BOARD OF DIRECTORS Meeting Date: Thursday, 28 January 2010

Transcription

1 Serving the people of North East Essex BOARD OF DIRECTORS Meeting Date: Thursday, 28 January 2010 Agenda Item: 14 (Disclosable) Title: Performance and Risk Assurance Report: Month 9 Purpose: Summary: Chief Executive/Executive Directors to draw attention to key areas under review by Executive Team Finance Monitor Financial Risk Rating 5 (Green). National Standards Monitor Compliance Framework Governance Rating = Red (Amber for the month). CQC Overall Rating - Good o Core Standards Fully Met o Existing Commitments Fully Met o National Priorities Good Clinical Indicators MRSA cases: 7 against a ceiling of 9. C.Diff. 36 hospital cases against a ceiling of 63. Hand Hygiene compliance was 97%. HSMR Relative risk score 89 (August) Workforce Variance between staff in post and target was 6.0%. Percentage of staff sickness 3.8%. Risk Management Risk Register - 3 Extreme Risks and 13 High Risks o 2 Extreme (Red) risks moved from holding to Trust risk register o 1 Extreme (Red) risk upgraded from Moderate (Yellow) o 5 High (Amber) risks moved from holding area to Trust risk register Recommendation: To receive and note the Performance and Risk Assurance Report. Prepared by: Mark Chessum (Assistant Director of Finance) in conjunction with Executive Directors & Director of Infection, Prevention and Control Presented by: Andrew Armour Director of Finance This report covers: (Please tick relevant box) Foundation Trust Compliance Complaints External Standards: NHSLA/HCC Patient Experience Assurance Framework Clinical Quality Strategic Development Financial Implications: YES / NO Annual Plan/Business Planning Legal Implications: POTENTIAL Financial Management Risk Implications: YES / NO Performance Management Other (Please specify)

2 Colchester Hospital University NHS Foundation Trust Performance and Risk Assurance Report December 2009 (Month 9 December 2009) MONTH 09 (December 2009) 1

3 Contents 1. Executive Summary 2. Finance 3. Activity 4. National Standards 5. Patient Safety 6. Workforce 7. Risk Management Appendices A. Trust Summary Performance Indicators MONTH 09 (December 2009) 2

4 1. Executive Summary YTD Rating Full Year Plan YTD Forecast Outturn EBITDA Margin EBITDA; % achieved Finance Return on Assets I&E Surplus Margin Liquidity WEIGHTED AVERAGE OVERALL RATING Monitor Governance Rating for month 1 Amber for the month - remain on Red rating for Governance Core Standards Fully Met CQC Health Care Standards Good Existing Commitments Fully Met National Priorities Good Rating Ceiling Actual MRSA cases 9 7 Infection Control C. Diff Hand Hygiene 95% 97% Workforce Target Actual Vacancies 3.0% 6.00% Sickness Absence 3.5% 3.80% New Total Extreme Risks 2 3 Risk Management High Risks 5 13 High to Extreme 0 MONTH 09 (December 2009) 3

5 2. Finance 2.1 Executive Summary 2.2 Income & Expenditure 2.2a NHS Clinical Income 2.2b Pay 2.2c Non Pay 2.3 Service & Cost Improvement Programme 2.4 Balance Sheet 2.4a Capital Programme 2.4b Cash Flow MONTH 09 (December 2009) 4

6 2.1 Executive Summary CURRENT FINANCIAL PERFORMANCE Year to Date Full Year Actual Actual/ Budget Actual 2008/09 Forecast m m m m FUTURE PROSPECTS 2010/ /12 Forecast Early Forecast 2009/10 m m m Income Expenditure Pay (115.1) (95.3) (96.7) (130.9) Non-pay (66.0) (50.6) (55.1) (75.1) Total Expenditure (181.1) (145.9) (151.8) (206.1) EBITDA Dep'n/PDC etc (11.5) (8.2) (8.1) (11.6) NET SURPLUS/(DEFICIT) Year to date performance o Income ahead of plan, principally due to increased non-elective activity o Non-pay above budget due to increased activity, budgeting issues and CIP underperformance o Current Monitor Financial Risk Rating of 5. Current cash levels c. 27m Full year forecast o Expenditure increases including new wards, recruitment to establishment, and certain one off costs (patient safety/fixed asset impairments) o Savings programme - 4.1m forecast (including 1m non-recurrent) against 5.3m target for year Finance strategic plans and challenges o Review of Trust s ability to provide ECH services at CGH and cost and benefit implications o KPMG currently undertaking non-pay benchmarking review to assist with 10/11 SCIP o Application being prepared for FT Financing Facility to ensure significant liquidity post strategic capex programme Income Expenditure Pay (130.9) (132.6) (132.2) Non-pay (75.1) (64.4) (64.5) Total Expenditure (206.1) (197.0) (196.7) EBITDA 21.3 Dep'n/PDC etc (11.6) (13.4) (16.2) NET SURPLUS/(DEFICIT) Next financial year o Operating Framework 2010/11: 0% uplift 2010/11 with 3.5% efficiency Reduced payment to 30% for non elective activity above 08/09 levels 1.5% ( 2.8m) available through CQUIN schemes but penalties for poor performance/unsafe care (50% achievement assumed) o Principal impact for CHUFT currently assessed: tariff changes ( 4.0m before CQUINS) only part payment of forecast activity increases ( 3.0m) additional service development costs ( 3.3m annual cost) incl. cancer, maternity matters, stroke etc. o CIP now at 3.5% of income an increase from 2% previously planned o Cultural changes to implement service line management (service line reporting in place). Patient level costing to be implemented o Delivery of 10/11 contract with Commissioners o New finance system being put in place for 1st April o Driving through quality improvements to achieve CQUIN of 1.5% in 10/11 MONTH 09 (December 2009) 5

7 2.2 Income & Expenditure 000 This Month Year to Date Full Year Forecast Budget Actual Variance Budget Actual Variance Budget Actual Variance Income NHS Clinical Income 16,745 17, , ,949 6, , ,330 7,236 Non NHS Clinical Income (114) 1,971 1,924 (47) 2,594 2,490 (104) Research & Training ,018 5,653 (365) 7,657 7, Other ,899 6, ,772 8,897 1,125 Total Income 18,185 18, , ,187 6, , ,399 8,282 Expenditure Pay (11,050) (11,220) (170) (95,263) (96,740) (1,477) (128,967) (130,924) (1,957) Drugs (1,424) (1,432) (8) (10,991) (11,337) (346) (14,476) (14,925) (449) Clinical Services (1,668) (2,000) (332) (14,184) (16,203) (2,019) (19,680) (22,021) (2,341) Other Non Pay (2,873) (3,189) (316) (25,424) (27,541) (2,117) (35,892) (38,196) (2,304) Total Expenditure (17,015) (17,841) (826) (145,862) (151,821) (5,959) (199,015) (206,066) (7,051) EBITDA 1,170 1,126 (44) 18,375 19, ,102 21,333 1,231 Profit/(loss) on asset disposals (22) (31) (381) Interest receivable(payable) (6) Depreciation & amortisation (605) (572) 33 (5,308) (5,192) 116 (7,260) (7,023) 237 PDC (409) (409) - (3,677) (3,678) (1) (4,902) (4,905) (3) NET SURPLUS/(DEFICIT) (29) 10,151 11,227 1,076 8,705 9,783 1,078 EBITDA % 6.4% 5.9% 11.2% 11.3% 9.2% 9.4% EBITDA forecast to exceed full year plan by 1.2m.Overall forecast surplus of 9.8m (including income from sale of the bungalow of 0.8m). The forecast includes additional non-recurrent expenditure on patient safety and provision for fixed asset impairments/capital to revenue transfers. Increased activity particularly non-electives continues to increase income, which will increase activity related consumables (drugs/ clinical services). Improvements in coding and richer casemix have improved the chargeable income position. Forecasts assume that the additional temporary staffing and outsourcing seen over the last few months will decline. SCIP is 0.8m behind YTD plan and the forecast outturn assumes the SCIP target of 5.3m will shortfall by 1.2m. MONTH 09 (December 2009) 6

8 2.2a NHS Clinical Income Elective Income Non-Elective Income 4,100 6,500 3,900 6,000 3,700 3,500 3,300 3,100 2,900 2,700 2,500 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual Budget Forecast 5,500 5,000 4,500 4,000 3,500 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual Budget Forecast 4,300 4,100 3,900 3,700 3,500 3,300 3,100 2,900 2,700 2,500 Outpatient Income Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual Budget Forecast Electives are ahead of plan by 0.6m year to date ( 0.4m last month). Underperformance against RDAs in Cancer and Haematology but day cases are ahead of YTD plan. Non electives are ahead of year to date plan by 3.3m ( 2.9m last month) due to higher than planned emergency attendances, principally in specialties such as general medicine, care of the elderly and maternity/gynaecology. Outpatients are 0.9m ahead of plan ( 0.6m last month). The number of outpatient first and follow up attendances is some 14,409 more than plan. Clinical coding and data capture continues to improve across the board increasing chargeable activity MONTH 09 (December 2009) 7

9 2.2b Pay Performance against budget by month 12,000 11,000 10,000 9,000 8,000 7,000 6,000 5,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Budget Actual Forecast Pay summary ( '000) Year to date Forecast Budget Actual Variance Budget Actual Variance Consultants 15,097 15,142 (45) 20,314 20,512 (198) Junior Doctors 12,374 13,131 (757) 16,658 17,556 (898) Nursing, Midwifery & HV 36,758 36, ,870 49, Dental S, T & T 16,468 16, ,133 22, Other Clinical Staff Non Clinical Staff 13,944 14,925 (981) 19,159 20,313 (1,154) Total 95,263 96,740 (1,477) 128, ,924 (1,957) The year to date overspend includes: the cost of using of additional locum consultants and junior doctors additional sessions to meet the 18 weeks RTT target (additional lists / sessions / extended days). The likely cost of SAS (staff and associate specialist grade) contract upgrades has been included. non-clinical temporary staffing arrangements ( 1.9m year to date, including Senior Managers and A&C). current levels of pay overspend are forecast to continue The forecast includes the cost of opening the new wards and the recruitment of additional nursing staff from the Philippines. The Board is committed to filling all vacancies to ensure the Trust has sufficient staffing capacity for the winter period. An update is provided in Section 6 (Workforce) of this report. Temporary / Permanent Pay Summary ( '000) Temporary Staff Full Year (All Staff) YTD FY In month Budget Perm Temp Total Variance Consultants 1,837 2, ,314 17,977 2,535 20, Junior Doctors 1,304 1, ,658 15,944 1,612 17, Nursing, Midwifery & HV 2,618 3, ,870 46,417 3,261 49,678 (192) Dental (16) S, T & T 1,026 1, ,133 20,720 1,352 22,072 (61) Other Clinical Staff (24) Non Clinical Staff 1,914 2, ,159 17,807 2,506 20,313 1,154 Total 8,785 11,388 1, , ,536 11, ,924 1,957 MONTH 09 (December 2009) 8

10 2.2b Pay cont. Overall Performance against budget Permanent Staff ,000 10,500 10,000 9,500 9,000 8,500 8,000 Staff Costs - Permanent vs. Temporary Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 1,400 1,200 1, Temporary Staff 000 Overall temporary staff costs remain at 10% of the Trust s permanent staffing paybill. This is expected to fall over the coming months Non clinical costs are expected to reduce as permanent appointments are made to the structure Permanent 9,907 9,141 9,871 9,812 9,752 9,831 9,706 9,836 10,097 10,518 10,427 10,637 Temporary , ,155 1,059 1, Permanent Temporary Temporary Staff costs as at Month 9 Apr May Jun Jul Aug Sep Oct Nov Dec YT D % of permanent Consultants - Agency (18) % Consultants - Locum (33) % 14.0% Junior Medical - Agency % Junior Medical - Locum % 11.1% Nursing - Agency % Nursing - Bank , % 7.7% STT - Agency , % 6.7% Non Clinical - Agency , % 14.7% Dental - Agency % 26.8% TOTAL , ,155 1,059 1,123 8, % 10.0% MONTH 09 (December 2009) 9

11 2.2c Non Pay Performance against budget by month Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Budget Actual Forecast Non Pay analysis ( '000) Year to date Forecast Budget Actual Variance Budget Actual Variance Drugs 10,924 11,337 (413) 14,409 14,925 (516) Clinical Supplies 14,254 16,203 (1,949) 19,750 22,021 (2,271) Non Clinical Supplies 5,411 5,749 (338) 7,816 7, Secondary Commissioning 3,483 4,466 (983) 4,430 5,636 (1,206) Establishment & Transport 3,102 3,693 (591) 4,213 4,916 (703) Premises & Fixed Plant 6,491 6,704 (213) 8,859 9,229 (370) Other 6,934 6, ,571 10,674 (103) Total 50,599 55,081 (4,482) 70,048 75,142 (5,094) Main areas of over spend include: clinical supplies ( 1.6m includes medical supplies ( 1.1m), blood ( 0.1m) and reagents 0.2m). Levels of spend on clinical supplies is forecast overspend by 2.2m by the year end. secondary commissioning overspend totals 1.0m YTD ( 0.2m MRI scans and lab tests; 0.4m renal contract 0.4m outsourcing elective activity etc.). Establishment & transport includes 0.2m overspend on transport (mostly ambulance car contacts) and 0.4m establishment expenses including telephones, printing and postage etc Clinical supplies continue to over spend, particularly on medical and surgical consumables, driven by activity. The forecast for clinical supplies includes 0.5m for additional equipment relating to patient safety and other includes 0.5m for transfer of costs from capital to revenue (accelerated depreciation write downs and project management costs). Provision has also been included for possible impairments on the new buildings ( 0.4m). A valuation exercise is being carried out by the District Valuer. MONTH 09 (December 2009) 10

12 2.3 Service & Cost Improvement Programme Performance against Plan by Month Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Efficiency analysis ( '000) Full Year Plan Year to date Plan Actual Variance Rating Infrastructure (65) Procurement (105) Workforce & payroll , Service transformation 2,912 2,439 1,144 (1,295) Income (116) Prescribing Performance Summary Actual Current Plan Total 5,301 4,001 3,237 (764) Divisional Summary Target Year to date Performance Forecast yearend position 5.3m to be achieved in 2009/10. No more than 10% to be delivered non recurrently. Month 9 reported year-to-date savings achieved of 3.2m The total SCIP plan is 5.3m and schemes totalling 4.1m are forecast although 1m are non-recurrent. This leaves a shortfall of 1.2m against the plan if no other savings are achieved. The individual Divisional position is as follows: 1. Planned Care Year-to-date savings achieved of 774k against a year to date plan of 744k. Schemes totalling 1,156k have been forecast to deliver. However, 894k of these savings are non recurrent. 2. Emergency Care Year-to-date savings achieved of 740k against a year to date plan of 940k. Schemes totalling 912k have been forecast, leaving a shortfall of 31k in year. All schemes are recurrent savings. 3. Corporate - against a year-to-date target of 2,317k, 1,744k of savings have been found. This includes 372k of non recurrent savings. 4. Trust-wide - against a year-to-date target of 4,001k, 3,237k of savings have been found - a shortfall of 764k year to date. MONTH 09 (December 2009) 11

13 2.4 Balance Sheet 000 Year to Date Full Year Forecast Budget Actual Variance Budget Actual Variance Assets Assets, Non Current Tangible & Intangible 162, ,435 (14,554) 166, ,386 (11,567) PFI 6,449 6,449-6,415 6,416 1 Receivables and Prepayments (429) (429) Total Assets, Non Current 170, ,102 (14,983) 174, ,020 (11,995) Assets, Current Inventories 3,923 4, ,810 4, Trade Receivables 4,338 4, ,368 3,357 (1,011) Cash 16,153 27,217 11,065 10,882 20,685 9,803 Other current Assets 2,391 9,869 7,478 1,796 9,988 8,192 Total Assets, Current 26,804 46,271 19,467 20,855 38,221 17,366 ASSETS, TOTAL 196, ,373 4, , ,241 5,371 Liabilities Liabilities, Current Trade and Other Payables (12,294) (10,107) 2,187 (10,570) (12,465) (1,895) Other Financial LIabilities (6,287) (8,908) (2,621) (5,017) (6,921) (1,904) Total Liabilities, Current (18,581) (19,015) (434) (15,587) (19,386) (3,799) NET CURRENT ASSETS (LIABILITIES) 8,224 27,256 19,032 5,268 18,835 13,567 Liabilities, Non Current (4,521) (5,204) (683) (4,432) (5,081) (649) TOTAL ASSETS EMPLOYED 173, ,154 3, , , Taxpayers Equity Public dividend capital 75,033 75,033-75,033 75,033 - Retained Earnings (Accumulated Losses) 31,472 34,106 2,634 32,580 32, Donated Asset Reserve 1,343 1,292 (51) 1,299 1,256 (43) Revaluation Reserve 65,185 65, ,185 65, Miscellaneous Other Reserves TOTAL ASSETS EMPLOYED 173, ,154 3, , , The Winter Capacity Business Case reprofiled the capital programme resulting in some 13m being reprofiled into 2010/11. The capital forecast now assumes that subject to the two storey ward block being given the final go ahead, some 3.9m will need to be spent this year to ensure completion on time. Cash ahead of YTD plan primarily due to capital slippage and stronger working capital position. Forecast for year reflects reprofiling of part of this year s capital programme to 2010/11. Other current assets includes accrued income of 8.1m against a plan of 1.9m relating to the overperformance on the PCT contracts. Other financial liabilities includes accruals of 6.7m against a plan of 4m The Balance Sheet includes all IFRS related adjustments MONTH 09 (December 2009) 12

14 2.4a Capital Performance against budget by month 5,000 4,000 3,000 2,000 1,000 0 Capital analysis ( '000) Capital Profile - Actuals/Forecast vs Budget Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual Budget Forecast Year to Date Full Year Planned Plan Actual Variance Plan Forecast Variance Status Finish Strategic Schemes Oncology Centralisation (800) C being prepa 2013 New Ward Block ,479 3,279 ow starting 20 01/10/2010 Elective Care Centre 2,504 2,295 (209) 2,504 2,395 (109) On site 01/12/2009 Isolation Ward 1,248 1, ,248 1, On site 06/11/2009 Stroke Ward 1,244 1,071 (173) 1,244 1,161 (83) On site 13/11/2009 Bed Store On site 01/10/2009 Villa 2 Conversion (5) (19) Completed 01/07/2009 Villa 3 Conversion (279) In Progress 01/03/2010 H&S Store Microbiology (111) (99) On site 01/11/2009 Digital Mammography In Progress 01/04/2010 ECH Ophtamology In Progress 01/04/2010 Other Schemes (63) Infrastructure and Other Medical Equipment 1, (882) 3,420 1,988 (1,432) Slipped linacc repl. Estates 1, (717) 2,025 1,497 (528) IM&T 4,081 1,523 (2,558) 4,549 3,382 (1,167) Several items of slippage Total 14,357 9,524 (4,833) 18,264 18,248 (16) RAG indicator is green if variance within 10% of plan. The year to date slippage has reduced to 4.8m and the year end forecast expects the profile to catch up. The capital forecast assumes that subject to the two storey ward block being given the final go ahead, some 3.9m will be spent this year to ensure completion on time. Expenditure of over 4m is forecast for March although it is possible there could be further slippage. Investment in digital mammography equipment has been brought forward from 2010/11 in order to ensure the necessary capacity is in place by the end of December 2010.Investment in ECH ophthalmology theatres is funded from estates capital. The capital investment in oncology, including the linacc replacement, is now expected to begin from 2010/11. The business case is being prepared for the March Board Medical equipment the majority of this slippage relates to the reprofiling of the linnac replacement as part of the radiotherapy business case. IM&T a number of business cases originally envisaged to be progressed earlier in the year have now been reprofiled to later in the year and are expected to be completed within the year. Slippage on implementation of some schemes is now forecast totalling 0.5m. MONTH 09 (December 2009) 13

15 2.4b Cash Flow Performance against Plan by Month m Cash Flow Profile Cash position is ahead of year to date plan due to slippage on capital programme and movements in working capital. Cash will end the year higher than plan this year due to reprofiling of Winter Capacity capital programme across financial years 2009/10 and 2010/11. The Winter Capacity Plan reprofiled this year s capital programme from some 30m down to 17.7m with a corresponding increase in the 2010/11 programme. 5 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The trust currently has 15m invested in medium term higher interest accounts. Budget Actual Forecast MONTH 09 (December 2009) 14

16 3. Activity 3.1 Variance against plan by division 3.2 Performance against Plan 3.3 YTD Variance by Speciality MONTH 09 (December 2009) 15

17 3.1 Performance against Plan 4,500 4,300 4,100 3,900 3,700 3,500 3,300 3,100 2,900 2,700 2,500 Elective (spells) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 3,400 3,200 3,000 2,800 2,600 2,400 2,200 2,000 Non-Elective (spells) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Budget Actual Forecast 2008/09 actual Budget Actual Forecast 2008/09 actual 40,000 35,000 30,000 25,000 20,000 15,000 10,000 Outpatients (attendances) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Budget Actual Forecast 2008/09 actual Elective (spells) Non elective (spells) Elective spells continue to under perform. YTD variances to plan are; day cases +2,808 (18.6%); RDAs -3,403 (-36.3%); in patients - 489(-7%). Elective activity is forecast to under perform for the year but will exceed last year s outturn. Non electives continue to over perform against plan with +3,078 (12.6%) (last month +2,795) spells above plan (notably general medicine +2,907 (78%), care of the elderly +363 (11%) and paediatrics +664 (36%)). Outpatients (attendances) The Trust has seen 14,409 more first and follow up outpatients than plan and 3,783 (20%) more outpatient procedures than the year to date plan. MONTH 09 (December 2009) 16

18 3.2 YTD Variance by Speciality Electives (D/C + RDPs) Electives (Inpatients) ,000-1, , General Surgery Urology Breast Surgery Colorectal Vascular T & O ENT Ophthalmology Oral Surgery Pain Management Critical Care General Medicine Gastroenterology Endocrinology Haematology Cardiology Dermatology Thoracic Nephrology Neurology Rheumatology Paediatrics Geriatric Maternity Gynaecology Podiatry Orthoptics Oncology General Surgery Urology Breast Surgery Colorectal Vascular T & O ENT Ophthalmology Oral Surgery Pain Management Critical Care General Medicine Gastroenterology Endocrinology Haematology Cardiology Dermatology Thoracic Nephrology Neurology Rheumatology Paediatrics Geriatric Maternity Gynaecology Podiatry Orthoptics Oncology 3,000 2,500 2,000 1,500 1, ,000 Non Elective 6,000 5,000 4,000 3,000 2,000 1, ,000-2,000-3,000 Outpatients (Firsts + Follow Ups) General Surgery Urology Breast Surgery Colorectal Vascular T & O ENT Ophthalmology Oral Surgery Pain Management Critical Care General Medicine Gastroenterology Endocrinology Haematology Cardiology Dermatology Thoracic Nephrology Neurology Rheumatology Paediatrics Geriatric Maternity Gynaecology Podiatry Orthoptics Oncology General Surgery Urology Breast Surgery Colorectal Upper Gastro Vascular Surgery T & O ENT Ophthalmology Oral Surgery Orthodontics A & E Anaesthetics Pain Critical Care General Gastroenterology Endocrinology Haematology Diabetic Audiological Clinical Genetics Cardiology Dermatology Respiratory G U Med Nephrology Medical Neurology Clinical Neuro Rheumatology Paediatrics Geriatric Maternity Gynaecology Midwife Physio Occ Therapy Podiatry Dietetics Orthoptics Clinical MONTH 09 (December 2009) 17

19 4. National Standards 4.1 Monitor Compliance Framework 4.2 CQC Health Care Standards MONTH 09 (December 2009) 18

20 4.1 Monitor Compliance Framework Weightings and thresholds for targets and national core standards Priority Target July Aug Sep Oct Nov Target Breached December Targets - weighted 1.0 (national requirements) 1 Clostridium difficile year on year reduction MRSA Year on Year reduction Max waiting time of 31 days for subsequent treatments for all cancers Maximum two month wait from referral to treatment for all cancers For admitted patients, maximum time of 18 weeks from point of referral to treatment For non-admitted patients, maximum time of 18 weeks from point of referral to treatment Targets - weighted Maximum waiting time of 4 hours in A&E - 98% achievement People with heart attack to receive thrombolysis within 60 minutes of call Max. waiting time 2 weeks from urgent GP referral to 1st outpatient appointment for all urgent suspect cancer referrals Maximum waiting time of 31 days from diagnosis to treatment for all cancers Screening all elective in-patients for MRSA National Core standards 2 Any core standard Number of breaches n/a Three Amber to Red rule n/a Any non-financial / non-target related issue Monitor Governance Risk Rating MONTH 09 (December 2009) 19

21 4.2 CQC Health Care Standards Quality Element - Summary Element Core Standards Existing Commitments National Priorities Overall Quality Rating Existing Commitments - Acute Trusts Rating Fully Met Fully Met Good Good RAG 1 48 Hour Access to genito-urinary medicine (GUM) clinics 2 Cancelled Operations and those not admitted within 28 days 3 Data quality on ethnic group 4 Delayed Transfers of Care 5 Inpatients waiting longer than the 26 week standard 6 Outpatients waiting longer than the 13 week standard 7 Patients waiting longer than three months for revascularisation - 8 Time to reperfusion for patients who have had a heart attack - 9 Total Time in A&E 10 Waiting times for rapid access chest pain clinic National Targets - Acute Trusts RAG 1 18 Week referral to treatment times 2 Access to healthcare for people with a learning disability - 31 day diagnosis (decision to treat) to treatment including 3 new stategy commitment 62 day urgent referral to treatment (including new cancer 4 strategy commitment) 5 2 week cancer wait 6 Engagement in Clinical Audits 7 Experience of Patients 8 Incidence of Clostridium difficile 9 Incidence of MRSA Bacteraemia Infant health & Inequalities: Smoking during pregnancy & 10 breast feeding initiatives 11 Maternity Hospital Episode Statistics: data quality indicator 12 NHS Staff Satisfaction 13 Participation in heart disease audits 14 Stroke Care Fully Met Good MONTH 09 (December 2009) 20

22 5. Patient Safety 5.1 Infection Control 5.2 Hand Hygiene 5.3 Saving Lives Compliance 5.4 Dr. Foster Mortality Summary MONTH 09 (December 2009) 21

23 5.1 Infection Control Performance against ceiling by month No. of cases MRSA bacteraemia Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Ceiling Actual (cum) C.Diff Swine Flu There has been a continued decline in cases, both locally and nationally. The joint weekly meeting with the PCT and the CHUFT weekly operational Swine flu meetings have been stood down. Proposed HCAI Objectives for next year The SHA have made the following recommendations; Any avoidable case of MRSA bacteraemia occurring 48hrs after admission will not be charged to the commissioning PCT for any aspect of the admission or subsequent treatments for the MRSA bacteraemia. The precise working of this recommendation is not given. No. of cases Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Ceiling Actual (cum) MRSA bacteraemia; A ceiling of 10 cases in the health economy, 6 of which may be in specimens taken more than 48 hours into patient admissions. Clostridium difficile A ceiling of 106 cases in the health economy, 51 of which may be in specimens taken more than 48 hours into patient admissions Both of these are our current level of performance. MONTH 09 (December 2009) 22

24 5.2 Hand Hygiene Performance against target by month 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Hand Hygiene Compliance by Staff Group - This Quarter Year to Date Dec Nov Oct Nursing 98% 99% 98% Doctors 93% 95% 85% HCA 99% 100% 99% Therapists/ODP/TODP 98% 98% 97% Other 92% 91% 93% Overall 97% 97% 94% Target Actual 2008/09 Hand Hygiene Compliance by Staff Group - This Month Nurses Doctors HCA Therapists etc. Other Overall ATS 94% 86% 93% 33% 72% 91% Care of the Elederly 99% 95% 100% 100% 95% 99% Childrens 100% 100% 100% 0% 100% 100% ECH/Cancer 99% 91% 100% 100% 100% 97% Medical 96% 94% 100% 100% 77% 94% Surgical 100% 99% 100% 100% 100% 100% Womens 95% 100% 92% 0% 100% 95% Emergency 94% 65% 100% 100% 97% 92% Outpatients Clacton No infomation received Overall 98% 93% 99% 98% 92% 97% Area Totals by Risk High Risk Medium Risk ATS 96% 89% Care of the Elederly 98% 99% Childrens 99% 100% ECH/Cancer 100% 95% Medical 93% 94% Surgical 100% 100% Womens 100% 93% Emergency 95% 90% Outpatients Clacton No data received Overall 98% 96% MONTH 09 (December 2009) 23

25 5.3 Saving Lives Compliance CVC PVC Renal Dialysis High Impact Intervention Surgical Site Infection Ventilated Ptients Unrinary Catheter Care Cdiff Area Anaesthetic & Technical Services Care of the Elderly Month Insertion Actions Continuing Care Insertion Actions Continuing Care Catheter - Insertion Actions Catheter Continuing Care PreOperative PeriOperative % % % % % % % % % % % % % % Key: December 90% 100% 87% 100% 100% 100% 0% 0% 82% 100% 93% 100% 100% 0% Red: <70% November 70% 88% 89% 100% 100% 100% 0% 0% 100% 100% 100% 100% 100% 0% Amber 70%-90% October 93% 100% 76% 100% 100% 100% 0% 0% 100% 100% 100% 100% 100% 0% Green >90% December 0% 0% 100% 95% 0% 0% 0% 0% 0% 0% 100% 99% 100% 100% November 0% 100% 87% 100% 100% 0% 0% 0% 0% 100% 92% 100% 100% October 0% 0% 94% 98% 100% 100% 0% 0% 0% 0% 100% 89% 100% 100% Regular Observations Continuing Care Insertion Actions Continuing Care Prevention Prevention of Spread Childrens Services Emergency ECH/Cancer Medical Surgical Womens Grand Total December 100% 100% 79% 100% 0% 0% 0% 0% 0% 0% 0% 0% 100% 100% November 100% 100% 53% 100% 0% 0% 0% 0% 100% 100% 0% 0% 100% 100% October 100% 100% 73% 100% 0% 0% 0% 0% 100% 0% 0% 0% 100% 100% December 100% 100% 100% 0% 0% 0% 0% 0% 0% 100% 0% 100% 0% November 100% 0% 100% 100% 0% 0% 0% 0% 0% 0% 100% 0% 100% 0% October 100% 0% 100% 100% 0% 0% 0% 0% 0% 0% 100% 0% 100% 0% December 0% 0% 77% 91% 0% 0% 0% 0% 0% 0% 100% 100% 100% 100% November 0% 0% 77% 100% 0% 0% 0% 0% 0% 0% 100% 20% 100% 0% October 0% 80% 57% 0% 0% 0% 0% 0% 0% 100% 100% 100% 100% December 0% 0% 90% 57% 0% 0% 0% 0% 100% 79% 100% 100% November 100% 100% 89% 95% 0% 100% 100% 0% 0% 0% 93% 94% 100% 100% October 100% 100% 90% 95% 0% 0% 87% 0% 0% 0% 94% 97% 100% 100% December 100% 94% 88% 0% 100% 97% 93% 100% 92% 100% 100% November 0% 100% 90% 92% 100% 98% 93% 0% 100% 100% 88% 90% 93% October 0% 100% 91% 83% 100% 0% 86% 93% 100% 100% 89% 89% 100% December 0% 0% 88% 100% 0% 0% 100% 0% 0% 100% 100% November 0% 0% 94% 77% 0% 0% 100% 100% 0% 0% 100% 100% 100% 100% October 0% 0% 92% 100% 0% 0% 100% 100% 0% 0% 100% 100% 100% 100% December 91% 100% 92% 87% 100% 100% 98% 93% 82% 100% 98% 94% 100% 100% November 89% 95% 91% 92% 100% 100% 99% 96% 100% 100% 99% 91% 97% 98% October 96% 100% 89% 92% 100% 100% 86% 96% 100% 100% 99% 91% 97% 100% MONTH 09 (December 2009) 24

26 5.4 Dr. Foster Mortality Summary There has been no Dr Foster update this month, this is due to a national SUS upgrade last month. The next scheduled update is January 31st. Therefore the last update was November 30th which incorporated the October snapshot / extraction of September discharges. April to August data is quoted because at the time of the October snapshot / extraction there was still over 900 uncoded September episodes. Alerts received this month: None Trust Target: HSMR <100 Residual codes outstanding at time of upload in October: 112 hospital episodes (1 death) Speciality (on discharge) Relative Risk Actual Deaths August Expected Deaths Change in Month August 2008/09 Year to Date 2009/10: April - August Actual Expected Deaths Deaths Relative Risk Change in Month 2008/ / 08 HSMR (All) HSMR (Elective) HSMR (Non-Elective) Crude (All) Crude (Elective) Crude (Non-Elective) Breast Surgery Cardiology Clinical Oncology Clinical Haematology ENT Gastroenterology General Medicine Geriatric Medicine General Surgery Gynaecology Neonatology Paediatrics Respiratory Medicine Trauma & Orthopaedics Urology Notes: HSMR is based on a subset of 56 key diagnoses which cause 80% of hospital deaths Red RAG ratings indicate performance above the 100 national benchmark Crude mortality is based on all hospital deaths Green RAG ratings indicate performance below the 100 national benchmark Data update: Dr Foster takes a snapshot of hospital episode data on or around the 5th of each month. There is then an 8 week delay before this data is uploaded into the online tool. To capture 100% of discharge data and provide an accurate HSMR takes weeks Residual Codes: These relate to uncoded or incompletely coded episodes at the time of upload i.e.october MONTH 09 (December 2009) 25

27 6. Workforce 6.1 Staff Turnover 6.2 Sickness Absence 6.3 Temporary Staff 6.4 Workforce Summary MONTH 09 (December 2009) 26

28 6.1 Staff Turnover 3350 In Post vs Establishment Vacancy Analysis 8% 18% Turnover % by Staff Group Rolling 12 Months, Jan Dec % 16% 14% % 5% 12% 10% % 8% 6% % 4% 2% 2% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 1% 0% 0% AHP Reg AHP Sup Medical & Dental Mgt, A&C N&M Reg N&M Sup Other ST&T Other ST&T Band 5+ Band 1-4 In Post Vacant WTE Vacancy % % Turnover CHUFT Turnover 10.1% In Post Movement by Staff Group, Month 9 & Financial Year to Date Other ST&T 1-4 Other ST&T 5+ N&M Sup N&M Reg Mgt, A&C Medical & Dental AHP Sup AHP Reg Mth WTE YTD WTE Recruitment levels are again higher than leavers this month. In post has risen from WTE in November to WTE in December. The Establishment has increased by 16.6 WTE giving vacancy levels of 6%. Projection of establishment to end of March from information provided by Finance has increased by 8.7 WTE. Rolling annual turnover has decreased slightly from last month to 10.1% (10.5%). Nursing staff have increased by 18.6 WTE in December and 88.3 WTE over the year to date. A reduction of 5 WTE occurred in the number of Medical and Dental Staff in post on 31 December compared to 30 November Leavers during December exceeded starters and are accounted for by 1 external promotion, 1 moving overseas, 1 locum and 4 fixed term contracts ending. Measures are in place to ensure that medical workload is covered. MONTH 09 (December 2009) 27

29 6.2 Sickness Absence 5.0% 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% CHUFT Sickness Absence % FTE Lost Monthly Breakdown Jan Dec 2009 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Rolling Year Monthly % Target 3.5% The monthly sickness figure for the Trust is 3.8%. The figure for the rolling year to date is 3.7%. Once again the highest level of sickness absence is amongst clinical support staff. Emergency Care again has the highest levels of divisional sickness, at 4.4%, for the year. CHUFT Sickness Absence % Days Lost - December 2009 % Available Days Lost by Staff Group Rolling 12 Months, Jan Dec % 4.5% 4.0% 3.5% 3.0% 2.5% ST&T 5+ ST&T 1-4 Other N&M Sup N&M Reg Mgt, A&C Medical & Dental 2.0% Emergency Care Planned Care Corporate CHUFT AHP Sup AHP Reg 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% Monthly % Target 3.5% % Days Lost MONTH 09 (December 2009) 28

30 6.3 Temporary Staff 14% 12% CHUFT Contingent Staff Expenditure % Pay Budget 25% 20% 15% Corporate Contingent Staff Expenditure % Pay Budget 10% 10% 8% 5% 6% 4% 0% Apr May Jun Jul Aug Sep Oct Nov Dec YTD % Pay Budget CHUFT Target 10% 2% 0% Apr May Jun Jul Aug Sep Oct Nov Dec YTD 14% 12% Emergency Care Contingent Staff Expenditure % Pay Budget % Pay Budget CHUFT Target 10% 10% 8% The Trust continues to experience high levels of maternity leave, along with significant sickness absence in some areas, contributes to high contingent staffing levels. Contingent Staff, in this analysis, relates to Bank, Agency and Locum. Month 9 K Year To Date K % of Pay Budget Bank Locum Agency Total Bank Locum Agency Total Pay Bgt M9 % ay Bgt YT YTD % AHP Reg % 5, % AHP Sup % % Medical & Dental ,777 1,555 3,332 3, % 26, % Mgt, A&C ,912 1,912 1, % 14, % N&M Reg ,905 3, % 30, % N&M Sup % 6, % Other % % ST&T Band % 2, % ST&T Band % 7, % Grand Total ,162 1,720 1,777 5,467 8,964 10, % 94, % 6% 4% 2% 0% 14% 12% 10% 8% 6% 4% 2% 0% Apr May Jun Jul Aug Sep Oct Nov Dec YTD %Pay Budget CHUFT Target 10% Planned Care Contingent Staff Expenditure % Pay Budget Apr May Jun Jul Aug Sep Oct Nov Dec YTD % Budget CHUFT Target 10% Pay MONTH 09 (December 2009) 29

31 6.4 Workforce Summary Workforce Summary Table Turn- Turn- Mth Mth Mth Mth YTD Mth Rolling Yr Bdgt Inpost Vac Vac over % over % Agency Bank Locum Temp Temp Sick % Sick % WTE WTE WTE % Mth Annual WTE WTE WTE % Pay Bdgt % Pay Bdgt WTE Lost WTE Lost Emergency Medicine % 0.0% 8.3% % 24.3% 6.2% 5.0% General Medicine % 0.2% 7.2% % 8.3% 3.3% 3.7% Pathology % 1.0% 11.4% % 3.9% 3.2% 3.2% Pharmacy % 1.0% 12.8% % 7.7% 5.6% 4.7% Specialist Medicine % 1.5% 12.7% % 13.8% 5.3% 4.5% Womens Services % 0.5% 4.9% % 3.1% 3.5% 4.8% Emergency Care 1, , % 0.7% 9.2% % 10.4% 4.4% 4.3% Ambulatory Care % 0.4% 7.1% % 14.7% 2.9% 5.0% Anaesthetics & Technical Services % 0.6% 6.5% % 5.1% 4.3% 3.7% Cancer Services % 1.0% 10.4% % 7.1% 3.3% 4.2% General Surgery % 0.0% 11.1% % 5.7% 2.5% 2.7% Radiology % 0.5% 5.3% % 11.8% 1.9% 2.2% Specialist Surgery % 1.0% 9.5% % 11.2% 3.7% 3.2% Therapies (1.0) -0.7% 0.0% 15.9% % 3.4% 2.7% 1.6% Planned Care 1, , % 0.5% 9.3% % 7.5% 3.3% 3.3% Business Transformation % 1.3% 20.9% % 25.8% 4.6% 3.5% Estates and Facilities % 0.0% 6.3% % 12.3% 1.7% 1.5% Finance % 0.0% 14.5% % 12.1% 3.6% 2.7% Medical Director (0.3) -3.7% 0.0% 62.8% % 7.0% 1.2% 1.8% Nursing and Patient Experience % 0.0% 20.6% % 5.5% 5.7% 2.4% Service Delivery % 0.0% 113.6% % 59.1% 0.0% 0.8% Strategic and Business Development % 0.0% 13.3% % 8.4% 0.0% 1.1% Workforce % 1.7% 9.8% % 10.1% 0.9% 2.6% Corporate % 0.7% 17.6% % 15.0% 3.3% 2.6% CHUFT Total 3, , % 0.6% 10.1% % 9.5% 3.8% 3.7% MONTH 09 (December 2009) 30

32 7. Risk Management 7.1 Risk Report Summary 7.2 Risk Report Detail MONTH 09 (December 2009) 31

33 7.1 Risk Report Summary (i) Risk Register Risk Register Summary As of the 19th January 2010 there are a total of 109 live risks held within the Trust section of the Datix Risk Register. There are no outstanding Extreme or High risks to be reviewed on the Trust Risk Register as of 19th January Extreme (Red) risks have been moved form the holding area onto the Trust risk register and reviewed. 1 Extreme (Red) risk has been upgraded from Moderate (Yellow) 381 on the High (Amber) risks have been reviewed. (5 High (Amber) risks have been moved form the holding area onto the Trust Risk Register.) 1 High (Amber) risk was downgraded to Moderate (Yellow) 450 on Risk Register Extreme High Moderate Low Total 17th August th September th October th November th December th January MONTH 09 (December 2009) 32

34 7.1 Risk Report Summary (ii) Risk Register Executive Summary Risk Register Action Plan Summary Director of Operations Director of Workforce Chief Information Officer Director of Nursing and Patient Experience Medical Director 1 Extreme & 4 High risks 1 High risk 2 Extreme & 5 High risks 1 High risk 2 High risks 3 Extreme (Red) risks: o 2 have action plans attached and 381 has a procedure 13 High (Amber) risks o 11 risks have action plans. (272, 402, 407, 442, 451, 467, 474, 475, 479, 481 & 484) o 1 risk (483) will be discussed at the Board, and an action plan will follow o 1 risk does not require an action plan because it is part of a wider remit including the Assurance Framework. (414) Actions during the next month Ensure all action plans are updated in accordance with timescales. Manage any new risks in accordance with the Risk Management Strategy & Policy. Ensure that the 1 Extreme (Red) risk and the 5 High (Amber) risks are correctly placed on the Trust Risk Register MONTH 09 (December 2009) 33

35 7.2 Risk Report (detail i) Initial Risk 17th December 2009 DATIX ID Area of Risk Responsible Executive Description of Risk Current Risk 18th January 2010 Summary of changes during this period 0 NEW EXTREME (RED) RISKS IN HOLDING AREA Radiology Sue Barnett Opened 29 th Dec 2009 PCT Ultrasound Units end of Life Action plan attached, awaiting risk assessment Inspection of kit arranged for NEW HIGH (AMBER) RISKS IN HOLDING AREAS Radiology Sue Barnett Opened 30th Dec 2009 Reporting of radiographical studies on Vitrea workstations New risk awaiting risk assessment and action plan Exploring opportunities for DTI with CRIS 489 Radiology Sue Barnett Opened 31st Dec 2009 Viewing of relevant prior images on PACS for reporting and patient management New risk awaiting risk assessment and action plan Met with Accenture who confirmed that SAN upgrade would be scheduled within 6 weeks. 486 Radiology Sue Barnett Opened 30th Dec 2009 Breast screening Radiology radiologist shortfall means Trust are unable to meet service requirements New risk awaiting risk assessment and action plan Revised template issued to Sue Barnett. Full Radiological service is compromised albeit sessions being operated are clinically safe. Two external consultants running ad hoc sessions. Consultant Radiographer position being considered. South African locum is a possibility from April MONTH 09 (December 2009) 34

36 7.2 Risk Report (detail ii) Initial Risk 17th December 2009 DATIX ID Area of Risk Responsible Executive Description of Risk Current Risk 18th January 2010 Summary of changes during this period 493 Corporate Julie Firth Opened 19 th Jan 2010 Out of date Trust Policies & proceudres & Guidelines Risk has been entered onto the Trust risk register holding area awaiting an action plan. Current status of 'out of date' policies, procedures and guidelines have been attached, therefore no need for a risk assessment. This will be discussed at the CEB and an action plan will be developed following this meeting. 494 Operations & ICT Nick Elliott Opened 19 th Jan 2010 Technical error within the PAS system which may cause a breach of the 13 week target New risk put into the holding area of the risk register. Action plan is required by ICT. Linda and Ralph to brief Nick Elliott. 0 HIGH (AMBER) RISKS STILL IN HOLDING AREA Children s Services Elizabeth Adair Review date 15th Jan weeks - patient pathways for ongoing treatment/care by other providers sent to Fiona Crump requesting risk assessment to be signed by an Executive and an action plan completed rd sent requesting risk assessment and action plan. AD copied in. MONTH 09 (December 2009) 35

37 7.2 Risk Report (detail iii) Initial Risk 19th December 2009 DATI X ID Area of Risk Responsible Executive Description of Risk Current Risk 18th January 2010 Summary of changes during this period 0 EXTREME (RED) RISKS REVIEWED Operations & ICT Nick Elliott Review date 14th Jan 2010 Information reporting capability risk updated by Nick Elliott. Action Plan via LEAP form completed. Actions progressing well. Skills Assessment in draft. system procured, implementation progressed. Risk assessment for external reporting underway. Risk 480 was entered onto the Trust Risk Register on 17th December Target grading is Moderate. Action plan attached. Next action due February Operations & ICT Nick Elliott Opened date 14th Jan 2010 Data quality Risk updated by Nick Elliott. LEAP from attached describing key actions and deadlines Risk 482 was entered onto the Trust Risk Register on 17th December Target grading is Moderate. Action plan attached. Next action due March EXTREME (RED) RISKS UPGRADED FROM MODERATE (YELLOW) Planned Care Sue Barnett Review date 18th Jan 2010 Great Bentley function and utilisation Due to excessive emergency activity and pressures the use of the Great Bentley ward has been opened to provide up to 18 additional beds. Due to the unforeseen pressures this area has opened with 27 patients, without the supporting structures in place to deliver safe patient care for this number. Risk escalated due to operating outside agreed framework MONTH 09 (December 2009) 36

38 7.2 Risk Report (detail iv) Initial Risk 17th December 2009 DATIX ID Area of Risk Responsible Executive Description of Risk Current Risk 18th January 2010 Summary of changes during this period 9 HIGH (AMBER) RISKS REVIEWED Pathology Sue Barnett Review date 16th Dec 2009 Disinfection of infectious material action plan updated. Next action due at the end of December Risk 402 was entered onto the Trust Risk Register on the 7th April Target grading is Low. Action plan attached. 2 Action outstanding, tender and installation/commissioning. Due for completion March Specialist Medicine Sue Barnett Review date 16th Dec 2009 Insufficient physical capacity to deliver 18 weeks and Bowel screening action plan updated Risk 407 was entered onto the Trust Risk Register on the 7th May Target grading is Low. Project Initiation Document (PID) and action plan attached. MONTH 09 (December 2009) 37

39 7.2 Risk Report (detail v) Initial Risk 17th December 2009 DATIX ID Area of Risk Responsible Executive Description of Risk Current Risk 18th January 2010 Summary of changes during this period 442 Anaesthetics Sue Barnett Review date 8th Jan 2010 Review of all resuscitation trolleys within the Trust as no standardised uniformity Funding approved, formal tender opening mtg set for the Evaluation team set up. Risk 442 was entered onto the Trust Risk Register on the 5 th August Target grading is Low. Risk assessment available, will be attached for next month. Action plan attached. Business case written, signed by Project Director 467 Cancer Services Sue Barnett Review date 15th Jan 2010 Lone Consultant Position Risk assessment and action plan written, therefore risk has been moved onto the Risk register. Risk 467 was entered onto the Trust Risk Register on 15th January Target grading is No risk. Action plan attached 272 Human Resources Rob Bowman Review date 15th Jan 2010 Recording and Reporting of Training Records Mapping session on cancelled due to weather conditions. Meeting took place on to process map implementation of the OLM system. Updated action plan attached. Risk 272 was entered onto the Trust Risk Register on the 21 st November Target grading is Low. Several action plans attached, the latest being 10 th December actions outstanding. Demonstration of new system and review of actions taken. Completion date March Corporate Nick Elliott 14th Jan 2010 Integrated IT systems not fully meeting data reporting requirements updated Nick Elliott. PAS alert being progressed. Strategy to board will provide long term solution if approved.. Risk 475 was entered onto the Trust Risk Register on the 20 th November Target grading is Low. Action plan attached. MONTH 09 (December 2009) 38