Public Board of Directors papers 27-10-22

Board of Directors meeting Thursday 27 th October 2022 at 12.45 pm Seminar Room, Christie at Macclesfield Agenda

Clinical presentation: Patient safety strategy

Public items

Page

33/22 Standard business a Apologies

Chair Chair Chair

b Declarations of interest

* *

c Minutes of previous meeting – 29 th September 2022 d Action plan rolling programme, action log & matters arising

2

CEO 7

34/22 Board assurance

Committee chair CEO

a Quality Assurance Committee report – September 2022

*

10 12 17

b Board assurance framework 2022/23 c Progress with annual objectives 2022/23

*

CEO

35/22 Key Reports a Trust report

* * * *

CEO 25 COO 33 FTSUG 69 EMD 83

b Integrated performance, quality & finance report c Freedom to Speak Up annual report

d Trust 5-year Strategy refresh

36/22 Any other business

Chair

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

CEO COO FTSUG EMD

Chief Executive Officer Chief Operating Officer Freedom to Speak Up Guardian Executive Medical Director

* paper attached v verbal p presentation

1

Public meeting of the Board of Directors Thursday 29 th September at 12.45 pm Trust meeting room 6 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 Fiona Blackhall (FB), Director of Research 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 Dr Neil Bayman (NB), Executive Medical Director Sally Parkinson (SP), Interim Director of Finance Prof Richard Fuller (RF), Director of Education

Minutes: Louise Westcott (LW), Company Secretary In attendance: Alistair Reid-Pearson (ARP), Chief Information Officer

Jo D’Arcy, Assistant Company Secretary Scott Davies, Public Governor Salford Ruth Dixon, CQC Inspection Manager Karen Stephenson, CQC Inspection Manager Colin Bamford, Public Governor, Trafford

Item

Action

29/22 Standard business a Apologies

CO explained that we have no clinical presentation to start this public meeting today. The Board are attending the patient experience day of the Peritoneal Tumour Service who are celebrating 20 years of the service. RS described the excellent patient involvement this service has, and their day happens to coincide with the Board meeting. The Board will hear from one of the patients about their story and experience as a patient in that service. CO described the change to the running order for the meeting to bring the feedback from the assurance committees further up the agenda. This is part of the overall refresh of the assurance processes for the Board. The new look Trust Report is also included for the first time, and this will develop as we progress with the updated format. b Declarations of Interest No declarations of interest noted. c Minutes of the previous meeting – 30 th June 2022 The minutes were accepted as a correct record.

2

d Action plan rolling programme, action log & matters arising All items from the rolling programme are noted on the agenda. 30/22 Board Assurance a Quality Assurance Committee report – June 2022

KW outlined the report and the levels of assurance assigned to the matters relating to BAF risks. IP&C delivered their report as did digital. No escalations were recommended to the Board. b Workforce Assurance Committee report – July 2022 TK noted that it was a very successful first meeting. There was an excellent presentation on diversity to start the meeting. No items were recommended for escalation to Board. It was made clear that this is an opportunity for spotting issues and celebrating staff. It was a very positive meeting. The focus on EDI was stressed as a priority. TK added that the communication to staff around the work that’s going on, how it is feedback to Board and the importance the Board place on this work is key. CH noted that the medical staff issues will be covered in this committee as well as other staff groups. It was noted that this committee takes some of the work previously done through the Quality Assurance & Audit Committees. JY added that she sits across all 3 committees so can support them in ensuring we are not duplicating or missing anything. GP added that the regular meetings of the chairs and exec leads also considers this. c Audit Committee report – July 2022 GP noted the comprehensive agenda and internal audit tracker report that allows the committee to focus on closing off actions from audits carried out. The meeting focused on 2 risks, the financial risk & the risk around our partnerships and high assurance was received for both. There were no escalations to note. A Digital update was also received that addressed outstanding issues. CO noted that we have clarified how the digital agenda is covered by Board and assurance committees. d Board assurance framework RS outlined the updated version of the framework and noted the updates that have been made. No significant changes have been identified because of the assurance committees this month. GP noted that the risk relating to the carbon zero risk has not yet been scored. This will be done at the next quality assurance committee.

31/22 Key Reports a Trust report

RS noted the executive summary of the report. Since the report was written we have received notification from the CQC that we are an outlier in the 2021/22 CQC Inpatient Survey in the ‘much better than

3

expected’ category. This will be published today. The detail will be discussed in the Quality Assurance Committee. The Board noted this excellent news. RS reminded the Board that the system in under significant operational pressure, we are providing mutual aid to support time critical cancer surgery. The situation across the system is getting very difficult. We have been notified that approximately 1000 staff have been balloted for industrial action, specifically those who are members of the RCN and RCR. The action is planned for the end October/beginning November. CO extended congratulations and thanks to our staff on the fantastic inpatient survey news. CO also asked for feedback on the new format of the report. b Integrated performance, quality & finance report BD outlined the August performance. There have been no serious incidents or never events in month. No major and 7 moderate incidents. In terms of infection control there were 7 cases of C Difficile in month, with no lapses in care. 4 cases of E-Coli post 48 hours and no covid nosocomial infections. There are 5 corporate risks over 15, 2 risks at 20 and 2 risks at 15. There were 16 new complaints in August, 48 PALS contacts and average length of stay was 6.72 days. There were 11 cancelled operations on the day. BD noted the high level of cancelled operations in August. 1 related to equipment breakdown and 10 related to critical care capacity. There was an unusual level of surgical patients requiring level 3 care at this time. All patients have been re-dated. This period is being reviewed through the RCA route to look at learning. JM asked if these patients are coming through the Hotline. BD noted that this is the case and we are looking at this process. JY noted that the AAU are managing the hotline patients and assessing these patients and dealing with them and discharging them where they can and following them up over the phone etc. This is reducing the pressure on admissions. This is being extended over the weekend. AM asked about the preparations with staff for winter / further waves of covid. JY noted that they are being supported and prepared and activity is managed daily. RA asked about patient safety incidents and the increase in numbers. BD noted that we have changed the way we report and have also added in covid 18 Weeks 97.7%, 62 day performance 71.3%, 24 day performance 79.6%, 31 day performance 98.2%. We had 48 ‘104 day’ waiters and referrals were within the predicted range. BD noted that the July 62 day performance was good, and this dipped in August as we had 3 full breaches as well as OPD activity. We continue to manage this daily with the teams. Activity was outlined. Outpatient activities are slightly behind plan in month. Non elective and surgical activity is above plan. nosocomial infections that account for the increase. In terms of our waiting times for August we achieved;

FB joined the meeting.

4

HR metrics were outlined. 85.5% personal development review (PDR) performance – this is a focus, SOO are looking at how these are undertaken and this may be helpful going forward. August showed a slight increase in sickness levels at 4.43% - this includes Covid related absence. We are carrying a significant number of vacancies, but we are beginning to see improvements in nursing and pharmacy recruitment. Financial position was outlined.  £57k surplus compared to a breakeven plan/£48k deficit in month  I&E deficit £7.4m  Cash balance £173,646k  Capital expenditure at 6.8% above NHSI plan (reflects Paterson and Linac at Oldham)  CIP - a further £614k of recurrent savings identified in month (total of £3.2m / 44% against the recurrent plan of 7.3m) GP asked about recruitment. BD noted that we are maintaining our standards in recruitment and are using all our capabilities to support this. EL also noted that we are looking at what we can do to support our staff in terms of cost of living – e.g. reassessing mileage/travel rates, looking at the real living wage etc. We are also widening our focus to attract more people from a wider pool. RA asked if there are areas with real problems. EL noted that the issues are across the board. c EPR update ARP presented on the electronic patient record (EPR), the current position and future strategy. 3 years ago the decision was taken to continue the development of our EPR system (CWP). To do this, we have developed a software engineering team alongside an external partner, implemented a governance process around EPR and re-coded CWP into a modern platform. We use Open EHR that is an open storage standard that defines how the clinical data is structured. This enables separation of the data layer and the application layer. ARP outlined the current set up of our data and how it is structured now and also where we want to get to in our data strategy. There will be one way in to the various elements of the system. Feedback has been sought from clinicians to ensure that the strategy for digital works for the staff and patients. CB joined the meeting. ARP explained that we are not looking to buy an EPR as any new benefits for clinical staff would not be seen until the new system was implemented and there would be significant programme capacity for 2 to 3 years. It would increase our revenue costs as well as impacting on research data availability. The additional flexibility Open EHR allows was described. ARP noted that we understand where our issues are from a digital perspective and outlined the self-assessment we have undertaken. This is the ‘Frontline digitisation – core capabilities’ assessment and is a national standard. ARP showed a graph outlining our assessment against the elements of this. Design principles have been set and the elements of the strategy that relate to CWP was shared as well as the governance and monitoring of this.

5

CO thanked ARP. KW thanked ARP and asked what the supplier benefits are for Open EHR. ARP noted that we are helping suppliers maintain their market share by going down this route. Others are also doing this – Leeds and NHS Wales. JM asked what the main worries are. ARP noted that cyber and recruitment are the 2 main worries but this is shared across all NHS organisations. AM asked about recruitment and skilling up staff. ARP noted that we are creating pathways for our staff and taking on staff straight from higher education. 32/22 Any other business No items raised. Date and time of the next meeting Thursday 27 th October 2022 at 12:45pm

6

Agenda item 33/22d

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

Month

From Agenda No

Issue

Responsible Director

Action

To Agenda no

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

DCEO

Interim review & update

34/22c

October 2022

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

DCEO COO FTSUG

Report

35/22e 35/22b 35/22d

Monthly report Annual report

Freedom to speak up guardian

Annual reporting cycle Integrated performance & quality report and finance report

COO

Monthly report

November 2022

December 2022 - no meeting

Integrated performance & quality report and finance report

COO

Monthly report

By email

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

COO

Monthly report Annual Review

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

7

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

8

Agenda item: 33/22d

Action log following the Board of Directors meetings held on Thursday 29 th September 2022

No. Agenda

Action

By who

Progress

Board review

No actions arising from the meeting

9

Agenda Item 34/22a

Meeting of the Board of Directors Thursday 27 th October 2022

Quality Assurance Committee report – September 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 September meeting and any subsequent actions required by the Board.

Summary / purpose of paper

Recommendation(s)

To note the report and any actions

nd September

Quality Assurance Committee papers 22

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.

10

Agenda item 34/22a

Meeting of the Board of Directors Thursday 27 th October 2022 Quality Assurance Committee report – September 2022

1 Introduction The Quality Assurance Committee took place on 22 nd September 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 September: Agenda item BAF reference Assurance rating given Associated action (where applicable) and/or comments to note Research & Innovation Good regular attendance at R&I Divisional Boards. Current staffing level and vacancies have an impact on CRF capacity.

Governance Six Monthly Report

2.1

Medium

Action: Assurance on PPIE comparisons against other organisations to be provided at next meeting. Challenges around complaint response timescales discussed and staffing recruited to help, response times are now improving. Friends and Family Test results 95-96% positive. 12 months to complete Patient Safety Incident Framework (PSIF). Proactive action and good learning noted. Self-assessment in progress and to be submitted by 28 th October deadline. Assurance level will be assessed at November meeting.

Patient Safety and Experience Quarterly Report (April – June 2022) Serious Incident Panels Report Q1 NHSE’s Emergency Preparedness, Resilience & Response

1.2 & 1.3

High

1.2 & 1.3

High

N/A

N/A

Framework Compliance Review

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 September 2022.

11

Agenda Item 34/22b

Meeting of the Board of Directors Thursday 27 th October 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.

12

Agenda Item 34/22b

Meeting of the Board of Directors Thursday 27 th October 2022 Board Assurance Framework 2022/23

1 Introduction The Board Assurance Framework (BAF) 2022/23 was presented to the Board of Directors and Quality Assurance Committee in September and Audit Committee in October. Further review of the BAF has taken place by the Executive team and Company Secretary since the meetings. 2 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. A risk score has been added to risk 8.2 ‘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’ of 8 (4/2). This was further considered by the Audit committee in October. 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. 3 4

13

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. Introduction of the TAB system. 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

14

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 . Baseline measures identified and presented to Board of Directors. Discussion at time out in March 2017. 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. Digital Maturity board meeting monthly (includes cyber security). 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. Treview of digital programme and to align ditial strategy with Service strategies. Key projects moving forward e.g.Order comms. EPMA, ePROMs, clinical outcomes. 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.

6.1 Key performance targets not achieved

COO 4 3

4

None identified

None identified

Cautious Audit / Quality High 12 12 12

Year end

12 To continue to report through Managment Board and Board of Directors via financial reports and updates. Executive Team monitor activity weekly.

Changes in national funding arrangements and delegation of commissioning functions.

12

None identified

Cautious Audit

High 20 20 12

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

EDoF 3 4

Year end

Internal capability & expertise to support system going forward.

4

4 Reports to Management Board & Board of Directors.

6.3 Digital programme unable to support delivery of operational objectives

COO 1 4

None identified

Cautious Audit

High 4 4 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

20 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 4 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

15

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

Key Control established

Assurance

Exec Lead

Key Gaps in Controls

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

None identified

9 9 9

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. Face to face training managed in line with social distancing. Performance will be monitored through the service and operational review process although this has been impacted throughout the year due to the Covid pandemic. Escalations of potential non-compliance through meeting structures (Trust Operational Group, risk/operation performance reviews/Management Board etc). 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

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

National staff shortages impacting recruitment

DoW 5 3

None identified

Averse Workforce

15

15 15 15

7.2

Year end

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

6

DoW 4 3

None identified

Averse Workforce

7.3 Poor workforce engagement impacting on delivery of services.

None identified

12 12 12

Year end

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

10 Regular reporting to Management Board and Board of Dircetors through the Workforce report and associated executive reports. 9 Discussion at Divisional operational & performance reviews and Management Board. Reports to Board through integrated performance report 9 Reports to Workforce Committee, Management Board and Board. Staff story at each Workforce Assurance Committee.

DOW / EMD /

5

None identified

Averse Workforce

10 10 10

7.4

None identified

COO 2 5

Year end

Impact of social distancing on delivery of training

DoW 3 3

None identified

Cautious Workforce

6

7.5 Risk of non compliance with essential training needs

9 9 9

Year end

9

None identified

Averse Workforce High 9 9 9

DoW 3 3

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

None identified

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

Cautious Board

6 6 6

None identified

Year end

Plan and progress have not been reviewed and risk rated by an Assurance Committee or subjected to formal review by auditors.

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

Cautious Audit

_ _ 8

DCEO 4 2

8.2

None identified

Year end

DCEO 2 4 Group in place to review supply chain

None identified

Cautious Audit

8 8 8

8 Reports to Audit Committee

8

Global position

8.3

Year end

16

Agenda Item 34/22c

Meeting of the Board of Directors Thursday 27 th October 2022

Progress with annual objectives 2022/23

Subject / Title

Louise Westcott, Company Secretary

Author(s)

Chief Executive Officer

Presented by

For the Board of Directors to receive an update on progress against the annual objectives for 2022/23 To approve the corporate objectives and board assurance framework 2022/23 Corporate objectives, board assurance framework 2021/22

Summary / purpose of paper

Recommendation(s)

Background papers

N/A

Risk score

• Trust’s strategic direction • Divisional implementation plans • 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 NHSE NHE England

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.

17

Agenda item 34/22c

Meeting of the Board of Directors Thursday 27 th October 2022

Progress with annual objectives 2022/23

1.

Introduction This paper outlines the progress against the annual objectives for 2022/23 (appendix 1).

2.

Background Our Strategy describes where the Trust wants to be, and the Operational Plan describes how we will work towards this in year. The eight Corporate Objectives, whilst reviewed annually, have remained relatively consistent over the last eight years. We currently have an amended planning process. Corporate objectives 2022/23 The Corporate Objectives are a fundamental element in the development of the annual plan and enabling the executives and divisions to align their proposed programme of activity to the Trust’s ambitions. The eight Corporate Objectives are provided at Appendix 1 and the proposed cascade to the annual executive objectives which will then be fed into Divisional Objectives. Monitoring of the objectives has been through the integrated performance report and reports to board. Assurance is managed through the board assurance framework.

3.

4.

Recommendation The board of directors is asked to note the progress against the annual objectives.

18

Executive Objectives 2022/23 1. To demonstrate excellent and equitable clinical outcomes and patient safety, patient experience and clinical effectiveness for those patients living with and beyond cancer Annual objective Measure Timescale Director Progress 1.1 To ensure delivery of the patient and public experience plans To develop and implement a Trust Patient and Public Engagement Strategy

Associate Chief Nurse for Patient Experience commencing in post Nov 22 to lead project.

31.3.23

ECN

Will align to NHS England 'Patient

Experience Framework'.

1.2 To support the divisions in the delivery of the Quality Strategy

To realise the year 2 goals of the 2022/24 Quality Plan

Proceeding to plan against Quality Plan objectives Risk awareness training live on Christie Learning Zone. Learning from excellence progressing 2 additional standards now included – Care in the last days of life and Care of the patient with Diabetes. Ward 2 first accredited 12/10/22 Clinical Research Facility first accreditation 03/11/22

31.3.23

ECN

1.3 To implement the Trust Risk Management Strategy

To realise the implementation of strategy objectives: i) launch a trust-wide revised risk awareness training programme; ii) implementation of ‘Risk Awareness Week’; implementation of Safety II – Learning from Excellence

31.3.23

ECN

1.4 Ensure all patient care areas provide high quality care and treatment

To implement stretch targets for ward CODE re-accreditation scheme assessments.

31.3.23

ECN

To implement CODE accreditation to ambulatory care, CRF

31.3.23

ECN

19