Public Board of Directors papers 260123

Board of Directors meeting Thursday 26 th January 2023 at 12.45 pm Trust Administration Room 6 Agenda Clinical presentation: Acute Oncology – patient flow & the Christie hotline – Dr Tim Cooksley, Consultant and Liz Perry, Matron - Acute & Critical Care

Public items

Page

01/23 Standard business a Apologies

Chair Chair Chair

b Declarations of interest

* *

c Minutes of previous meeting – 24 th November 2022 d Action plan rolling programme, action log & matters arising 02/23 Board assurance a Quality Assurance Committee report – November 2022

2

CEO 8

*

11

Committee chair

b Board assurance framework 2022/23

*

CEO 14

03/23 Key Reports a Trust report

* *

CEO 19 COO 25

b Integrated performance, quality & finance report

p

c Industrial action

COO/DoW

05/23 Any other business

Chair

Date and time of the next meeting Thursday 30 th March 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

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Public meeting of the Board of Directors Thursday 2 4 th Novem ber at 12.45 pm Trust Admin meeting room 6 & by virtual means

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 Alveena Malik (AM), Non-Executive Director

Tarun Kapur (TK), Non-Executive Director Grenville Page (GP), Non-Executive Director Prof Chris Harrison (CJH), 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 John Wareing, Director of Strategy

Minutes: Louise Westcott, Company Secretary In attendance: Jo D’Arcy, Assistant Company Secretary

Anne Cairns, Regional Access Manager- Janssen Clinical presentation Public Involvement Process to Enhance Diversity in Technology Clinical Trials, Donna Graham, Consultant & Leanna Goodwin, Research Practitioner LG Introduced herself as part of the Digital Experimental Cancer Medicine Team (ECMT) There are a number of groups who are underserved by clinical research. In the UK there are no legal requirements to represent the underserved populations in research trials. The patient, practical, community and research barriers were outlined. Training, communication and other ways of improving inclusivity were outlined. LG described the process of finding out the barriers to research covering things like bringing research closer to home, flexibility of study design, training of research staff and digital technology to enable remote access. The Digital ECMT conducts technology clinical trials. This covers medical devices, software and AI, study designs are the same as with drug trials. They were looking to change the role of the patient and to bring clinical benefits to all patients. A key aspect of the ECMT strategy is to make the patient a co-worker in trials. The team are looking to include all patients in this. They partnered with a company called VOCAL. Workshops were put in place. Mapping of the technology for the clinical trials process identified ways to improve inclusivity. Looked at developing improvements in the design, development and delivery of the trials by breaking down each element and getting feedback. The insights gained from this project led to the development of principles to govern future trials. 5 stages were identified around taking action to identify inequalities, being informed by data, involving people from diverse backgrounds, removing barriers and documenting & sharing learning. An interactive checklist was developed for use in future Technology Clinical Trials.

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LG summarised that the project enabled reflection on trial design from different perspectives. The workshop discussions identified immediate changes to trial design and management processes that will be adopted. The work highlighted the value of collaborating with others to both question practice and identify solutions. The outputs from the project will make processes and practice more inclusive in future technology clinical trials, and will contribute to the wider discussion of addressing the digital divide in clinical research. Next steps were outlined including publication of an online case study with NIHR to share across their platform and a manuscript is being drafted for submission to the Journal of Oncology Practice. CO asked what the changes were from the initial stages. LG noted that the initial involvement with sponsors changed. Grant applications and having an accessibility fund attached for people who may need that money. FB noted the major shift in thinking that this represents in how we engage patients in research. The learning is applicable to all research and will become embedded in all our research work. It was noted that the team recently won the GM Cancer Inclusivity award. JM asked if there were any surprises and if the engaged groups became empowered to want to do things you don’t want to do and how this was managed. LG noted that the surprises were the obvious things that hadn’t been thought of before. The team were challenged and pushed and it resulted in things being adapted in the constraints of clinical research. AM noted the genuine commitment to inclusion. She asked about nudge techniques and incentivisation. LG responded that as part of the funding process it became clear we don’t think about incentivisation, working with VOCAL outlined the different aspects of incentivising people for their time and the practicalities. The group worked with were not aware of nudge this will be considered. CH asked about the project outputs and to what extent the results of these patients applies to a more general population and not just GM/NW. DG noted that the patient group were carefully chosen with VOCAL so should be general enough to be applied to other cultural contexts. The checklist can be adapted to be applicable. CO noted that this is very timely for the Board in terms of the focus on research and inclusivity generally. KR asked about barriers and if they were different for different groups. LG noted that there was a mix, some communities had very specific barriers that weren’t in other communities. KR asked if things have changed already. LG noted that the change is incremental and some elements have already been changed. DG noted the importance of having research practitioners to take this work forward. CO thanked them for attending. Acknowledged MAHSC & Health Innovation Manchester. CO thanked LG for the presentation and invited questions.

Item

Action

37/22 Standard business a Apologies

Prof Kieran Walshe (KW), Non-Executive Director b Declarations of Interest No declarations of interest noted. c Minutes of the previous meeting – 27 th October 2022 The minutes were accepted as a correct record.

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d Action plan rolling programme, action log & matters arising All items from the rolling programme are noted on the agenda. 38/22 Board Assurance

CO noted that we have more business getting further scrutiny in the assurance committees to cover all risks and feed back to the Board. This is still being refined. The assurance committee reports will be further developed to give a bit more detail of items that have received assurance. a Audit Committee report – October 2022 GP outlined the report from Audit. The finance environment and management of this risk received high assurance. In relation to the partnerships risk – The Christie Pharmacy report received high assurance in terms of the developments and restructuring. Data security & protection / cyber risk – high assurance was given. It was noted that for 2023/24 there are going to be more challenging targets and clear action plans are in place to meet the challenges. Risk on sustainable development – medium assurance given, a lot of work is being undertaken but there is a recognition of the huge challenges this represents and we are only a small part of a much bigger picture. RA noted that there are difficulties with staff recruitment in pharmacy and this is getting worse and is getting more attention. Consideration is being given to the use of agency. b Workforce Assurance Committee report – November 2022 TK noted that high assurance is given when we are doing all the right things even if we are still concerned about the risk. Escalation to the Board is different from us just telling the Board about what’s been considered. TK noted that the EDI issues should be reported in more detail to Board at a future meeting. SP noted the importance of being consistent in the application of assurance. LW to include definitions of low, medium and high assurance definitions in future assurance committee papers. JM asked for some more information on our definitions of who our administration staff are as we are an outlier compared to other organisations. This is often cited as a political issue in terms of reduction of this group. RS noted that other organisations have about ¾ nursing staff, we have about ½. We have higher levels of scientific/technical staff and administration staff that is a general profile that contains lots of different kinds of staff. The Workforce Committee could look at this in more detail to understand who sits in these definitions. We do have a different profile to other Trusts. EL noted that most of the research staff fit into the admin & clerical group. RS noted that the ESR system is a national system and nurses are defined in a specific way and HCAs who provide nursing are not counted in this group. b Board assurance framework 2022/23 RS noted the latest version of the BAF reflects the assurance levels given. This will be updated as we continue to review risks through the assurance committees. Level of risk and application of assurance received needs constant review and reflection.

LW

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CH noted that risk 8.2 – net carbon zero, this has now been reviewed by the Audit Committee. This risk refers to our in-year achievement of the objectives in our plan. 39/22 Key Reports a Trust report RS noted the reference to our top operational risks in the report. The report describes details of our performance. Financial performance is on plan for break even. The ICB have escalated a deteriorating financial problem for the system, this will be further discussed. Operational performance remains strong, we still have some late referrals for 62 days. RS highlighted the notification from the Covid-19 public enquiry who have contacted every Trust to tell us that they will send us a questionnaire as part of the enquiry. Sustainability – we have won a National NT award for best social responsibility for our green crusade led by the sustainability team and Angela Hayes. The work has been done with community partners to progress our sustainability plans. RS noted the item about feedback on the MCRC review, this was from international partners and the feedback was excellent, particularly about organisational arrangements and some specific research areas (Radiotherapy / Lung etc). CO noted that we had our CQC Inspection last week and thanked everyone for their input into the process and for the tremendous amount of work undertaken. The inspection process has not yet concluded. GP asked about the industrial action and how robust our planning has been. CO noted that there is an item to follow that covers this in more detail. b Integrated performance, quality & finance report BD outlined the September performance. There have been no SI incidents, never events or major incidents. 11 moderate incidents that are going through review and 12 falls that is higher than normal. These are being reviewed in detail. There were 2 cases of C.difficile with no lapses in care, 5 cases of E-Coli post 48 hours and 15 Covid nosocomial infections. We had 13 new complaints in month with 37 PALS contacts received, LOS at 6.34 and 4 cancelled operations, 2 relating to radiology. 62 days improved compared to the previous month, we are still getting a lot of late referrals. 5 corporate risks at 15+; 1 at 16 and 4 at 15. In terms of things to note for access, 24-day performance is key and this was 85.5%. 31-day performance at 96.5% which is the area for the majority of Activity is overall on plan, surgical operations are above plan and day cases slightly behind. New attendances are slightly behind – validation is taking place as chemotherapy /radiotherapy first treatments are on plan. PDR compliance has dropped slightly to 81.8%, the clinical divisions are the main focus. Essential training overall is at 85.9%, additional sessions are being patients. There are 40 104+ day patients. Referrals are within the predicted range.

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put on to address this and sickness is at 3.64%. The number of staff coming into post has increased compared to our vacancies. Finance;  £58k surplus compared to a breakeven plan/£1k surplus in month  I&E deficit £10.4m  Cash balance £161,426k  Capital expenditure at 13.9% below NHSI plan  CIP - a further £7k savings identified in month and £194k transacted. Focus groups arranged in December to progress with this. RA asked about CIP and whether we anticipate on achieving our target. SP noted that we will rely on non-recurrent savings to hit this. The target was very challenging, we are doing better than many but there is more to do and we will be focusing more on this. CO asked about the cancelled operations on the day. BD noted that this includes procedures done in the IPU. We have had some cancelled because of critical care beds, we have an escalation plan and we monitor this closely. JM asked about the PDR’s and any risk associated with not undertaking them. EL noted that this is about staff not having a wellbeing conversation as well as a conversation about development. FB added that the once a year PDR is not the only time the well being conversation happens. There can also be issues with managers not being around and we need to be more flexible about who undertakes the PDR. GP asked if we are confident that we’re providing the toolkit and skills for managers to have these conversations. Is there a need for training and development. EL noted that the feedback is not about having the conversations but about having the time to actually sit and have a chat. We are looking at how we support and develop our staff. RF commented that there is a different approach being trialled within the school of oncology around talent conversations – early data is very promising. Noted c Industrial action / winter planning preparedness EL outlined the current position with balloting and the potential for industrial action. RCN – over 50% turnout and 95% in favour of strike action. We are one of 4 organisations in GM who will strike. We have asked the RCN for more information, this is anticipated today. UNISON ballot closes tomorrow, we have heard that we will hear the outcome on 30 th November. Both UNITE and CSP are out to ballot. The key controls were outlined. We are engaging with the trade unions, there is a 14 day notice of strike action, we are looking at derogations (exemptions). We are linking with the ICB and NHSE and reporting appropriately. We have developed guidance for managers and FAQ’s for staff. A full risk assessment and business continuity plan is in development as we get more information. EL outlined the derogations. Some of the work of The Christie fits in to the definition of a derogation. We wouldn’t expect we will be fully exempted but are

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discussing this with the unions. Models of derogation were outlined. Once we receive the outcome of the ballot, the earliest they can strike is 14 days later. BD outlined the current planning. We have business continuity and escalation plans. This covers redeployment / safe staffing levels / restriction on annual leave etc We will have an incident control room approach and daily reporting. The priority is to maintain clinical service. Clinical prioritisation and risk assessments will be undertaken. The last resort is to cancel clinical activities. The key is to communicate with our patients and to support staff. We will have on site management of the picket line and we will co-ordinate internal communications so that everyone knows what we are doing. JY noted that we need to be mindful of looking after all of our staff. EL noted that some staff are in other sites and we also need to factor them into the plans. KR asked about agency staff. BD noted that if they are in a union they could strike. EL noted that those who are not in a union can also go out to strike. RS noted that we have over 1000 staff in RCN / UNISON with about a 50 / 50

split. There are a lot of HCAs in UNISON. Junior doctors will be balloted in January. It is the first time the RCN have balloted to strike. Noted

40/22 Any other business No items raised.

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

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

Agenda item 01/23d

Month

From Agenda No

Issue

Responsible Director

Action

To Agenda no

Annual reporting cycle Integrated performance report

COO

Monthly report

03/23b 03/23c

January 2023

Update on Industrial action

DoW/COO

Update

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

5 year strategy 2023-29

Approve

March 2023

Digital Update Workforce update

EMD/Dep CEO Update

DoW

Quarterly review Annual Review

Annual reporting cycle Risk Management strategy 2021-24

CN&EDoQ

Responsible Officer report

EMD

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

Undertake survey Quarterly update

Freedom to speak up Guardian report

FTSUG

Annual reporting cycle Integrated performance & quality report and finance report

COO

Monthly report

Provider licence

Self certification declarations

EDoF&BD

To approve the declarations

May 2023

Annual reporting cycle Annual compliance with the CQC requirements

ECN ECN

Declaration / approval

Annual sustainability report

Update

Annual reporting cycle Annual reports from audit & quality assurance committees

Committee chairs

Assurance

8

Month

From Agenda No

Issue

Responsible Director

Action

To Agenda no

Annual reporting cycle Integrated performance & quality report and finance report

COO CCIO

Monthly report Progress 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

Report

COO

Monthly report Annual report

Freedom to speak up guardian

FTSUG

November 2023

Annual reporting cycle Integrated performance & quality report and finance report

COO

Monthly report

39/22b

December 2023 - no meeting

Integrated performance & quality report and finance report

COO

Monthly report

By email

9

Agenda item: 01/23d

Action log following the Board of Directors meetings held on Thursday 24 th November 2022

No. Agenda

Action

By who

Progress

Board review

Include definitions of assurance levels (low, medium, high) in assurance committee papers

1 38/22b

LW

N/A

Complete

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Agenda Item 02/23a

Meeting of the Board of Directors Thursday 26 th January 2023

Quality Assurance Committee report – November 2022

Subject / Title

Author(s)

Louise Westcott, Company Secretary

Presented by

Committee chair

This paper provides the board with a summary of the assurance items considered by the Quality 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

th November

Quality Assurance Committee papers 17

Background papers

2022

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

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.

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Agenda item 02/23a

Meeting of the Board of Directors Thursday 26 th January 2023 Quality Assurance Committee report – November 2022

1 Introduction The Quality Assurance Committee took place on 17 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 Quality Assurance Committee for assurance in November: Agenda item BAF reference Assurance rating given Associated action (where applicable) and/or comments to note Infection

Concise update provided on the changes since the last version of the IPC BAF provided to the Committee. No actions from Committee review. Key points noted: • 94% of incidents were reported within 48 hours of knowledge of the incident. • Targets met in terms of patient falls and pressure ulcers. • incidents reported to StEIS in quarter. Actions: • Analysis to be provided on reasoning for increase in incidents over the last 18 months and whether the increase is proportionate to the increase in activity. • Lost to follow up update to come back to the Committee at a future meeting. Key points noted: • Needle sticks accidents and falls remain the highest in terms of staff accidents. • No HSA reported accidents in the last quarter. • Addressing low compliance for moving and handling training. • Supplier for the provision of waste management – going out to market. No actions from Committee review.

prevention & control board assurance framework (IPC BAF) Patient Safety and Experience Quarterly Report (July – Sept 2022)

1.1

High

1.2 & 1.3

High

Health and Safety Quarterly Reports

7.3

High

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Key points noted: • 42% increase in the number compared to the previous financial year; consistent with other Trusts. • 1 complaint was referred to the Parliamentary and Health Service Ombudsman (PHSO) in year providing assurance that the Trust is dealing well with complaints. • Team now have the extra resource to support dealing with complaints. • 11 claims were opened in-year, 10 clinical negligence and 1 employer’s liability. 12 claims were closed 12 in the period with 7 claims settled and 5 claims successfully defended. • 2 high value claims settled in-year, which had been on-going for several years. Each claim was valued in excess of £1million. • GIRFT data reviewed and gained assurance of no concern with Trust procedures. Comments to be fed back to the national team. No actions from Committee review. Key points noted: • 62-day compliance relates to 23.3% of overall referrals to the Trust. • 24-day compliance seen a steady improvement from Aug - Oct. • Consistently achieved all 31-day standards. • 104 days is monitored weekly as this can lead to more complex patients. • There has been an improvement with the radiotherapy booking forms, this was not a capacity issue, identified as a process issue. No actions from Committee review.

Learning from Complaints & Claims

1.2

High

Cancer waiting times

6.1

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 Quality Assurance Committee in November 2022.

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Agenda Item 02/23b

Meeting of the Board of Directors Thursday 26 th January 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.

14

Agenda Item 02/23b

Meeting of the Board of Directors Thursday 26 th January 2022 Board Assurance Framework 2022/23

1

Introduction The Board Assurance Framework (BAF) 2022/23 was presented to the Board of Directors and the Workforce Assurance Committees 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. Updates have been made to the assurance and key controls columns for some of the risks. Where one of the assurance committees has reviewed a risk, the level of assurance they have assigned has been added into the assurance level column. The position at the end of quarter 3 has been added for all risks. Risk 7.2: Risk of negative impact on delivery of services and staff engagement levels due to Trust wide staffing gaps in some occupations and ability to recruit and retain – the risk score has been reduced from 15 (5/3) to 12 (4/3) in line with the corporate risk. Risk 7.5: Risk of non-compliance with essential training needs – the key gap in control relating to the impact of social distancing has been removed. 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

15

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.

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

None identified. No formal threshold set by commissioners.

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

6

1.1

ECN 2 3

None identified

Averse Quality High 6 6 6 6

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.

4

1.2

ECN 2 3

None identified

None identified

Averse Quality High 6 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 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

1.4

COO 3 4

None identified

Cautious Quality High 12 12 12 12

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

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 8

consideration of any impact from COVID-19 pandemic

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.

None identified

Cautious Board High 10 10 10 10

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

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

8

3.1

EMD 3 2

None identified

Cautious Workforce

8 8 6 6

Year end

16

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

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

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

6

4.1

DCEO 2 3

None identified

Cautious Board

6 6 6 6

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

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

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.

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.

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

5.1

COO 2 4

Workforce

None identified

Averse Quality

8 8 8 8

4

Year end

0

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

None identified

None identified

Averse Quality

8 8 8 8

COO 2 4

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 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.

None identified

Cautious Audit

High 20 20 12 12

EDoF 3 4

Year end

Internal capability & expertise to support system going forward.

4 Reports to Management Board & Board of Directors.

4

6.3 Digital programme unable to support delivery of operational objectives

None identified

Cautious Audit

High 4 4 4 4

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

6

6.4

EDoF 2 3

None identified

None identified

Averse Audit / Board High 6 6 6 6

Year end

The Trust does not currently have cyber security insurance.

15

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

None identified

Averse

Audit

High 20 20 20

COO 3 5

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

6.6

COO 3 4

None identified

None identified

Cautious Audit

High 12 12 12

Year-end

17

Corporate objective 7 - To be an excellent place to work and attract the best staff

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 9 Monthly sickness levels as reported in Integrated performance and quality report. Return to work audits presented to workforce committee.

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

3

7.1 Target reductions in sickness levels not achieved DoW / COO 3 3 Adherence with sickness management policy. Sickness levels monitored & reported through Service and Operational meetings

None identified

Cautious Workforce

9 9 9

None identified

Year end

R&R Trust wide group in operation reporting to the workforce committee. Commenced programme of work with an external organisation to develop our recruitment offer, advertising and brand.Commenced a programme of recruiting international nurses of a 6 month period. Quarterly oversight of Trust wide vacancies and recruitment activity presented to the workforce committee. Divisional oversight of recruitment activity and vacancies discussed at the monthly service review meetings. Turnover analysis and exit interview data presented and discussed six monthly at the workforce committee.PDR comliance Divisional and Trust wide action planning of staff survey results to be monitored at monthly service reviews and Workforce Committee. Development of a wellbeing dashboard to be presented to workforce committee triangulating Employee Relations activity, absence, turnover and other related data. Refresh of the Christie People Plan focus of priorities based on the organisation needs/staff survey responses. Extension of two staff health & wellbeing advisor posts to support workforce wellbeing. Facilitating Trust internal management structures to deliver improved engagement. Implementation of the Christie People Plan priorities for example Respect Campaign, cultures and values programme of work, management development programmes and creation of supportive toolkits. Delivery of training through virtual and e-platforms. Performance will be monitored through the service and operational review process. Escalations of potential non-compliance through meeting structures (Trust Operational Group, risk/operation performance reviews/Management Board etc). A review of the effectiveness of essential training has been commissioned by HEE, a number of recommendations have been made which will be implemented and monitored through the workforce committee. Staff networks established, Board development sessions planned across the year focussing on discrimination. EDI programme board monitors delivery of the EDI plan and escalation of risks. Monitoring of WRES / WDES data in Workforce Committee

Risk of negative impact on delivery of services and staff engagement levels due to Trustwide staffing gaps in some occupations and ability to recruit and retain

12 National staff survey 2021 results. Reports to Management Board . Agency spend. Workforce Committee Oversight

National staff shortages impacting recruitment

15

7.2

DoW 4 3

None identified

Averse Workforce High 15 15 15

Year end

9 Regular reporting to Management Board and Board of Directors through the integrated performance report.

6

7.3 Poor workforce engagement impacting on delivery of services.

None identified

None identified

Averse Workforce High 12 12 12

DoW 3 3

Year end

10 Regular reporting to Management Board and Board of Dircetors through the Workforce report and associated executive reports.

Failure to deliver organisational development plans to create a sustainable evolving organisational culture that is adaptive to change

DOW / EMD

5

7.4

None identified

None identified

Averse Workforce High 10 10 10

/ COO 2 5

Year end

9 Discussion at Divisional operational & performance reviews and Management Board. Reports to Board through integrated performance report

6

7.5 Risk of non compliance with essential training needs

None identified

None identified

Cautious Workforce

9 9 9

DoW 3 3

Year end

9 Reports to Workforce Committee, Management Board and Board. Staff story at each Workforce Assurance Committee.

9

7.6 Race/Disability discrimination impacting staff experience and therefore patient care

None identified

None identified

Averse Workforce High 9 9 9

DoW 3 3

Year end

Corporate objective 8 - To play our part in improving the local healthcare economy, community & environment

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

Close working with Manchester City Council (MCC) planning and development issues as well as implementation of the Trust's green travel plan. Strategic planning framework approved which includes current and future requirements for travel to site. Regular communication with residents through the Neighbourhood Forum and newsletters and with local councillors. Agreement by MCC of strategic development plan and delivery of the Trust's 5 year Capital Plan delivery Progress against SDMT plan regularly reported to Sustainability Committee and to Management Board as part of Integrated Performance Report. Progress against objectives overseen and reviewed by DCEO as Trust Net Zero lead. Board training on net zero Carbon arranged for November 2022

6 Monitored through Management Board & Board of Directors. Capital programme shared with MCC and Board of Directors.

3

8.1 Impact on our ability to obtain planning approval for future capital developments.

EDoF 2 3

None identified

None identified

Cautious Board

6 6 6

Year end

Failure to progress towards achievement of the NHS net zero Carbon targets through failure to achieve the annual milestones for The Christie set out in the Sustainable Development Management Plan Reduced ability to provide services and support to patients due to national / global influences (supplies / fuel costs etc)

8 Progress against SDMT plan regularly reported to Board of Directors as part of Integrated Performance Report. Annual Report to Board of Directors. Oversight by Quality Assurance Committee

High (in context of challengin g targets)

8.2

DCEO 4 2

_ _ 8

None identified

None identified

Cautious Audit

Year end

8 Reports to Audit Committee

8

8.3

DCEO 2 4 Group in place to review supply chain

Global position

None identified

Cautious Audit

8 8 8

Year end

18