TB2015.62
Appendix 1
Ref.
Recommendation
Lead Director
H1.0.1
The Trust should supply detailed supporting information to enable Finance &
the impact of the ORH/NOC merger to be separately analysed at Procurement
Stage 2.
Due by
Progress made by May 2014
Recommendation met
by May 2014
Information provided 4 October 2012.
Update to May 2015
Issue analysed by Monitor in Stage 2 of assessment and agreed
position included in assessor case.
Recommendation met
by May 2015

Finance &
Procurement
18-Oct-12
LTFM revision in October 2012 used recommendations from HDD1.

The Trust should consider weekly monitoring of key 'at risk' [CIP] Finance &
schemes to ensure sufficient time is given to respond to
Procurement
developing challenges.
28-Nov-12
Project management approach established, with Project board meeting weekly.

Each CIP project (subject to de minimus limit) is entered onto a
"tracker" system, enabling the monitoring of progress. Monitoring
arrangements are in place with a scheduled weekly meeting. Regular
reports on progress are made to the CIP Executive Group. CIP
implementation is a standard part of the regular finance report to the
Finance & Performance Committee and Trust Board.

Backlog maintenance plans for FY12 and plans over the
Forecast Period will need to be available for analysis at Stage 2.
Finance &
Procurement
04-Oct-12
October 2012 LTFM incorporated estimated building maintenance and equipment replacement costs.

Six-facet survey completed and incorporated in February 2014 into
capital programme, LTFM and IBP. Noted by FT Programme Board
March 2014.

Management should obtain confirmation from DH regarding the
availability of the new £20m working capital loan as this forms a
key aspect of working capital going forward.
Finance &
Procurement
31-Jan-14
Liaison with SHA then NHS TDA on working capital loan. April 2014 IBP included a loan (reduced to
£10m) as part of FT application.
OUH FT application (23.4.15) includes £22.0m FT Working Capital
Loan to meet revised Monitor liquidity requirements (IBP update para
6.159). This formed part of the FT application approved by NTDA in
2014.
Ongoing to point of
authorisation
Management should review the terms of the facility offers for a
material adverse change clause to ensure the facility is
committed.
Finance &
Procurement
30-Apr-14
Advice sought and decision made not to include Working Capital Facility in 2014 FT application.

OUH FT application (23.4.15) does not envisage the Trust taking out a
Working Capital Facility (IBP update para 6.158)

H1.4.1
The Trust should consider providing more detail around
quantification of the key risks and mitigating actions in the IBP,
specifically the basis for forecast assumptions and probabilities
associated with each downside case.
Finance &
Procurement
28-Nov-12
Formed part of Risk chapter in 2012 IBP.

Details of latest assumptions are set out in the April 2015 IBP update.

H1.5.1
The role of non-voting Board members and impact in practice on Chief Executive
balance of the Board should be reviewed.
30-May-13
Board size reviewed in 2013. Voting membership of Executive Directors reduced.

Voting Board membership has formed part of the Trust's FT
application since 2013.

H2.1.1
The Trust should continue to identify development needs of the
Board and provide the necessary support.
A review has been commissioned of the knowledge, experiences and skills of Board members to
govern the organisation effectively post-authorisation.


H2.1.2
The Trust should ensure that there is an appropriate balance in
Chief Executive
Board agendas and discussion between operational and strategic
matters.
28-Feb-13
Agendas clarify items in each category and at each Board meeting. A Board member reviews and
gives feedback on the time spent on strategic and operational matters.


H2.2.1
Planned action to improve effectiveness of operation of
committees through development of work plans and increased
support should be implemented as soon as possible.
Assurance
30-Nov-12
Programme of business in place for Board and its committees.


H2.2.2
Operation of the new structure should be reviewed as it becomes Assurance
fully operational and embedded to ensure that it is operating
effectively and delivering the improvements anticipated.
08-May-13
Review in April 2013 to learn from cycles of the new committee structure. Assessment reported to
Board May 2013.


H2.2.3
The Trust should review the effectiveness in practice of holding
multiple meetings in the same day.
Assurance
08-May-13
Assessment reported to Board in May 2013.


H2.2.4
The Trust will need to ensure that areas highlighted in the BGAF
self-assessment and independent review are addressed in a
timely manner.
Assurance
H1.0.2
H1.1.1
H1.2.1
H1.3.1
H2.3.1
H2.4.1
H2.4.2
H2.4.3
H2.5.1
H2.5.2
H2.5.3
Update the LTFM to reflect the recommendations in HDD1.
OD & Workforce
Ongoing
Actions incorporated in update to Board Governance Memorandum.
Following the implementation of significant changes in
Chief Executive
governance structure and roles & responsibilities, the operation of
Executive portfolios and NED roles should remain under review.
Ongoing
The Director of Clinical Services portfolio has a wide remit and is Chief Executive
central to the many challenges facing the organisation. This
should continue to be an area of review for resilience.
Ongoing
The Trust should finalise appointment of a Trust company
Assurance
secretary.
The Trust should ensure that Non Executive Director
Chief Executive
appointments are secured for the coming year, and appointment
terms are staggered.
Effectiveness of Board meetings should continue to be an area of Assurance
focus in the new governance structure.
30-Nov-12
Planned enhancements to committee support should be
implemented to ensure improvements in effectiveness are
realised.
30-Nov-12
Assurance

Board agreement of Board Governance Memorandum in 2014 (paper
TBC2014.51).

Interim Head of Performance appointed to support Director of Clinical
Services.
Head of Corporate Governance in post.


Ongoing
NTDA appointments have taken place and Chairman and NED terms have been extended.


Ongoing
Year-end review of effectiveness of Board and sub-committees completed May 2013 and subcommittee Terms of Reference updated. Committee Handbook approved and revised report
templates issued August 2013. Report from a Director at each Board meeting to highlight
effectiveness. Mid-year review of effectiveness completed for QC and FPC, October 2013.
Forward work programme in place. Handbook developed for Committee chairs.

Page 1 of 4

Committee effectiveness review continues, with annual review under
way to report to Board in July 2015.


TB2015.62
Ref.
Appendix 1
Recommendation
Lead Director
A self-assessment exercise that incorporates the views of all
attendees and includes a review of performance against the AC
handbook and other good practice guidance should be
undertaken.
Assurance
08-May-13
Timetable for Audit Committee agreed at September meeting. Self-assessment initiated at 9/1/13
meeting through questionnaire based on national guidance. Desktop review conducted with key
messages to Audit Committee's May 2013 meeting.

Review undertaken in 2013 and further review of effectiveness
identified on 'Cycle of Business paper to February Audit Committee
(AC2015.16)' due to take place in May 2015.

The Trust should review the remit and effectiveness of the
Finance and Performance Committee following a period of
operation.
Assurance
08-May-13
Review in April-May 2013. Assessment reported to Board 8 May, individual results to FPC June 13.

Review undertaken in 2013 and further review of effectiveness
identified on 'Cycle of Business paper to April 2015 Finance &
Performance Committee (FPC2015.23)' due to take place in June
2015.

The Trust should ensure that the Quality Committee
Assurance
demonstrates effective operation with areas highlighted in the selfassessment being addressed.
08-May-13
Objectives set in September 2012. Committee review in April-May 2013. Assessment reported to
Board in May, individual results reported to Quality Committee June 2013.


The Trust will need to ensure that the revised Board Assurance
Framework is implemented in the shortest timescale possible to
allow a period of operation and embeddedness.
Assurance
31-May-13
BAF revised: to Audit Committee 14 November, Board 9 Jan 2013. BAF & Corporate Risk Register
embedded into reporting at all relevant committees. Standard Operating Procedure developed and
used.


The control of agency costs should be subject to review and a
more granular understanding of overspends developed.
Finance &
Procurement
12-Dec-12
Review complete. Reported to FPC 12 December.

Analysis of agency costs a regular feature of finance report to Board,
e.g. TB2015.30.

The Trust will need to finalise the format and content and
progress implementation of the integrated performance report in
a timely manner. A period of operation will ne required to
demonstrate effective operation and allow further refinement.
Clinical Services
28-Feb-13
Action described at H8.3.1

Integrated Performance report is standard item on Trust Board agenda
e.g. TB2015.29 and annual review of proposals for 2015/16 due to be
considered at Trust Board in May.

H3.3.1
H3.3.2
The Trust should ensure planned actions to enhance the Finance Finance &
Procurement
Report are implemented.
30-Nov-12
To FPC 15 Oct 2012.

Format of Finance report continues to evolve as required.

Development and successful implementation of SLR should
continue to be a priority for the Trust.
Finance &
Procurement
31-Mar-14
Paper to TME 24.1.2013 set strategic direction. Action continues.
Management should ensure detailed mitigation strategies are
developed and the Trust can demonstrate achievability of the
mitigation strategies should the downside business case occur.
Finance &
Procurement
28-Feb-13
The Trust should ensure arrangements for assessment of quality Finance &
impact are formalised and strengthened.
Procurement
The Trust should review the routine reporting of progress on
capital spend to the Board.
H5.1.1
H2.6.1
Due by
Progress made by May 2014
Recommendation met
by May 2014
H2.7.1
Update to May 2015
Recommendation met
by May 2015
H2.8.1
H3.1.1
H3.2.1
Partially complete
Regular SLR performance information is shared with the divisions and
the Clinical Costing Development Group (CCDG). A recent Internal
audit report on Service Line Reporting concluded that significant
assurance could be provided. The Trust is also a founder member of
the HFMA Healthcare Costing for Value Institute and participates in the
Monitor collection of PLICs data as part of the reference costs
exercise.
Ongoing
Considered by Board and Divisional Directors October 2012. Part of 2013 IBP.

Updated mitigation strategies are set out in IBP update document Risk
section (23.4.15).

28-Feb-13
CIP quality impact assessment (QIA) described in IBP and reviewed by NTDA as part of FT
application.

QIA process reviewed and strengthened, most recently following
review by Medical Director. Details of revised process set out in
QC2014.87 and in QC2015.28. The revised process covers both the
process of achieving an initial QIA as part of the approval process of
each CIP and how the ongoing impact on quality as a result of
implementing schemes is monitored.

Finance &
Procurement
30-Nov-12
To FPC 15/10/12.

Format of Finance report continues to evolve as required.

The Trust should continue to review the Financial Performance
Report to the Board and ensure it includes assessment of likely
outturn position and progress against the capital plan to date.
Finance &
Procurement
30-Nov-12
To FPC 15/10/12.
Capital reporting shows both year-to-date progress and forecast
outturn (TB2015.30).

H5.1.2
Frequency of Board meetings and timeliness of reporting to
Board on Finance and Performance.
Chief Executive
30-Nov-12
Reporting schedule in place.

H5.1.3
The Trust should continue to closely monitor progress against the Finance &
CIP schemes and ensure that action plans are put in place should Procurement
performance slip.
Weekly project board in place.

H3.3.3
H4.2.1
H4.3.1
H4.4.1
Ongoing
Page 2 of 4

Revised monitoring arrangements are in place with a weekly meeting
scheduled. A recent review of CIP by Internal Audit provided
"significant assurance with minor improvements"

TB2015.62
Ref.
Appendix 1
Recommendation
Lead Director
Due by
Progress made by May 2014
Recommendation met
by May 2014
The Trust should consider the main reason for originally planned
schemes needing to be replaced to ensure that lessons are
learned for CIP planning.
Finance &
Procurement
31-Dec-12
Reported to F&PC in paper FPC2012.15, Dec 2012
Focussed KPIs around capital spend and Treasury Management Finance &
should be introduced as the Trust moves towards Foundation
Procurement
Trust status.
31-Jul-14
Following review of KPIs in the Integrated Performance Report, systems established to report revised
KPIs from M2 reporting (to July 2014 Board) on Capital servicing capacity (as defined by Monitor),
Cumulative % Capital spend compared to plan, and Liquidity ratio (days) as defined by Monitor.
The Trust should review the Finance function following a period of
operation to ensure the new structure is appropriately resourced,
operating effectively and providing appropriate support to the
divisional structure.
The Trust should ensure review of working capital arrangements
is undertaken as planned to identify and address underlying
causes of underperformance.
Finance &
Procurement
30-Jun-13
Review commissioned and report received. Report on support to Divisions enacted, strengthening
support arrangements.
Finance &
Procurement
30-Nov-12
Plan to improve performance on debtors and creditors and report to Audit Committee.
The appropriateness of reporting results as a single segment
should continue to be agreed with the auditor, especially given
the merger with the Nuffield Orthopaedic Centre.
The process of developing a Treasury Management Policy should
be concluded in preparation for FT status.
Finance &
Procurement
13-Mar-13
Accounting Policy considered at Audit Committee 13.3.13 and single segment agreed.

Date of
Draft Treasury Management policy agreed by TME in November 2013. Ready for approval by Audit
authorisation Committee as FT authorisation date becomes clear.
Partially complete
The Trust should ensure that the budget setting process is
aligned with the LTFM.
Finance &
Procurement
31-Mar-13
Paper to 24/10/12 TME set aligned budget setting process for 2013/14.

Budget setting is aligned with the LTFM and the 2015/16 budgets are
set from the LTFM adjusted for subsequent contractual agreements
and planned activity.

H6.4.1
The Standing Orders and SFIs should be updated as necessary
for recent changes in committee structures.
Finance &
Procurement
09-Jan-13
Requested by Audit Committee and completed by 14/11/12 Audit Committee meeting. Board
approval 9 January 2013.

Standing Orders & SFI's updated annually in January. Latest update
set out in TB2015.15.

H6.5.1
The Trust should ensure that the findings of Internal Audit reviews Finance &
are appropriately addressed, and that it works with the new
Procurement
Internal Audit Provider to identify areas of weakness in controls
and ensure that those are rectified on a timely basis. This should
enable the Trust to improve its overall HoIA opinion received.
28-Feb-13
Revised arrangements in place with KPMG / Audit Committee

Robust working arrangements established with KPMG and latest Head
of Internal Audit opinion (as set out in AC2015.20) states that
significant assurance with minor improvements can be given on the
overall adequacy and effectiveness of the organisations framework of
governance, risk management and control.

H7.1.2
The Trust should ensure that timescales agreed with internal
audit around reporting are met.
Finance &
Procurement
28-Feb-13
Revised arrangements in place with KPMG / Audit Committee

Performance KPIs for 2014/15 set out in Internal Audit Annual Report
(AC2015.20)

The Trust should ensure that the timeliness of working papers
issues identified by external audit are rectified as the finance
team becomes more embedded.
Finance &
Procurement
22-Apr-13
Monthly meetings instituted between finance dept. and audit leads. Draft accounts submitted on 22nd
April 2013.

Regular meetings continue to be held with External Audit as part of the
Annual Accounts process.

H7.1.3
There should be a continued focus on ensuring agreed actions
are implemented on a timely basis.
Finance &
Procurement
Ongoing
See actions on H7.1.1 and H7.1.2

Management focus on this issue has been maintained and regular
reports are made to Executive Directors and to the Audit Committee
(e.g. AC2015.27)

H7.1.4
The Trust should continue to develop its Integrated Performance Clinical Services
Report and ensure it is constantly reviewed to ensure appropriate
focus on the key areas of concern for the Trust.
Ongoing
IPR in place. Developments commissioned by Board. Action shown at H8.3.1

IPR a regular Board item and annual review of indicators considered
by TME as set out in TME2014.127.

H8.1.1
The Trust should ensure that action plans to address
underperformance against targets are closely monitored and
action is taken where the desired impact is not being achieved.
Finance &
Procurement
Ongoing
Monthly and quarterly performance reviews take place.

Regular Performance review meetings continue to take place.

H8.1.2
The Trust will need to ensure data quality concerns following
EPR implementation are addressed in a timely manner.
Planning & Information
Data quality assurance framework rolled out for all KPIs. Data quality monitoring structures
established in all Divisions. EPR stabilisation project conducted. Internal audit review of data quality
arrangements reported to Audit Committee May 2013 and provided 'significant assurance' rating.


Update to May 2015
Recommendation met
by May 2015
Regular reports are made to Finance & Performance Committee
including a review of the outturn position (FPC2014.25)

Revised KPIs agreed for 2014/15 focussing on Continuity of Service
rating and Capital Plan

Divisional Structure revised in November 2013 with a reduction from 7
to 5 divisions. Finance Structure amended to ensure each of the five
Divisions had a Senior Business Partner and appropriate support.

Current LDP (23.4.15) indicates that trade receivables and inventories
are forecast to remain broadly consistent and constant over the period
whilst trade payables days will reduce as the impact of increasing the
use of purchase orders and other changes takes effect.

Accounting Policy regularly reviewed as part of the Annual accounts
process, most recently in AC2014.74 which addresses segmental
analysis at para 20.
policy approved by Trust Board in January 2015 (TB2015.16) for
implementation when authorised.

H5.1.4
Partially complete
H5.2.1
H6.1.1
H6.1.2
H6.2.1
Finance &
Procurement


H6.3.1
H7.1.1
H8.2.1
30-May-13
Page 3 of 4

TB2015.62
Appendix 1
Ref.
Recommendation
Lead Director
The Integrated Performance Report should include more
consideration of forecast performance and should also include
factors impacting on future performance and risks identified.
Clinical Services
30-Nov-12
Revised format of Integrated Performance Report contained this from 1 November 2012.


H8.3.1
Management should consider implementing formal scheduled
data recovery testing.
DPI
31-Dec-12
The Trust restores data every week from its back-up solutions. A monthly restore of a complete
system has been run since 1/12/12 to ensure that system restore procedures are robust.


H9.1.1
31-Aug-13
Six-facet survey complete and incorporated in February 2014 into capital programme, LTFM and IBP.
Noted by FT Programme Board March 2014.


Management should update the LTFM to reflect updated backlog Development and the
Estate
H10.1.1 maintenance plans once condition survey has been completed.
Management should update the LTFM and IBP to reflect the
Finance &
H10.1.2 availability of the new £20m [liquidity] loan once confirmation has Procurement
Due by
Progress made by May 2014
Recommendation met
by May 2014
Liaison with SHA then NHS TDA on working capital loan. April 2014 IBP included a loan (reduced to
£10m) as part of FT application.
been received from the SHA.
Page 4 of 4
Update to May 2015
OUH FT application (23.4.15) includes £22.0m FT Working Capital
Loan to meet revised Monitor liquidity requirements (IBP update para
6.159). This formed part of the FT application approved by NTDA in
Recommendation met
by May 2015
Ongoing to point of
authorisation