Public Board of Directors papers 241122

Board of Directors meeting Thursday 24 th November 2022 at 12.45 pm Trust Administration Room 6 Agenda Clinical presentation: Donna Graham, Consultant & Leanna Goodwin, Research Practitioner - Digital Apps and Inclusivity

Public items

Page

37/22 Standard business a Apologies

Chair Chair Chair CEO

b Declarations of interest

* *

c Minutes of previous meeting – 27 th October 2022 d Action plan rolling programme, action log & matters arising

2 9

38/22 Board assurance

Committee chair CEO

a Audit Committee report – October 2022

* * *

12 15 18

b Workforce Assurance Committee report – November 2022

c Board assurance framework 2022/23

39/22 Key Reports a Trust report

* *

CEO COO

23 30

b Integrated performance, quality & finance report c Industrial action / winter planning preparedness

p

DoW/COO

40/22 Any other business

Chair

Date and time of the next meeting Thursday 26 th January 2023 at 12:45pm

CEO COO ECN DoW

Chief Executive Officer Chief Operating Officer Executive Chief Nurse Director of Workforce

*

paper attached

v verbal p presentation

1

Public meeting of the Board of Directors Thursday 27 th October at 12.45 pm Seminar room, Christie at Macclesfield and through virtual access

Present: Chair: Chris Outram (CO), Chairman

Roger Spencer (RS), Chief Executive Officer Kathryn Riddle (KR), Non-Executive Director Dr Jane Maher (JM), Non-Executive Director Robert Ainsworth (RA), Non-Executive Director Prof Kieran Walshe (KW), Non-Executive Director

Grenville Page (GP), Non-Executive Director Alveena Malik (AM), Non-Executive Director Tarun Kapur (TK), Non-Executive Director Prof Chris Harrison (CJH), Medical Director and Deputy CEO Bernie Delahoyde (BD), Chief Operating Officer Eve Lightfoot (EL), Director of Workforce Prof Janelle Yorke (JY), Executive Chief Nurse & Director of Quality Dr Neil Bayman (NB), Executive Medical Director Sally Parkinson (SP), Interim Executive Director of Finance

Prof Richard Fuller (RF), Director of Education Prof Fiona Blackhall (FB), Director of Research Minutes: Jo D’Arcy, Assistant Company Secretary In attendance: Sue Mahjoob, Freedom to Speak Up Guardian

Matthew Bilney, Associate Chief Nurse, Quality and Patient Safety Benjamin Vickers, Patient Safety Specialist & Risk Lead Scott Davies, Public Governor for Salford Eric Solomons, observer

Clinical presentation: Patient safety strategy CO welcomed MB and BV to the meeting to present on the patient safety strategy. MB presented to the Board and informed that there are changes coming in terms of how the Trust manages patient safety incidents, which is a big piece of work for the Trust, and a national requirement. There has been an increase in the number and complexity of complaints received, which has put a demand on the team. The quality and standards team have been through a restructure, which has also led to the creation of new roles. A further Associate Chief Nurse is also due to join the team. A key appointment is the introduction of the Patient Safety Specialist role, undertaken by BV who has been with the Trust for 4 weeks and has a wealth of governance experience. MB handed over to BV to continue with the presentation. BV gave an overview of the patient safety strategy 2020. The patient safety strategy enables the NHS to achieve its safety vision; to continuously improve patient safety. To do this the NHS will build on two foundations: a patient safety culture and a patient safety system. Three strategic aims will support this development: insight, involvement and improvement. The process will involve recruiting patient safety partners, this will be a volunteer role. The shift in process relates to a required culture change and the strategy is aimed at moving the focus towards improvement. The patient safety strategy is 2 years old and is underpinned by 2 pieces of work, the Patient Safety Incident Response Framework (PSIRF) and Learning from Patient Safety Events (LFPSE). The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. An overview was given as to how this will be embedded within the Trust. The 4 key aims of the PSIRF were also described.

2

The PSIRF focusses on proportionality and compassionate engagement with those affected. The PSIRF is supported by guidance documents which the team are digesting and formulating a granular action plan for implementing by September 2023. The Learning from Patient Safety Events (LFPSE) replaces the National Reporting and Learning System (NRLS) and the Strategic Executive Information System (StEIS) and the LFPSE will provide live data to NHS England and CQC (the process and governance of this is under review nationally). The aims of the LFPSE are to record patient safety events (organisations, staff and patients will be able to record the details of patient safety events) and to be able to access data about recorded patient safety events (providers will be able to access data that has been submitted by their team). The requirements for the LFPSE will be automated through the Trust’s current use of the Datix system and will provide live data to NHSE and CQC on reporting. The original deadline for implementation was March 23 but this has been pushed back to align with the implementation of the PSIRF. A delivery team is in place to support the implementation of the PSIRF with JY as Executive sponsor, Dr Vidya Kaspandian as Medical Lead, Matt Bilney as Senior Responsible Officer supported by Ben Vickers as Project Lead, Katerina Pearson, Clinical Patient Safety Manager and Benjamin Cain, Risk and Patient Safety Officer. There is currently also a vacancy for Patient Safety and Risk Manager. BV’s role is a national role and every Trust needs to have at least one in post. The role is clearly mandated with the key aspects and linkage with other Trust areas outlined to the Board. An overview of the work required locally was provided including the linkage with other areas, an action plan is in place but will be refined as more of the guidance is understood. The timeline towards implementation was presented, currently in the orientation phase with the key stages identified requiring completion by September 2023 3 with an expected 3–4-year programme for fully embedding. Opened out for any questions. CO asked that as the Quality Assurance Committee looks at patient safety and risks across a range of subjects, what is the biggest thing that will benefit christie patients from the new system. BV stated that from reading the national strategy and the PSIRF, the biggest benefit will be the involvement of the patient safety partners. Patients have a different insight to staff and rich learning can come from this. GP commented that a 3–4-year plan for embedding seems like a long time. BV stated that the national strategy is based on a 5–10-year strategy but can start to embed now as the Trust works through the PSIRF. Every day behaviours are required to be adopted and may need bespoke methodologies implementing along the way as things will continuously evolve. JM asked on proportionality and the reduction in root cause analysis (RCA) and whether it is going to be difficult to work out if something needs a RCA or not. BV stated that when he has gone to the network meetings, this is being discussed. It’s around the real focus on what is the 1 root cause, there are often multi contributory factors so this will be the shift but there is a need to ensure the documentation captures everything. MB added commenting on thematic reviews, there is already good culture in the Trust so it will be easier to transition. KW commented on the old framework for serious incident investigations, the Trust did it well so sceptical as to whether the solution is to have a new information system, implementing it now feels like a real hill to climb. The Trust is good at incident investigation and follow up so don’t want to lose the benefit of what we already have. BV agreed and stated that these questions have been asked within the network. The PSIRF does make the distinction as it directly states it’s not an incident management framework that Trusts have to follow so will be based on what works for the Trust. EL asked on the just and fair culture and leadership and whether there had been any engagement as yet with the Workforce team. BV confirmed that key stakeholder teams have been identified and have put in introductory meetings. No further comments or questions raised.

3

CO thanked MB and BV. MB and BV left the meeting.

Item

Action

33/22 Standard business a Apologies

Louise Westcott, Company Secretary b Declarations of Interest No declarations of interest noted. c Minutes of the previous meeting – 29 th September 2022 The minutes were accepted as a correct record. d Action plan rolling programme, action log & matters arising All items from the rolling programme are noted on the agenda. 34/22 Board Assurance a Quality Assurance Committee report – September 2022 KW outlined the report and the levels of assurance assigned to the 4 matters relating to BAF risks. Revised assurance committee structure working well. No escalations were recommended to the Board. b Board assurance framework 2022/23 RS outlined the updated version of the framework and proposed one update relating to risk 8.2 where the risk score had been added. Noted around the allocation of BAF items to assurance committees. Opened out for any comments or questions. CH commented to confirm that following discussion and agreement, risk 8.2 now falls to the Audit Committee. GP added that the risk score wasn’t agreed at the Audit Committee, good work was noted with some significant challenges. Questioned the impact score of 2 with looking at the seriousness of the issue. CH added that Audit committee will be providing narrative as part of the next update to Board further on the risk. GP raised a query in relation to the likelihood score of 4 for risk 7.3 as felt this feels high. EL agreed to pick up along with a review of the risk description. Action RS added on the important points to raise on the BAF noting that the workforce risk also relates to the potential impending strike action. CO summarised and asked for Board approval to the proposed risk score update. Approved c Progress with annual objectives 2022/23 RS informed Board that it is now the 6-month point for reporting where the Trust is up to in terms of progress with the annual objectives. The paper provides the information and there has been no changes to the risks.

EL

4

Opened out for any questions. No comments or questions raised. Noted

35/22 Key Reports a Trust report

RS informed the Board that on 12 th October CQC began their review as part of a routine inspection process. CQC have given a schedule of 15 th -17 th November for the well-led inspection part of the review and a number of colleagues will be engaged as part of the process. The designation of Manchester as a Biomedical Research Centre with an award of £59.1 million has been announced which is double the original award value, a large proportion is in relation to cancer. Living with and beyond cancer is a new theme as part of the new programme for the centre. NHS England (NSHE) have released its new operating framework that the Trust needs to become familiar with. Further information has just come through on the required changes to provider licence terms, this will come back to the Board in RA asked on the doubling of the award to GM for the Biomedical Research Centre and if this also equates to a doubling of the cancer research fund. RS stated there were originally 7 themes with just over half related to cancer, this is now nearer to 12, the scope and volume for each theme is different so may increase the amount of funding into cancer themes but won’t be double. FB added that there have also been increases to funding to partners elsewhere within the North West. GP asked if any practical changes for the Trust and if there are any challenges. FB stated that existing researchers will continue to be funded with a bit more money for other research work. A few posts may be able to be recruited to along with posts within the science labs. Can provide further details as things develop. NB added that it is a real opportunity in relation to living with and beyond cancer. No further comments or questions raised. Noted b Integrated performance, quality & finance report BD outlined the September performance. There have been no SI incidents, never events or major incidents. 7 moderate incidents and 5 sepsis 1-hour breaches, there is an action plan associated with this. There were 6 cases of C.diff with no lapses in care, 5 cases of E-Coli post 48 hours and 5 Covid nosocomial infections. The number of new complaints has reduced in month with 46 PALS contacts dure course with the changes. Opened out for any questions.

received, LOS at 6.74 and 2 cancelled operations. 5 corporate risks at 15+; 1 at 20, 1 at 16 and 3 at 15.

In terms of things to note for access, 24-day performance is key and this was 82.0%. 31-day performance at 97.4% which is the area for the majority of patients. Referrals within predicted range.

5

Activity is overall on plan with the exception to radiotherapy fractions although 1st fractions are above plan. This could be to do with a possible glitch in the data which is being reviewed. PDR compliance has dropped slightly. Work is ongoing within the School of Oncology to improve. Essential training overall is at 85.5%, all areas are reviewing and this is also picked up in service and operational reviews. Have seen an improvement with sickness levels in month. CO asked on when the slippage started with essential training compliance. BD noted the slippage began in October 2021 due to the covid wave, there has been a constant chase since and also do deep dives with divisions. JY added this is also noted on divisional risk registers with action plans in place. In relation to staffing, currently carrying a number of vacancies, approx 500. 90% of these are in recruitment stages with bank and agency filling gaps in rotas for safe staffing. TK asked on the vacancies which are in the recruitment process, how many of those are not expected to convert to filling the roles. BD stated it is very rare to not appoint to a role. KW asked on leavers’ numbers and the adjusted 12-month turnover % reasoning. EL confirmed this relates to staff on fixed term contracts. Benchmarking has been done and the Trust is on par within GM. There are a lot of healthcare support workers moving to other roles in other organisations. It’s a system wide picture but the Workforce Committee do look at the information as to why staff choose to leave the Trust. There are plans in place to address as part of the workforce risk. JY added that it is currently a top risk with an associated action plan. RS noted that there is a need to be clear that on comparative terms it’s not a big cost, 75-80% of the posts needed are currently being delivered by bank staff. BD continued providing the month 6 finance details; £58k surplus compared to a breakeven plan/£1k surplus in month, I&E deficit of £8.91m, cash balance of £160,008k, capital expenditure at .12.7% below NHSI plan and a further £211k savings delivered for CIP with a further £84k of recurrent savings identified in month which is a 45% of the target identified. Opened out for any further comments or questions. GP commented in relation to the friends and family test, noting that there continues to be great feedback with a very small percentage of poor responses. Linking to patient safety, asked if the Trust are understanding what is driving any poor responses and providing insights for improvement. BD confirmed that the feedback gets fed back to the ward areas, although it is a small sample size the comments are picked up. JY added that this feedback is also triangulated with other areas of patient experience feedback and the Patient Experience Committee go through the feedback in detail. No further comments or questions raised. Noted c Freedom to Speak Up annual report SM attended to present confirming to the Board that she is based in the Quality and Standards team and also links in with the patient safety aspects of the team.

6

Bar charts were presented showing the number of FTSU contacts by quarter since Q1 2019/20, Q1 for 2020/21 represents the highest number of contacts with the majority related to staff anxiety due to covid. Having looked at the analysis of the cases, pre-covid there was an element of cases relating to attitudes and behaviours. These relate to a lot more one on one cases rather than a group. With more staff working from home this has seen less on an impact post covid. There has been a lot of work on getting messages across on the importance to listen to concerns and communicate them. 31% of concerns related to attitudes and behaviours (50% and 39% previous six months), 32% related to policies, procedures and processes and 2 concerns could have affected patient safety currently waiting on further information and going through the process as normal. There have been 2 concerns in the last 6 months regarding a one-on-one attitude and behaviour issue with the staff member happy to move departments. There was a requirement to speak to the FTSUG due to the time being taken to resolve. Through conversations with senior leaders, talking about the cultural side more. When having these conversations, can see that they see the benefit. Some leaders are also willing to be filmed on their FTSU experience demonstrating a willingness to talk about can help in getting messages across. Next step as an organisation is to keep giving support and translate into actions. With the restart of the CODE inspections, there is also a part which asks staff if they feel comfortable in raising concerns with their manager to which 100% have responses to say yes so far. In terms of achievements, the use of videos has been expanded videos, these are power stories and have been using in training sessions. The Board self assessment has also been achieved. There is a procedure which focuses on type of concerns. A EDG video of staff experiences has also been completed. The staff survey results have been to the EDG group to get their thoughts and will also be taken to other groups. Items in progress relate to the requirement to update the policy, the NHSE refreshed board self-assessment and FTSU action plan which will come to Board. The values and behaviour framework is going through consultation at the moment, staff were asked what they wanted values and behaviours to be. A Schwartz round is scheduled for November on speaking up and October is FTSU month, which has been promoted for people to support the value that it brings to the Trust. There are different modules of training levels for staff. Training is also available in paper format as well as on-line. There have been mixed feelings on the effectiveness of doing FTSU training as it’s a cultural thing. Most essential training is ‘how to’ where as FTSU is a behaviour. Opened out for any questions. CO commented that doing a Schwartz round is great as it aims to give a safe space for staff to talk about experiences and listen to each other. RA asked on standard operating procedures and whether these replace the previous documents. SM stated they have not been replaced but have been added to and refined, this is to ensure they reflect national policy.

7

RA commented on the flowchart being questions rather than a policy telling you what to do and if this was the right format. SM confirmed this is correct as every case is different, if made too transcriptive it wouldn’t fit each scenario. There is a need to make sure the questions are asked and have the robust discussions to reach decisions. Different people have different views on their concerns. RA thanked SM. KW added comment on much of it being about the people and relationship side for the FTSUG. Need to normalise the idea that speaking up is OK and safe and asked if more could be done with examples being shared with others. NB agreed and if could look to get more examples into the essential training this would help. SM agreed and commented that with the training, this is what was given nationally. The intention comes from the organisation but need to also maintain confidentiality. KW agreed noting that there would be a need to anonymise or fictionalise. SM added it is about people thinking about it and making it safe to speak up. No further comments or questions raised. CO thanked SM. Report noted d Trust 5-year Strategy refresh NB informed the Board that the paper sets out the strategy refresh for the next 5 years with recognition to the risks and enablers. The creating of the strategy now in a different environment and the paper sets out the opportunities from the last 12 months and the going forward with the next steps. There is a Trust wide engagement event on 4 th November open to all staff which has had lots of interest. Will also be putting on a second event in January. The 5-year plan for 2023-2028 will be published in March 2023. Opened out for questions. JM stated when the Trust first started a strategy there was lots of patient and public involvement and asked if this happens now. NB confirmed the refresh of the strategy brings together all the different components, which involved PPI. CO asked on the refresh of the Christie values and where this was up to. EL confirmed that this is an agenda item for the next Workforce Assurance Committee. No further comments or questions raised. Noted

36/22 Any other business No items raised.

Date and time of the next meeting Thursday 24 th November 2022 at 12:45pm

8

Agenda item 37/22d

Meeting of the Board of Directors - November 2022 Action plan rolling programme after October 2022 meeting

Month

From Agenda No

Issue

Responsible Director

Action

To Agenda no

Annual reporting cycle Integrated performance & quality report and finance report

COO

Monthly report

November 2022

39/22b

December 2022 - no meeting

Integrated performance & quality report and finance report

COO

Monthly report

By email

COO

Monthly report Annual Review

Annual reporting cycle Integrated performance report Annual reporting cycle Risk Management strategy 2021-24

January 2023

CN&EDoQ

Integrated performance & quality report and finance report

COO

Monthly report

By email

February 2023 - no meeting

Annual reporting cycle Corporate planning (corporate objectives / BAF 2022/23) Annual reporting cycle Letter of representation & independence Annual reporting cycle Integrated performance & quality report and finance report Annual reporting cycle Declaration of independence (non-executive directors only) Annual reporting cycle Register of directors interests

Executive directors

Approve next year's BAF

Chair Chair COO Chair DCEO

Directors to sign Report for approval

Monthly report

For completion by NEDs

March 2023

5 year strategy 2023-29

Approve

Digital Update Workforce update

EMD/Dep CEO Update

DoW EMD

Quarterly review

Responsible Officer report

Medical Appraisal & Revalidation Annual report

Annual reporting cycle

Chair

Approve

Annual reporting cycle Integrated performance & quality report and finance report

COO CEO CEO CEO

Monthly report

Register of matters approved by the board

April 2022 to March 2023 Review 2022/23 progress

Annual reporting cycle Annual Corporate Objectives

April 2023

Modern Slavery Act update Board effectiveness review

Approve

Chairman FTSUG

Undertake survey Quarterly update

Freedom to speak up Guardian report

9

Month

From Agenda No

Issue

Responsible Director

Action

To Agenda no

COO

Monthly report

Annual reporting cycle Integrated performance & quality report and finance report

Self certification declarations

To approve the declarations Declaration / approval

EDoF&BD

Provider licence

May 2023

Annual reporting cycle Annual compliance with the CQC requirements

ECN ECN

Annual sustainability report

Update

Committee chairs

Assurance

Annual reporting cycle Annual reports from audit & quality assurance committees

COO CCIO

Monthly report Progress report

Annual reporting cycle Integrated performance & quality report and finance report

Digital update

June 2023

Annual reporting cycle Annual report, financial statements and quality accounts (incl Annual governance statement / Statement on code of governance)

EDoF&BD

Approve

July 2023 - no meeting

Integrated performance & quality report and finance report

COO

Monthly report

By email

August 2023 - no meeting

Integrated performance & quality report and finance report

COO

Monthly report

By email

Annual reporting cycle Integrated performance & quality report and finance report

COO

Monthly report

Sep-23

Annual reporting cycle Strategy refresh, corporate objectives & board assurance framework

DCEO

Interim review & update

October 2023

Christie role in addressing healthcare inequalities Integrated performance & quality report and finance report

DCEO COO FTSUG

Report

Monthly report Annual report

Freedom to speak up guardian

10

Agenda item: 37/22d

Action log following the Board of Directors meetings held on Thursday 27 th October 2022

No. Agenda

Action

By who

Progress

Board review

Risk scores on the BAF to be reviewed by appropriate assurance committee

To note BAF following reviews in assurance committees as usual

1 34/22b

Exec leads

Complete

11

Agenda Item 38/22a

Meeting of the Board of Directors Thursday 24 th November 2022

Subject / Title

Audit Committee report – October 2022

Author(s)

Company Secretary’s Office

Presented by

Committee chair

This paper provides the board with a summary of the assurance items considered by the Audit Committee at their October meeting and any subsequent actions required by the Board.

Summary / purpose of paper

Recommendation(s)

To note the report and any actions

Background papers

Audit Committee papers 20 th October 2022

Risk score

BAF references noted within report

• Trust’s strategic direction • Divisional implementation plans • Our Strategy • Key stakeholder relationships

Link to:  Trust strategy  Corporate objectives

You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.

DoF CIO

Director of Finance

Chief Information Officer

12

Agenda item 38/22a

Meeting of the Board of Directors Thursday 24 th November 2022

Audit Committee report – October 2022

1 Introduction The Audit Committee took place on 20 th October 2022. The following summary gives the Board information on the items that were considered and any actions required by the Board. Audit Committee agenda items The items listed below were all presented to the Audit Committee for assurance. Agenda item BAF reference Assurance rating given Comments and associated action (where applicable) 2

Executive Director of Finance report

6.2

High

Key parts of the report were summarised with the following actions noted: • Confirmation to be obtained as to whether the Trust are insured against the loss of key personnel. • Report on exception list of items which don’t require a PO under the policy to be provided to ensure full visibility. • To confirm the reasoning for the 1 mandated external instruction. Updates provided on any changes since last update in April. Noted for further discussion with assurance committee chairs and exec leads as to where to place future Pharmacy updates to avoid overlap and duplication across committees. The assessment of the Trust’s self-assessment achieved substantial assurance with an overall assurance level of moderate assurance achieved. There is no required improvement plan with NHS Digital required from the 2021/22 submission and work continues to maintain and progress with the required standards for the 2022/23 submission. The external status reported for the 2021/22 DSPT submission is “Standards Met”. The medium assurance level is specifically for the achievement of the Trust’s SDMP actions. An assurance level for wider climate change goals has not been assigned as these relate to actions beyond those of the Trust.

The Christie Pharmacy Company report

6.4

High

Data Security and Protection Toolkit update

6.4

High, noting that there are actions to be delivered.

Compliance with Sustainable Development Management Plan 2021-24

8.2

Medium

13

The Committee chair will note any actions required by Board and make escalations to Board as necessary.

3

Recommendation The Board are asked to note the reports received for assurance by the Audit Committee in October.

14

Agenda Item 38/22b

Meeting of the Board of Directors Thursday 24 th November 2022

Workforce Assurance Committee Report – November 2022

Subject / Title

Author(s)

Company Secretary Office

Presented by

Committee Chair

This paper provides the board with a summary of the assurance items considered by the Workforce Assurance Committee at their November meeting and any subsequent actions required by the Board.

Summary / purpose of paper

Recommendation(s)

To note the report and any actions

Workforce Assurance Committee papers 8 th November 2022

Background papers

Risk score

BAF references noted within the report

• Trust’s strategic direction • Divisional implementation plans • Our Strategy • Key stakeholder relationships

Link to:  Trust strategy  Corporate objectives

EDG BAF

Ethnic Diversity Group

You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.

Board Assurance Framework Workforce race equality standard Workforce disability equality standard

WRES WDES FTSU

freedom to speak up

15

Agenda item 38/22b

Meeting of the Board of Directors Thursday 24 th November 2022 Workforce Assurance Committee report – November 2022

1 Introduction The Workforce Assurance Committee took place on 8 th November 2022. The following summary gives the Board information on the items that were considered, and any actions required by the Board. 2 Quality Assurance Committee agenda items The items listed below were all presented to the Workforce Assurance Committee for assurance in November. Agenda item BAF reference Assurance rating given Key points and associated action (where applicable)

The Christie People Plan

7.1 - 7.5

High

Committee supportive of the plan and to seek further assurance from specific outcome measures. A deep dive review of sickness identified for presentation at the next meeting. Committee supportive of the plan, assurance to be further measured by the outcomes and reported to the Committee. Committee supportive of the WRES and WDES action plans, assurance to be further measured by the implementation progress and reported to the Committee. Committee supportive of the plan, which has milestones in place to monitor progression. Assurance to be further measured by the implementation progress. No exception reports within the period and no fines issued. No concerns noted within the report. E-Roster review completed with substantial assurance achieved. Good practice overview provided to the Committee along with detail in relation to the recommendations from the review.

Culture/Values and Behaviours update

7.7

High

WRES and WDES Annual Submission

7.7

High

Equality and Diversity Annual Report 2021/22

7.7

High

Guardian of Safe Working Hours Report

7.2

High

Safe Staffing Six Monthly Report

7.2

High

Internal Audit Progress Report

7.2

High

16

Agenda item

BAF reference

Assurance rating given

Key points and associated action (where applicable) Substantial assurance achieved. Key recommendations arising from the review are referenced in the People Plan and are being worked on as a priority.

E-Rostering Audit Final Report

7.2

High

The Committee Chair will note any actions required by Board and make escalations to Board as necessary.

3

Recommendation The Board are asked to note the reports received for assurance by the Workforce Assurance Committee in November 2022.

17

Agenda Item 38/22c

Meeting of the Board of Directors Thursday 24 th November 2022

Subject / Title

Board Assurance Framework 2022/23

Author(s)

Louise Westcott, Company Secretary

Presented by

Chief Executive Officer

This paper provides the board with the Board Assurance Framework 2022/23 that summarises the risks to achievement of the corporate objectives. The cover paper gives detail of the refreshed risks for the new financial year.

Summary / purpose of paper

Recommendation(s)

To note the Board Assurance Framework (BAF) 2022/23

Board assurance framework 2021/22. Corporate objectives 2022/23, operational plan and revenue and capital plan 2021/22.

Background papers

N/A

Risk score

• Trust’s strategic direction • Divisional implementation plans • Our Strategy • Key stakeholder relationships

Link to:  Trust strategy  Corporate objectives

BAF Board assurance framework CN&EDoQ Chief nurse & executive director of quality EDoF&BD Executive director of finance & business development EMD Executive medical director COO Chief operating officer DoW Director of workforce

You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.

18

Agenda Item 38/22c

Meeting of the Board of Directors Thursday 24 th November 2022 Board Assurance Framework 2022/23

1

Introduction The Board Assurance Framework (BAF) 2022/23 was presented to the Board of Directors and Audit Committee in October and Workforce Assurance Committee & Quality Assurance Committee in November. Further review of the BAF has taken place by the Executive team and Company Secretary since the meetings. Updates to risks All risks in the 2022/23 framework have been reviewed to reflect the most up to date situation in the Trust and wider system, as well as the significant global factors impacting the NHS going forward. There have been minor updates to key controls and assurance levels have been added where risks have been through an assurance committee. Suggested updates There are no other suggested updates to the risks identified in the Board Assurance Framework. Consideration will be given to the allocated risks at each Assurance Committee meeting, and these have been added to rolling programmes to ensure appropriate oversight. Recommendation To note the Board Assurance Framework (BAF) 2022/23 that reflects the risks to achievement of the corporate objectives and the levels of assurance given to the various risks.

2

3

4

19

BOARD ASSURANCE FRAMEWORK 2022-23

Corporate objective 1 - To demonstrate excellent and equitable clinical outcomes and patient safety, patient experience and clinical effectiveness for those patients living with and beyond cancer

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Exec Lead

Key Control established

Key Gaps in Controls

Assurance

Number

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Patients with known or suspected HCAI are isolated. Medicines management policy contains prescribing guidelines to minimise risk of predisposition to C-Diff & other HCAI's. Need to maintain low levels of Gram negative bacteraemia. RCA undertaken for each known case. Review of harm undertaken. Induction training & bespoke training if issues identified. Close working with NHS England at NIPR meetings. Clinical advisory group in place. Daily monitoing of staff / patient impact of covid cases. Following national guidance. IPC BAF presented to Board Jan 22. Monthly patient satisfaction survey undertaken and reported through performance report. Negative comments fed back to specific area and plans developed by ward leaders to address issues. Action plans developed and monitored from national surveys. Complaints and PALs procedures in place. Action plans monitored through the Patient Experience Committee Trust aim to maintain 2016/17 levels. Collaborative projects in place. All falls come through executive nursing panel process. Call don't fall initiative. Falls group. Executive review group looks at attribution of avoidable / unavoidable. System for assessment of ulcers / grading used. Training across the trust (focus on theatres/critical care). NHSI criteria for assessment & expectations around pressure ulcers - internal review undertaken.Maintain low rates of catheter associated UTI's and maintain 95%+ VTE assessments. Increase in low harm Approval for the trust to further expand the management of local oncology and chemeotherapy services across GM. Focus on improved digital access e.g. appointments / ePROMs and Shared Decision Making. Chemotherapy services in locations across GM & Cheshire - strategy on track but constrained by other trusts.

Levels reported through performance report to Management Board and Board of Directors and quarterly to NHS Improvement.

Risk to patients and reputational risk to trust of exceeding healthcare associated infection (HCAI) standards

None identified. No formal threshold set by commissioners. 6

1.1

6

None identified

Averse Quality High 6 6 6

ECN 2 3

Year end

Failure to learn from patient feedback (patient satisfaction survey / external patient surveys / complaints / PALS)

6 Management Board and Board of Directors monthly Integrated performance and quality report. National survey results presented to Board of Directors.

1.2

4

ECN 2 3

None identified

None identified

Averse Quality High 6 6 6

Year end

6 Regular reports to Quality Assurance committee and board (through the integrated performance report).

4

1.3 Risk of exceeding the thresholds for harm free care indicators (falls, pressure ulcers)

ECN 2 3

None identified

None identified

Averse Quality High 6 6 6

Year end

Inequity of access for patients to Christie services due to delays in expanding care closer to home provision

Workforce and engagement from other trusts.

12 Reports to Management Board

8

None identified

Cautious Quality High 12 12 12

1.4

COO 3 4

Year end

Corporate objective 2 - To be an international leader in research and innovation which leads to direct patient benefits at all stages of the cancer journey

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Exec Lead

Key Control established

Key Gaps in Controls

Assurance

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Regular dialogue with national funding organisations on potential impact; open dialogue with strategic pharma partners; strong academic investment strategy to retain and attract world leading academics. Reporting to NHSE/I as and when required. Engaging in national webinars and updates. Sign up to regulators alerts - legislative changes assimilated into local processes as they arise. Any associated risks discussed and communicated. Levels of risk and mitigation reported through Research Division Board and Christie Research Strategy Committee

Oversight of potential legislative impact and consideration of any impact from COVID-19 pandemic

Risk to research profile and patient access to trials through reduced funding & changes to funding streams

8 Reports to Quality Assurance Committee

8

2.1

EMD 2 4

None identified

Cautious Quality Mediu m 8 8 8

Year end

10 Robust programme management (Steering Group, Finance Committee, Change Committee, Paterson Board) providing regular assurance reports to BoD

Impact of current economic environment on supply chain

10

2.2 Failure to deliver the Paterson building within timescale and budget.

EDoF / EMD 2 5 Build continues on plan and budget with established governace & reporting through board & committees.

None identified

Cautious Board High 10 10 10

Feb-23

Corporate objective 3 - To be an international leader in professional and public education for cancer care

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Exec Lead

Key Control established

Key Gaps in Controls

Assurance

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Review the deliverables and prioritise in line with financial investment available. Maximise the potential of external income. Refresh the School of Oncology focus on integration of objectives with clinical and research divisions. Work with finance to review funding options, develop business cases for high priority initiatives and look at alternative funding sources. School of oncology board reports to Management Board.

Continuing inability to deliver all strategic objectives due to difficulty in accessing curent investment funds to deliver new initiatives.

Risk to delivery of the School of Oncology strategy due to restrictions of post COVID 19 financial regimes, creating strategic, financial, reputational and operational implications

6 Reporting to Workforce Assurance Committee and Board

3.1

EMD 3 2

None identified

Cautious Workforce

8 8 6

8

Year end

20

Corporate objective 4 - To integrate our clinical, research and educational activities as an internationally recognised and leading comprehensive cancer centre

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Key Control established

Assurance

Exec Lead

Key Gaps in Controls

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Reaccreditation by OECI - reinspection due. Baseline measures identified and presented to Board of Directors. Looking at how we can be part of International Benchmarking. MCRC Strategy. Designated as the most technologically advanced cancer centre in the world outside North America. In segment 1 (System oversight framework).

Lack of evidence to show progress against the ambition to be leading comprehensive cancer centre

Availability of comprehensive data with which to compare ourselves

6 Updates to Board Time Outs / Board of Directors meetings

4.1

None identified

Cautious Board

6 6 6

6

DCEO 2 3

Year end

Corporate objective 5 - To provide leadership within the local network of cancer care

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Key Control established

Key Gaps in Controls

Assurance

Exec Lead

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

8 Integrated performance report to Management Board and Board of Directors. Reports to Quality Assurance Committee. 8 Progress monitored through integrated performance report to Management Board and Board of Directors. Reports to Quality Assurance Committee.

Expansion of ambulatory care models. Impemetion of the programmes to reduce LOS. Twice daily huddles. Monitor via weekly performance reports and IPQFR. Number of patients sent elsewhere reported through Exec Team weekly. Biosecurity measures regularly reviewed across the organisation. Transformation projects within OP (virtual clinics). Activity monitored daily. Planning submissions sent. Weekly review of theatre and anaesthetic schdules in place. Work continuing to develop relationships with partnering Trusts to progress the use of mutual aid.

Lack of on site capacity for Christie patients resulting in additional pressure on neighbouring organisations

COO 2 4

None identified

Averse Quality

8 8 8

4

5.1

Workforce

Year end

0

5.2 Non delivery of the cancer element of the GM recovery plans

COO 2 4

None identified

None identified

Averse Quality

8 8 8

Year end

Corporate objective 6 - To maintain excellent operational, quality and financial performance

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Exec Lead

Key Control established

Key Gaps in Controls

Assurance

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Executive led monthly divisional performance review meetings. Integrated performance & quality report to Management Board and Board of Directors monthly. Weekl;y performance reporting via trust operational group. Escalation internally & across GM of delays impacting waiting time targets. Monitoring cancer waiting time standards through GM Cancer & IPR. Participating at national level and ICS (Greater Manchester) level to influence the new financial framework and its implementation. Development of mitigating strategies including efficiency and transformational programmes. Identification and consideration of new models of working to deliver and finance the Trust's strategic plan. CWP (clinical web portal) on stable platform. Review of digital programme and to align ditial strategy with Service strategies. Key projects moving forward e.g.Order comms. EPMA, ePROMs, clinical outcomes. Progress and objectives set/reviewed by Quarterly Digital board. Partnership Boards in place. Review of contract arrangemnts for CPP. TCP - Internal and external auditors in place. MIAA governance audit gave significant assurance. KPI's reported via partnerhip board structure. Risk committee regular reporting on cyber security alerts established. Digital Programme progression of key cyber security improvement projects continues. Digital Board reporting. NHS Digital linked monitoring tools being deployed. Internal scanning tools deployed. External summary reports provided. Regular testing and reporting of security vulnerabilities. Staff training mandatory. Cyber incident response support established via NHS Digital. Data Centre co-location business case approved April 2021. Additional time and mitigations identified with detailed project plan working through with all vendors, will continue to be monitored through project board. Hardware ordered with indicative timescales for delivery. Further contingencies identified (with cost) within the project budget.

12 Executive Team monitor activity weekly. Integrated performance report to Management Board, Quality Assurance Committee and Board of Directors. 12 To continue to report through Managment Board and Board of Directors via financial reports and updates. Executive Team monitor activity weekly.

4

6.1 Key performance targets not achieved

COO 4 3

None identified

None identified

Cautious Audit / Quality High 12 12 12

Year end

Changes in national funding arrangements and delegation of commissioning functions.

12

6.2 Change in financial regime resulting in inability to deliver the Trust's strategic plan.

EDoF 3 4

None identified

Cautious

Audit

High 20 20 12

Year end

Internal capability & expertise to support system going forward.

4

4 Reports to Management Board & Board of Directors.

None identified

Cautious

Audit

High 4 4 4

6.3 Digital programme unable to support delivery of operational objectives

COO 1 4

Year end

Not delivering the objectives of our commercial partnerships resulting in negative financial / patient experience or reputational impact

6 Close contact with partners & management of joint incidents. Regular reports to Board and Audit Committee

None identified

Averse Audit / Board High 6 6 6

6

6.4

EDoF 2 3

None identified

Year end

15 Data Security and Protection Toolkit submissions with audits undertaken. Digital board reporting. Board level Senior Information Risk Owner in place.

The Trust does not currently have cyber security insurance.

COO 3 5

15

None identified

Averse

Audit

High 20 20 20

6.5 Reputational damage, service disruption and financial loss due to cyber-attack.

Year end

Networked infrastructure failure due to out of support computer room hardware and capacity limitations.

12 Reports to Digital Maturity Board, Management Board & Board of Directors.

0

COO 3 4

6.6

None identified

None identified

Cautious

Audit

High 12 12 12

Nov-22

21