Trust Board papers November 2012 - Barking Havering and ...

More documents

Recommendations

Info

TITLE: EXECUTIVE SUMMARY BOARD/GROUP/COMMITTEE: Single Operating Model – Self certification template Trust Board 1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE: Delivering the NHS Foundation Trust Pipeline: Single Operating Model (SOM) sets out the requirement for □ PEQ……….…...……. □ STRATEGY……….….……. Trusts to complete a self-assessment. □ FINANCE ……..……… □ AUDIT ………….……..…. The SOM requires NHS Trusts to regularly self-certify governance and financial risk ratings on a monthly basis. They are also required to submit a template of quality and contractual information and provide an accurate selfassessment against a series of Board statements drawn from the Monitor Compliance Framework. □ CLINICAL GOVERNANCE …………..………….....…… □ CHARITABLE FUNDS ………………………………...… TRUST BOARD – Oct 2012 □ REMUNERATION ………………………………….…... □ OTHER …………………………..……. (please specify) All declarations and self-certification should have been robustly discussed and approved by the Trust Board with the discussion minuted. Where an issue of non-compliance is identified the Trust should submit the relevant Board approved action plan to rectify the issue. In line with the principle of avoiding duplication this would normally be the same level of detail that has been presented to the Board to provide them with assurance that an issue can be rectified. 2. DECISION REQUIRED: CATEGORY: The Trust Board is asked to discuss and approve the contents of the Trust Self-Assessment NATIONAL TARGET □ CQC REGISTRATION □ CNST □ HEALTH & SAFETY 3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST: Not applicable. 4. DELIVERABLES □ ASSURANCE FRAMEWORK □ CQUIN/TARGET FROM COMMISSIONERS □ CORPORATE OBJECTIVE …………………………….... □ OTHER …NHS Operating Framework AUTHOR: Claire Burns, Head of Planning, Commissioning and Information PRESENTER: Neill Moloney, Director of Delivery DATE: Oct 2012 Meeting the Delivering the NHS Foundation Trust Pipeline: Single Operating Model (SOM) requirement for Trusts to complete a self-assessment 5. KEY PERFORMANCE INDICATORS Please see attached self-assessment which includes indicators AGREED AT ______________________ MEETING OR REFERRED TO: __________________________ DATE: ____________________________ DATE: ____________________________ REVIEW DATE (if applicable) ___________________________
SELF-CERTIFICATION RETURNS Organisation Name: BHR University Hospitals NHS Trust Monitoring Period: September 12 NHS Trust Over-sight self certification template
Page 1 and 2:
TRUST BOARD MEETING Wednesday, 7 No
Page 3 and 4:
2 Following Mr White’s concerns r
Page 5 and 6:
4 forecast in terms of community be
Page 7 and 8:
6 The Trust Board noted the Plan fo
Page 9 and 10:
8 The Co-Chair of the Improving Pat
Page 11 and 12:
TRUST BOARD MEETING Actions from Mi
Page 13 and 14:
Agenda Item Action Deadline Date Da
Page 15 and 16:
Question: Mr Skillman was pleased t
Page 17 and 18:
CQC Trust-wide Action Plan Review a
Page 19 and 20:
1.0 PURPOSE 1.1 Background This rep
Page 21 and 22:
• Review the Senior Responsible O
Page 23 and 24:
APPENDIX 1 ‐ CQC ACTION PLAN - EX
Page 25 and 26:
RECORDS records management to ensur
Page 27 and 28:
CQC Update Report 2012 Theme CQC Re
Page 29 and 30:
CQC Update Report 2012 ASSESSING &
Page 31 and 32:
CQC Update Report 2012 ASSESSING &
Page 33 and 34:
CQC Update Report 2012 pathways thr
Page 35 and 36:
CQC Update Report 2012 identified i
Page 37 and 38:
CQC Update Report 2012 outlining th
Page 39 and 40:
CQC Update Report 2012 improvements
Page 41 and 42:
CQC Update Report 2012 aware of the
Page 43 and 44:
CQC Update Report 2012 are now supe
Page 45 and 46:
CQC Update Report 2012 autumn. RECO
Page 47 and 48:
CQC Update Report 2012 of the pilot
Page 49 and 50:
EXECUTIVE SUMMARY TITLE: Informatio
Page 51 and 52:
INFORMATION GOVERNANCE STRATEGY 201
Page 53 and 54:
Information is a vital asset in ter
Page 55 and 56:
starters as well as being mandatory
Page 57 and 58:
The standards are split into the ar
Page 59 and 60:
10a Reapproval of IG training progr
Page 61 and 62:
343 Directorate Anaesthetic: Risk:
Page 63 and 64:
Table of Contents TRUST PRINCIPAL O
Page 65 and 66:
BHRUT STRATEGIC OBJECTIVES WITH EAC
Page 67 and 68:
DIRECTORATES RISKS REVIEW 12 10 8 6
Page 69 and 70:
RISKS DETAILS PRINCIPAL RISK What c
Page 71 and 72:
PRINCIPAL RISK What could prevent t
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
RISK DESCRIPTORS OBJECTIVE SAFE, HI
Page 79 and 80:
BOARD ASSURANCE FRAMEWORK ELEMENTS
Page 81 and 82:
EXECUTIVE SUMMARY TITLE: Risk Manag
Page 83 and 84:
Contents Section Page 1 Introductio
Page 85 and 86:
incorporate mitigation controls wit
Page 87 and 88:
“Risk Register” “Risk Registe
Page 89 and 90:
potential risks they may face in ac
Page 91 and 92:
4.1.1 Quality and Safety Committee
Page 93 and 94:
• Financial risks: risks associat
Page 95 and 96:
Proactive risk assessment enables t
Page 97 and 98:
Trust’s risk matrix and will popu
Page 99 and 100:
Risk Grading Staff Group Evidence R
Page 101 and 102:
4.8 RISK REGISTER The Risk Register
Page 103 and 104:
5.1 Consultation and Communication
Page 105 and 106:
The Trust recognises the importance
Page 107 and 108:
timescale with supporting evidence
Page 109 and 110:
Checklist for the Review and Approv
Page 111 and 112:
Equality Impact Assessment Tool To
Page 113 and 114:
Plan for Dissemination of Procedura
Page 115 and 116:
Consequence score (severity levels)
Page 117 and 118: Frequency How often might it/does i
Page 119 and 120: Appendix 3 Framework for Risk Manag
Page 121 and 122: Risk Register inventory they are ex
Page 123 and 124: 2. DECISION REQUIRED: CATEGORY: The
Page 125 and 126: • A review of data capture to ens
Page 127 and 128: Pilot Wards Division Discharges Per
Page 129 and 130: Workforce Appraisals - the actions
Page 131 and 132: Delayed transfers of care (DTOC) -
Page 133 and 134: EXECUTIVE SUMMARY TITLE: Emergency
Page 135 and 136: • Training competencies are being
Page 137 and 138: Appendix A: Trajectory for all type
Page 139 and 140: would welcome feedback from the Tru
Page 141 and 142: Maternity Services Monthly Performa
Page 143 and 144: 4. Capping The maternity service is
Page 145 and 146: 7. Obstetric Assessment Unit (OAU)
Page 147 and 148: 10. Serious Incidents Reported Inci
Page 149 and 150: 12. Maternity Dashboard The dashboa
Page 151 and 152: It should also be noted that the ta
Page 153 and 154: Priority Action Lead Monitoring Too
Page 155 and 156: Priority Action Lead Monitoring Too
Page 157 and 158: Contents Section No: Description Pa
Page 159 and 160: 3. Complaints Activity 3.1 Total Co
Page 161 and 162: 3.5 Themes General care issues and
Page 163 and 164: Corporate Non Clinical Category Num
Page 165 and 166: order to resolve concerns. Particul
Page 167: The findings of the review were tha
Page 171 and 172: 12 AA - Quality Improvement Strateg
Page 173 and 174: TFA Progress BHR University Hospita
Page 175 and 176: 25 TFA - Final IBP /; LTFM Dec-12 H
Page 177 and 178: Effectiveness GOVERNANCE RISK RATIN
Page 179 and 180: Safety 4b MRSA Enter Are you below
Page 181 and 182: FINANCIAL RISK RATING BHR Universit
Page 183 and 184: CONTRACTUAL DATA BHR University Hos
Page 185 and 186: 4 Single Sex Accommodation Breaches
Page 187 and 188: TITLE: EXECUTIVE SUMMARY BOARD/GROU
Page 189 and 190: causes/ Not specified' will be remo
Page 191 and 192: Staff In Post Starters & Leavers FT
Page 193 and 194: TURNOVER Actual Versus Target Annua
Page 195 and 196: FTE Lost due to Sickness Absence by
Page 197 and 198: The data on the previous page has b
Page 199 and 200: Indicator Target Apr-12 May-12 Jun-
Page 201 and 202: Starters *¹ 7.00 3.60 5.00 7.43 6.
Page 203 and 204: EXECUTIVE SUMMARY TITLE: COST IMPRO
Page 205 and 206: Month 6 CIP Performance Workstream
Page 207 and 208: Governance The Cost Improvement Pro
Page 209 and 210: 1 REPORT TO: REPORT FROM: Trust Boa
Page 211 and 212: 3 Preparations for winter planning
Page 213 and 214: 5 Preparing the Payment by Results
Page 215 and 216: 7 People with dementia to receive m
Page 217 and 218: 9 Clinical Patient Management and H
Page 219 and 220:
102/2012 Apologies Apologies were r
Page 221 and 222:
Action Members were advised that ac
Page 223 and 224:
Action 115/2012 Any Other Business
Page 225 and 226:
EXECUTIVE SUMMARY TITLE: Finance Re
Page 227 and 228:
1. EXECUTIVE SUMMARY Monthly I&E Ru
Page 229 and 230:
Trust I&E summary by Division/Direc
Page 231 and 232:
Income by POD In Month Year to date
Page 233 and 234:
Devolved income Annual Budget Forec
Page 237 and 238:
4. BALANCE SHEET Balance Sheet Curr
Page 239:
6. Business Unit Summaries Attached
show all

Trust Board papers November 2012 - Barking Havering and ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?