TB2013.67
Trust Board: Wednesday, 8 May 2013
TB2013.67
Title
NHS Trust Oversight Self-Certification
Status
For information and decision
History
Board papers of 5 July 2012, 6 September 2012,
1 November 2012, 9 January 2013, 12 February 2013 and
13 March 2013
Board Lead(s)
Mr Andrew Stevens, Director of Planning and Information
Key purpose
Strategy
TB2013.67 NHS Trust Oversight Self-Certification
Assurance
Policy
Performance
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Oxford University Hospitals
TB2013.67
Summary
1
The Trust’s NHS Trust Oversight Self-Certification return for March 2013 shows an
Amber-Red Governance Risk Rating (GRR).
2
This rating is due to the annual trajectory for cases of clostridium difficile being
exceeded, the two week wait to first appointment for cancer referrals not being met
and the Accident and Emergency four hour wait standard not being met.
3
Other standards contributing to the Governance Risk Rating continued to be met.
4
The Trust’s Governance Risk Rating for February was 1.0, with the Accident and
Emergency four-hour wait standard not met, giving an Amber-Green rating.
5
The Board is asked to receive and note the self-certification submission for March
TB2013.67 NHS Trust Oversight Self-Certification
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Oxford University Hospitals
TB2013.67
NHS Trust Oversight Self-Certification
Introduction
1.
The Trust has submitted its self-certification template for March 2013 as required of
all applicant NHS Foundation Trusts on a monthly basis. March’s self-certification is
attached.
2.
Since the most recent self-certification report to the Board at its February meeting,
the return for February has also been submitted.
3.
With the transfer of responsibility for the Foundation Trust application pipeline to the
NHS Trust Development Authority (TDA), self-certification submissions are now
made to the TDA.
Current Status
4.
In February’s submission the Trust’s Governance Risk Rating (GRR) continued to
score 1.0 due to not meeting the standard for four-hour Accident and Emergency
waits, giving an Amber-Green rating. Lower GRR scores represent lower risk.
5.
The Trust’s GRR score for March rose to 2.5, giving an Amber-Red rating.
6.
The score for March was made up of three factors. The annual trajectory for cases
of clostridium difficile was exceeded, the two week wait to first appointment for
cancer referrals was not met and the Accident and Emergency four hour wait
standard was not met. Achievement of the four hour target continues to prove
challenging in the context of emergency activity which has been above both the plan
for 2012/13 and the level of activity which took place in 2011/12.
7.
Performance has again been maintained against the MRSA cases trajectory and
against both the admitted and non-admitted Trust-wide referral to treatment (RTT)
standards.
8.
Data quality issues have prevented the Trust from being able to submit current data
for the incomplete RTT measure. Following work under the Electronic Patient
Record stabilisation project it is anticipated that reporting of these data will
recommence in April.
9.
The Trust continues to report internally validated figures for access to its cancer
services for the relevant month. National verification of shared breaches for January
and February confirmed that OUH met all cancer standards for those months.
Internally-validated data indicate, however, that OUH did not meet the two week
cancer standard in March as a result of unexpected staffing issues in the breast
cancer service and a significant increase in referrals during the month.
10. As part of the Board Statement, the Trust continues to be unable to confirm
achievement of Level 2 compliance with the requirements of the Information
Governance Toolkit, due to the percentage of staff trained in Information Governance
being below target. A significant drive to train staff has taken place in recent months
but the percentage trained was 81.3% on 30 April against a target of 95%.
11. The Trust’s Financial Risk Rating (FRR) score remains 3 which gives a Green rating.
The FRR scale is 1 to 5 with higher scores representing lower risk.
TB2013.67 NHS Trust Oversight Self-Certification
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Oxford University Hospitals
TB2013.67
Conclusion
12. Self-certification for March 2013 gives a Governance Risk Rating of Amber-Red,
resulting from the annual trajectory for cases of clostridium difficile being exceeded,
the two week wait to first appointment for cancer referrals not being met during the
month and the Accident and Emergency four hour wait standard not being met.
13. The Trust remains non-compliant with Level 2 of the Information Governance toolkit.
14. The Trust’s Financial Risk Rating remains Green.
Recommendation
15. The Board is asked to receive and note the content of the self-certification return for
March.
Neil Scotchmer, Programme Manager
Andrew Stevens; Director of Planning and Information
May 2013
TB2013.67 NHS Trust Oversight Self-Certification
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