urgent care
Registration and Ratings - Previous Registration - Current Wythenshawe MRI – MRI, REH, SMH, Hospital RMCH Requires Manchester Royal Good Wythenshawe Improvement Infirmary Trafford Hospital Hospital Trafford Hospital Altrincham Hospital Community Withington Services – to Good Good Altrincham Hospital Hospital include revised LCO arrangements University Dental Manchester Royal Withington Hospital Community Services Renal Satellites Hospital Eye Hospital Good Good / RI Royal Manchester Saint Mary’s University Dental Children’s Hospital Hospital Renal Satellites Hospital Good Not Inspected
Where are we now? • Comprehensive Inspection Self Assessment – completed – overall self assessment rating of ‘Good’ • Well-led self-assessment – Completed and submitted to the Board in July - overall self assessment rating of ‘Good’ • All action plans progressing with improvements being seen • Regular engagement with CQC and other stakeholders e.g. Lead Commissioner • CQC have undertaken walk rounds and focus Groups at a number of Hospitals • Pre-inspection Request (PIR) part one received and submitted, part 2 received and in progress
Phased Communications Plan The plan will be phased into four focus areas around the CQC inspection: Phase 1: • Awareness raising of Shine • Focus on patient benefits as a result of the merger March – end of • Focus on improvements since the last CQC inspection April/early May • Preparation for forthcoming visit Phase 2: • Focus on patient benefits as a result of the merger Mid May – end of August • Focus on improvements since the last CQC inspection Phase 3: • Countdown • Focus on patient benefits as a result of the merger September • Energising and enthusing • During and after the inspection Phase 4: • Focus on patient benefits as a result of the merger October onwards
Next Steps April May June July Aug Sept Quality and Possible Briefing Final CEO Self Safety formal notice Assessment Committee preparation Presentation Draft CEO given Update Presentation Engagement Briefings Engagement Improvement Comms Plan Meeting Updates Meeting Circulated Comms and possible Comms and Comms and Review of Comms and Comms and Focus possible possible Legacy Action possible Focus possible Focus Groups Focus Focus Plans Groups Groups Groups Groups
Discussion
Well Led Council Of Governors 17 th July 2018 Margot Johnson Group Executive Director of Workforce & Organisational Development
Well-led By well-led, we mean that: The leadership, management and governance of the organisation assures the delivery of high-quality person- centred care, supports learning and innovation, and promotes an open and fair culture.
Process and Timescale OCTOBER - NHS I collate SEPTEMBER Well Led and Use of - NHS I Resources undertake Use review of Resources AUGUST information review on site including - Final for 1 to 1.5 stakeholder assessment sent days including opinions and to NHSI interviews provide CQC with key with an overall - NHS I review executives rating self assessment CFO/COO/ JULY and confirm date DWOD to undertake Use - Board of of Resources on Directors sign site MAY - JULY off - External - Group Well- - Review of self opinion on led Self assessment is Hospital Assessment informed by Governance & - KPMG follow external data golden thread up on and stakeholders Reporting including Accountant National NHS I Actions team
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