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Board of Directors (Public)
Date: Wednesday 1st October 2025
Time: 2:00pm – 5:00pm
Location: Post Graduate Lecture Theatre, North Manchester General Hospital
Items marked with an asterisk have been discussed at the relevant Board Committee
Agenda
Item
Purpose
Lead
Time
1.
Apologies for absence & confirmation of quoracy
(verbal)
Meeting
admin
Trust Chair
2.
Declaration of interest (verbal)
Meeting
admin
Trust Chair
3.
Patient Story
4.
Minutes of the previous meeting (30th July 2025)
Meeting
admin
Trust Chair
5.
Action Log
Discussion
Trust Chair
6.
Matters Arising
Discussion
Trust Chair
7.
Trust Chair’s report (verbal)
Discussion
Trust Chair
8.
Trust Chief Executive’s report
Discussion
Trust CEO
9.
Assurance Reporting
9.1
Integrated Performance Report*
Discussion
Executive
Directors
10
Strategic aim 1: Work with partners to help people live longer, healthier lives
10.1
Research, Innovation and Population Health Board
Committee (10/09/25) escalation and assurance report
Discussion
NED (AB
10.2
Strategic Developments
Discussion
Acting CSO
10.3
MFT Strategy Review
Discussion
Acting CSO
11
Strategic aim 2: Provide high quality, safe care with excellent outcomes and experience
11.1
Quality, Safety and Performance Board Committee
(03/09/25) escalation and assurance report
Discussion
NED (DR)
11.2
Mortuary Report*
Discussion
Deputy CEO /
CNO
11.3
Annual Medical Revalidation Report and Annual
Organisational Audit (Satement of Compliance)*
Discussion
JCMO
11.4
Learning from Deaths*
Discussion
JCMO
11.5
Management of Never Events*
Discussion
Deputy CEO /
CNO and
JCMO
11.6
EPRR Core standards statement of compliance*
• MFT Business Continuity Policy*
• MFT EPRR Policy*
Discussion
CDO
11.7
Improvement Strategic Delivery Plan
Discussion
CDO
11.8
Update on the pathology collaboration
Discussion
Acting CSO
12
Strategic aim 3: Be the place where people enjoy working, learning and building a career
12.1
People Board Committee (03/09/25) escalation and
assurance report
Discussion
NED (AA)
12.2
Safer Staffing Report (nursing) *
Discussion
Deputy CEO /
CNO
12.3
Safer Staffing Report (midwifery and newborn services)*
Discussion
Deputy CEO /
CNO
13
Strategic aim 4: Ensure value for our patients and communities by making best use of
resources
13.1
Audit and Risk Committee (16/09/25) escalation and
assurance report
Discussion
NED (NG)
13.2
Finance Board Committee (26/08/25) escalation and
assurance report
Discussion
NED (TR)
13.3
Digital and Estates Board Committee (09/09/25)
escalation and assurance report
Discussion
NED (SL)
13.4
Chief Finance Officer’s report*
Discussion
CFO
14.
Any Other Business (verbal)
Discussion
Trust Chair
15.
Meeting Evaluation (verbal)
Meeting
admin
Trust Chair
Date of next meeting: Wednesday 26th November 2025 at 2:00pm, Wythenshawe Hospital
Agenda Item 4
Board of Directors
(Public)
Wednesday 30th July 2025
Present:
Trust Non-Executive Director
Interim Deputy Chief Executive
Trust Non-Executive Director
Trust Chair
Trust Chief Executive
Trust Non-Executive Director
Trust Non-Executive Director
Joint Chief Medical Officer
Chief People Officer
Joint Chief Medical Officer
Trust Non-Executive Director
Interim Deputy Chief Executive/
Chief Nursing Officer
Chief Digital and Information Officer
Chief Finance Officer
In
attendance:
Deputy Trust Board Secretary
Director of Performance and Planning
1.
Apologies for absence and confirmation of quoracy
Apologies were received from Ashley Blom, Vanessa Gardener, Nick Gomm, Mark Gifford,
Sam Liscio, Tom Rafferty and Trevor Rees.
2.
Declarations of Interest
No interests were declared.
3.
Patient Story
KSJ introduced the patient story which described the experiences of several patients,
belonging to the same family, who had been referred to different services across the Trust.
Several challenges were experienced by each patient with improvements being made in
response to their complaints raised, specifically in relation to communications, triage
processes and referral pathways.
page 1
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted
the patient story.
None
n/a
n/a
4.
Minutes of previous meeting held on 21st May 2025
The minutes of the Board of Directors’ (Board) meeting held on the 21st May 2025 were
approved as a true record of the meeting.
5.
Action Log
Check consent to publish
names of staff members
with pictures included in
the plan.
TRa
Complete
Audit and Risk Committee
to further review the SFIs
and SoD in April 2025.
NGo
Ongoing – to assess impact of the new NHS 10-
year plan, added to work plan for February 2026
meeting.
6.
Matters arising
There were no matters arising.
7.
Trust Chair’s Report
KC provided an update on matters of interest which have taken place since the last Board
meeting:
•Professor Ashley Blom has been appointed as the Trust’s Non-Executive Director
for the University of Manchester and started in post on 1st July 2025, replacing
Professor Luke Georghiou. Ashley’s clinical and research background will
complement the Board’s skill set with his key Non-Executive Director duties
including chairing the Trust’s Research, Innovation and Population Health Board
Committee.
•Thanks and appreciation were forwarded to Dr Damian Riley who will be stepping
down from his role as Trust Non-Executive Director over the coming months. The
Council of Governors’ Remuneration and Nominations Committee supported the
recruitment process to replace Damian, with the Council of Governors formally
approving the appointment of a new Non-Executive Director at their general
meeting in July 2025.
•At the invitation of the Secretary of State for Health (Wes Street), several Senior
Leaders (Kathy Cowell, Kimberley Salmon-Jamieson and Kathy Murphy) recently
attended a Maternity and Neonatal summit to learn more about the work being
undertaken to tackle underlying challenges.
•Professor Duncan Ivison (President and Vice Chancellor) at the June 2025
Manchester University Assembly Meeting presented the University’s 10 Year
Strategy with key elements including the collaborative working with the Trust and
Greater Manchester partners.
page 2
• A Caribbean and African Health Network event was held in July 2025 to celebrate
Black Healthcare staff with three Trust colleagues receiving awards.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted
the Trust Chair’s
report.
None
n/a
n/a
8.
Trust Chief Executive’s Report
MC introduced the Trust Chief Executive’s report and drew attention to:
• The Government’s new 10-Year Health Plan has recently been released (July
2025) with the Trust’s Strategy aligning with several key elements. A refresh will be
undertaken to further align and update the Trust’s strategy over the coming weeks
which will include engagement with staff, members and wider networks. The new
plan builds on the work that has been progressing across the Greater Manchester
conurbation and provides an opportunity for both transformation and innovation
across the wider NHS landscape.
• The disaggregation programme of work as part of the Pennine Acute Hospital Trust
dissolution process has neared completion with good engagement work between
the Northern Care Alliance and the Trust being progressed over the duration of this
process. Thanks and appreciation were forwarded to the teams involved in the
successful achievements made to date, with work being taken forward in relation to
the remaining Colorectal service over the coming months.
• Thanks and appreciation were forwarded to Trust colleagues who provided cover
over the recent resident doctors’ industrial action period. The learning from
previous industrial action periods supported the development of robust plans which
sustained patient safety alongside a significant number of services continuing
under business as usual arrangements to ultimately minimise disruption.
• Winter planning (2025/26) arrangements have been brought forward with
acknowledgement being given to the teams involved in supporting this programme
of work.
• Three Trust colleagues have recently been recognised in the King’s Birthday
Honours list specifically, Mark Gifford, Kathy Murphy and Professor Andrew
Rowland.
• Recent new leadership team appointments to the Trust include the Director of
Communications and Engagement. In addition, leadership team departures over
the coming months will include the Director of Research and Innovation and the
Joint Chief Medical Officer with tribute being forwarded to the contributions that
these colleagues have made to the Trust.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted
the report.
None
n/a
n/a
9.1
Board Assurance Framework (BAF)
DB introduced the Board Assurance Framework for July 2025. He drew attention to:
• Future Board Assurance Framework reports will be received at alternating Board of
Directors’ Meetings specifically July, November and March. In addition, the Trust’s
strategic and corporate risks will also be reviewed at each Board Committee.
page 3
• New actions relating to the Interim Deputy Trust Chief Executive/Chief Nursing
Officer’s portfolio since the Trust’s Quality, Safety and Performance Board
Committee have been captured in the report.
KC highlighted the work undertaken to develop the Trust’s Board Assurance Framework
with attention being drawn to the presentation format of the report which supports
colleagues in triangulating information/data across various sources. MC outlined the day-
to-day use of the Board Assurance Framework to support the Trust’s operations.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted
the report.
None
n/a
n/a
9.2
Integrated Performance Report (IPR)
Trust Executive Directors introduced the sections of the IPR relevant to their portfolios.
KSJ drew attention to:
• Improvements have been seen in relation to Duty of Candor cases in July 2025,
which is more evident in the Clinical Scientific Services Clinical Group. Monitoring
continues through the Trust’s Quality, Performance and Safety Committee and
associated sub-board Committee.
• Six MRSA bacteraemia incidents have occurred with deep-dives being undertaken
to determine themes and corresponding infection control actions going forward.
Clostridioides difficile incidents are reducing with antimicrobial and gram-negative
plans supporting this programme of work.
• Improvements across a number of maternity metrics have been achieved, with
some improvements also being realised across the remaining advise assurance
related metrics including caesarean sections cancelled on day, and triage at 15
minutes with work ongoing to further improve these positions going forward.
• Safeguarding training level 3 in children and adults has an improving position with
plans in place to achieve this standard.
• For the Mental health compliance metric, four patients did not have conversations
within designated timeframe with a review confirming that the safety of these
patients was not compromised.
• Friends and Family tests in the Trust’s Emergency Care Departments has revealed
waiting times as a key improvement theme with work being undertaken to
determine supporting key factors to inform the development of robust plans going
forward.
• Focus continues around each sepsis metrics with the oversight and monitoring
continuing at the Trust’s Quality, Performance and Safety Board Committee with
additional focus and improvement works being progressed via the Trust’s Quality
and Safey Clinical Groups.
SM drew attention to:
• Five never events have occurred over the past year and whilst no patient harm has
occurred, improvement alongside key learning is required going forward. Patient
safety investigations are underway which will conclude over the coming weeks with
outcomes being reported through the Trust’s governance systems with a Swartz
Round being held focused on the key learning.
• Whilst progress has been made against the venous thrombo-embolism (VTE)
target compliance, the Trust’s current position is to be improved upon. Attention
page 4
was drawn to data quality issues for the Specialist Hospitals Clinical Group relating
to children’s data recording. Learning, to rectify this issue, is being progressed via
collaborative working with Guys and St Thomas’s Hospital. VTE dashboards are
underdevelopment with further improvements being anticipated over the coming
months.
• Learning from deaths improvement works include process standardisation with
discussions being held with Coroners to determine key areas of learning. The new
Joint Chief Medical Director will support this programme of work going forward.
RB drew attention to:
• Improvements have been realised around the Trust’s Elective Referral to Treatment
metric resulting in a reduction in longest waits for elective treatments alongside
cancer delivery improvements in comparison to last year.
• Further work is being taken forward to support improvements across the Trust’s 18-
week wait performance delivery programme.
• The Trust continues to deliver against the activity levels, diagnostic waits,
community waiting lists, specifically in podiatry and musculo-skeletal services.
• Emergency Department performance is lower than the target rate with
improvements being progressed as part of the Trust’s Winter Plan initiatives.
• Whilst achievements against the stroke 4-hour access standard have been made,
further improvements are required to reach the compliance rate.
MN drew attention to:
• Whilst achievement against a variety of measures has been sustained including
vacancy establishment against plan for the medical workforce and mandatory
training level 1, sickness absence improvements, whilst being seen over the past 3
months, the sustained delivery of this key programme of work will be challenging
going forward.
• Mandatory training levels 2 & 3 alongside appraisal target compliance rates have
seen some improvements, with further work to be progressed to achieve targets.
• Temporary staffing including bank and agency have seen additional controls and
governance processes put in place to reduce numbers.
MC highlighted the robust monitoring that is undertaken by Senior Leaders and Clinical
Groups to ensure progress is made to achieve compliance against all constitutional
standards/targets. Attention was drawn to the work that has been undertaken to improve
understanding of staff sickness absence, appraisal and mandatory training compliance
factors to drive forward improvements.
CW drew attention to:
• An amber warning for sickness absence which is having an impact on bank/agency
staffing usage/costs.
• Three other areas of alert are:
Capital which was under plan during Q2 however has recently balanced out.
Cash preservation initiatives are being stepped up with regular oversight/monitoring
being undertaken as part of weekly Cash Committee meetings with good progress
being made over the past few weeks.
Value for Patients (VfP) non-recurrent savings during month 2 has seen 67% being
delivered. In addition, 50% of recurrent savings have been delivered to date with
100% of VfP initiatives being identified with supporting plans in place. Good
progress is being made to achieve delivery against all these initiatives/plan to date.
DB highlighted that the areas of underperformance across the Integrated Performance
Report are recorded in the Trust’s Board Assurance Framework with robust oversight and
monitoring being undertaken via the Trust Risk Oversight Committee and Trust Leadership
page 5
Team Committee. The active management of each risk is progressed as part of the
relevant Management Committee.
KC highlighted the importance of the Integrated Performance Report and Board Assurance
Framework in cohesively linking together to provide the Trust’s key risks and assurance
information. From these reports key areas of focus are determined, with progress updates
being fed into relevant Board Committees. The new report formats and training
undertaken to gain sound understanding was outlined with a dedicated Integrated
Performance Report training session being delivered to Governors in September to
support their learning and development.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report and the
performance
assurance provided.
None
n/a
n/a
10.1
Research, Innovation and Population Health Board Committee (22/05/25)
escalation and assurance report
MB introduced the report and drew attention to:
• Greater Manchester has put itself forward to be a prevention demonstrator as part
of the Government’s new 10 Year Plan through the Local Care Organisations and
Integrated Neighbourhood Teams with alignment with the Live Well agenda.
• Progress against the socio-economic duty/objectives are being regularly reported
following the Trust’s support to proactively comply with this process.
• Progress is being made against the Trust’s Green Plan.
• The Trust has a complete suite of National Institute for Health and Care Research
(NIHR) infrastructure which supports the Trust in driving forward the Research and
Innovation agenda.
• Citizens Advice work that has been supported by the Trust has realised £10m of
benefits for patients over the past 12 months.
MC highlighted the establishment of Integrated Performance Report (IPR) metrics for
Research and Innovation alongside this new committee which builds upon and supports
the progression of this key area of work, including clinical trials and future direction. A
further update will be provided at the next Board of Directors’ Meeting.
MB highlighted the benefits of the Committee’s work around linking the Research and
Innovation Strategy to the Population Health agenda, with acknowledgement being given
to the strategic focus around clinical trials.
CMcL highlighted the positive step change over the recent months that the Committee has
driven around the population health agenda which will support the tackling health
inequalities programme of work and ultimately residents across Manchester and the wider
Greater Manchester conurbation, with the strategic alignment across the ‘Live Well’
agenda being outlined.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report.
Update around the
Research & Innovation
programme/clinical trials
Sohail
Munshi
October 2025
page 6
including
national/international
contributions to be provided
to the next Board of
Directors’ Meeting.
10.2
Strategic Developments
DB introduced the report which summarised national, regional/local, and MFT strategic
developments. DB drew attention to:
• The Government’s new 10-Year Plan whilst ambitious is aligned with the Trust’s
Strategy with a refresh being undertaken to take forward the key elements.
• Work is being undertaken to ensure appropriate measures/metrics are being
captured and plans recalibrated to support key Greater Manchester plans,
specifically the Oversight Framework and the Urgent and Emergency Care Plan.
• The Penny Dash report findings/recommendations have been reviewed which look
to simplify the quality and safety landscape. Key recommendations around the
National Freedom To Speak Up Guardian with attention being drawn to the
supporting service that the Trust has in place.
• The NHS Greater Manchester Integrated Care System new model as a strategic
commissioner was highlighted.
• The collaborative working between the Trust’s Clinical Scientific Services Clinical
Group and the Northern Care Alliance in relation to Laboratory Services was
outlined. The majority of pathology services are collectively delivered by these
organisations with further collaborations being determined around the delivery of
faster turnarounds and higher quality services which ultimately may benefit other
organisations going forward.
AA and DB highlighted the Trust’s Freedom to Speak Up arrangements in place,
specifically the regular meetings that are held between the Executive Freedom to Speak
Up lead (DB), Non-Executive Freedom to Speak Up led (AA) and the Trust’s Freedom to
Speak Up Guardian (Andrew Lloyd). The Board of Directors’ support around this key area
of work is regularly fed back to the Trust’s Freedom to Speak Up Champions. KC
emphasised the importance of the Freedom to Speak Up service to support staff in raising
concerns.
MC highlighted the number of national plans that have been published/trailed recently with
further detail anticipated around the Government’s new 10-Year Plan and the likely
Foundation Trust application process. A more detailed update will be provided at a future
Board Seminar.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report and the
updates in relation to
strategic
developments
nationally, regionally
and across
MFT.
The new FT application
process/10-Year Plan
programme of work to be
brought to a future Board
seminar.
Darren
Banks/
Nick Gomm
February 2026
11.1
page 7
Quality, Safety and Performance Board Committee (25/06/25) escalation
and assurance report
DR presented the escalation and assurance report from the Quality, Safety and
Performance Board Committee (QSPBC) held on the 25/06/25. DR drew attention to:
• The Quality, Performance and Safety metrics incorporated in the Trust’s Integrated
Performance Report are scrutinised at each Committee meeting with deep dives
being undertaken to take forward areas requiring improvements.
• Alert areas included:
o Creation of governance arrangements for those areas that have departed
from national standard governance/guidance for example robotic surgery,
triage model etc.
o Clinical audit data submission improvement work is being progressed with a
further update being planned going forward.
• Advise areas included:
o Eye Hospital patient waiting times are reducing.
o Greater Manchester Integrated Care Board trauma review plans are under
development with the importance of interdependencies with other services
being considered as part of the planning process.
o Peer reviews have been undertaken recently around the Patient Safety
Framework and the Mersey Care Mental Health review.
o An update was received around the new mortality portal.
• Assurance areas included:
o Improvements around the 62-day cancer waiting times.
DR also noted that the following reports on the Board of Directors’ agenda (items 11.2,
11.3, 11.4, 11.5 and 11.6) had been discussed at the QSPBC meeting in detail.
DB highlighted that the Greater Manchester Integrated Care Board trauma review has
recently arranged some broader clinical workshops with the Trust’s Clinicians being invited
to actively contribute/outlined the interdependencies of other services.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report.
None
n/a
n/a
11.2
Annual Safeguarding Report
KSJ introduced the report which provided an overview of safeguarding governance,
activities, and assurance within MFT for the year 2024/25. The report had been discussed
in detail at the QSPBC in June 2025. KSJ drew attention to:
• Report provides significant assurance that multiple professionals across the
safeguarding arena are actively collaborating with the report being shared across
Greater Manchester partners and safeguarding boards.
• Evidence of high-quality safeguarding documentation and timely child protection
safeguarding meetings with consistent attendance of safeguarding leads.
• 42,000+ safeguarding referrals have been received over the 12-month period which
is an increase from the previous year at 38,000.
page 8
• The key areas of safeguarding concerns are around neglect and self-neglect with
other factors around mental health and domestic abuse being outlined. Around
47% of children live below the poverty line.
• Circa. 10 very serious safeguarding cases are received per week with support
provided by senior nursing and other colleagues for each of these cases.
• 28 out of the 33 standards have been met in this report with plans being put in
place to support delivery of and achieve the remaining 5 standards (currently
partially met). Progress against the safeguarding improvement plans is being
undertaken via appropriate Sub-Board Committees.
DR congratulated the Safeguarding Team for the work and report completed. Attention
was drawn to the report findings which highlighted the rise in safeguarding concerns in
cases where learning disabilities are found, with reasonable adjustments being put in place
(for 94% of cases), the rise in staff undertaking the Oliver McGowan training alongside the
rise in staff undertaking level 3 mandatory training which were all cited as being positive
improvements to support this key area of work.
CMcL highlighted the Safeguarding Effectiveness Committee and the thoroughness of
work undertaken, when reviewing and monitoring performance against each safeguarding
case.
KC highlighted the safeguarding priorities for 2025/26. KSJ confirmed that the
safeguarding priorities are mapped against various strategies alongside safeguarding
workshops being held focused on the 2025/26 priorities. A date typo was highlighted
which would be rectified going forward.
TO highlighted the length of time taken to undertake level 2 and 3 safeguarding training
with new arrangements being made for resident doctors (including rotational) having
dedicated time allocated to complete this key training.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report and the
assurance provided
that the Trust is
meeting expected
statutory and
regulatory
standards.
The Board of
Directors
acknowledged the
continuous
improvement work of
the Safeguarding
team and Clinical
Groups
to ensure the Trust
recognises and
responds effectively
to safeguarding
concerns.
The Board of
Directors supported
None
n/a
n/a
page 9
the safeguarding
work programme to
continuously deliver a
person-centred high-
quality safeguarding
response to people at
risk of or experiencing
abuse and neglect.
11.3
Annual Complaints Report 2024/25
KSJ introduced MFT’s Annual Complaints Report for 2024/25 which had been discussed in
detail at the QSPBC in June 2025. KSJ drew attention to:
• There has been an overall reduction in complaints alongside an improved position
in relation to the complaint response/resolution process, over the past year.
Further improvement work is to be undertaken over the coming year with plans
being put in place to progress this.
• The Trust’s Complaints Review Scrutiny Group has been strengthened with the
Interim Deputy Chief Executive/Chief Nursing Officer taking the role as Chair of this
key group with expertise/support from NG as the Non-Executive lead. A
strengthened/renewed focus for the group is around the learning/sharing of key
complaints findings across the Trust.
• PALs and Complaints management processes have been strengthened around the
collection of Equality and Diversity information alongside implementing changes to
improve the accessibility of service with further work being undertaken around the
complaints to be in keeping with the new 10-Year Plan.
• External assurance around the Trust’s complaint handling process has been
received following a review by the Trust’s Internal Auditors (KPMG).
NG confirmed that the strengthening of the Trust’s Complaints Review Scrutiny Group has
been positively received as a way of improving the sharing of learning across the Trust.
KSJ outlined the support provided by Senior Leaders to progress/effect change.
SM highlighted that the largest proportion of complaints was related to administration staff
and out-patient appointments with actions being taken forward to address issues. DR
highlighted the importance of having appropriate escalation processes in place to support
staff to highlight service pressures.
MN and KSJ highlighted potential models to support patient feedback in terms of
compliments and challenges with work being progressed to explore options going forward.
AA sought clarification around the plans in place for AI opportunities in the complaint
handling process with the importance of ensuring appropriate staff interactions/empathy is
also sustained going forward. KSJ highlighted that the NHS currently does not have any
AI assistants in place around the Trust’s complaints processes, with clear parameters
needing to be put in place alongside the appropriate staff interactions, before an AI agent
programme was developed. DW confirmed that currently there are not plans in place to
develop AI agents to support the Trust’s complaints process however benefits to patients
could be realised around the tracking of complaints with any future developments being
codesigned with patients.
TO highlighted the importance of learning and development feedback from complaints
alongside staff being empowered to share improvement ideas. The appointment of a new
Director of Improvement was highlighted as being a key driver around
improvement/support these areas going forward.
page 10
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report and
understood the
performance
achieved via the
PALS and Complaints
processes. The
Board of Directors
recognised the
continuous
improvement work of
the Central PALS and
Complaints
Department
and Clinical Group
teams, to ensure that
MFT is responsive to
concerns and
complaints to meet
regulatory
compliance.
The Board of
Directors supported
the approach to
promote MFT wide
learning from
complaints and
PALS.
None
n/a
n/a
11.4
Annual Patient Experience Report
KSJ introduced MFT’s Annual Patient Experience Report for 2024/25 which had been
discussed in detail at the QSPBC in June 2025. KSJ drew attention to:
• 33% increase in completion rates for the Trust’s ‘What Matters to Me’ patient
survey. The format of the survey is being updated to enable more real-time data to
be collected.
• Engagement with patients has grown significantly over the past 12 months as a
result of the Bee Involved/Bee Brilliant programme. Coproduction training/service
redesign improvement work and roll out has been progressed with Clinical Groups.
• Patient inclusivity and experience improvements are being progressed, with the
Trust’s Interpretation and Chaplaincy services seeing increases in take up and
accessibility arrangements are also being strengthened.
• A comprehensive volunteers review is being undertaken with updated
arrangements being developed around the volunteer recruitment process with an
outcome report being taken to the Trust’s People Board Committee.
• As part of the new NHS 10-Year Plan, a key element is around patient experience
with further updates being taken to the Trust’ Quality, Performance and Safety
Committee.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report and formally
None
n/a
n/a
page 11
acknowledged the
2024/25 Patient
Experience Report,
recognising the
significant work
undertaken and the
progress made in
strengthening MFT’s
approach to
experience of care.
The Board of
Directors supported
the priorities for
2025/26, which are
designed to further
embed patient
experience
insight into care
quality improvement
and strategic delivery.
11.5
Annual Infection Prevention and Control Report
KSJ introduced MFT’s Annual Infection Prevention and Control (IPC) Report for 2024/25
which had been discussed in detail at the QSPBC in June 2025. KSJ drew attention to:
• Improvements in relation to some organisms were outlined with challenges around
Clostridioides difficile infections being highlighted and plans being progressed to
take forward improvements in alignment with antimicrobial prescribing. The CQUIN
target was met in relation to Intravenous oral antibiotic switching.
• Cleaning review and associated action plans have been developed with the Clinical
Groups implementing these plans and oversight being undertaken at the Trust’s
Infection Prevention and Control Committee. A second cleaning review has been
commissioned going forward.
• Decontamination training alongside oversight structures have been put in place
which have had a positive impact on the Trust’s Infection Prevention and Control
programme.
DR highlighted that at the recent Quality, Safety and Performance Board Committee, there
was a deep dive into the Trust’s antimicrobial stewardship, specifically augmenting Co-
amoxiclav, with positive improvements being seen around reducing Clostridioides difficile
infections.
MC highlighted the importance of the antimicrobial framework, alongside the day-to-day
infection prevention and control regimes to make improvements around this key area, with
acknowledgement being given to KSJ and team in progressing this programme of work.
Further initiatives are being taken forward to make further improvements going forward.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
information provided
in the Executive
Summary, and
accepted the Infection
Prevention and
None
n/a
n/a
page 12
Control Annual
Report for 2024/25.
11.6
2025/26 MFT Winter Plan
RB introduced the report which outlined MFT’s preparations and operational approach for
the winter period 2025/26. The report had been discussed in detail at the QSPBC in June
2025. RB drew attention to:
• The early submission of the Winter Plan (2025/26), with initial development started
following the last winter period to pick up learning, with early submission permitting
additional time to ensure robust/detailed operational planning arrangements are put
in place.
• An evaluation against the national Urgent and Elective Care Plan has been
undertaken with areas of strength being identified alongside areas of improvement.
• The plan has been developed based on assumptions with associated risks and
mitigations being put in place.
• A focus of the plan is to increase the vaccination of staff by circa. 5% which
equates to 1500 more staff alongside protecting the Trust’s elective patient
programme to ensure delivery of the 18-week target and eliminate long waits
across the Trust.
• Regular stress testing of the plan will be undertaken going forward as part of the
Trust’s elective preparedness, resilience and response arrangements with any
identified changes being progressed in readiness of the winter months.
KC acknowledged the efforts of key Trust staff/teams in developing the winter plan earlier
in the planning cycle.
AA sought clarification around the violence and aggression prevention working group in
the winter plan, specifically if is the same reference group that is supporting compliance
against the updated NHSE violence prevention and reduction standard. In addition, further
detail was requested around the plans in place to engage seldom heard/BAME groups with
the Trust’s vaccination programme. RB confirmed that the violence and aggression
prevention working group is the same reference group that is working to improve
compliance against the NHSE standards. Confirmation was also provided that the Trust’s
vaccination programme includes various initiatives to encourage uptake across groups
including staff administering vaccinations direct in departmental locations alongside
educational awareness campaigns. MN highlighted the current vaccination hesitancy that
is being experienced nationally as well as internationally with a risk around the
achievement of an additional 5% uptake being highlighted. Confirmation was also
provided that the Trust’s violence and aggression prevention group meets regularly to
progress compliance against the NHSE standards alongside supporting/progressing the
associated programme of work. KC highlighted opportunities to support BAME groups
through connections with Caribbean and African Health Network and the Trust’s Chaplains
Service with key updates around the vaccination programme being reported to the Trust’s
People Board Committee.
MC acknowledged the Trust’s Winter Plan which was cited as being comprehensive and
the best plan developed to date. Alongside vaccine hesitancy in staff and patients,
another key factor is around the respiratory syncytial virus (RSV) vaccine for children, with
additional support from primary care colleagues being required going forward. Innovative
work across the urgent care pathway was highlighted which would be tested over the
forthcoming winter months with resilience supporting the delivery of planned improvements
going forward.
DB highlighted that the Trust’s Winter Plan requires system-wide support including the
Manchester and Trafford Local Care Organisations, primary and social care, Greater
page 13
Manchester Mental Health etc. all working collectively to develop robust winter plans that
support the delivery of health services throughout the challenging winter months ahead.
KC drew attention to the Winter Plan Communications and specifically the public
messaging outlined around OPEL 3 & 4 with the request being made to review/make the
different messages clearer to the public. RB highlighted that recent collaborative working
with the Manchester and Trafford Local Care Organisations had highlighted the need to
improve public messaging including incorporating associated health inequalities initiatives.
MB sought clarification around the mechanisms in place to support winter replanning
arrangements if assumptions prove incorrect going forward. RB highlighted the scenario
testing that will be undertaken in September 2025 which will work through a series of key
risks to test the effectiveness of the mitigation plans developed. KSJ highlighted the step-
up procedures that are available to support changing influenza strains that may present
over the winter months.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report and approved
the Trust’s winter
plan.
The Trust’s Winter Plan
communications/public
messaging re; OPEL 3 & 4
to be relooked at to make
differences clearer to the
public.
Rachel
Burnham
October 2025
12.1
People Board Committee (25/06/25) escalation and assurance report
AA presented the escalation and assurance report from the People Board Committee
(PBC) held on the 25/06/25 and drew attention to:
• An update around the Trust’s compliance against NHSE’s Violence Prevention and
reduction standards was reported.
• The work progressed by the Trust’s Head Freedom to Speak Up Guardian
(Andrew Lloyd) to increase the number of Freedom to Speak Up Champions from
30 to now have around 160 Champions (recruited over the past 18 months).
• The Trust’s Employee Health and Wellbeing Report (2024/25) was received with
the quality standard being sustained around the Trust’s Occupational Health
Services.
• An action plan has been developed to progress improvements following the recent
General Medical Council (GMC) survey findings around the Obstetrics and
Gynaecology training curriculum/rotas at North Manchester General Hospital.
Monitoring around the action plan will be supported by the People Board
Committee.
TO confirmed that the GMC has applied enhanced monitoring with conditions around the
Trust’s training programme specifically rotas and resident doctors’ training experiences at
North Manchester General Hospital.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report.
None
n/a
n/a
page 14
12.2
Safer Staffing report (nursing)
KSJ introduced the Bi-monthly Safer Staffing Report (Nursing) report which included the
bi-annual Safe Nurse Staffing Establishment Review. The report had been discussed in
detail at the PBC in June 2025. KSJ drew attention to:
• The Trust is compliant with national guidance in relation to safer staffing for
nursing.
• The Trust-wide average Care Hours Per Patient Day level is 9.4 hours per patient
against a Shelford Group average of 9.7 hours, indicating that the Trust’s staffing
levels are at a very safe position.
• The biannual ward safer nursing care assessment has been undertaken to
determine patient acuity alongside clinical areas funded establishment levels with
the professional judgement framework being used to act on the assessment
findings.
AA confirmed that the PBC reviewed the Bi-monthly Safer Staffing Report (Nursing) report
and were satisfied with the findings presented.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors received the
report and noted that
MFT remains
compliant with the
national guidance
(NQB 2026; DWS
2018) in relation to
safer nurse staffing.
The Board of
Directors noted the
plan to receive an
update report on the
annual strategic
nurse staffing review
in November 2025.
None
n/a
n/a
12.3
Safer Staffing report (midwifery and newborn services)
KSJ introduced the Saint Mary’s Managed Clinical Services (SM MCS) Midwifery and
Newborn Services bi-monthly Safer Staffing report which had been discussed in detail at
the PBC in June 2025. KSJ drew attention to:
• Maternity Services are compliant with the nationally recommended establishments
in accordance with Birthrate Plus (BR+) calculations. Plans are underway to take
forward the BR+ process (as part of its 3-year cycle).
• The Trust has a positive position in relation to the turnover of midwifery staff which
has reduced over a number of years.
• There has been a sustained reduction in overall Red Flag midwifery staffing
incidents.
• Positive recruitment of student midwives has been seen across Greater
Manchester.
page 15
CMcL highlighted that as the Non-Executive Lead for Maternity services, each month the
opportunity is available to meet with maternity leads across the Trust’s three sites (Oxford
Road Campus, North Manchester and Wythenshawe) with positive feedback being
received around staffing levels at a recent meeting. Preparations and planning processes
are underway to accommodate an anticipated Care Quality Commission inspection with
acknowledgement being given to the work that has been progressed in response to the
Ockenden report.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors accepted
the report and noted
the progress
undertaken to support
midwifery staffing in
the Division of
Maternity Services
and nurse staffing in
the Division of
Newborn Services
The Board of
Directors noted SM
MCS maternity
division remains
compliant with the
national guidance in
relation to safer
staffing.
The Board of
Directors noted the
sustained reduction in
midwifery red flag
incidents reported.
The Board of
Directors noted the
risk related to
Qualified in Specialty
(QIS) and supported
the recommendation
to continue to support
40 nurses per year
access QIS training.
None
n/a
n/a
13.1
Audit and Risk Committee (24/06/25) escalation and assurance report
NG presented the escalation and assurance report from the Audit and Risk Committee
held on the 24/06/25 and drew attention to:
• Focus of meeting was to approve year-end processes with several pre-meetings
being held/documents shared to support this process.
• The Trust’s Annual Accounts and Report (2024/25) were approved.
page 16
• The External Auditor Reports were received with acknowledgement being given to
both the new External Audit Team (Grant Thornton who started with the Trust in
December 2024) and the Trust’s internal finance team for successfully achieving
the NHS audit timetable.
• The External Auditor report on the Trust’s accounts has been received by
Governors at their formal meeting held on 23rd July 2025.
• The External Auditor report on the Trust’s Value for Money arrangements issued an
amber rating with areas of improvement being associated to achieving the Trust’s
financial plan (2025/26) alongside its associated Value for Patients’ targets.
• Head of Internal Audit opinion was also received.
CW highlighted that a dedicated session with the External Auditors and the Trust’s finance
teams is being held shortly to share and take forward learning from this year’s annual
accounts process to support arrangements for next year going forward.
KC forwarded thanks and appreciation to NG for the support provided to the Council of
Governors throughout the External Auditor appointment process.
DB highlighted the work undertaken by various Corporate Teams in producing core
elements of the Trust’s Annual Report.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted the
report.
None
n/a
n/a
13.2
Finance Board Committee (24/06/25) escalation and assurance report
NG presented the escalation and assurance report from the Finance Board Committee
(FBC) held on the 24/06/25 and drew attention to:
• The Trust achieved its financial targets during the first two months of the new
financial year (2025/26).
• Challenges around current cash levels were outlined with this remaining a key
focus, and corresponding measures being taken/monitored going forward.
• Value for Patients programme is in an advanced position in comparison to last year
with initiatives being identified for the full plan/target (2025/26).
CW highlighted that cash levels are regularly reported to the Trust Leadership Team
Committee with this remaining a key focus across Executive team members alongside
Clinical Groups.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted
the report.
None
n/a
n/a
13.3
Digital and Estates Board Committee (19/06/25) escalation and assurance
report
CMcL presented the escalation and assurance report from the Digital and Estates Board
Committee (DEBC) held on the 19/06/25 and drew attention to:
page 17
• National funding to improve the Trust’s digital offer was discussed.
• Trafford and Altrincham Hospitals have been retro-fitted to net zero with key
messaging to highlight this significant achievement being taken forward.
• A new strategic risk around the Trust’s network infrastructure was identified and will
be reported to the Trust’s Risk Oversight Committee with remedial steps taken
being monitored going forward.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted
the report.
None
n/a
n/a
13.4
Chief Finance Officer’s report – Month 2
CW introduced the report which presented the financial position of the Trust as at month 2
of 2025/26. The report had already been discussed in detail at the FBC meeting in June
2025. CW drew attention to:
• A deficit of circa. £11.3m has been reported for month 2 against the plan.
• The Trust’s Financial Plan (2025/26) requires the Trust’s Value for Patients target
(£165m) to be delivered through a reduced run-rate by year-end. 100% of the
Value for Patients schemes have been identified to deliver the required target.
However, 30% of these schemes are currently not mature enough yet to be fully
implemented/facilitate delivery. Each Clinical Group and Corporate Team has been
asked to produce a delivery plan for schemes that are behind trajectory.
• Elective activity is within contract arrangements agreed with Commissioners with
overperformance amounting to £1.4m at month 2. This strong performance has
and will continue to support the Trust over lower performance activity periods with
monitoring to ensure appropriate trajectories are maintained over the coming year
supported by activity management plans.
KC highlighted that delivery of the Trust’s Financial Plan continues to be aligned with the
Trust’s quality programme of work to support quality outcomes for patients.
MB sought clarification around the non-operating adjustments figure for month 2. CW
confirmed that the non-operating adjustment figure would be circulated to Board members
outside of the meeting.
Decision
Action
Lead
Complete / date
for completion
The Board of
Directors noted
the report.
The non-operating adjustment
figure for month 2 to be
circulated to Board members.
Claire Wilson
October 2025
14.
Any Other Business
No items were raised by Board members.
Decision
Action
Lead
Complete / date
for completion
Noted
None
n/a
n/a
page 18
15.
Meeting Evaluation
MC outlined the robust challenges and scrutiny made by Board members throughout the
various Board Committees held in the lead up to Board of Directors’ meetings.
16.
Date and time of next meeting: 1st October 2025
Action log from meeting
Action
Lead
Complete / date for
completion
Update around the
Research & Innovation
programme/clinical trials
including
national/international
contributions to be provided
to the next Board of
Directors’ Meeting.
Sohail Munshi
October 2025
The new FT application
process/10-Year Plan
programme of work to be
brought to a future Board
seminar.
Darren Banks/
Nick Gomm
February 2026
The Trust’s Winter Plan
communications/public
messaging re; OPEL 3 & 4
to be relooked at to make
differences clearer to the
public.
Rachel Burnham
Complete
October 2025
The non-operating
adjustment figure for month
2 to be circulated to Board
members.
Claire Wilson
October 2025
Incomplete actions from previous meetings
Audit and Risk Committee to
further review the SFIs and
SoD in April 2025.
NGo
Ongoing – to assess impact
of the new NHS 10-year
plan, added to work plan for
February 2026 meeting.
page 19
Public Board of Directors
Wednesday 1st October
Paper title:
Trust Chief Executive Report
Agenda
Item
8
Presented by:
Mark Cubbon, Trust Chief Executive
Prepared by:
Leo Clifton, Senior Business Manager
Meetings where content has
been discussed previously
Trust Leadership Team Committee
Purpose of the paper
Please check one box only:
☐For approval
☒For discussion
☐For support
Executive summary / key messages for the meeting to consider
The Trust Chief Executive has shared a report which provides an overview of activities at the
Trust, an overview of operational delivery, and progress made on strategic aims and objectives.
They have outlined issues of current interest to the Board and have shared their top three
areas of concern.
Recommendation(s)
The Board of Directors is asked to note this report.
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐Yes (please set out in your report what action
has been taken to address this)
☒No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☒
LHL objective 2
☒
HQSC objective 1
☒
HQSC objective 2
☒
HQSC objective 3
☒
PEW objective 1
☒
PEW objective 2
☒
VfP objective 1
☒
page 1
VfP objective 2
☒
R&I objective 1
☒
R&I objective 2
☒
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks:
•All strategic objectives in the Board Assurance
Framework.
Care Quality Commission
domains
Please check all that apply
☒Safe
☒Effective
☒Responsive
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
•None.
Main report
The purpose of this report is to provide a general update on matters that the Trust Chief
Executive Officer (CEO) wishes to highlight to the Board since the last public board meeting.
The report is divided into 5 sections:
Contents
1. Work with partners to help people live longer, healthier lives ........................ 3
2. Provide high quality, safe care with excellent outcomes and experience ...... 5
3. Be the place where people enjoy working, learning and building a career .... 9
4. Ensure value for our patients and communities by making the best use of our
resources .................................................................................................... 11
5. Deliver world-class research and innovation that improves people’s lives .. 12
6. Strategic Updates and Policy Developments ............................................... 14
7. Leadership Updates .................................................................................... 15
8. Top three concerns...................................................................................... 16
Full content of the report is included as Appendix A.
page 2
1. Work with partners to help people live longer, healthier lives
Organisational Strategy Review
It is now two and a half years since we published our Organisational Strategy, and we are
progressing well with a process to refresh the strategy following the publication of the 10
Year Health Plan. Since the end of July, we have been engaging people within MFT and
beyond, including our members, to help inform a refresh of our strategy. This work is being
done at pace so that an updated strategy can inform our plans for 26/27, which this year
we are due to have finalised by December in-line with national timelines.
Whilst there is a strong alignment between our strategy and the 10 Year Plan, there are
some areas in which our strategy could go further to refine our ambitions. This includes
providing more services at a neighbourhood level in the community, and the importance of
digital innovation in transforming the way we deliver our services. A full report for
discussion at today’s session describes the changes that are proposed through our
strategy refresh, and our draft priorities for 26/27.
We will continue our engagement over the coming months before presenting a final
version of the refreshed strategy to the Board in January. In the meantime, our draft
strategy and priorities will guide teams across MFT as we develop our plans for the
coming year.
Neighbourhood Health Services
The establishment of Neighbourhood Health Services was a cornerstone of the 10 Year
Health Plan and key to delivering the shifts from hospital to community, and from the
treating of sickness to prevention. Thanks to the work over many years of colleagues from
across the wider health and care system, integrated neighbourhood working across health
and care is already well-established in Manchester and Trafford, with our Local Care
Organisations playing an important role. The challenge now is for us to go further to
support more people to live well in the community, improving their health and reducing
their need to access health and care services.
Linked to wider discussions on the future of place-based partnerships, changes to the role
of the ICB and the GM Live Well programme, work is underway to agree how we further
strengthen our integrated neighbourhood teams. A joint plan for how this will work in
Manchester is being finalised this month. Trafford partners are keen to develop
neighbourhood health and care arrangements and are supporting a pilot of Integrated
Neighbourhood Team MDTs which have been operating in central Trafford since July. The
model will be evaluated over the next coming months with an ambition to expanding the
approach across all Trafford localities by April 2026.
Population Health
page 3
MFT has recently made a joint appointment with the University of Manchester, to a new
role of Dental Public Health Consultant, who will lead on oral health improvement
initiatives. This is an important area of focus for our work tackling health inequalities and
will enhance our approach to improving oral health across Manchester and the GM
system.
Our work to embed health prevention into our clinical service models continues with the
expansion of our employment advice partnership work with Growth Company. This builds
on successful work with Musculoskeletal (MSK) to now include the additional specialties of
Gynaecology, Cancer, Respiratory, and Rheumatology. This is being complemented by
work with the digital team to develop prevention functionality within Hive, which will begin
being piloted in September, starting at North Manchester General Hospital. Initially this
functionality will help clinicians to screen for housing, financial and transport related issues
that patients may be experiencing and connect them to partner organisations who can
offer support. Following the pilot this will be expanded to other sites and include other
themes, including employment and physical activity.
In August, MFT Charities provisionally supported the development of health and wellbeing
hubs at our largest hospital sites to help provide prevention services a base on our estate
and provide a physical space where patients and our teams can offer support which
complements our existing services. The hubs are envisaged to support patients to access
services around the wider determinants of health and further work with Clinical Groups and
patients will develop the detailed delivery model and phased funding approach.
Regional Genomic Medicine Service Tender
NHS England has launched a tender process to establish regional Genomic Medicine
Services across the country. These regional services will bring together and replace the
current regional Genomic Laboratory Hubs and Genomic Medicine Service Alliances and
will play a key role in mainstreaming genomic medicine across the NHS, as signalled in
the 10 Year Plan.
MFT is actively engaging with NHS England through this process. A decision on contract
award is expected later this year with the new services established from April 2026.
Manchester Brain Health
Since late 2024, an innovative new clinic which aims to improve the early diagnosis and
treatment of dementia, has been piloted in the Clinical Research Facility on the Oxford
Road Campus. Jointly run by clinicians and researchers from MFT and Greater
Manchester Mental Health NHS Foundation Trust (GMMH), and supported by charitable
funding, the service provides a comprehensive, same-day diagnostic pathway for patients
with early cognitive impairment. The clinic offers integrated clinical and cognitive
page 4
assessments, advanced imaging, biomarker testing, risk factor management and access
to social support as well as contributing to research.
A partnership has now been established between MFT, GMMH, The University of
Manchester, GM Integrated Care Board and the Alzheimer’s Society to consider how we
might further develop the pilot into a new model of clinical care and research. A workshop
was held in August, with representatives from all the partner organisations, to help develop
the joint vision for this work ahead of an inaugural partnership board meeting which is
planned for November. We look forward to updating on the Board on further developments
with this exciting initiative following the initial partnership board meeting.
MFT Corneal Eye Retrieval Service
Specialist Hospitals Clinical Group recently launched the new Corneal Eye Retrieval
Service. Led by the Manchester Royal Eye Hospital (MREH) in partnership with NHS
Blood and Transplant, the service went live on 28 July 2025 and will help to meet the
growing demand for corneal transplants across the NHS. Within days of being established,
the team successfully undertook its first retrieval procedure thanks to the generosity of a
donor and the kind support of their family.
Initially operating five days a week from our Oxford Road Campus, the plan is for the
service to expand to other MFT sites throughout 2026. Our ambition is to provide around
155 corneas each year to the national transplant bank in the first instance, helping to
reduce waiting times and improve outcomes for patients requiring corneal transplants. We
have a number of people requiring corneal grafts at MREH who can only be treated when
tissue becomes available. This has at times led to considerable waiting times for
treatment, so as well as making a national contribution, this new service is helping to
improve the care we provide locally.
2. Provide high quality, safe care with excellent outcomes and experience
Operational Delivery
• Urgent Care
This year we aim to achieve 78% performance for the 4-hour target across all types by
March 2026. For the month of August, performance was 72.2% against a plan of 75.09%.
‘Non-Admitted, Non-Referred’ and Urgent Treatment Centre pathways were the primary
causes of under-performance which aligned with a rise in attendances during twilight
hours.
Ambulance handover within 15 mins during August was 52.8%, against the national
standard of 65%, which the Trust is planning to achieve by March 2026. Average handover
time in August was 15.15 minutes against the Trust’s plan for the month of 16.16 minutes
and compares well to the NHS average in July 2025 of 25 minutes 3 seconds.
page 5
Plans are in place to deliver our year-end ambitions, with specific emphasis on our winter
planning to ensure resilience across the Trust over the coming months.
• Elective Care
The most recent reported data for elective care is July, when the month end position for
18-week referral to treatment (RTT) reported 53.34% performance against our plan of
52.69%. We reported 6,997 patients waiting over 52-weeks for elective treatment against
our plan of 6,754 and 16 patients waited over 65 weeks for elective treatment against the
plan of 0 for the month. The 65-week breaches reported were in paediatric services and
trauma and orthopaedics, with plans in place to eliminate all 65-week breaches by the end
of Q3.
Our ‘Care on Time’ programme is the elective transformational workstream which will help
deliver our year end ambitions related to improving compliance against the 18-week
standard, with further details on the progress of this programme outlined later in this
report.
• Cancer Care
Our performance against the 62-day standard for July reported 61.1% against a plan of
67.2%. The main area of non-compliance was urology which was 22% below plan. A
recovery plan is in place, which includes additional diagnostic and treatment activity and a
GIRFT visit scheduled to assist with pathway re-design and sustainable improvement.
The latest data available for the Faster Diagnosis Standard (FDS) is for July, where
performance was 75.2% against a trajectory of 77.1%. This reduced performance was
driven by Urology, Gynaecology and Lower Gastrointestinal. Improvement work is in place
across the organisation to reduce the time taken for both appointment and diagnostics.
A programme of recovery is in place to enable the Trust to deliver the year end ambitions
of 75% for 62-day RTT and 80% for FDS, with a particular focus on pathway
improvements in both urology and gynae-oncology pathways over the coming weeks.
• Diagnostics
Performance for the month of August across all DM01 modalities was 12.7% against a
plan of 12.9%.
Improvement has been seen over recent weeks in imaging waits following the successful
opening of the North Manchester Community Diagnostic Centre in late June, which has
increased capacity for our patients in the North of the city.
Industrial Action (IA)
page 6
During the recent period of industrial action by Resident Doctors between 25-30 July, a
total of 1,778 patient appointments were cancelled or rescheduled. Despite these
challenges, service continuity was largely maintained: outpatient services delivered 98% of
usual activity, while elective inpatient and day case activity reached 95% of usual levels
over the period of the five-day strike. This compares positively to the period of industrial
action in July 2024, when MFT maintained 97% of outpatient activity and 93% of usual day
case and elective activity, reflecting improved resilience and operational planning
compared to previous rounds of IA.
While unfortunately some patient disruption was unavoidable, the Trust’s mitigation efforts
significantly reduced clinical risk and ensured continuity of care for the majority of patients.
The Trust experienced a financial impact of approximately £3.8 million, comprising an
estimated £1.2 million in lost income and £2.6 million in additional costs, including pay-
related expenditure.
National Oversight Framework Position Update
MFT has been placed into segment 3 of the NHS National Oversight Framework (NOF) in
the latest NHS England ranking, issued week ending 7th September, ranking 71st out of
134 acute and specialist providers with an average metric score of 2.41.
The Trust has demonstrated improvements in patient safety as well as targeted
improvements in cancer access metrics - most notably in 62-day cancer waits. Finance
and productivity performance ranking remain strong (Segment 1), and the Trust also
demonstrated top-quartile performance in C. Difficile infection rates (1st nationally), and
urgent community response times (10th).
The segmentation trajectory and associated improvement requirements have been
embedded into internal recovery plans as well as the annual planning process for 2026/27,
which is underway across the Trust.
Urgent and Emergency Care Resilience Planning for Winter
The Trust’s Winter Plan sets out a system-wide approach to managing seasonal
pressures, focusing on maintaining safe, high-quality care during peak periods of demand.
Key priorities include robust operational planning for elective and non-elective pathways,
strengthened governance and escalation processes, and collaborative working with
system partners. Preparations are aligned with national Urgent and Emergency Care
(UEC) guidance and informed by lessons from Winter 2024/25, with emphasis on reducing
4-hour breaches, improving ambulance handovers, and mitigating risks from infectious
disease surges.
We have stress tested our plan through September via Operation Aegis, a regional event
which tested system-wide decision-making, escalation, and command structures under
page 7
winter pressure scenarios and Operation Tempest, a Manchester and Trafford multi-
agency exercise which validated escalation triggers and coordinated actions by partners at
times of surge. Findings from both exercises will feed into Trust governance and Board
assurance and any key actions identified will be incorporated into the Winter 25/26 plan,
ensuring alignment with GM and NHSE requirements and strengthening resilience across
acute, community, and mental health pathways
Care on Time
The Care on Time elective improvement programme continues to progress well, with a
particular focus currently being applied to our outpatient activity. A number of digital pilots
have been launched to improve patient access and experience, including the Fast Pass
self-scheduling tool, which is already reducing waiting times and improving flexibility for
our patients. Alongside this, increased usage of MyMFT is helping to support patient
communication, while a systematic review of clinic templates is underway to ensure
efficient use of clinical capacity. Clinical engagement remains strong, with specialties
working collaboratively to design changes that are clinically appropriate and sustainable.
Strengthening system working has also been a priority. A series of joint events between
MFT and primary care colleagues have been held to expand the use of Advice &
Guidance, to avoid unnecessary outpatient attendances and enable more patients to be
supported in the community. A pilot in Gastroenterology has commenced in September,
drawing on a successful model implemented in Northumbria NHS Foundation Trust.
In parallel, focused work on waiting list validation and improving the quality of patient
information is underway, ensuring patients are kept informed and delays minimised.
Overall, we are making progress which can be seen in our performance to date, but there
is still more for us to do.
Improvement Developments
In line with our strategic improvement plan, MFT has recently joined the Institute of
Healthcare Improvement's European Alliance, an international network of healthcare
organisations. The Trust has also been selected to participate in the second cohort of
NHSE-funded Operational Improvement Training for Band 6–8a clinical and operational
managers. This complements our Improvement Capability training programme which saw
the launch of the Improvement Pioneers training in September 2025.
On 8 September the Trust commenced the programme of Staffing Wisely Rapid Process
Improvement Events. These events bring together multidisciplinary teams, using Lean
methodology, to identify and test immediate solutions to address variable pay while
maintaining safe and affordable staffing. As a result, MFT have also been selected to be
part of the first cohort of Trusts selected by NHSE as part of their Variable Pay
Improvement Programme which launched on 15 September.
Inpatient Survey Results
page 8
On 9 September the CQC published the results of the 2024 National Inpatient Survey. The
survey showed an improvement from last year’s results, and in how we compare to other
providers. 97% of patients reported being treated with dignity and respect, 99% had
confidence in their doctors, and 85% rated their overall experience positively. The
improvements reflect MFT’s continued focus on strengthening communication, building
patient trust, and supporting safe transitions of care. There were notable improvements
made at Manchester Royal Infirmary and Wythenshawe Hospital.
The survey results also highlighted opportunities for improvement including how we can
better support individual dietary and accessibility needs as well as facilitating better access
to food outside of normal mealtimes. Multidisciplinary teams across MFT are now
reviewing the results so that we can both share the positive findings and identify areas to
apply efforts to drive further improvements. A substantive report on the results and actions
plans will be reviewed at Quality Safety and Performance Board Committee and Board of
Directors in due course.
3. Be the place where people enjoy working, learning and building a career
One MFT – Phase Three Implementation
Work to refresh our operating model, looking at our Clinical Group leadership structures is
well progressed, and we are making final preparations for Go Live of the new structures on
6 October 2025.
All staff who were required to go through the assessment centre process have done so,
and we have confirmed staff into their new roles. There remain a small number of
colleagues who at this stage haven’t been placed into a role in the new structure, and we
are actively working to redeploy these staff into suitable alternative roles, ensuring we
retain their skills and experience in MFT wherever possible.
Alongside appointments to new structures, we have delivered a robust implementation
plan so that our people are supported with a comprehensive Organisational Development
plan, structured inductions and clear handovers, as well as processes and systems that
enable them to get started in their new roles. We remain grateful for the engagement,
feedback and support of our staff, and Staff Side representatives, as we work towards the
implementation of our new operating model as of 6 October.
Staff Survey Engagement
Hearing from our colleagues on their experiences of working at the Trust is essential to
ensuring MFT is a place where people enjoy working, learning and building a career, and
the NHS Staff Survey is a key mechanism to gain insights alongside more direct
page 9
engagement initiatives. The 2025 NHS Staff Survey campaign aims to improve response
rates across all staff groups by enhancing confidence in confidentiality and increasing
visibility of actions taken in response to feedback. Through inclusive engagement, targeted
communications, and real-time reporting, the campaign seeks to strengthen local
ownership and leadership involvement in encouraging our colleagues to share their
feedback. Weekly updates will be provided to the Trust Leadership Team through the
Chief People Officer, highlighting progress, challenges, and targeted interventions,
building on the approach used in 2024.
Power of Three Initiative
Embedding our new Clinical Leadership Model is an essential element of our One MFT
programme which will require leaders from across the organisation to learn and define new
ways of collaborative working. The Power of 3 programme is a bespoke leadership
development initiative designed to embed clinical leadership through shared responsibility
among leadership triumvirates. Delivered through in-person workshops, it aims to improve
leadership confidence, team collaboration, and strategic alignment. Impact will be
measured through leadership assessments, team cohesion metrics, RACI clarity, and
progress of SMART objectives linked to our annual plan and organisational strategy.
Events and Celebrations
There were a number of events and celebrations taking place over the period since our
last meeting that I would like to highlight:
• Dr Jon Ghosh’s shortlisting for the Association of Surgeons in Training
(ASiT) 2025 Silver Scalpel Award – I would like to congratulate Dr Jon Ghosh,
Consultant Vascular Surgeon at Manchester Royal Infirmary, who was shortlisted
for the prestigious Silver Scalpel Award – one of the highest honours in UK surgical
education. This award highlights those who set the standard for excellence in
supporting and training the next generation of surgeons, and Dr Ghosh’s
nomination and shortlisting is a testament to his dedication to excellence in patient
care and medical education.
• Visit from Lord Patrick Vallance – on 1 July Lord Patrick Vallance, Minister of
State for Science, Research and Innovation, visited the Royal Manchester
Children’s Hospital to observe a live demonstration of the Versius robotic surgery
system. Led by Mr David Keene and supported by Dr Toli Onon, the demonstration
showcased the system’s transformative impact on paediatric surgery, including
reduced recovery times and enhanced surgical precision. The visit highlighted the
Trust’s pioneering use of robotic technology, with the team sharing the story of
Mohammed, the youngest patient globally to undergo surgery using Versius at just
four months old.
• Visit from Dr Claire Fuller - On 4 September, Dr Claire Fuller, National Medical
Director for NHS England, visited the Trust to see first-hand the progress and
page 10
impact of integrated neighbourhood health services across Manchester and
Trafford. The visit included a discussion with local leaders and partners to discuss
the maturity of integrated neighbourhood working, place-based partnerships, and
the positive outcomes being delivered for local people. Dr Fuller also visited Moss
Side Powerhouse and the Manchester Control Room to meet Integrated
Neighbourhood Teams and Neighbourhood Health Champions, highlighting the
Trust’s commitment to collaborative working and innovation in community-based
care.
Consultant Appointments
Since our last Board meeting in July, 34 Consultants (22 substantive and 12 locum) have
been appointed to roles at MFT.
Substantive Appointments were made to the following specialities Child and Adolescent
Psychiatry, Gynaecology, Dental and Maxillofacial Radiology, General Medicine,
Geriatrics, Haematology, Obstetrics, Otolaryngology, Paediatric Surgery, Radiology,
Reproductive Medicine, Respiratory Medicine and Urology.
Locum Consultants were appointed to roles within the following specialties: Anaesthetics,
Ophthalmology, Cardiac Surgery, Oral Surgery, Otolaryngology, Cell Therapies, Paediatric
Malignant Haematology, Paediatric Nephrology, Pain Medicine, Rheumatology and
Vascular Surgery.
MFT continues to draw in exceptional candidates for consultant positions who are not only
attracted by our range of services and specialisms, but also our established development
programme specifically for new consultants transitioning from their positions as Resident
Doctors.
4. Ensure value for our patients and communities by making the best use of
our resources
Value for Patients Programme Update
Delivery against the Value for Patients (VfP) programme continues to progress well, with
the full target of £165.8m of schemes identified. Year-to-date delivery has been on track,
however, 12% of our planned schemes for the year are below level three in our financial
planning framework, meaning they are not yet fully mature, and require further work to
ensure that delivery plans are in place. This continues to be a major focus for us until the
appropriate maturity levels are reached.
AI Waiting List Initiatives
MFT is currently exploring opportunities using advanced predictive technologies to support
clinical prioritisation of our waiting list. This will support clinical teams to provide care in a
page 11
timely way to those who need it most. This technology can support clinical teams to
identify patients on our waiting lists who have a lower risk of adverse outcome and maybe
appropriate for less intensive care pathways such as patient initiated follow up (PIFU).
PIFU offers patients greater control and flexibility by ensuring they can see a specialist if
they feel they need more advice or support. It can also help reduce waiting times by
allowing clinicians to prioritise those with active health issues and higher risk of adverse
outcomes for scheduled follow-ups. Digital and Clinical teams are working closely together
to ensure the criteria for risk stratification is robust and safe and clinically validated.
MFT is in the process of contracting a risk stratification predictive modelling supplier, with
aims to pilot the analysis, validate the findings and trial proactive interventions in Q3 of the
25/26 financial year.
Ambient AI Pilot
Following the successful phase one pilot earlier in the year, in which artificial intelligence
software was used to transcribe and document patient consultations, phase two of the
Ambient AI pilot is planned to start early October.
50 consultants took part in the phase one pilot, which spanned a number of services
across both adult and paediatric specialities. The feedback from both clinicians and
patients was positive; the main feedback from patients being that their clinician felt more
focused on them.
Phase two will involve 100 consultants, with an improved product which is directly
integrated with Hive. The pilot will run for three months with an evaluation in December
2025. If the expected benefits are demonstrated this will lead to a larger rapid deployment
of the product.
Our forecast benefit profile for this work will continue to be refined through our proof of
value pilots, but there is high confidence that the findings from phase two will demonstrate
improved patient experience through more present, personable interactions; efficiency
savings and improved productivity by reducing documentation delays and increasing
clinical throughput; and enhanced clinician wellbeing and experience.
5. Deliver world-class research and innovation that improves people’s lives
Manchester Academic Health Science Centre Appointments
Congratulations to Professor Ngozi Edi-Osagie – Consultant in Neonatal Medicine /
National Clinical Director Neonatology at NHS England, Professor Ashu Gandhi –
Consultant Breast Surgeon, Professor James Harvey – Consultant Breast Surgeon,
Professor Vaibhav Modgil – Consultant Urologist, Professor John Moore – Consultant
page 12
Anaesthetist / Interim Joint Deputy Medical Director (CSS), Professor Rhona Kearney –
Consultant in Urogynaecology / Deputy Medical Director Saint Mary's Managed Clinical
Service, Professor Mars Skae – Consultant in Paediatric Endocrinology / Deputy Medical
Director Royal Manchester Children’s Hospital, Professor Karen Kemp – Nurse Consultant
Inflammatory Bowel Disease, Professor Fiona Reid – Consultant in Urogynaecology and
Professor Michael McNicholas – Consultant in Trauma and Orthopaedic who have been
appointed as Honorary Clinical Chairs in the Faculty of Biology, Medicine and Health for
the Manchester Academic Health Science Centre (MAHSC), and Professor Hannah
Durrington, Honorary Consultant in Respiratory Medicine at Wythenshawe Hospital who
has been awarded an academic promotion to Clinical Chair within the Division of
Immunology, Immunity to Infection and Respiratory Medicine.
These appointments reflect the significant contribution that they have made to patient care,
to their profession, and to research in their field. We know that there is a very high bar for
these appointments, and rightly so. It is fantastic to see our colleagues recognised for
their achievements as clinicians, researchers, educators, and leaders
Cystic Fibrosis treatment trialled at MFT now approved for NHS use
A new once daily cystic fibrosis (CF) treatment, trialled in National Institute for Health and
Care Research (NIHR) Manchester Clinical Research Facility (CRF) at Wythenshawe
Hospital has been approved for NHS use, following a recommendation by the National
Institute for Health and Care Excellence (NICE). Trials have shown the new triple therapy
to be at least as effective as current standard treatment at improving lung function for
people aged over 12 with CG caused by a specific gene (F508del) mutation. The CRF at
Wythenshawe was the top recruiting UK site for the adult study, including Adam Higson,
45, from Rochdale who was diagnosed with CF in 1980 when he was 11 months old. You
can Read Adam’s story and more about the research study here.
Manchester announces major investment drive to accelerate life sciences growth
Manchester’s Inward Investment Agency, MIDAS, recently launched the ‘Investing in Life
Sciences in Manchester’ prospectus – showcasing the city region’s position as one of the
most dynamic health innovation ecosystems in the UK’s £120 billion, growing life sciences
market, and why it is the perfect place for businesses to invest in their future innovation
and growth. MFT’s hosted research and innovation infrastructure, alongside our clinical
and academic partners across Greater Manchester, play a crucial role in the future of UK
life sciences, with strengths including data, genomics, oncology, and real-world evidence
clinical trials.
As part of the launch, it was announced that IQVIA has acquired the Medicines Evaluation
Unit (MEU), co-located at our Wythenshawe Hospital campus. This is a fantastic
investment, and we look forward to building on our existing relationships with IQVIA and
the MEU to bring new opportunities for communities across Greater Manchester to benefit
page 13
from cutting edge research and innovation, delivering new tests, treatments and
technologies, along with economic growth, that makes a real difference to people’s lives
6. Strategic Updates and Policy Developments
There are several key updates I would like to bring to the Board’s attention:
Greater Manchester Strategy
A renewed Greater Manchester strategy ‘Together we are Greater Manchester’ was
launched over the summer, with a focus on growing the local economy and supporting
people to live well, recognising that economic and social progress go hand-in-hand. The
strategy aims to create the conditions for people and businesses to succeed, unlocking a
new form of inclusive economic growth. The strategy has a particular focus on housing,
community safety, employment, transport, health and wellbeing.
The GM Live Well programme is an important part of the strategy which pledges to provide
people with access to one-stop-shops providing practical help on housing and debt, for
example. This is part of a commitment to reduce inequalities which features alongside
pledges to reduce smoking, increase activity and deliver year-on-year improvements in
NHS waiting time standards.
As a provider of health and care, a large employer and contributor to the life sciences
sector, MFT has an important contribution to make in supporting the delivery of the GM
strategy. Further detail on these initiatives is provided in a substantive report later on
today’s agenda.
Assessing provider capability: guidance for NHS trust boards
As part of the NHS Oversight Framework (NOF) there is a new requirement for NHS trust
boards to annually assess their organisation’s capability in domains including strategy and
leadership, quality of care, people and culture, and financial performance. The outcome of
this self-assessment will be used by NHS England, alongside the NOF segment that the
organisation has been allocated, to assess what actions may be required at each trust.
Guidance on the process has recently been issued which describes the criteria and the
examples of the evidence that Boards should use to determine if they can positively self-
certify.
The deadline for completing the annual self-assessment is 22 October 2025 and MFT has
its draft submission for discussion as a substantive item on today’s agenda.
10 Point Plan to improve resident doctors’ working lives
On the 29 August 2025, NHS England published a 10 Point Plan to improve resident
doctors’ working lives. The Plan include a range of actions that Trusts are required to
page 14
undertake within the next 12 weeks. Progress is required to be reported to the Board and,
where actions are not met, corrective measures must be identified.
Dr Sohail Munshi, Joint Chief Medical Officer, is leading on a comprehensive programme
of work to support improvements and enhanced engagement with Resident Doctors here
at MFT and a report will be presented to the Board in November providing an update on
progress made in delivering against the plan.
Actions to tackle sexual misconduct in the NHS
On 30 August 2025, NHS England wrote to Trusts to request further actions are taken to
identify and act against potential perpetrators of sexual misconduct in the NHS. The letter
introduces an assurance framework and a request to audit processes in line with this
framework. This is already a key area of work for us, and the framework mirrors the
principles of the Sexual Safety Charter, which the Trust has been supporting, and
introduces a suite of actions against the 10 principles within the Charter.
Overseen by the Chief People Officer, the actions identified in the framework will be
audited and a report will be presented to the People Board Committee in December 2025
on the progress the Trust has made.
7. Leadership Updates
Appointment of Joint Chief Medical Officer
I am pleased to announce the appointment of Dr Vin Diwakar, currently national Clinical
Transformation Director at NHS England, as Joint Chief Medical Officer (JCMO) for MFT.
A paediatrician and nationally recognised medical director with 17 years of experience, Vin
brings a wealth of expertise as medical director for the NHS in London, at Great Ormond
Street Hospital, Birmingham Children’s Hospital, and as National Medical Director for
Secondary Care. Vin’s starting date will be confirmed in due course. His appointment
comes at a pivotal time as we renew our Trust Strategy to ensure that it helps drive
forward the aims of Fit for the Future, the 10 Year Health Plan for England, and our joint
working with partners to improve the health and quality of life of our patients and
communities.
Recruitment underway for Director of Research and Innovation
After five years as Director of Research and Innovation (R&I), Professor Rick Body will be
stepping down to take up a new part-time role as Chair of the Interventional Procedures
Advisory Committee at the National Institute for Health and Care Excellence (NICE). Our
search is now underway for a new Director of R&I and in order to integrate the leadership
of R&I into the day-to-day running of MFT, the role will also become a formal member of
the Trust Leadership Team. This is a critical time for this appointment as MFT considers
page 15
how we take forward the opportunities set out in the 10-Year Health Plan and in the
recently published Life Sciences Strategy for the UK.
8. Top three concerns
The current top three concerns I would like to highlight to the Board are:
Financial Position
The financial position continues to be challenging and whilst we are making good progress
on our Value for Patients’ programme, further improvement is required during the second
half of the year. The Chief Finance Officer’s report on today’s agenda provides more detail
on the latest position, but we are now reporting an adverse variance to our plan and have
a more challenging Value for Patients target in the remaining months of the year. We have
taken decisive action to accelerate these initiatives and each of our Clinical Groups have
developed recovery plans to help ensure that we deliver the plan we agreed.
The above concern is reflected in strategic objective 8 in the Board Assurance Framework.
One MFT Programme
Whilst the initial process to identify candidates for leadership positions through an
assessment centre approach has now been completed; it was always anticipated that
there would remain some gaps in our final structures which would need to be filled through
conventional recruitment alongside redeployment processes. Streamlining and
standardising our recruitment processes and ensuring sufficient resources are available to
support the process have lowered the level of risk. To ensure business continuity in these
essential leadership positions, we are putting in place interim arrangements so that
structures are complete, and we are in a position to go live safely. Although we have taken
steps to mitigate these risks, there is still a risk of some disruption or interruption to service
delivery with any change of this size. We will be monitoring the situation closely over the
go live period and take actions to address any issues that arise.
The above concern is reflected in strategic objective 5 and 6 in the Board Assurance
Framework.
Industrial Action
Whilst our planning and effective coordination of the recent period of industrial action by
resident doctors led to less disruption to our services than previous recent strike periods;
some planned appointments were unavoidably affected leading to cancelled appointments
and procedures which have a significant impact on the patients involved. Alongside
delayed treatments and longer waiting times for our patients, our clinical and
administrative teams have been required to focus their resources on coordinating the
Trust’s response, which further disrupted our ability to deliver our day-to-day services as
page 16
we would like to. We hope steps are taken to avoid future episodes of Industrial Action,
given the disruption to patients as well as the operational and financial performance
consequences.
The above concern is relevant to all of the strategic objective 3 in the Board Assurance
Framework.
page 17
Public Board of Directors
Wednesday 1st October 2025
Executive summary / key messages for the meeting to consider
Members of the Board are requested to note the updates provided in the Trust Integrated
Performance Report (IPR).
Of note is the inclusion of information regarding the new National Oversight Framework. MFT
have been placed into segment 3 in the latest NHSE ranking, with a ranking of #71 out of 134
acute and specialist providers.
Recommendation(s)
The Trust Board is asked to:
• Note the performance assurance provided
Paper title:
Integrated Performance Report (IPR)
Agenda
Item
9.1
Presented by:
Chief Delivery Officer
Chief Nursing Officer
Joint Chief Medical Officers
Chief Finance Officer
Chief People Officer
Chief Digital & Information Officer
Prepared by:
Director of Performance and Planning (performance)
Director of Clinical Governance (quality and safety)
Deputy Chief People Officer (workforce)
Deputy Director of Financial Reporting & Planning (finance)
Managing Director, R&I
Meetings where content has
been discussed previously
Board Committees
Purpose of the paper
Please check one box only:
☐ For approval
☒ For discussion
☐ For support
page 1
Do the recommendations in this paper have any
impact upon the requirements of the protected
groups identified by the Equality Act?
☐Yes (please set out in your report what
action has been taken to address
this)
☒No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☐
LHL objective 2
☐
HQSC objective 1
☐
HQSC objective 2
☐
HQSC objective 3
☐
PEW objective 1
☐
PEW objective 2
☐
VfP objective 1
☐
VfP objective 2
☐
R&I objective 1
☐
R&I objective 2
☐
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks:
•All strategic risks
Care Quality Commission
domains
Please check all that apply
☐Safe
☐Effective
☐Responsive
☐Caring
☒Well-Led
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
•N/A
page 2
MFT Integrated
Performance Report
All domains
October 2025
page 3
Structure of this document
Provide high quality, safe care with excellent outcomes and experience – operational performance
Introduction to SPC measurement and icons used
Provide high quality, safe care with excellent outcomes and experience – quality and safety
Performance against National Oversight Framework (NOF)
3
4
5
92
Be the place where people enjoy working, learning and building a career
127
Ensure value for our patients and communities by making the best use of our resources
161
*Note: data supplied is the most recent available data received and approved by Board Sub-committees
Deliver world-class research & innovation that improves peoples lives
171
page 4
Measuring our performance
Escalating performance concerns
Using the four SPC rules and outcomes of our benchmarking , we use an Alert, Advise and Assure model to ensure that both risks and improvements associated with performance are escalated
appropriately using the Trust’s risk escalation framework, through the Trust’s Governance Infrastructure. Risks identified through the assessment of and assurance associated with any element of
performance that may have an impact on the delivery of the Trust’s Strategic Objectives are reflected within the Trust’s Board Assurance framework.
Compliance Variation
Target being met Target not met For information, no target
set or target not due
Common cause – no
significant change
Special cause of
concerning nature or
higher pressure due to
(H)igher or (L)ower
values
Special cause of improving
nature or lower pressure
due to (H)igher or (L)ower
values
Assurance
Variation indicates
Inconsistently
passing and falling
short of
the target
Variation indicates
consistently
(P)assing the target
Variation indicates
Consistently
(F)alling short of the
target
Action Status
Active
surveillance –
continue to
observe in order
to better
understand the
current position
Improvement –
continue actions
to support
improvement
until steady
state achieved
Deterioration or
maintained
underperformance –
instigate or review
actions to ensure
drivers of current
position are
mitigated
Steady state – continue
to monitor achievement
of level of performance
which is satisfactory,
and which requires no
intervention to maintain
page 5
Domain Domain Score Segment Direction of
Travel since last
segmentation Previous score (July 2025 initial segmentation)
Effectiveness and experience of care 2.01 2 Domain Score 2.35 / Segment 2
Patient safety 2.37 2 Domain Score 2.61 / Segment 3
Access to services 3 2.68 Domain Score 2.55 / Segment 3
People and workforce 3.18 4 Domain Score 3.2 / Segment 4
Finance and productivity 1.28 1 Segment 1
National Oversight Framework
MFT has been placed into segment 3 of the NHS oversight framework (NOF) in the latest
NHSE ranking, with a ranking of #71 / 134 acute and specialist providers and an average
metric score of 2.41
page 6
Provide high quality, safe
care with excellent
outcomes and experience –
quality and safety
page 7
Trust IPR Executive Summary – July 2025
Focus
Compliance
Variation
Assurance
Action
Status
Indicator
Incident Reporting & Safety
Culture
Ratio Notifiable: Non notifiable Patient Safety Incidents
No incidents per 1,000 bed days
No incidents (moderate + harm) per 1,000 bed days
No incidents (low/no harm) per 1,000 bed days
Incidents of violence / disruptive behaviour (moderate + harm)
Number of never events in month
Duty of Candour Compliance
Harm Free Care
Surgical safety checklist compliance
Attributable pressure ulcers (grade 3-4)
Falls per 1000 bed days (level 4 & 5 harm)
VTE screening compliance
Incidents relating to delays on waiting lists (moderate + harm)
Incidents relating to delays in follow ups (moderate + harm)
Infection,
Prevention &
Control
Trust attributable MRSA bacteraemia
Trust attributable C. Diff infections
Gram negative infection – E. Coli
Gram negative infection – Klebsiella
Gram negative infection – Pseudomonas
Maternity
Neonatal deaths per 1,000 live births (standard <4%)
Still births per 1,000 live births (excluding TOP, standard < 6%)
Maternal deaths
Focus
Compliance
Variation
Assurance
Action
Status
Indicator
Maternity
Non-SPC Incidents accepted by MNSI for investigation
Patient Safety incidents (maternity moderate harm and above, standard <4)
% of term admissions to neonatal unit (standard < 6%)
Category 3 caesarean deliveries cancelled on the day (standard <10)
% Initial Midwifery Triage assessment within 15 mins (standard 90%)
% Initial Midwifery Triage assessment within 30 mins (standard 90%)
Non-SPC % Delays over 96 hours on induction of labour pathway (standard 0)
Non-SPC % Delays >72 hours and <96 hours on induction of labour pathway (standard 2%)
Non-SPC % Delays >48 hours and <72 hours on induction of labour pathway (standard 15%)
Non-SPC % Delays >24 hours and <48 hours on induction of labour pathway (standard 25%)
Non-SPC % Transferred on induction of labour pathway <24 hours (standard 60%)
% Delays >24 hours for transfer for augmentation (standard 20%)
Births outside of intrapartum birth setting
Non-SPC % Maternity specific training compliance (aggregated, standard >90%)
Non-SPC Achieving Maternity Incentive Scheme Actions (standard 10)
Number of babies with suspected HIE Grade 2/3
MNSI/NHSR/CQC/Coroner Reg 28
* Further safety metrics in development
page 8
Trust IPR Executive Summary – July 2025
Focus
Compliance
Variation
Assurance
Action
Status
Indicator
Patient Experience
Single sex compliance breaches
What Matters to Me (overall score)
Friends & Family Test – Inpatient/Day Case
Friends & Family Test – Emergency Department
Friends & Family Test - Outpatient
Friends & Family Test – Community Services
Friends & Family Test – TP1 - Antenatal Care
Friends & Family Test – TP2 - Birth
Friends & Family Test – TP3 – Care on Postnatal Ward
Friends & Family Test – TP4 – Postnatal Community Provision
Number of formal complaints opened in last month
Number PHSO complaints
Number reopened (not new) complaints in last month
Non-SPC Closed complaints in month (theme)
% Complaints resolved in agreed timescale
Patient Advice & Liaison Service Concerns
Safer
staffing
Care hours per patient day
Ratio of actual : planned hours (excluding maternity)
Non-SPC % of maternity triage shifts where actual midwifery staffing = planned (>95%)
Focus
Compliance
Variation
Assurance
Action
Status
Indicator
Safeguarding
Number of patients with DoLs
Number authorised DoLs notified to CQC
Training – Safeguarding Children L1
Training – Safeguarding Adults L1
Training – Safeguarding Children L2
Training – Safeguarding Adults L2
Training – Safeguarding Children L3
Training – Safeguarding Adults L3
Mental Health Strategy
MHA compliance – section 132 – provision of information to patients
Patients subject to MHA detention missing from hospital care
Training – Mental Health L1
Training – Mental Health L2
Metric under
development – MH Group
overseeing process of
development
Number inappropriate admissions of MH patients to inpatient wards
Number inappropriate admissions of MH patients to inpatient wards >48hr LoS
Number inappropriate admissions of MH patients to inpatient wards >7 day LoS
Number of patients detained under section 136 > 12 hours
LD
Strategy
% of people with LD / autism who have evidence of reasonable adjustment within
48 hours of admission
page 9
Trust IPR Executive Summary – July 2025
Focus
Compliance
Variation
Assurance
Action
Status
Indicator
Sepsis 7
Medical Review On Time
Oxygen Administered
Blood Cultures Taken
Antibiotics Administered
Lactate Taken
IV Fluid Bolus Administered
Urine Output Measured
Medicines
% of Critical Medication Administrations Omitted
% of Critical Med Omissions due to Medicines Unavailable
% of Antimicrobial Omissions
Controlled Drugs Audit Compliance
Safe & Secure Handing of Medicines Audit Compliance
% of Patients on O2 who had an O2 prescription
24-hour Admissions Medicines Reconciliation
48-hour Admissions Medicines Reconciliation
Focus
Compliance
Variation
Assurance
Action
Status
Indicator
Learning from Deaths
Number of deaths with identified learning disability
Number of LEDER referrals
Hospital standardised mortality ratio (HSMR) (rolling 12 month)
Crude mortality rate (12 mth rolling)
Standardised healthcare crude mortality indicator (SHMI)
Prevention of Future Deaths
MUST
% of Admitted patients with MUST scores
% of Admitted patients with MUST scores within 24 hours
% of Admitted patients with MUST scores within 7 days
page 10
Executive summary
Safeguarding training – Adults & Children
L1&L2
Mental Health training – L1
Detained patients missing from care
FFT – Outpatient; Community; TP1 (antenatal);
TP2 (birth)
Reopened complaints
Care Hours per patient day
Controlled drug audit compliance
Safe & secure handling of medicines audit
compliance
Midwifery triage > 30 mins
% patients with autism/LD with reasonable
adjustment within 48 hours
Never Events; C diff infections
Neonatal deaths and Stillbirths/1000 live births
Maternal deaths; Maternity patient safety incidents
% term admissions to neonatal unit
Cat 3 caesareans cancelled on day
Delays in augmentation of labour
Births outside intrapartum setting
Babies with suspected HIE grade 2/3
FFT – Inpatient/day case; TP3 (postnatal ward);
TP4 (postnatal community)
PHSO complaints
Actual: planned hours (excl maternity)
Sepsis – Oxygen administered
PFDs
Duty of Candour Compliance
Surgical Safety Checklist compliance
MRSA
Authorised DoLs
No patients detained on S136 >12 hours
Single sex compliance breaches
FFT –ED
% complaints resolved in timescale
Sepsis – medical review; Blood cultures;
Antibiotics; Lactate; IV fluid; Urine output
% patients on O2 with prescription
24 and 48 hours medicines reconciliation
Improvement continues to be made in the
following areas:
Safeguarding children and adults L3
training, mental health level 2 training and
other mental health and LD metrics
reasonable adjustments being made for
patients with learning disabilities.
Particular risk is evident in the
achievement of:
VTE screening, Patient experience in ED,
Sepsis scores, infection control,
medication safety and MUST scores – all
of which have recovery plans in
development
Variation
Assurance
Achieving standard Inconsistently Achieving standard Not Achieving standard
Special Cause
Improvement
Common
Cause
Special
Cause
Concern
Consistent assurance can be provided
about:
Improvements in maternity triage,
safeguarding children and adults training
at level 1 and 2,maternity staffing
VTE screening compliance
Midwifery triage > 15 mins
Safeguarding training Adult & Children L3
MHA compliance (info for patients)
Mental Health training L2
WMTM – overall
% admitted patients with MUST scores
% admitted patients with MUST scores >24 hours
% admitted patients with MUST scores >48 hours
page 11
Overall number of incidents per 1,000 bed days
Number of incidents per 1,000 bed days
June-25 Target
106.8 0
Clinical Group Overview
Updates since previous month
No Special Cause Variation noted in June 25 data
Key dependencies
Further analysis and active surveillance completed
on incident categories to identified identify themes
and areas of opportunities for improvement within
incidents
Current issues
Surveillance data continues to show an increase in low/no harm
incidents of disruptive, aggressive behaviour, medical devices and
medication, indicating a good reporting culture
Future actions
Surveillance dashboard presented at August Patient Safety Group;
Further triangulation work with other data sources e.g. Patient
demographics / locations
Compliance
Variance
Assurance
Actions
Quality & Safety - Incident Reporting & Safety Culture
Advise
725
779
946
1615
1838
2111
CSS
NMGH
LCO & Dental
MRI
Specialist
WTWA
0
20
40
60
80
100
120
140
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of incidents
Month
page 12
Number of incidents per 1,000 bed days –
comparison of incidents with harm v no/low harm
Number of incidents per 1,000 bed days
June-25 Target
Clinical Group Overview
Updates since previous month
Trends of no/low harm remaining relatively static.
Key dependencies
Analysis of surveillance data allows identification of specific
areas of concern to be addressed by relevant improvement
workstreams. Reporting culture work linked to embedding a
patient safety culture
Current issues
No issues identified
Future actions
Further work required to encourage near miss and low/no
harm reporting. This will be overseen by the Patient Safety
Group.
Compliance
Variance
Assurance
Actions
Quality & Safety - Incident Reporting & Safety Culture
Advise
719
766
944
1607
1830
2090
4
3
2
6
8
21
CSS
NMGH
LCO & Dental
MRI
Specialist
WTWA
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
Number of incidents
Month
0
20
40
60
80
100
120
140
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
Number of incidents
Month
page 13
Incidents of violence / disruptive behaviour
(moderate + harm)
Incidents of violence / disruptive behaviour (moderate + harm)
June-25 Target
2 0
Clinical Group Overview
Updates since previous month
There were 2 moderate or above harm incidents
of violence / disruptive behaviour reported in June 25
Key dependencies
Active Surveillance completed on violence /
disruptive incident categories to support identified
areas of interest and continue for identification of
themes
Current issues
Ongoing monitoring to see if the shift to low/no level harm being
reported is sustained
Future actions
Violence Prevention and Sexual Safety Meeting overseeing more
detailed performance dashboard, improvement plans and actions
Compliance
Variance
Assurance
Actions
Quality & Safety - Incident Reporting & Safety Culture
Advise
-4
-2
0
2
4
6
8
10
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of incidents
Month
0
0
0
0
1
1
LCO & Dental
Specialist
NMGH
WTWA
CSS
MRI
page 14
Never events
Never Events
June-25 Target
1 0
Clinical Group Overview (12
months)
Updates since previous month
1 never event reported in June 2025. Total
reporting never events for last 12 months is 8
Key dependencies
Ongoing work on surgical safety (NatSSIPs and
LoCSSIPs) through OSIP Steering Group. Cultural
work around Patient Safety Cultures overseen by the
Patient Safety Group
Current issues
The never event reported in June 2025 was regarding wrong sight
insertion of chest drain
Future actions
Thematic review of reported never events since 2023 underway. Current
Never event Incident Investigations initiated; Progress monitored via the
Patient Safety Assurance and Oversight Group
Compliance
Variance
Assurance
Actions
Quality & Safety - Incident Reporting & Safety Culture
Alert
0
1
1
1
2
3
LCO & Dental
NMGH
WTWA
MRI
Specialist
CSS
-2
-1
0
1
2
3
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of Never Events
Month
page 15
Duty of candour compliance
Duty of Candour Compliance
June-25 Target
93.18% 100%
Clinical Group Overview
Updates since previous month
Since June's IPR (May data), the reporting of DOC
compliance has been updated to demonstrate the
Statutory (Stage 2) DOC compliance. In June 25 93%
of patient stage 2 had recorded as completed within the
Ulysses system
Key dependencies
Presentation of the DoC data under review as SPC not
considered the most appropriate format. Monitoring
arrangements to be updated following policy review
Current issues
Data indicates delays in recording of Statutory DOC stage 2. In each case an
explanation has been provided to Patient Safety Oversight & Assurance Group.
Ongoing daily and weekly scrutiny
Future actions
DOC policy currently under review. New Policy aims for a more sensitive
measure that reflects patient circumstances in line with national guidance. This
will be finalised in October / November 25
Compliance
Variance
Assurance
Actions
Quality & Safety – Incident Reporting & Safety Culture
Alert
0%
20%
40%
60%
80%
100%
120%
140%
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
50.0%
66.7%
100.0%
100.0%
100.0%
100.0%
NMGH
CSS
Specialist
MRI
WTWA
LCO & Dental
page 16
Surgical safety checklist compliance
Surgical safety checklist compliance
Clinical Group Overview
This indicator is only measured at
Trust level. Updates since previous month
Point of time metric available in HIVE therefore
does not allow for longitudinal comparison
Key dependencies
Surgical safety workshop held on 15 July. Plans
in place to review 1300 LocSSIPS. Next steps
include capturing good practice to share, &
developing a training & education package
Current issues
Data would indicate non-compliance in a number of areas. This data
will be considered as part of review of recent Never Events
Future actions
Actions include. Relaunching of key safety initiatives; review of
LocSSIPs; accelerating revision of Safer Surgery checklist;
strengthening OSIPs steering group, reinforcing importance of local
leadership
Compliance
Variance
Assurance
Actions
Quality & Safety – Harm Free Care
Advise
June-25 Target
N/A N/A
page 17
Attributable pressure ulcers (grade 3-4)
Attributable pressure ulcers (grade 3-4)
June-25 Target
8 0
Clinical Group Overview Updates since previous month
Slight reduction in cases occurring since
previous month
Key dependencies
National Stop the Pressure programme
NHS England
Compliance with European Pressure
Ulcer Advisory recommendations
Current issues
Completion of integrated care pathway
Non recognition of conditional changes in patients and lack of reassessments
Lack of personalised care plans for patients with contractures
Incorrect completion of Purpose T categorisation
Future actions
Quality improvement plans in progress within LCO
Review of themes related to incidents and learning identified with focussed
training for hotspot areas
Compliance
Variance
Assurance
Actions
Quality & Safety – Harm Free Care
Advise
1
7
Specialist
NMGH
MRI
CSS
WTWA
LCO & Dental
-5
0
5
10
15
20
25
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of pressure ulcers
Month
page 18
Falls per 1,000 bed days (level 4 & 5 harm)
Falls per 1,000 bed days (level 4 & 5 harm)
June-25 Target
3 0
Clinical Group Overview
Updates since previous month
Level 4 and 5 harm falls for June 25 are in expected
variance level, with 3 reported in June
Key dependencies
Appropriate completion of falls risk assessments
Lying and Standing Blood Pressures
Capacity Assessments are key areas of focus for
improvement work
Current issues
WTWA continues to see high falls activity. Deep dive underway to
understand patterns and drivers
Future actions
Trust Group Falls Collaborative presented to Patient Safety Group in
July 2025. Falls Strategy reviewed- aligned Clinical Group falls work.
Falls Awareness Week 22 - 26 September 2025
Compliance
Variance
Assurance
Actions
Quality & Safety – Harm Free Care
Alert
0
0
0
0
1
2
LCO & Dental
Specialist
Corporate
NMGH
MRI
WTWA
-0.4
-0.2
0
0.2
0.4
0.6
0.8
1
1.2
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of Falls
Month
page 19
VTE screening compliance
VTE screening compliance
June-25 Target
82.89% 95%
Clinical Group Overview Updates since previous month
No significant changes since last month
Key dependencies
Digital Team - to develop HIVE improvements
Medics –residents and consultants - to support
education and compliance
Current issues
Linking VTE assessment to prescriptions for prophylaxis in HIVE – in
progress, this will mean that if a VTE assessment is not in place
clinicians will be unable to prescribe for inpatients.
Future actions
VTE Buddy Meeting August 2025
Linking prescriptions to VTE assessment / creating Hardstop - no VTE
assessment –clinicians unable to prescribe
Compliance
Variance
Assurance
Actions
Quality & Safety – Harm Free Care
Alert
28.60%
81.40%
85.00%
89.70%
90.40%
92.60%
93.00%
RMCH
MRI
WYTH
MREH
NMGH
TGH
SMH
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
page 20
Incidents relating to delays on waiting lists
(moderate + harm)
Incidents relating to delays on waiting lists (moderate + harm)
June-25 Target
3 0
Clinical Group Overview
Updates since previous month
Incidents identified with moderate or above harm reported in
June 2025. Variation noted due to increased awareness and
reporting of incidents since April 24. Data will continually
refresh due to retrospective reporting
Key dependencies
Productivity and efficiency work driving reductions in waiting
lists (including follow up activity). Key part of Care on Time
Programme
Current issues
Overall linked to delays in reporting and diagnostic pathways,
especially with in lung cancer/cardiac specialties
Future actions
Validation tools identified, training to be delivered in September.
Waiting safely messaging to be embedded within waiting list
validation communications. Risk stratification pilots agreed, data
analysis August / September. Framework started to roll out
Compliance
Variance
Assurance
Actions
Quality & Safety – Harm Free Care
Advise
-2
-1
0
1
2
3
4
5
6
7
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of incidents
Month
0
0
0
0
1
2
MRI
CSS
LCO & Dental
NMGH
Specialist
WTWA
page 21
Incidents relating to delays in follow ups
(moderate + harm)
Incidents relating to delays in follow ups (moderate + harm)
June-25 Target
4 0
Clinical Group Overview
Updates since previous month
4 incidents identified with moderate or above harm
reported in June 2025. Variation noted due to increased
awareness and reporting of incidents since April 24. Data
will continually refresh due to retrospective reporting
Key dependencies
Productivity and efficiency work driving reductions in
waiting lists. Key part of Care in Time Programme
Current issues
Overall linked to delays in reporting and diagnostic pathways,
especially with in lung cancer/cardiac specialties
Future actions
Validation tools identified, training to be delivered in September.
Waiting safely messaging to be embedded within waiting list
validation communications. Risk stratification pilots agreed, data
analysis August / September. Framework commenced roll out
Compliance
Variance
Assurance
Actions
Quality & Safety – Harm Free Care
Advise
-4
-2
0
2
4
6
8
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of incidents
Month
0
0
0
0
0
1
3
MRI
Corporate
CSS
NMGH
LCO & Dental
Specialist
WTWA
page 22
MRSA Bacteraemia
MRSA Bacteraemia
June-25 Target
1 0
Clinical Group Overview
Updates since previous month
1 case of MRSA bacteraemia reported,
totalling 3 cases since April 2025
Key dependencies
Zero tolerance to MRSA bacteraemia
(NHS England, 2014)
Current issues
Delay in prescribing Mupirocin as part of the Integrated care pathway
Future actions
MRSA bacteraemia improvement plan including education and policy review
and vascular access device management.
Development of Hive dashboard to support decolonisation therapy improvement
Compliance
Variance
Assurance
Actions
Quality & Safety - IPC
Alert
1
LCO & Dental
NMGH
Specialist
CSS
WTWA
MRI
0
1
2
3
4
5
6
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of MRSA Cases
Month
NOF metric
Score = 3.98
page 23
Clostridioides difficile infection
Clostridioides difficile infection
June-25 Target
21 0
Clinical Group Overview
Updates since previous month
Increase in cases of CDI since May 2025
although remains below threshold.
Key dependencies
CDI threshold as per the NHS Standard Contract
Current issues
Antimicrobial stewardship (AMS)
Delays in sampling
Inability to isolate all patients due to lack of single room availability and
competing priorities for isolation
Future actions
AMS dashboard now available in Hive to target appropriate prescribing
Inclusion of SPC charts within weekly surveillance reports to target
interventions
Revised Trust wide action plans in place tracking targeted actions and
progress
Compliance
Variance
Assurance
Actions
Quality & Safety - IPC
0
5
10
15
20
25
30
35
40
45
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of C.Diff Cases
Month
3
3
7
8
LCO & Dental
Specialist
CSS
NMGH
MRI
WTWA
Alert
NOF metric
Score = 1
page 24
Gram negative infection – E. Coli
Gram negative infection – E. Coli
June-25 Target
18 0
Clinical Group Overview
Updates since previous month
Reduction in case numbers from May 2025
Key dependencies
2024-2029 National Action Plan (NAP) focuses on
preventing any increase in infections from a 2019-20
baseline, rather than setting a reduction target
Current issues
Catheter associated urinary tract infections
Care of intravascular devices
Future actions
Development of a risk factor proforma to understand where to focus
priorities for reduction
AMS dashboard now available in Hive to target appropriate
prescribing
Inclusion of SPC charts within weekly surveillance reports to target
interventions
Compliance
Variance
Assurance
Actions
Quality & Safety - IPC
Advise
1
2
3
5
7
LCO & Dental
CSS
NMGH
Specialist
WTWA
MRI
0
5
10
15
20
25
30
35
40
45
50
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of E.Coli Cases
Month
NOF metric
Score = 2.29
page 25
Gram negative infection – Klebsiella
Gram negative infection – Klebsiella
June-25 Target
15 0
Clinical Group Overview
Updates since previous month
Case numbers remain static compared to May 2025
Key dependencies
2024-2029 National Action Plan (NAP) focuses on
preventing any increase in these infections from a
2019-20 baseline, rather than setting a reduction
target.
Current issues
Catheter associated urinary tract infections
Care of intravascular devices
Future actions
Development of a risk factor proforma to understand where to
focus priorities for reduction
AMS dashboard now available in Hive to target appropriate
prescribing
Inclusion of SPC charts within weekly surveillance reports to target
interventions
Compliance
Variance
Assurance
Actions
Quality & Safety - IPC
Advise
0
5
10
15
20
25
30
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of Klebsiella Cases
Month
1
1
3
5
5
LCO & Dental
CSS
Specialist
NMGH
WTWA
MRI
page 26
Gram negative infection – Pseudomonas
Gram negative infection – Pseudomonas
June-25 Target
4 0
Clinical Group Overview
Updates since previous month
Case numbers remain static compared to May
2025
Key dependencies
2024-2029 National Action Plan (NAP) focuses on
preventing any increase in these infections from a
2019-20 baseline, rather than setting a reduction
target
Current issues
Immuno-compromised patients at risk of Pseudomonas infection.
Compliance with ANTT principles and care of invasive devices
Future actions
Development of a risk factor proforma to understand where to focus
priorities for reduction
AMS dashboard now available in Hive to target appropriate prescribing
Inclusion of SPC charts within weekly surveillance reports to target
interventions
Compliance
Variance
Assurance
Actions
Quality & Safety - IPC
Advise
1
1
2
LCO & Dental
NMGH
Specialist
WTWA
MRI
CSS
-4
-2
0
2
4
6
8
10
12
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of Pseudomonas Cases
Month
page 27
Neonatal deaths per 1000 live births
Neonatal deaths per 1000 live births
June-25 Target
1.42 <4 per 1000
births
Clinical Group Overview
Key dependencies
PMRT reviews
Current issues
Awaiting confirmation from Leeds Teaching Hospital NHS
Foundation Trust regarding support with external PMRT reviews in
line with Safety Action 1, MIS Year 7
Future actions
Continue with PMRT review process, working towards full
compliance with MIS Year 7
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Advise
Assure
0
1
2
3
4
5
6
7
8
9
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of deaths per 1000 births
Month
Updates since previous month
Common cause variation continues with the rate
being below standard for 4 months
page 28
Stillbirths per 1000 live births (excluding TOP)
Stillbirths per 1000 live births (excluding TOP)
June-25 Target
4.26 <6 per 1000
births
Clinical Group Overview
Updates since previous month
Common cause variation continues with the rate
being below standard for 9 months
Key dependencies
PMRT reviews
Incidents with moderate harm and above
Current issues
One case with catastrophic harm – lack of holistic care and counselling
relating the antenatal appointment schedule
Future actions
AN Pathway Action Plan developed (August 2025)
Actions led the clinical teams-tacked locally via Ulysess. Compliance
with actions monitored weekly at Patient Safety Summit, chaired by the
Assistant Director of Clinical Governance for Saint Mary's Managed
Clinical Service
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Assure
0
1
2
3
4
5
6
7
8
9
10
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of Stillbirths per 1000 births
Month
page 29
Number of Maternal deaths
Number of Maternal deaths
June-25 Target
0
Clinical Group Overview
Updates since previous month
No maternal deaths reported in June 2025.
Key dependencies
MBRRACE-UK reporting
MNSI reporting
Current issues
No issues
Future actions
SM MCS active member of the GM Maternal Mortality group
looking at standardised reporting and developing improvement
workstream
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Assure
0
1
2
3
4
5
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of deaths
Month
page 30
Number of incidents accepted for MNSI investigation
Number of incidents accepted for MNSI investigation
June-25 Target
0
Clinical Group Overview
Updates since previous month
Common cause variation continues with no cases
accepted by MNSI in June 2025
Key dependencies
Cases of suspected HIE (Hypoxic-Ischaemic
Encephalopathy)
Current issues
No issues
Future actions
None
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Assure
0
1
2
3
4
5
6
7
8
9
10
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of incidents
Month
page 31
Number of incidents with moderate harm and above
Number of incidents with moderate harm and above
June-25 Target
2≤4
Clinical Group Overview
Updates since previous month
Reduction in the number of harm cases from May
2025
Key dependencies
Education and training
Escalation
Activity and acuity
Current issues
Lack of holistic care and counselling related to antenatal care and
appointments
Surgical technique and delayed follow up following perineal tear
Future actions
Perineal Clinic referral process to be reviewed.
Ante Natal Pathway action plan in development and will be monitored
via Division Quality & Safety meetings
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Assure
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of incidents
Month
page 32
Escalation: Term admissions to the Neonatal Unit
Escalation: Term admissions to the Neonatal Unit
June-25 Target
4.5 <6%
(60 per 1000)
Clinical Group Overview
Updates since previous month
Common cause variation continues for SM
MCS with the target being met for 5 months
Key dependencies
Planned term admissions
Current issues
4/63 admissions were considered avoidable. 2 related to infant feeding
support, and 2 related to asphyxia. Learning has been shared to inform fetal
surveillance training, ongoing education in place to support NG feeding on
PNW
Future actions
Aligned to quality improvement workstreams to reduce overall term
admissions and maintain rate below 6% target
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Assure
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Term Admissions Per 1,000 Births
Month
page 33
Category 3 Caesarean sections cancelled on the day
Category 3 Caesarean sections cancelled on the day
June-25 Target
8
<10 per month
Clinical Group Overview
Updates since previous month
Common cause variation continues with an ongoing
decrease in the number of caesarean sections
cancelled on the day
Key dependencies
Acuity and activity across SM MCS
Current issues
No current issues – continued improvement from May 2025
Future actions
Working with medical and midwifery teams to improve documentation
at Sign Out
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Alert
Assure
0
2
4
6
8
10
12
14
16
18
20
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number cancelled on the day
Month
page 34
Initial assessment time (Maternity Triage -15 mins)
Initial assessment time (Maternity Triage -15 mins)
June-25 Target
79.1% >90%
Clinical Group Overview
Updates since previous month
Special cause variation continues demonstrating an
improving position for 6 months since the
implementation of MMAT
Key dependencies
Year-on-year growth in attendances recorded at all
sites across SM MCS
Current issues
Variation shows that the standard is not yet met
Future actions
MMAT data being reviewed with findings to be reported though
Divisional Quality and Safety Committee and MODG.
Band 7 Coordinator for Triage at ORC business case has been
reviewed by SH SLT - decision on investment end of August 2025
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Alert
Advise
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Within 15 minutes
Month
page 35
Initial assessment time (Maternity Triage -30 mins)
Initial assessment time (Maternity Triage -30 mins)
June-25 Target
96.3% >90%
Clinical Group Overview
Updates since previous month
Special cause variation continues demonstrating an
improving position including target being met for 6
months since the implementation of MMAT
Key dependencies
Activity and acuity across SM MCS
Current issues
No current issues – Standard being met
Future actions
MMAT data on outcomes, classifications and safety being
reviewed with findings to be reported though Divisional Quality
and Safety Committee and MODG
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Advise
Assure
0%
20%
40%
60%
80%
100%
120%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Within 30 minutes
Month
page 36
Induction pathway delays
Induction pathway delays
June-25 Target
49.42% 60%
Clinical Group Overview
Updates since previous month
33.08% (86 women) waited between 24 and 48 hours.
13.08% (34 women) waited between 48 and 72 hours.
04.23% (4 women) waited between 72 and 96 hours
1 woman waited over 96 hours (1st since December 2023)
Key dependencies
Acuity and activity across SM MCS
Current issues
Increased activity and acuity impacting on the elective
pathway
Future actions
A comprehensive analysis of data presented to Maternity
ODG
Significant improvement has been achieved in July 2025 (not
included in this data)
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Alert
page 37
Augmentation of labour pathway delays
Augmentation of labour pathway delays
June-25 Target
19.04% <20%
Clinical Group Overview
Updates since previous month
Common cause variation with improvement seen with the
standard met in June 2025.
Harmonised process in place to support accuracy of
recording time ready for transfer and subsequent transfer to
Delivery Units
Key dependencies
Activity and acuity on each site and across SM MCS
Current issues
Increased activity and acuity impacts on timely transfer –
twice daily monitoring to support timely transfer, including
support across SM MCS
Future actions
Further action includes ensuring process being followed with
data validation
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Assure
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Labour pathway delays
Month
page 38
Births outside of intrapartum birth setting
Births outside of intrapartum birth setting
June-25 Target
6<4 per month
Clinical Group Overview
Updates since previous month
Common cause variation continues with six births outside
an intrapartum setting with two being potentially avoidable
Key dependencies
Not Applicable
Current issues
Listening to women and undertaking holistic reviews for women
on the IOL pathway – lessons learnt shared with focus on
listening to women being undertaken
Future actions
Review of all births in 2024/25 to identify any additional themes
- Site Obstetric Quality and Safety Committee
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Alert
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of births
Month
page 39
Number of babies with suspected HIE Grade 2/3
Number of babies with suspected HIE Grade 2/3
June-25 Target
0.72 <0.75 per 1000
Clinical Group Overview
Updates since previous month
Common cause variation continues – one
suspected case in June 2025
Key dependencies
Cases accepted by MNSI
Current issues
Lack of counselling regard the risk of cord prolapse
Future actions
Case shared with education team to be used in MDT training to support
education and counselling offered.
Systems action related to checklists to support equipment checks in
theatre –action completed June 2025
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Alert
Assure
0
1
2
3
4
5
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of babies
Month
page 40
MNSI/NHSR/CQC/Coroner Reg 28 or other organisation with a
concern or request for action made directly to Trust
MNSI/NHSR/CQC/Coroner Reg 28 Concern or request for action
June-25 Target
10
Clinical Group Overview
Updates since previous month
One CQC concern received
Key dependencies
Inquests, CQC compliance and MNSI reporting
Current issues
CQC enquiry linked to formal patient complaint relating to alleged staff
attitude and behaviour. Actions related to incident disclosed and
timeline for formal patient complaint response detailed
Future actions
To continue with current reporting and oversight process
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
0
1
2
3
4
5
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of requests
Month
Advise
page 41
Number of patients with Deprivation of Liberty Safeguards
(DoLs)
Number of patients with DoLs
June-25 Target
355 -
Clinical Group Overview Updates since previous month
DoLS applications have slightly increased
to 355 this month from 342 in May 2025
Key dependencies
Collaborative partnership with MFT
Safeguarding Team with the Manchester
Local Authority best interest assessment
(LA BIA) team to promote completion of the
DoLS
Current issues
Audit data and DoLS tracking in Q1 indicates 64% (683 patients) with DoLS
application have died or been discharged from MFT care prior to DoLS being
completed by LA BIA team in Q1
Future actions
Revised DoLS policy on track for implementation September 2025.
Assessment period for those temporarily lacking capacity extended to 14
days to evaluate treatment impact before DoLS application. Immediate care
under MCA Best Interests; implementation if revised policy overseen by Trust
Safeguarding Group
Quality & Safety - Safeguarding
Advise
0
100
200
300
400
500
600
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of patients
Month
1
4
92
120
138
Specialist
LCO & Dental
CSS
MRI
WTWA
NMGH
Compliance
Variance
Assurance
Actions
page 42
Number of authorised DoLS
Number of authorised DoLS
June-25 Target
8 -
Clinical Group Overview
Updates since previous month
8 DoLS were completed by the Local Authority
Best Interest Assessment Team and notified to
the CQC by MFT
Key dependencies
DOLS partnership meeting - MFT Safeguarding
Team with the Manchester LA BIA team to
review authorization rates
Current issues
<1 % of MFT DoLS applications authorised by the Local Authority National
data indicates 19% of standard authorisations are authorised in 21 day
statutory timescales
Future actions
Revision of MFT DoLS policy informed by case law and deep dive of MFT
DoLS processed by Manchester LA BIA
Approved by Trust Safeguarding Group August on track for implementation
September 2025
Quality & Safety - Safeguarding
Advise
-5
0
5
10
15
20
25
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Numberof authorised DoLs
Month
3
5
Specialist
CSS
LCO & Dental
MRI
NMGH
WTWA
Compliance
Variance
Assurance
Actions
page 43
Training – Safeguarding Children L1
Training – Safeguarding Children L1
June-25 Target
95.93% 90%
Clinical Group Overview
Updates since previous month
Expected standard consistently met
Key dependencies
Reported and overseen by to Trust Safeguarding
Group
Current issues
No issues
Future actions
Continue to monitor performance
Quality & Safety - Safeguarding
Assure
94.69%
94.98%
95.41%
96.04%
96.20%
96.21%
96.57%
WTWA
R&I
CSS
MRI
NMGH
LCO & Dental
Specialist
80%
85%
90%
95%
100%
105%
110%
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
Compliance
Variance
Assurance
Actions
page 44
Training – Safeguarding Adults L1
Training – Safeguarding Adults L1
June-25 Target
96.04% 90%
Clinical Group Overview
Updates since previous month
Expected standard consistently met
Key dependencies
Reported and overseen by to Trust Safeguarding
Group
Current issues
No issues
Future actions
Continue to monitor performance
Quality & Safety - Safeguarding
Assure
80%
85%
90%
95%
100%
105%
110%
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
94.99%
95.40%
95.45%
96.25%
96.30%
96.33%
96.49%
WTWA
R&I
CSS
NMGH
LCO & Dental
MRI
Specialist
Compliance
Variance
Assurance
Actions
page 45
Training – Safeguarding Children L2
Training – Safeguarding Children L2
June-25 Target
94.69% 90%
Clinical Group Overview
Updates since previous month
Expected standard consistently met
Key dependencies
Reported and overseen by to Trust Safeguarding
Group
Current issues
No issues
Future actions
Continue to monitor performance
Quality & Safety - Safeguarding
Assure
92.83%
93.59%
95.32%
95.47%
95.63%
96.09%
98.64%
WTWA
CSS
MRI
Specialist
LCO & Dental
NMGH
R&I
80%
85%
90%
95%
100%
105%
110%
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
Compliance
Variance
Assurance
Actions
page 46
Training – Safeguarding Adults L2
Training – Safeguarding Adults L2
June-25 Target
94.82% 90%
Clinical Group Overview
Updates since previous month
Expected standard consistently met
Key dependencies
Reported and overseen by to Trust Safeguarding
Group
Current issues
No issues
Future actions
Continue to monitor performance
Quality & Safety - Safeguarding
Assure
80%
85%
90%
95%
100%
105%
110%
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
93.02%
93.93%
95.43%
95.63%
95.70%
95.88%
98.64%
WTWA
CSS
Specialist
LCO & Dental
MRI
NMGH
R&I
Compliance
Variance
Assurance
Actions
page 47
Training - Safeguarding Children Level 3
Training - Safeguarding Children Level 3
June-25 Target
85.25% 90%
Clinical Group Overview
Updates since previous month
Improving training trajectory. (1% increase
in compliance from May 2025)
Trust standard not met
Key dependencies
Trust Safeguarding Group oversees the
implementation of the level 3
safeguarding training improvement plan
Current issues
Nursing and midwifery workforce compliance – 88% (2% increase in month)
AHP workforce compliance 88%
Medical and Dental workforce compliance 70% (4% increase in month)
Future actions
CG Medical and Nursing Directors continue to oversee improvement plans for
NMAHP, Medical and Dental workforce
Plan in place and on track to improve compliance by end October 2025
Quality & Safety - Safeguarding
Alert
70.83%
74.00%
82.18%
82.31%
83.94%
88.29%
89.72%
NMGH
WTWA
R&I
MRI
CSS
LCO & Dental
Specialist
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
Compliance
Variance
Assurance
Actions
page 48
Training - Safeguarding Adults Level 3
Training - Safeguarding Adults Level 3
June-25 Target
86.14% 90%
Clinical Group Overview
Updates since previous month
Improving training trajectory. (1% increase in
compliance from May 2025)
Trust standard not met
Standard met in SHS, LCO/UDHM and R&I
Key dependencies
Trust Safeguarding Group oversees the
implementation of the level 3 safeguarding
training improvement plan
Current issues
Nursing and midwifery workforce compliance – 90%
AHP workforce compliance 90%
Medical and Dental workforce compliance 68%
Future actions
Medical and Nursing Directors continue to oversee improvement plans
for NMAHP, Medical and Dental workforce in Clinical Groups reported
to Trust Safeguarding Group and TLTC. Aim to achieve compliance
end October 2025
Review of training content to support improved compliance - Aug 2025
Quality & Safety - Safeguarding
Alert
50%
60%
70%
80%
90%
100%
110%
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
80.53%
83.84%
85.12%
85.47%
90.45%
91.28%
91.93%
WTWA
CSS
NMGH
MRI
LCO & Dental
R&I
Specialist
Compliance
Variance
Assurance
Actions
page 49
MHA Compliance – Section 132 – Provision
of information to patients
MHA Compliance – Section 132 – Provision of information to patients
June-25 Target
89% 100%
Clinical Group Overview
Updates since previous month
89% of patients had received their rights
following detention under the Mental Health Act,
an increase from 85% in May 2025
No patients were detained under MHA in CSS
or LCO
Key dependencies
Delegation of Statutory Functions –MHA
Patients Reported to MH Subgroup
Current issues
39 out of 44 patients detained under a MHA section received rights within
statutory timescales. MHA compliance gaps escalated to wards and
monitored by MHA Manager
Future actions
Revised Mental Health Act training programme delivered to improve
knowledge and skills in applying the Delegation of Statutory Functions for
MFT patients detained under the MHA. Clinical Group SLT, operational
managers, and senior nursing teams trained; current focus is ED training
Quality & Safety – Mental Health Strategy
Alert
0%
20%
40%
60%
80%
100%
120%
140%
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
May 25
% Compliance
Month
75.00%
83.33%
83.33%
92.85%
LCO &
Dental
CSS
Specialist
NMGH
WTWA
MRI
Compliance
Variance
Assurance
Actions
page 50
Patients detained under MHA missing from hospital care
Patients detained under MHA missing from hospital care
June-25 Target
0 0
Clinical Group Overview
Updates since previous month
There were 0 patients detained under the MHA
missing from care
Key dependencies
Application of The Prevention and Management of
Missing Patient Policy is overseen by the Right Care
Right Person Task and Finish Group, reporting to the
Mental Health subgroup
Current issues
In June 2025 there were 44 patients detained under the MHA, 28 in
MRI, 6 in WTWA, 6 NMGH, 4 SHS (excluding Galaxy House)
Future actions
Positive behaviour training; escalation for timely patient transfers
Quality & Safety – Mental Health Strategy
CSS
LCO & Dental
WTWA
Specialist
MRI
NMGH
Assure
Compliance
Variance
Assurance
Actions
-2
-1
0
1
2
3
4
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
May 25
Number of patients
Month
page 51
Training - Mental Health Level 1
Training - Mental Health Level 1
June-25 Target
95.13% 90%
Clinical Group Overview
Updates since previous month
Training compliance standard is consistently met
Key dependencies
Training compliance is reported to the Mental Health
Subgroup
Current issues
No issues
Future actions
Continue to monitor performance
Assure
93.50%
94.49%
94.83%
94.84%
95.78%
95.88%
96.72%
WTWA
MRI
CSS
R&I
NMGH
Specialist
LCO & Dental
80%
85%
90%
95%
100%
105%
110%
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
May 25
% Compliance
Month
Compliance
Variance
Assurance
Actions
Quality & Safety – Mental Health Strategy
page 52
Training - Mental Health Level 2
Training - Mental Health Level 2
June- 25 Target
85.03% 90%
Clinical Group Overview
Updates since previous month
Compliance in Mental Health Level 2 training increased
by 1% this month. R&I and NMGH are achieving the
standard; MRI and CSS showing improved trajectories
since May 2025
Key dependencies
Level 2 Mental Health training performance will continue
to be monitored through the Mental Health Subgroup as
part of the Mental Health Improvement Plan
Current issues
Mental Health Level 2 training compliance is 85.03%, below
the Trust’s 90% standard. CSS remains the lowest-performing
Clinical Group, requiring targeted support and oversight
Future actions
Clinical Groups asked to produce detailed trajectories and
improvement plans to address training performance. Plans
will be tracked and monitored through the Mental Health
Subgroup – August 2025
Alert
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
May 25
% Compliance
Month
79.99%
82.70%
85.07%
85.48%
86.77%
95.09%
96.44%
CSS
WTWA
Specialist
LCO & Dental
MRI
NMGH
R&I
Compliance
Variance
Assurance
Actions
Quality & Safety – Mental Health Strategy
page 53
Number of patients detained under Section 136 > 12 hours
Number of patients detained under Section 136 > 12 hours
May-25 Target
17 0
Clinical Group Overview
Updates since previous month
17 out of 25 patients detained under a section
136 of the Mental Health Act remained ED over
12 hours
Key dependencies
The Right Care, Right Person task and finish
group, reporting to the Mental Health Subgroup,
is overseeing Section 136 improvement work
Current issues
A Section 136 Mental Health Act SOP has been implemented across all
EDs. Weekly SITREPs highlight the need for targeted support in NMGH,
WTWA, and MRI, with oversight by Clinical Group SLTs and reporting to
the RCRP Assurance Group and Mental Health Subgroup
Future actions
ED Nursing MH Escalation Pathway in consultation; report due August
2025
Quality & Safety – Mental Health Strategy
Advise
1
8
8
LCO & Dental
CSS
Specialist
WTWA
NMGH
MRI
0
5
10
15
20
25
30
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
May 25
Number of patients detained
Month
Compliance
Variance
Assurance
Actions
page 54
% of people with LD / Autism who have evidence of
reasonable adjustment within 48 hours of admission
% of people with LD / Autism who have evidence of reasonable adjustment within 48 hours of admission
June-25 Target
96% 100%
Clinical Group Overview
Updates since previous month
Compliance has risen from 92% in May 2025 to
96%, continuing the upward trajectory seen since
November 2023
Key dependencies
Monitoring of performance of completed
reasonable adjustments overseen by the Learning
Disability Steering Group
Current issues
Of 89 patients with a learning disability admitted to MFT hospitals, 4
had no documented reasonable adjustments in the Hive record.
Quality checks are completed within 48 hours of admission for all
patients with an LD/A flag to support appropriate care delivery
Future actions
RMCH LD/A mapping completed; pathway in development for future
reporting
Quality & Safety – Learning Disability Srategy
Alert
80.0%
89.7%
100.0%
100.0%
100.0%
LCO & Dental
Specialist
MRI
NMGH
WTWA
CSS
0%
20%
40%
60%
80%
100%
120%
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
Compliance
Variance
Assurance
Actions
page 55
Mixed Sex Breaches
Mixed Sex Breaches
June-25 Target
37 0
Clinical Group Overview
Current issues
Flow and ward capacity constraints delaying transfers
Future actions
Active surveillance is focused on identifying early drivers
of underperformance of standards
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Alert
6
11
20
CSS
LCO & Dental
Specialist
NMGH
MRI
WTWA
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of breaches
Month
Updates since previous month
Compared to the previous month’s totals (MRI 23,
WTWA 9, NMGH 8), there has been a slight
reduction of 3 MSA cases overall
Key dependencies
Operational bed management and flow
page 56
What Matters to Me (Overall score)
What Matters to Me (Overall score)
June-25 Target
93.97% 95%
Clinical Group Overview
Updates since previous month
No significant overall change – Previous month: 93.54%.
CSS performance increased from 90.51% to 91.75%
Key dependencies
Adequate resource allocation (staffing, technology, and budget) to
support improvement initiatives
Real-time patient feedback mechanisms to identify and address
issues promptly
Leadership visibility and sponsorship to keep patient experience a
high organisational priority
Current issues
Wi-fi and connectivity problems in parts of the
organisation.
Future actions
Following the successful launch of the revised
patient experience survey for RMCH on 10 March
2025, the Adult Inpatient survey is scheduled for
August 2025
Compliance
Variance
Assurance
Actions
Quality & Safety – Patient Experience
Alert
80%
85%
90%
95%
100%
105%
110%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Performance
Month
page 57
Friends & Family Test – Inpatient/Daycase
Friends & Family Test – Inpatient Performance
June-25 Target
92.67% 95%
Clinical Group Overview
Updates since previous month
Overall performance declined to 93.78% (down from previous
month).
Total submissions: 6,305 – an increase of 146 from last month.
CSS: score increased to 94.01%.
MRI: score decreased to 90.50%
Key dependencies
Clear ownership of improvement plans with measurable
outcomes. Systematic recognition of positive feedback to drive
staff engagement. Visibility and alignment with strategic and
objective quality priorities
Current issues
Wi-fi connection in areas of the organisation continue to
affect access to data collection systems, contributing to
reduced staff engagement and participation in key
processes
Future actions
Continue to embed patient feedback education in staff
induction and refresher training.
Monitor impact on FFT response rates and adjust
approach based on feedback
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Alert
80%
85%
90%
95%
100%
105%
110%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Positive
Month
-1%
0%
1%
2%
3%
4%
5%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Negative
Month
page 58
Friends & Family Test – Emergency Department
Friends & Family Test – ED Performance
June-25 Target
82.89% 95%
Overview
Updates since previous month
Overall performance declined to 83.35%
Total submissions: 3,007 –
a decrease of 2,217 from last month, with
MRI showing the most significant drop (previous month: 1,657).
Score increases recorded for SMH (from 83.33%), RMCH (from
83.67%), and NMGH (from 78.86%)
Key dependencies
Delivery of improvement plans with measurable outcomes.
Systematic recognition of positive feedback to drive staff
engagement. Visibility and alignment with strategic and objective
quality priorities
Current issues
Overall themes include 'waiting'.
Work is being undertaken to reduce the wait time in
ED and increase patient flow across the Trust
Future actions
Continue to embed patient feedback education in
staff induction and refresher training.
Monitor impact on FFT response rates and adjust
approach based on feedback
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Alert
0%
20%
40%
60%
80%
100%
120%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Positive
Month
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Negative
Month
page 59
Friends & Family Test – Outpatient
Friends & Family Test – Outpatient Performance
June-25 Target
97.70% 95%
Clinical Group Overview
Updates since previous month
Total submissions: 7,608 – an increase of 898 from last
month.
Overall score: slight rise to 97.16%.
Specialist Hospital CG recorded the largest increase in
submissions from last month (up from 1,774)
Key dependencies
Clear ownership of improvement plans with measurable
outcomes. Systematic recognition of positive feedback to
drive staff engagement. Visibility and alignment with
strategic and objective quality priorities
Current issues
The outpatient areas in Clinical Groups identifying opportunities
to improve and sustain patient experience and patient
satisfaction scores
Future actions
Continue to embed patient feedback education in staff induction
and refresher training.
Monitor impact on FFT response rates and adjust approach
based on feedback
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Assure
85%
90%
95%
100%
105%
110%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Positive
Month
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Negative
Month
page 60
Friends & Family Test – Community Services
Friends & Family Test – Community Performance
June-25 Target
98.89% 95%
Service Overview Updates since previous month
Total submissions: 1,622 – a decrease of 25 from May
2025.
Overall score: slight increase to 98.17%.
Children and Family Services saw a notable drop from
100% last month, though submission numbers remained
low at three per month
Key dependencies
Implementation of improvement plans with measurable
outcomes. Systematic recognition of positive feedback to
drive staff engagement. Visibility and alignment with
strategic and objective quality priorities
Current issues
Wi-Fi connectivity issues in bed-based areas have impacted
real-time FFT collection. Booster devices have now been
installed to improve access. In community settings, FFT cards
and QR codes remain the primary method for collecting
feedback in patients’ homes, supporting continued data
capture
Future actions
Actively promoted survey to maximise visibility and response
rates across all care settings
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Assure
85%
90%
95%
100%
105%
110%
115%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Positive
Month
0%
0%
0%
0%
1%
1%
1%
1%
1%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Negative
Month
page 61
Friends & Family Test –TP1 – Antenatal Care
Friends & Family Test – Antenatal Care
June-25 Target
97.90% 95%
Site Overview Updates since previous month
Total submissions 619, increase from previous month
by 337. Slight increase from previous month overall
score of 97.87%. TGH saw an increase from 90.91%.
WYT saw a decrease from100%
Key dependencies
Clear ownership of improvement plans with
measurable outcomes. Systematic recognition of
positive feedback to drive staff engagement. Visibility
and alignment with strategic and objective quality
priorities
Current issues
SM MCS continue to review ways to increase submission rates. The
journey is currently looked at as an entirety
Future actions
Continue to work with Maternity Network Voices Partnership to gain
feedback to improve services. A new patient experience survey is
being trialed to capture feedback on the birth and postnatal journey,
issued post-discharge. It is anticipated that the Friends and Family
Test (FFT) will be incorporated into this approach, alongside
existing collection methods, supporting an increase in response
rates and deeper insight into women’s experiences
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Assure
0%
20%
40%
60%
80%
100%
120%
Apr 23
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
% Positive
Month
-2%
0%
2%
4%
6%
8%
10%
12%
Apr 23
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
% Negative
Month
page 62
Friends & Family Test –TP2 – Birth
Friends & Family Test – Birth
June-25 Target
97.53% 95%
Site Overview
Updates since previous month
Total submissions 81, decrease from previous
month by 38. Increase from previous month
overall score of 95.80%.
SMH saw an increase from 80%
Key dependencies
Clear ownership of improvement plans with
measurable outcomes. Systematic recognition of
positive feedback to drive staff engagement.
Visibility and alignment with strategic and
objective quality priorities
Current issues
The immediate post-partum period is a sensitive time, often making new
mothers reluctant or unable to provide feedback which is being reviewed
in line with the new PE survey
Future actions
A revised patient experience survey is being piloted post-discharge to
gather feedback on the birth and postnatal journey. It is anticipated that
the Friends and Family Test (FFT) will be incorporated into this
approach, alongside existing collection methods, supporting an increase
in response rates and deeper insight into women’s experiences
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Assure
0%
20%
40%
60%
80%
100%
120%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Positive
Month
-2%
-1%
0%
1%
2%
3%
4%
5%
6%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Negative
Month
page 63
Friends & Family Test (FFT) –TP3 – Care on Postnatal Ward
Friends & Family Test – Care on Postnatal Ward
June-25 Target
92.45% 95%
Site Overview Updates since previous month
Total submissions 318, decrease from previous month by 82.
Decrease from previous months score of 96.50%
WTWA saw an increase from 93.33%
NMGH and ORC both saw a reduction from 98.41% and 97.17%
respectively
Key dependencies
Clear ownership of improvement plans with measurable
outcomes. Systematic recognition of positive feedback to drive
staff engagement. Visibility and alignment with strategic and
objective quality priorities
Current issues
The immediate post-partum period is a sensitive time,
often making new mothers reluctant or unable to provide
feedback which is being reviewed in line with the new PE
survey
Future actions
A revised patient experience survey is being piloted post-
discharge to gather feedback on the birth and postnatal
journey. It is anticipated that the FFT will be incorporated
into this approach, alongside existing collection methods,
supporting an increase in response rates and deeper
insight into women’s experiences
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Alert
0%
20%
40%
60%
80%
100%
120%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Positive
Month
-2%
-1%
0%
1%
2%
3%
4%
5%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% negative
Month
page 64
Friends & Family Test – Maternity TP4 – Postnatal Community Provision
Friends & Family Test – Postnatal Community Provision
June-25 Target
80% 95%
Site Overview Updates since previous month
Decrease on overall score from previous month of 100%.
Total submissions 5, an increase from previous month by 2
Key dependencies
Clear ownership of improvement plans with measurable
outcomes. Systematic recognition of positive feedback to
drive staff engagement. Visibility and alignment with
strategic and objective quality priorities
Current issues
There has been a continued decline in the number of
responses within maternity since July 2024 despite an
increased focus during Q4 supporting women to complete FFT
at home, using QR codes and cards
Future actions
A revised patient experience survey is being piloted post-
discharge to gather feedback on the birth and postnatal
journey. It is anticipated that the Friends and Family Test (FFT)
will be incorporated into this approach, alongside existing
collection methods, supporting an increase in response rates
and deeper insight into women’s experiences
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Alert
0%
20%
40%
60%
80%
100%
120%
140%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Positive
Month
-1%
-1%
0%
1%
1%
2%
2%
3%
3%
4%
4%
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Jun 25
% Negative
Month
page 65
Number of formal complaints opened
Number of formal complaints opened
June-25 Target
193 N/A
Clinical Group Overview
Updates since previous month
5% increase in new complaints – sustained rise since
March 2025
Key dependencies
Successfully resolving concerns through PALS and at
department level
Implementation of Trust-wide standardized approach to
complaint handling and early resolution
Current issues
Increased complaints regarding medication errors, clinical
assessment, car parking and security
Future actions
Escalation of recurrent themes/learning to Patient Safety Group,
Clinical Group SLTs and Executives, to target actions
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Advise
2
10
10
25
41
44
61
Corporate
LCO & Dental
CSS
MRI
NMGH
WTWA
Specialist
0
50
100
150
200
250
300
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of complaints opened
Month
page 66
Number of PHSO complaints
Number of PHSO complaints
June-25 Target
0 N/A
Clinical Group Overview
Updates since previous month
No new PHSO cases
Key dependencies
None
Current issues
No issues
Future actions
PHSO visit scheduled for October 2025
Compliance
Variance
Assurance
Actions
Quality & Safety – Patient Experience
Advise
CSS
WTWA
NMGH
LCO & Dental
MRI
Specialist
-2
-1
0
1
2
3
4
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of PHSO Complaints
Month
page 67
Number of reopened (not new) complaints
Number of reopened (not new) complaints
June-25 Target
34 N/A
Clinical Group Overview
Updates since previous month
Decrease in re-opened complaints
Key dependencies
Quality assurance within governance teams
Increase in number of complaint local resolution meetings
(LRMs) to compassionately engage with patients and
families and resolve complaints first time
Current issues
High number of re-opened complaints in Specialist Hospitals
Future actions
Targeted complaints response training in Specialist Hospitals
Compliance
Variance
Assurance
Actions
Quality & Safety – Patient Experience
Advise
1
1
2
5
6
7
12
LCO & Dental
Corporate
CSS
WTWA
NMGH
MRI
Specialist
0
10
20
30
40
50
60
70
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of complaints reopened
Month
page 68
Closed complaints in month (theme)
Closed complaints in month (theme)
June-25 Target
N/A N/A
Clinical Group Overview
Updates since previous month
Rise in complaints related to clinical assessment
and appointment delays/cancellations
Key dependencies
Complaints data currently related to date of
complaint not date of event
Current issues
Trauma & Orthopaedic appointment delays/cancellations
Future actions
Triangulate data with Patient Safety to identify themes across dates and
departments
Compliance
Variance
Assurance
Actions
Quality & Safety – Patient Experience
Advise
0%
5%
10%
15%
20%
25%
Apr-25 May-25 Jun-25
Treatment/Procedure Clinical Assment (Diag,Scan) Communication Attitude Of Staff App, Delay / Cancellation (OP)
page 69
% complaints resolved in agreed timescale
% complaints closed in agreed timescale
June-25 Target
88.0% 90%
Clinical Group Overview Updates since previous month
Drop in number of complaints responded to within agreed
timescale
Key dependencies
Potential breaches escalated to SLT
Development of Power BI dashboards with live data for
Clinical Groups
Current issues
Low compliance within Specialist Hospitals and Corporate
Services, due to backlog of overdue complaints. Corporate
Services backlog all responded to in June & July, to progress
towards future compliance of 100%
Future actions
Central Complaints Team supporting early resolution of
Corporate complaints
Specialist Hospitals resolving backlog of overdue complaints as
part of recovery plan
Compliance
Variance
Assurance
Actions
Quality & Safety – Patient Experience
Advise
33.30%
76.27%
96.00%
94.90%
100.00%
100.00%
100.00%
Corporate
Specialist
NMGH
WTWA
MRI
LCO & Dental
CSS
0%
20%
40%
60%
80%
100%
120%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Complaints resolved in agreed timescale
Month
page 70
Patient Advice & Liaison Service Contacts
Patient Advice & Liaison Service Contacts
June-25 Target
780 N/A
Clinical Group Overview
Updates since previous month
14% increase in PALS contacts
Key dependencies
Senior colleagues calling patients to resolve concerns
quickly
Current issues
Rise in contacts relating to 'attitude of staff' and 'communication'
Future actions
Deep-dive into 'attitude of staff' concerns,
analysing professions/divisions/departments, to be shared
with Clinical Group SLTs to identify and implement improvement
actions
Compliance
Variance
Assurance
Actions
Quality & Safety - Patient Experience
Advise
29
37
75
105
157
174
203
LCO & Dental
Corporate
CSS
NMGH
WTWA
MRI
Specialist
0
200
400
600
800
1000
1200
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of PALS Concerns received
Month
page 71
Care Hours Per Patient Day
Care Hours Per Patient Day
June-25 Target
9.6 9.7
Clinical Group Overview
Updates since previous month
CHPPD at MFT is in the middle of the range
when compared to the Shelford Group of NHS
Trusts MFT (6th out of 10 Trusts when ranking
highest to lowest CHPPD)
Key dependencies
Monthly average is higher than peer organisations
due to inclusion of critical care bed information-
exclusion of CSS data CHPPD is 8.8
Current issues
No issues
Future actions
Continue to monitor
Compliance
Variance
Assurance
Actions
Quality & Safety – Safer Staffing
Assure
7.7
8.5
8.3
10.8
10.8
14.2
34.1
LCO & Dental
WTWA
MRI
MREH
NMGH
SMH
RMCH
CSS
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of care hours
Month
page 72
Ratio of actual : planned hours (excluding maternity)
Ratio of actual : planned hours (excluding maternity)
June-25 Target
94.7% 95%
Clinical Group Overview
Updates since previous month
Fill rate maintained within normal statistical variation
in June 2025
Key dependencies
Registered Nurse vacancy position at 2.4%
against Shelford average of 4.3% (May 2025).
Nursing Support Worker vacancy rate at 12.9%
against Shelford average of 8.6% (May 2025)
Current issues
Fill rates at MREH (1 ward), RMCH, MRI and WTWA confirmed no
safety concerns in areas with lower fill rate
Future actions
Maintain recruitment pipeline for Spring and Autumn 2025
graduates, Continue unregistered recruitment events at Clinical
Groups and widening participation programme
Compliance
Variance
Assurance
Actions
Quality & Safety – Safer Staffing
Assure
92.8%
92.8%
94.6%
94.1%
96.6%
96.6%
100.0%
LCO & Dental
MREH
RMCH
MRI
WTWA
SMH
NMGH
CSS
86%
88%
90%
92%
94%
96%
98%
100%
102%
104%
106%
108%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Actual v Planned Hours
Month
page 73
Maternity triage staffing – actual v planned
Maternity Triage staffing – actual v planned
June-25 Target
100% >95%
Clinical Group Overview
Current issues
No issues
Future actions
To continue with current monitoring and reporting processes
Compliance
Variance
Assurance
Actions
Quality & Safety – Maternity
Assure
Key Dependencies
Midwifery staffing establishment
100%
0%
Actual Planned
Updates since previous month
100% compliance with midwifery staffing continues
page 74
Sepsis 7 - Medical review on time
Sepsis 7 - Medical Review On Time
July-25 Target
89% 100%
Clinical Group Overview Updates since previous month
The data indicates that the overall percentage score has
remained below the expected trust standard - 100%
Key dependencies
Early recognition and escalation is essential and can be
achieved through completion of sepsis screening tool.
Sepsis screening link on EWS BPAs
Automated alerts to raised EWS in ORC and WTWA, not
available at NMGH - plan for Q2
Standards for response to EWS alerts set out in Policy –
Hive report available for compliance
Manual alerting requires nursing staff to recognise sepsis
signs and confidence in escalation
Current issues
Sepsis audit data shows standards of sepsis care are reliant on
timely medical reviews. Issues –medical teams not signing in
to provider care groups therefore do not achieve alerts/sepsis
screening not mandatory
Compliance
Variance
Assurance
Actions
Quality & Safety –Sepsis 7
Advise
Future actions
World Sepsis Day 2025 (13th September) - "Sepsis
September," targeted program of education, awareness, and
improvement initiatives across MFT
Sepsis deep dive (Feb–July 2025) - recommendations for
adult, maternity, and paediatric services - Targeted
improvement led locally by Clinical Groups and coordinated
through the Trust Sepsis Group to track progress
79%
89%
92%
94%
CSS
LCO & Dental
MRI
WTWA
Specialist
NMGH
0%
20%
40%
60%
80%
100%
120%
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Jul 25
% Compliance
Month
page 75
Sepsis 7 - Oxygen administered
Sepsis 7 - Oxygen Administered
July-25 Target
97% 100%
Clinical Group Overview
Updates since previous month
The data indicates that the overall percentage score
has remained below the expected trust standard-
100%
Key dependencies
Incomplete clinical observation documentation will
cause variations to the overall early warning score,
which may lead to underscoring not reflecting the
actual patient acuity
Current issues
Documentation of oxygen not always completed on submission of
clinical observations or in medical notes
Future actions
Development of trust clinical observation audit to enable a deep
dive into compliance standards, to support improvement work
needed –Q2
Clinical observation policy update –Q2
Compliance
Variance
Assurance
Actions
Quality & Safety –Sepsis 7
Advise
0%
20%
40%
60%
80%
100%
120%
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Jul 25
% Compliance
Month
94%
94%
100%
100%
CSS
LCO & Dental
WTWA
MRI
Specialist
NMGH
page 76
Sepsis 7 - Blood cultures taken
Sepsis 7 - Blood Cultures Taken
July-25 Target
87% 100%
Clinical Group Overview Updates since previous month
The data indicates that the overall percentage score
has remained below the expected trust standard -
100%
Key dependencies
Blood cultures - primary diagnostic test available to
detect BSI, ascertain the causative organism, and
direct the most appropriate antimicrobial to treat the
infection
Current issues
Timely collection of blood cultures is not consistently achieved in
sepsis cases, with cultures often taken after antibiotic
administration or not taken
Future actions
Clinical Groups - review compliance in Inpatient and Emergency
Department areas undertaking blood culture training as part of the
trust IV therapy course
Acute Care team – Development sepsis order set with digital team
to be available on Hive – expected delivery end of Q2
Compliance
Variance
Assurance
Actions
Quality & Safety –Sepsis 7
Advise
80%
84%
91%
92%
CSS
LCO & Dental
MRI
WTWA
NMGH
Specialist
0%
20%
40%
60%
80%
100%
120%
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Jul 25
% Compliance
Month
page 77
Sepsis 7 - Antibiotics administered
Sepsis 7 - Antibiotics Administered
July-25 Target
80% 100%
Clinical Group Overview Updates since previous month
The data indicates that the overall
percentage score has remained below the
expected trust standard - 100%
Key dependencies
Delay in antibiotics - timely medical
review, communication to nursing staff,
availability of IV trained staff and delay in
gaining IV/IO access
Current issues
Delay in antibiotic administration results from prescription delays,
administration delays, or a combination of both.
In July 2025, 36 prescription delays and 16 administration delays were
reported
Future actions
Acute Care Team – Review themes of non-compliance to provide targeted
feedback and education to areas requiring additional support
Acute Care Team deep-dive into sepsis management across MFT for Q4/Q1
25/26 data to support workplan for sepsis
Compliance
Variance
Assurance
Actions
Quality & Safety –Sepsis 7
Advise
0%
20%
40%
60%
80%
100%
120%
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Jul 25
% Compliance
Month
69%
72%
86%
92%
CSS
LCO & Dental
MRI
WTWA
NMGH
Specialist
page 78
Sepsis 7 - Lactate taken
Sepsis 7 - Lactate Taken
July-25 Target
87% 100%
Clinical Group Overview
Updates since previous month
The data indicates that the overall percentage
score has remained below the expected trust
standard - 100%
Key dependencies
Lactate is a marker to aid in the diagnosis and
management of sepsis and septic shock, including
need for fluid resuscitation and ICU review
Current issues
Lactate measurement not consistently undertaken or delayed in sepsis
cases, with missed or delayed measurements occurring more
frequently in inpatient areas than in Emergency Departments
Future actions
Acute Care Team –detailed data analysis from inpatient ward areas to
understand the barriers to lactate measurement will be sheared with
Clinical Group Q&S with actions.
Acute Care team – developing sepsis order set with digital team to be
available on Hive, which will include all required blood/lab tests
required including lactate
Compliance
Variance
Assurance
Actions
Quality & Safety –Sepsis 7
Advise
78%
81%
88%
100%
CSS
LCO & Dental
MRI
WTWA
Specialist
NMGH
0%
20%
40%
60%
80%
100%
120%
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Jul 25
% Compliance
Month
page 79
Sepsis 7 - IV fluid bolus administered
Sepsis 7 - IV Fluid Bolus Administered
July-25 Target
83% 100%
Clinical Group Overview Updates since previous month
The data indicates that the overall percentage score
has remained below the expected trust standard -
100%
Key dependencies
Administration of IV fluids to patients with
hypovolemia or shock from sepsis may improve
cardiac output, oxygen delivery, organ function, and
mortality outcomes
Current issues
IV fluid administration in septic patients with raised lactate or
hypovolemia delays influenced by late medical review, limited IV
access, and delayed lactate results, with emergency prescriptions
not always recorded on the Medication Administration Record,
leading to gaps in evidence of treatment
Future actions
The Acute Care Team is reviewing incidents of delayed or missed
fluid resuscitation in septic shock to identify themes and report
findings to Clinical Groups and Sepsis Groups for targeted actions.
Clinical Groups will promote the Acute Care Study Day to adult
nursing staff on the PGD for sodium chloride bolus
Compliance
Variance
Assurance
Actions
Quality & Safety –Sepsis 7
Advise
80%
80%
83%
89%
CSS
LCO & Dental
WTWA
NMGH
MRI
Specialist
0%
20%
40%
60%
80%
100%
120%
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Jul 25
% Compliance
Month
page 80
Sepsis 7 - Urine output measured
Sepsis 7 - Urine Output Measured
July-25 Target
42% 100%
Clinical Group Overview Updates since previous month
The data indicates that the overall percentage score
has remained below the expected trust standard -
100%
Key dependencies
Accurate monitoring of urine output is essential to
guide fluid resuscitation and enable the early detection
of Acute Kidney Injury
Current issues
Issues –daily fluid balance report in place, however lack detail for
effective oversight
Future actions
Launch of digital fluid balance dashboard in September to support
improvement work. Clinical Group Education Teams have
developed a fluid balance competency document to be completed
during induction.
The Acute Care Team run focus groups with nurses, midwives, and
nursing assistants to identify barriers to effective fluid balance
monitoring
Compliance
Variance
Assurance
Actions
Quality & Safety –Sepsis 7
Advise
30%
32%
50%
54%
CSS
LCO & Dental
WTWA
NMGH
MRI
Specialist
0%
20%
40%
60%
80%
100%
120%
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Jul 25
% Compliance
Month
page 81
% of Critical medication administrations omitted
Percentage of Critical Medication Administrations Omitted
June-25 Target
4.40% 3%
Clinical Group Overview Updates since previous month
The SPC chart demonstrates improvement since June 2024
following a review of all stock lists to improve availability of critical
medicines in clinical areas and delivery of communication clarifying
the process to obtain critical medicines
Key dependencies
Medicines Safety Group supported target reset from 0% to 3%
acknowledging omission of a critical medicine may be clinically
appropriate or unavoidable.
Trajectory for improvement:
•4% in 12 months, by August 2026
•3% in 24 months, by August 2027
Current issues
Access to the data is only currently available by
running a Hive report which limits oversight,
identification and rectification of issues
Future actions
An interactive dashboard is in development to
provide real-time access to critical medicine
omission data enabling oversight at hospital,
division, directorate, and ward level
to support rapid identification and rectification of
issues related to critical medicine unavailability
Compliance
Variance
Assurance
Actions
Quality & Safety – Medicines
Alert
2.43%
3.89%
4.08%
5.70%
Specialist
NMGH
WTWA
MRI
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% of omissions
Month
page 82
% of Critical medicine omissions due to medicines unavailable
Percentage of Critical Med Omissions due to Medicines Unavailable
June-25 Target
0.27% 0%
Clinical Group Overview
Updates since previous month
The SPC chart shows special cause variation for improvement
reflecting outcomes of improvement work.
Medicines Safety Group supported trajectory for improvement:
of 50% in 12 months to a target of 0.24% by August 2026
Key dependencies
Access to data; increase use of patients own medicines; regular
stock list reviews in clinical areas. Education of staff on critical
medicines. Staff awareness of processes for accessing critical
medicines during and out of hours
Current issues
Access to the data is only currently available by running a
Hive report which limits oversight, identification and
rectification of issue
Future actions
Integrate the interactive dashboard in pharmacy
processes to support rapid identification and rectification
of issues related to critical medicine unavailability
Compliance
Variance
Assurance
Actions
Quality & Safety – Medicines
Alert
0.00%
0.10%
0.20%
0.30%
0.40%
0.50%
0.60%
0.70%
0.80%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% of ommissions
Month
0.16%
0.21%
0.30%
0.35%
Specialist
WTWA
NMGH
MRI
page 83
% of Antimicrobial omissions
% of Antimicrobial Omissions
June - 25 Target
1.41% 1%
Clinical Group Overview
Updates since previous month
Trajectory for improvement approved by Anti Microbial
Stewardship Group: Reduce the percentage of omitted
antimicrobials to target of 1% by April 2026
Key dependencies
Regular stock list reviews in clinical areas. Processes for
accessing critical medicines during and out of hours.
Education of staff on critical medicines
Current issues
Deep dive for May 2025 completed to inform improvement
workstreams - submitted to Antimicrobial Stewardship
operational group to develop action plan
Future actions
Action plan and improvement trajectory by AMS Group in
September
Compliance
Variance
Assurance
Actions
Quality & Safety – Medicines
Alert
1.17%
1.24%
1.41%
1.59%
NMGH
Specialist
WTWA
MRI
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% of Ommissions
Month
page 84
Controlled drugs audit compliance
Controlled Drugs Audit Compliance
Q4 24-25 Target
95.5% 95%
Hospital Overview
Updates since previous month
Medicines Safety Group agreed target to be reset to 95% for
SSHM to align with Trust audit assurance framework
Key dependencies
Trajectory for improvement:
•1% in 12 months, following the introduction of a mandatory CD
e-learning module (reaching 96%)
•2% in 24 months, reflecting the increased number of staff who
will have completed the e-learning module and competency
assessment (reaching 97%)
Current issues
Gaps in compliance CD documentation: crossing out
in CD registers and documentation of waste of part-
used syringes
Future actions
Develop and roll out e-learning module and
competency assessment focusing on CD
documentation
Compliance
Variance
Assurance
Actions
Quality & Safety – Medicines
92.2%
92.2%
95.5%
96.3%
96.5%
97.0%
97.1%
98.7%
99.1%
MRI
TGH
RMCH
WYTH
MREH/UDHM
CSS
SHM
NMGH
LCO
85.0%
90.0%
95.0%
100.0%
105.0%
110.0%
Jun 24
Sep 24
Dec 24
Mar 25
% compliance
Month
Assure
page 85
Safe & secure handing of medicines audit compliance
Safe & Secure Handing of Medicines Audit Compliance
Q4 24-25 Target
95.0% 95%
Clinical Group Overview
Updates since previous month
MSG agreed target to be reset to 95% for SSHM to align
with Trust audit assurance framework.
Key dependencies
Estates issues –temperature control in treatment rooms
Current issues
Gaps in compliance with room and fridge temperature
monitoring and documentation of action taken.
Future actions
Projects are in progress at NMGH and MRI to improve
compliance with fridge and room temperature monitoring. The
findings will inform the trajectory for continued improvement.
The projects will report to Medicines Safety Group in Q3
2025/26 and Q4 2025/26 respectively.
Compliance
Variance
Assurance
Actions
Quality & Safety – Medicines
89.3%
92.7%
94.2%
94.4%
94.7%
96.2%
96.4%
96.6%
98.3%
100.0%
TGH
SHM
RMCH
WYTH
CSS
MRI
NMGH
MREH/UDHM
LCO
R&I
80.0%
85.0%
90.0%
95.0%
100.0%
105.0%
110.0%
Jun 24
Sep 24
Dec 24
Mar 25
% compliance
Month
Assure
page 86
% of Patients on O2 who had an O2 prescription
% of Patients on O2 who had an O2 prescription
June-25 Target
49% 100%
Hospital Overview
Updates since previous month
HIVE report now available to drill down into areas of
non-compliance.
Proposed trajectory for improvement: target to reach
60% by December 2026 and 80% by August 2026
Key dependencies
Clinical lead to be identified to support development
of Oxygen Strategy within the Trust including HIVE
build
HIVE training material to be developed
Current issues
Oxygen guidelines outstanding. Clinical lead (consultant) to be
agreed to lead on finalisation of guidelines.
Future actions
Medicines Safety Committee received plan (August 12th) outlining
the use of anew HIVE report to target areas of non-compliance and
drive improvement, alongside a proposal for a Trust-wide clinically
led group to enhance oxygen prescribing systems
Compliance
Variance
Assurance
Actions
Quality & Safety – Medicines
Alert
0%
10%
20%
30%
40%
50%
60%
70%
0%
20%
40%
60%
80%
100%
120%
Jan 25
Feb 25
Feb 25
Feb 25
Mar 25
Mar 25
Mar 25
Mar 25
Apr 25
Apr 25
Apr 25
Apr 25
Apr 25
May 25
May 25
May 25
Jun 25
Jun 25
Jun 25
Jun 25
Jul 25
Jul 25
Jul 25
Jul 25
% of Patients on O2 who had an O2
prescription
Month
page 87
24-hour admissions medicines reconciliation (MR)
24-hour Admissions Medicines Reconciliation
June-25 Target
56% 95%
Clinical Group Overview Updates since previous month
Site visits in key areas, with Hive, medical, and pharmacy
input, reviewed ED acute take admission workflows to identify
issues and potential solutions.
The improvement trajectory targets 70% compliance by
August 2026 and 80% by August 2027
Key dependencies
Includes all healthcare professionals undertaking medicines
reconciliation;
A separate metric is needed to measure pharmacy
performance, aligned with the change in practice to prioritise
pharmaceutically high-risk patients
Current issues
Most clinicians do not use the admissions navigator to
review medicines, resulting in reviews/reconciliations of
patients’ home medications not being recorded
Future actions
A detailed action plan has been developed to address the
issues above, reporting to Medicines Safety Group.
A joint working group will be stood up in September 2025 to
review the admission medicines reconciliation workflow to
capture the review by all healthcare professionals.
Compliance
Variance
Assurance
Actions
Quality & Safety – Medicines
Alert
31%
51%
59%
80%
The LCO & Dental
CSS
Specialist
WTWA
NMGH
MRI
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Completed in 24 hours
Month
page 88
48-hour admissions medicines reconciliation
48-hour Admissions Medicines Reconciliation
June-25 Target
75% 95%
Clinical Group Overview
Compliance
Variance
Assurance
Actions
Quality & Safety – Medicines
Alert
47%
72%
75%
95%
The LCO & Dental
CSS
Specialist
NMGH
WTWA
MRI
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Completed in 48 hours
Month
Updates since previous month
Site visits in key areas, with Hive, medical, and pharmacy
input, reviewed ED acute take admission workflows to identify
issues and potential solutions.
The improvement trajectory targets 70% compliance by
August 2026 and 80% by August 2027
Key dependencies
Includes all healthcare professionals undertaking medicines
reconciliation.
A separate metric is needed to measure pharmacy
performance, aligned with the change in practice to prioritise
pharmaceutically high-risk patients
Current issues
Most clinicians do not use the admissions navigator to
review medicines, resulting in reviews/reconciliations of
patients’ home medications not being recorded
Future actions
A detailed action plan has been developed to address the
issues above, reporting to Medicines Safety Group
A joint working group will be stood up in September 2025 to
review the admission medicines reconciliation workflow to
capture the review by all healthcare professionals
page 89
Number of deaths with identified learning disability
Number of deaths with identified learning disability
June-25 Target
3
Clinical Group Overview
Updates since previous month
3 deaths of patients with a learning disability (LD)
in June 2025, decrease from 7 in May
Key dependencies
All deaths of patients with a learning disability are
reviewed according to LeDeR criteria and
reported to the Integrated Care Board for review
Current issues
A structured judgement review and best practice review is completed for
all deaths of person with a LD
Future actions
As part of the review of Learning From Deaths (LFD) processes, learning
from LeDeR reviews is triangulated with broader learning outcomes at
the Learning from deaths group, 3 year review of LD strategy being
completed to be reported to Trust Safeguarding Group November 2025
Quality & Safety - Learning from Deaths
Advise
1
2
LCO & Dental
Specialist
MRI
NMGH
CSS
WTWA
-4
-2
0
2
4
6
8
10
12
14
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of LD deaths
Month
Compliance
Variance
Assurance
Actions
page 90
Number of Learning from the Lives and Deaths of People with a Learning Disability and Autistic
People (LeDeR) referrals
Number of LEDER referrals
June-25 Target
3
Clinical Group Overview Updates since previous month
3 deaths of patients with learning disability in
June
3 cases met the LeDeR criteria
Key dependencies
Learning from LeDeR is reported quarterly to the
Learning Disability Steering Group
Learning from Deaths Group
Reporting to Trust Safeguarding Group
Future actions
LeDeR improvement work reported to LD Steering group and will inform
revised Learning Disability Delivery Plan 2025-2028 currently in
development reporting to Trust Safeguarding Group (November 2025)
Quality & Safety – Learning from Deaths
Advise
Current issues
LeDeR improvement work focused on
Improvement of documentation of DNCPR decision making, immediate
escalation process in place when identified in Quality Check for all LD
patients.
Policy Guidance and training to support Mental Capacity Assessments.
Focused MCA training delivered through Medical Leaders Forum
-4
-2
0
2
4
6
8
10
12
14
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of referrals
Month
1
2
LCO & Dental
Specialist
MRI
NMGH
CSS
WTWA
Compliance
Variance
Assurance
Actions
page 91
Hospital standardised mortality ratio (HSMR)
(rolling 12 month)
Hospital Standardised Mortality Ratio (HSMR) (rolling 12 month)
Feb-25 Target
89.76 N/A
Clinical Group Overview
Updates since previous month
MFT as a whole is within the expected range; and aligned
to our Shelford Peers. MFT recorded a ratio of 89.76 in
Feb 2025 (latest validated available in HED); a slight
fall from January 25
Key dependencies
Continued monitoring a for any arising issues
Ensuring coding and data quality standards are
maintained and improved. Data is always significantly
retrospective due to external validation processes
Current issues
HSMR for SHG shows significant variation. This is due to very
small numbers of deaths (14 in Feb) having a significant
influence on figures making them unreliable as a measure.
Due to this the numbers are not published nationally
Future actions
Trust review of Learning from Deaths in MFT underway including
the harmonising processes across MFT, optimise our learning,
and ensure we fulfil our statutory obligations; Training with
clinical groups on use of Telstra mortality data commenced
Compliance
Variance
Assurance
Actions
Quality & Safety - Learning from Deaths
Advise
87.02
88.17
88.73
131.99
CSS
LCO & Dental
WTWA
MRI
NMGH
Specialist
0
20
40
60
80
100
120
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
HSMR Mortality Ratio
Month
page 92
Crude mortality rate (12 month rolling)
Crude mortality rate (12 month rolling)
Mar-25 Target
2.81% N/A
Clinical Group Overview
Updates since previous month
Crude mortality gives, view of mortality across MFT- (not
risk-adjusted). The latest validated data for March shows
a small increase to 2.81% within the expected variance
Key dependencies
Ensuring coding and data quality standards are
maintained and improved
Data is always significantly retrospective due to external
validation processes
Current issues
No current issues
Future actions
Trust review of Learning from Deaths in MFT
underway optimising learning, and ensuring statutory
compliance. Training with Clinical Groups on use of Telstra
mortality data commenced
Compliance
Variance
Assurance
Actions
Quality & Safety - Learning from Deaths
Advise
0.96%
2.83%
2.93%
4.38%
CSS
LCO & Dental
Specialist
WTWA
MRI
NMGH
0%
1%
1%
2%
2%
3%
3%
4%
4%
5%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Crude Mortality rate
Month
page 93
Standardised healthcare mortality indicator (SHMI)
Standardised Healthcare Crude Mortality Indicator (SHMI)
Feb-25 Target
105.55 N/A
Clinical Group Overview Updates since previous month
MFT is within the expected range and aligned to
Shelford Peers.
MFT recorded a validated ratio of 105.55 in
Feb 25 (latest available in HED)
Key dependencies
Continued monitoring for any arising issues
•Ensuring coding and data quality standards are
maintained and improved
•Data is always significantly retrospective due to
external validation processes
Current issues
No issues or alerts within the Feb 25 data. However, ongoing awareness
of persistently raised SMHI at NMGH. Deep dive underway, however
early indications that deprivation (not adjusted for in SHMI) may play a
role in this.
SHG shows significant variation due to very small numbers of deaths (14
in Feb) having a significant influence on figures making them unreliable
as a measure. Due to this the numbers are not published nationally
Future actions
All Clinical Groups have in place local Learning From Deaths (LfD)
Group – work in underway to harmonise data for each group, increase
effective scrutiny and ensure robust escalation to the Trust LfD group
Compliance
Variance
Assurance
Actions
Quality & Safety - Learning from Deaths
Advise NOF metric
102.64
105.28
110.70
164.63
CSS
LCO & Dental
WTWA
MRI
NMGH
Specialist
0
20
40
60
80
100
120
140
160
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
SHMI
Month
Score = 2
page 94
Prevention of future deaths (PFDs)
Prevention of Future Deaths
June-25 Target
0 0
Clinical Group Overview (12
months)
Updates since previous month
1 new PFD report issued on 9th May 2025 for MRI
No new PFD reports issued in June 2025
Key dependencies
Ongoing work relating to the continuous
improvement of assurance/learning statements to
mitigate the Coroner needing to issue PFD reports
due to issues the Trust is able to resolve
Current issues
May PFD was responded to with assurance addressing HMC’s
concern relating to a perceived lack of joined up working with the
mental health trust to ensure speedy and safe discharge of patients
There are no outstanding issues currently
Future actions
Learning from PFD reports is shared though a variety of mechanisms,
including the weekly Patient Safety Oversight and Assurance Group
and reporting of weekly surveillance of national PFDs to inform internal
assurance
Compliance
Variance
Assurance
Actions
Quality & Safety – Learning from Deaths
Not SOF3 metric
Assure
1
3
CSS
LCO & Dental
NMGH
Specialist
WTWA
MRI
0
1
2
3
4
5
6
7
8
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of prevention of future death notices
Month
page 95
% of admitted patients with MUST scores
% of admitted patients with MUST scores
Clinical Group Overview
.Updates since previous month
Removed SMH data from IPR due to inappropriate tracking in this
patient cohort (i.e. physiological changes in pregnancy and post-
partum).
Improved overall trend performance from 60% to 80% remains
below expected Trust standard of 100%
Key dependencies
Digital team / Data analysis teams / Training in MUST completion in
Hive
Current issues
Inability to drill down in MUST dashboard to present a
collective ward level data to understand areas with
reduced performance in real time and direct focused
improvement work
Future actions
Ensure MUST Hive dashboard is reporting all areas
within Clinical Groups appropriately though targeted
improvement plan
Compliance
Variance
Assurance
Actions
Quality & Safety – Harm Free Care
Advis Not SOF3 metric
June-25 Target
82.19% 100%
Alert
0%
20%
40%
60%
80%
100%
120%
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
79.03%
80.95%
89.79%
93.33%
93.49%
WTWA
CSS
NMGH
MREH
MRI
page 96
% of admitted patients with MUST scores within 24 hours
% of admitted patients with MUST scores within 24 hours
Clinical Group Overview
.Updates since previous month
Improved performance compared with
previous 3 months, overall
percentage remains below expected
trusts standard – 100%
Key dependencies
Digital team / Data analysis teams /
Training in MUST completion in Hive
Current issues
Inability to drill down in MUST dashboard to present a collective ward level
data to understand areas with reduced performance in real time and direct
focused improvement work
Future actions
Ensure MUST Hive dashboard is reporting all areas within Clinical Groups
appropriately
Compliance
Variance
Assurance
Actions
Quality & Safety – Harm Free Care
Not SOF3 metric
June-25 Target
68.63% 100%
Alert
57.14%
62.92%
79.40%
80.48%
92.22%
CSS
WTWA
MRI
NMGH
MREH
0%
20%
40%
60%
80%
100%
120%
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
page 97
% of admitted patients with MUST scores within 7 days
% of admitted patients with MUST scores within 7 days
June-25 Target
80.81% 100%
Clinical Group Overview
Updates since previous month
Improved performance compared with previous
3 months, but overall percentage score remains
below expected trusts standard – 100%
Key dependencies
Digital team / Data analysis teams / Training in
MUST completion in Hive
Current issues
Inability to drill down in MUST dashboard to present a collective ward
level data to understand areas with reduced performance in real time
Future actions
Ensure MUST Hive dashboard is reporting all areas within Clinical
Groups appropriately
Compliance
Variance
Assurance
Actions
Quality & Safety – Harm Free Care
Not SOF3 metric
Alert
0%
20%
40%
60%
80%
100%
120%
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
% Compliance
Month
76.19%
76.85%
88.63%
92.68%
93.33%
CSS
WTWA
NMGH
MRI
MREH
page 98
Provide high quality, safe
care with excellent
outcomes and experience –
operational performance
page 99
Trust IPR Metric Assurance Summary
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Operational Performance
page 100
Trust IPR Metric Assurance Summary
This slide contains the following visuals: image ,textbox ,shape ,shape ,shape ,shape ,shape ,shape ,shape ,shape ,tableEx ,shape ,slicer ,Reporting Period ,actionButton ,Hide Slicers Button ,card ,card ,textbox ,textbox. Please refer to the notes on this slide for details
This slide contains the following visuals: image ,textbox ,textbox ,tableEx ,shape ,shape ,shape ,shape ,shape ,shape ,shape ,shape ,shape ,slicer ,Reporting Period ,Hide Slicers Button ,actionButton ,card ,card ,textbox. Please refer to the notes on this slide for details
Operational Performance
page 101
Executive summary
Consistent assurance can be provided in:
- RTT total waiting list size, which continues to
be better than plan
- 18ww performance – where we can see
significant improvement and achievement of
plan again in M3
Significant improvement has been made in the
following areas:
- RTT 52 week waits – where we can see a
significant reduction in long waits, marginally
below plan in M4
- DM01 6-week performance, which met plan
In M4
Particular risk is evident in the achievement of:
- DM01 total list size – below plan in M4 and
requiring intervention to improve.
- The cancer 62-day standard, which is
reporting a statistically significant
improvement
Operational Performance
page 102
Benchmarking of National Oversight Framework (NOF) Indicators (1 of 2)
AED 4hr Performance - July AED 12hr Performance - July
RTT Incomplete 52 Weeks - June RTT Incomplete 18 Week Standard - June
MFT
74.3%
MFT
2.4%
MFT
52.22%
MFT
4.01%
Operational Performance
page 103
Benchmarking of National Oversight Framework (NOF) Indicators (2 of 2)
DM01 6 Week Standard - June DM01 Waiting <13w - June
Cancer 28 Day FDS - June Cancer 62 Day All Routes - June
MFT
13.25%
MFT
95.39%
MFT
78.4%
MFT
61.22%
Operational Performance
page 104
Updates since previous month
UEC Stocktake identified 4 focus areas to improve 4hr
Performance; UEC medical staffing against demand
profile review, SPOA and SDEC programme, CYP
improvement workstreams and Ambulance Handover .
Plans in place with Clinical Groups to deliver on these
ahead of Winter.
Current issues
Whilst No Criteria To Reside (NCTR) continues to reduce from
the April position, it still remains high. This position continued
to have an impact on hospital flow during July. Performance
during twilight and overnight leads to deterioration following
good performance during the day.
Key dependencies
Attendances in July were 0.6% above plan (45,917 vs
45,794). 4hr breaches were marginally above plan
(11,788 vs 11,635) with overall performance 0.3pp
below plan.
Future actions
Delivery of the UEC Stocktake through the UEC Improvement
group.
Advise NOF metric
Operational Performance
Score = 3.11
page 105
Updates since previous month
NWAS reviewing HAS screen availability to ensure
Crews have better access to ‘Pin’ in and out. Think 15
SOP reviewed and recirculated along with HO45
communication
Current issues
MRI and WTWA have the longest handovers / turnaround
times at MFT linked to increased conveyances challenges
with PCI handovers. Manchester Foundation Trust (MFT)
remains the highest performing Trust in GM.
Key dependencies
Average turnaround decreased in July to 25.06 mins
from 26.48 mins last month with handover times
decreasing to 16.21 mins (17.41mins prior month).
NWAS average across GM in July was 30.06 mins for
turnaround.
Future actions
Committed to optimising ambulance handover processes,
aiming to maintain our leading performance in Greater
Manchester. Our ongoing collaboration with NWAS includes the
'call before convey' initiative to reduce the number of
ambulance conveyances.
Advise
Operational Performance
page 106
Updates since previous month
Think 15 being reviewed to ensure clear escalation of
45 min breaches
Release to rescue, crews are able to leave at 45 mins
but this has not happened as breaches are mainly
outside of ED within Cath labs.
Current issues
MRI and WTWA have the longest handovers / turnaround times
linked to increased conveyances and department / wider bed
occupancy.
PCI breaches are the main cause for breaches equating to >75% of
the reason.
Key dependencies
MFT has shown a significant reduction in >45 minute
handovers since February 2025 and is now exhibiting normal
variation.
Future actions
Continued focus on ambulance handover processes with ambition
to sustain best performance in GM. Project with NWAS to
undertake reduction in PCI handovers. Review of Think 15 SOP
following implementation.
Advise
Operational Performance
page 107
Updates since previous month
Implemented validation of over 45 mins breaches, this
includes those at 60 mins. Began formal reporting and
deliver of HO45, where ambulance can leave department at
45 mins. SOP and escalation process in place
Current issues
Breaches driven by high acuity on transfer, particularly at the MRI
site. Direct transfers to a Cath Lab for percutaneous coronary
intervention (PCI) are the most frequent driver of a 60+minute
handover breach.
Key dependencies
Latest reported position for July was 9 delays over 60
minutes, down from 36 reported in June with previous high of
186 in Dec 24. North reported 0 handovers over 60 minutes in
the last month with MRI and WTWA both reporting a lower
number of over 60-minute handovers than in June.
Performance remains within normal variation.
Future actions
Review of HO45 SOP implementation and update. Review planned
with NWAS for PCI and inter hospital transfers, which now make
up the majority of breaches
Advise
Operational Performance
page 108
Current issues
High levels of bed occupancy particularly within receiving
wards – see slide 14
Mental health demand within Emergency Departments (ED) -
see next slide
Key dependencies
July performance of patients waiting over 12 hours reported
2.4% vs the 5.2% plan. Performance has improved since
January and is exhibiting special cause improving variation.
Performance is now at the lower control limit.
Assure
Updates since previous month
Continued to track 12-hour performance through Clinical
Groups and MFT Co-ordination centre. Reported 3 times a
day through UEC Sitrep. Ongoing dialogue with GMMH
regarding significant number of MH patients with Eds that
spend >12 hours in dept.
*Monitoring of regional plan for 12 hour waits commenced in April 2025, therefore plans in the previous financial year are not included.
Future actions
Ongoing escalation processes through MFT Coordination Centre.
UEC improvements to ED systems and processes
NOF metric
Operational Performance
Score = 1.84
page 109
Current issues
High levels of bed occupancy particularly within receiving wards
and discharges occurring too late in the day.
Of the 101 patients who were delayed over 12 hours in A&E, 94.1%
(95) were due to mental health delays.
Key dependencies
Overall significant improvement continues for patients
waiting more than 12 hours from decision to admit to
admission to a ward, with 101 for July (108 in June). Mental
health delays contributed 94.1% of the total (95)
Advise
Updates since previous month
G&A bed occupancy levels were marginally below plan at
90.1% in July, with levels of no reason to reside patients
above plan reporting 330 vs. a plan of 300.
Future actions
GMMH, GM Locality and MFT Co-ordination centre review all
mental health patients through escalation processes.
Ongoing escalation processes through MFT Coordination Centre
with Clinical and Operational leadership
Operational Performance
page 110
Updates since previous month
Occupancy rates are reviewed and reported throughout the
day with Clinical Groups and MFT Co-ordination centre
taking action to address as required. OPEL actions are linked
to site occupancy and associated actions are undertaken to
improve pressured times.
Current issues
Occupancy was below plan in month, returning to common cause
variation after a period of significant increase. Suboptimal rates of
patients with 'No Reason to Reside’ (NR2R) continues to impact
overall occupancy, but to a lesser extent in July as performance
recovered to sustainable levels.
Key dependencies
Occupancy levels are variable across all sites. MRI’s
occupancy was above plan whilst all other clinical groups
reported occupancy below end of July plans.
Future actions
Care Closer to Home programme supporting work to reduce acute
Length of stay. CG actions in place to support greater flow of P0
patients and July continued to focus with LCO on complex
discharges.
Advise
Operational Performance
page 111
Advise
Current issues
Increased volumes of patients residing past expected discharge
date adding to already high numbers of patients with a length of
stay greater than 21 days accounting for 6,586 bed days lost in
July.
Key dependencies
Specialist Hospitals has sustained 100% occupancy in July,
impacted by a low denominator (27).
MRI, WTWA and North decreased in the latest month.
Future actions
Continued focus on utilising H@H capacity and ward reviews of
those patients passed their expected discharge date with a view to
expedited discharge and repatriation
Updates since previous month
- Low staff absence levels
- Attendances in line with plan
- Admission thresholds within expectation
Operational Performance
page 112
Updates since previous month
- Low staff absence levels continue to be a driver for
improved occupancy in Specialist
-
Reduced attendances has helped to maintain sustainable
occupancy levels
Current issues
Long length of stay patients at RMCH requiring repatriation or with
ongoing complex care needs
Key dependencies
Occupancy levels remain at sustainable levels.
Average occupancy being reduced by low occupancy at
WTWA, but occupancy at WTWA increased by 3.2% in the
latest month; highest occupancy continues at Royal
Manchester Children’s Hospital (within Specialist Hospitals)
Future actions
Programme streamlining paediatric admissions, with heightened
reviews and escalations for long length of stay patients. Continued
focus on utilising H@H capacity which has been under plan for the
last quarter.
Advise
Operational Performance
page 113
Current issues
LCO 10-day discharge rates are being monitored daily against a
target of 38 per weekday (27 Manchester and 11 Trafford) with new
weekly actions agreed to increase discharges across the week
Key dependencies
Performance is showing common cause variation with the
plan not met in July. There is inconsistent improvement
across clinical groups.
Alert
Updates since previous month
Care Closer to Home workstreams
Attendance rates
Availability of in-reach and support services
Future actions
Plan continues to reduce No criteria to reside patients to 259 by
November 2025 – with the July plan stepping down to 300. Out of
Area is above normal parameters and actions with locality teams
are taking place
Operational Performance
page 114
Current issues
Acute vacancies in North, Community ACP/GP staffing continues
to be reduced, impacting capacity.
Key dependencies
Performance dropped below plan for July and continues to
show common cause variation. Staffing continues to be a
challenge across localities which has resulted in reduced
capacity and concerning variation in performance at North.
Advise
Updates since previous month
Community navigator role commenced in post at Central to
aid identification and flow across MRI. Locum staff agreed to
increase capacity.
South capacity temporarily reduced due to IA. This is now
returned to 30. Development of a “potentials” list has
supported Central in maintaining consistent occupancy.
Future actions
Community – Utilisation plan underway with focus on referrals
from step up / down sources to ensure maximum occupancy.
NHSP support secured with 6 AHPs expected to qualify in
September.
Awaiting staff to commence in post at North with further roles out
to advert.
Operational Performance
page 115
Hold for slide on #NOF
Updates since previous month
MFT has delivered average time to surgery performance for Fractured Neck of Femur patients over the target of 36h since April
2024, with performance showing common cause variation. The volume of patients receiving surgery in July was 107, the highest
volume in the previous 18 months.
In the most recent month, MRI had the highest average time to surgery (193.5h), but performance is skewed by low of complex
patients volumes (3)
. NMGH (50) and WTWA (51) delivered similar amounts of surgeries, but WTWA’s average time to theatre was
below plan (34.3) whilst NMGH were above plan (59.3). A full NMGH improvement plan is in place and a Board update planned for
the next QPSBC.
- Average time to surgery
Operational Performance
page 116
Compliance
Variance
Assurance
Actions
Stroke performance – Admissions to Stroke unit (4hrs)
Admission to Stroke unit within 4 hours of emergency presentation
Dec-24 Plan
56.0% 60.0%
Note: stroke data is available quarterly in arrears and the most recently available data is displayed here (Dec 24)
Updates since previous month
MFT sits in the 2nd quartile of national performance with a ranking of 68, mid range of
Shelford providers and 5th out of 6 within GM in Q3 24/25. Performance shows common-
cause variation.
Escalation capacity being utilised to facilitate step-downs, and in-reach model has been
developed to ensure improved stroke input at WTWA
WTWA and MRI have been collaborating to establish a joint model and new pathways for
stroke services, supported by the Trust Strategy Group and in conjunction with the GM
Stroke Network
Future actions
Joint working between MRI and WTWA clinical groups continues with an
aim to deliver increased stroke capacity through bed utilisation and
length of stay improvement wor.
Operational Performance
page 117
Updates since previous month
Surgeon core capacity
Theatre productivity
Anaesthetic cover
Recovery plan success
Current issues
Surgical capacity for treatment in high volume treatment areas.
Some areas with delays to anaesthetic review due to complex
patient cohorts. Robotic access for relevant tumour groups.
Key dependencies
No significant variation in performance observed, and the
Trust is above the plan for the month of June at 90.3%
performance
Future actions
Continue monitoring weekly surgical numbers and waits, focus on
LGI, Breast and Urology due to performance and volumes.
There is also a requirement to review average waits in line with
average days to a cancer diagnosis and to comply with breach
reallocation rules.
Assure
Operational Performance
page 118
Current issues
June performance was a deterioration from May. There have been
diagnostic delays in the Lung, Gynaecology, Head and Neck and
Urology pathway with a large volume of Urology diagnostics
insourced and carried out in April and May leading to late
conversions to cancer. Skin and breast referrals have been 17-
19%
higher than the previous year and higher than the expected 5.7%
growth.
Key dependencies
Cancer 62d performance shows common cause variation
but remains consistently been below the constitutional
standard in 25/26. In the latest period, performance was
4.9% below plan.
Advise
Updates since previous month
Continue to progress actions agreed in
collaborative improvement groups covering all tumour
groups. Utilisation of weekly post breach report to bring
forward patients and reduce breach volumes
Future actions
2025/26 plans through Cancer Collaborative continue to be
focussed on performance improvements required. Continued weekly
senior oversight of performance and issues. Increased focus on LGI
and Urology currently with a GIRFT review in progress for Urology.
Recovery for urology is expected in October with current plans.
Operational Performance
Score = 3.34
page 119
Cancer 62 day Performance by Tumour Group (2 of 2)
Updates since previous month
June performance was below trajectory with Breast and Lung having reduced
breach volume by 15% and 20% respectively from June 2024. Head and
Neck improvement in June saw a year on year reduction of 24%. Urology has
increased by 51%, Gynaecology by 107% year on year
Key dependencies
Continue to progress actions agreed in Collaborative Improvement groups
covering all tumour groups. Utilisation of weekly post breach report to bring
forward patients and reduce breach volumes
Current issues
Urology and Gynaecology below plan and lowest performing large tumour
groups. Continued focus on both pathways with increased diagnostic
capacity in urology. Full pathway transformation workstreams are in place
for both tumour groups including a GIRFT review for Urology.
Future actions
Lung, Haematology and LGI were above plan. All other tumour groups
continue to enact improvement plans with a focus to improve the front end
diagnostics and FDS performance to reduce tip in rates to backlog
2.5
4
5.5
8.5
11
11
13
14.5
33.5
33.5
47.5
010 20 30 40 50
Other
Sarcoma
Haematology
UGI
Head and Neck
Skin
LGI
Gynaecology
Lung
Breast
Urology
Tumour Group
62 day Breaches by Tumour Group - June
Operational Performance
page 120
Updates since previous month
Continue to progress actions agreed in
Collaborative Improvement groups covering all tumour
groups.
Current issues
Breast, LGI, Skin, Haematology, UGI and head and neck were all
above plan for June. Lung ION diagnostic procedures are currently
experiencing capacity issues with mitigations in place.
Key dependencies
FDS performance in June was 78.4%, above the MFT planned
trajectory. Performance continues to show normal variation,
with recovery continuing from January's reduced position
Future actions
The insourced diagnostics in urology is likely to affect FDS
performance whilst capacity and demand exercises are carried
out and one stop diagnostic clinics put in place.
Advise NOF metric
Operational Performance
Score = 2.79
page 121
Current issues
To sustain performance improvements in long waits, further
waiting list reduction are required through 2025/26, with the
aim to deliver a maximum list size of 175,000 by March 2026.
Key dependencies
The overall PTL size continues to show improving
performance and is performing better than July planned
levels.
Specialist and North are above plan with all other
clinical groups below.
Assure
Updates since previous month
Ensuring capacity is maximised and bookings are made
timely to reduce long waiters, outcoming is timely and
accurate.
Future actions
MFT’s Elective Recovery Programme, Care on Time, will
deliver workstreams aiming to deliver a sustainable waiting
list size through pathway transformations.
Operational Performance
page 122
Key dependencies
Outpatient capacity
Theatre capacity for complex cases
Mutual aid
Mitigating against risk of summer annual leave
Current issues
Largest volumes of 52WW patients are in Gynaecology (979),
T&O (811), OMFS (679), Urology (535), Paediatric ENT (561),
and Ophthalmology (425). T&O and Paediatrics detailed
recovery plans to reduce 52ww and support MFT delivery.
Resources are required to validate the waiting lists
effectively and reprioritise clinical resources.
Updates since previous month
Significant reduction of the overall 52 week wait cohort
continues with in month performance 243 higher than
plan. Performance was 3.8% in July, 0.24pp above
plan.
Future actions
Plans for 2025/26 focus on 52W delivery as the key long-
wait
metric, with the expectation that long waits will continue to
reduce as we reprioritise our capacity and ensure our waiting
lists are free of data quality errors.
Advise
13
391
2846
1646
90
1524
487
0
468
2842
1030
11
1521
881
Unall…
LCO…
Speci…
North
CSS
WTWA
MRI
NOF metric
Operational Performance
Score = 3.64
page 123
Key dependencies
Tissue availability for grafts continues to improve, with
the number of corneal long waits due to be zero at
August month end
Current issues
Remaining risks in this cohort relate to paediatric patients
within Specialist Hospitals, with additional capacity planned
to bring wait times down.
Updates since previous month
Final validated data for July is 16 >65-week waits vs a
plan of 0. 8 patients were in paediatric specialties, 5 in
Trauma and Orthopaedics, 1 in Diagnostics, 1 in
Plastics and 1 in Gynaecology.
Future actions
Continue weekly oversight, ensuring delivery of actions.
Prioritisation of corneal graft patients in place nationally.
Increase capacity for paediatric specialties
Advise
Operational Performance
page 124
Updates since previous month
Sustainable PTL size
Sufficient activity levels
Prioritisation and operational focus
Validation support
Current issues
MFT PTL needs to be ~100,000 patients to sustainably
deliver 18 weeks: first milestone is MFT plan to achieve list
size of 175,000 patients by March 2026
which is presently on
track.
Key dependencies
Continued improvement in MFT's 18-week
performance, with performance in July 53.3% and
above the plan of 52.7%.
Future actions
Care on Time programme has a range of workstreams aiming
to deliver 18-week performance, including programmes of
work on operational management, technical support and
engagement and training
Assure NOF metric
Operational Performance
Score = 3.82
page 125
Compliance
Variance
Assurance
Actions
RTT - CYP 18 week Performance
RTT 18 week performance %
Clinical Group Overview
Updates since previous month
CYP 18 week performance has improved in July to
50.7%.
Statistical analysis is not yet available due to
limited data points but does not yet show a
statistically significant shift in performance.
Key dependencies
Capacity in key specialties
Sufficient activity levels sustained through summer
holidays
Prioritisation within paediatric theatres
Current issues
Largest volume of waits for CYP are within Paediatric ENT
(4,154 with performance of 37.5%), Paediatric Dentistry
(3,579 with performance of 48.7%) and Paediatric Urology
(2,201 with performance of 41.5%)
Future actions
RMCH Theatre Improvement Group aims to deliver
increased productivity to support surgical specialties in
increasing capacity
Advise
July 25
Actual Plan Variance
50.7%
87.10%
49.80%
50.40%
47.60%
62.90%
52.70%
52.30%
Unallocated
LCO Dental
Specialist
North
CSS
WTWA
MRI
Operational Performance
page 126
Key dependencies
Use of Resources working group is aiming to deliver
theatre improvements and efficiencies, increasing the
throughput of elective activity
Current issues
Whilst MFT cancelled less activity than previous industrial
action periods, this negatively impacted the ability to deliver
to plan in July.
Updates since previous month
Elective activity under plan (-1449), but historical
performance shows continued delivery over plan year-
to-date for inpatient activity.
Future actions
Delivering volumes required to maintain performance and
achieve this year’s performance goals and maintain
oversight of industrial action rescheduling to ensure activity
can deliver to plan.
Advise
Operational Performance
page 127
Updates since previous month
Elective activity is over plan (+7,937), which supports
elective recovery initiatives and RTT performance.
Specialist Hospitals had the most significant volumes
of additional activity against plan (+11,609)
Current issues
MFT cancelled less activity than previous industrial action
periods, and this enabled activity to deliver over plan in July
Key dependencies
Outpatient improvement programme and outcoming
are key workstreams to support delivery.
Future actions
Development of activity monitoring structures internally and
externally to enable formal commissioned activity to be
reviewed in year, and maintain oversight of industrial action
rescheduling to ensure activity can deliver to plan.
Advise
Operational Performance
page 128
Key dependencies
Modality level tracking and recovery plans
Additionality provision
Utilisation of CDC
Current issues
Continuing to manage demand observed across planned
and elective activity with high volumes of activity seen in
MRI, NOUS, CT, Echo, and Audiology.
Updates since previous month
Overall waiting list has risen above plan in July at
32,221 vs a plan of 29,545 and is now showing
concerning variation for the second moth
Future actions
Weekly oversight meetings at modality level tracking
performance and waiting list size
Alert
0
1,187
293
19,552
7,297
3,524
0
647
231
19812
6289
2572
LCO…
Specialist
North
CSS
WTWA
MRI
Operational Performance
page 129
Key dependencies
Modality level tracking and recovery plans
Additionality provision – overall activity increased in
July to enable delivery below plan
Utilisation of CDC
Current issues
Unscheduled demand saw a significantly increasing trend
throughout June and July, impacting total resource available.
Updates since previous month
Performance delivered below plan in July (-0.2%
variance) and continues to show improving variation in
performance.
Future actions
Monitoring of challenged modalities (MRI, echo, sleep and
gastroscopy) driving performance
Demand management programme to streamline demand
and deliver performance improvements
Advise
0.0%
50.72%
2.39%
7.34%
22.95%
9.19%
0.00%
67.20%
8.66%
9.61%
20.78%
5.79%
LCO…
Special…
North
CSS
WTWA
MRI
Operational Performance
page 130
Diagnostics – DM01 6 week performance
Updates since previous month
Performance challenges continue within urodynamics, gastroscopy, cystoscopy,
echocardiography and audiology all at variance to plan in month. Modality level
recovery plans are being tracked through the Trust Leadership Committee to
improve performance and address risks
Key dependencies
Success of modality level performance improvement programmes and activity
increases in echo, sleep and imaging.
New MRI scanning capacity following a move to North Manchester in July
increased capacity
Current issues
Demand and capacity misalignment for gastroscopy, echocardiography,
urodynamics and audiology. Unplanned scanner downtime impacted MRI.
Planned and elective levels of activity currently tracking above plan and
unscheduled demand continues to challenge performance
Future actions
Continue modality level recovery plans with weekly oversight
Sustainable recovery plan for echocardiography with demand and capacity
support from Trust performance
Operational Performance
page 131
Key dependencies
Prioritising DM01 performance vs P2/long waits in theatre
Adults to paeds capacity conversion for NOUS
Additionality for sedation MRI and for sedation endoscopy
Current issues
Insufficient capacity for sedation lists for MRI scans
Access to theatres for endoscopy procedures requiring
sedation, impacting gastroscopy performance
Updates since previous month
MRI, gastroscopy and sleep continue to be the key
drivers of reduced paediatric DM01 performance, with
MR and gastroscopy contributing the largest by volume
Future actions
New CT scanner at Wythenshawe dedicated to reducing CYP
waits in place 25/26 and being utilised to maximise
improvement in these waits
Advise
0%
67.17%
0%
36.35%
18.18%
8.10%
LCO…
Spe…
Nor…
CSS
WT…
MRI
Operational Performance
page 132
Current issues
Long waiters in Trafford Occupational Therapy Assessment Team and are being
actively monitored. Increased referrals particularly for paediatrics are being
monitored.
Advise
Key dependencies
Total waiting list size had significantly reduced since July 2024 and continues to
show special cause improving variation. This has been driven by reductions in
the number of waiters in MSK and Podiatry across both Manchester and Trafford
localities. The increase in waiting list this financial year is as reported last month
and was a result of the local definition of the waiting list report improving.
Updates since previous month
Non-standardised implementation of the community EPR (EMIS) means waiting
list reporting carries higher data quality risk, with oversight in place.
Future actions
Continue to closely monitor performance following improvements in defining
the waiting list which resulted in an increase in total waiting list size from June.
Operational Performance
page 133
Updates since previous month
ACP vacancies across the city leading to increased
service closures but performance expected to be
maintained above national target
Current issues
The proportion of referrals seen in two hours is 98.5% within
South and 87.0 % at the Central locality – a variance of
11.5% in performance.
Key dependencies
As reported in previous months, the proportion of
referrals seen in two hours remains above the
standard. Lower performance is noted particularly at
Central but this is still above national standard.
Future actions
Ongoing ACP recruitment
Community Urgent Care Front door review (including H@H)
Assure
Operational Performance
NOF metric
Score = 1.35
page 134
Be the place where people
enjoy working, learning
and building a career
page 135
Measuring our performance
Escalating performance concerns
Using the four SPC rules and outcomes of our benchmarking , we use an Alert, Advise and Assure model to ensure that both risks and improvements associated with performance are escalated
appropriately using the Trust’s risk escalation framework, through the Trust’s Governance Infrastructure. Risks identified through the assessment of and assurance associated with any element of
performance that may have an impact on the delivery of the Trust’s Strategic Objectives are reflected within the Trust’s Board Assurance framework.
Compliance Variation
Target being met Target not met For information, no target
set or target not due
Common cause – no
significant change
Special cause of
concerning nature or
higher pressure due to
(H)igher or (L)ower
values
Special cause of improving
nature or lower pressure
due to (H)igher or (L)ower
values
Assurance
Variation indicates
Inconsistently
passing and falling
short of
the target
Variation indicates
consistently
(P)assing the target
Variation indicates
Consistently
(F)alling short of the
target
Action Status
Active
surveillance –
continue to
observe in order
to better
understand the
current position
Improvement –
continue actions
to support
improvement
until steady
state achieved
Deterioration or
maintained
underperformance –
instigate or review
actions to ensure
drivers of current
position are
mitigated
Steady state – continue
to monitor achievement
of level of performance
which is satisfactory,
and which requires no
intervention to maintain
Workforce
page 136
Trust IPR Metric Assurance Summary
Key Oversight Performance Metrics
Focus
Ref
Status
Variation
Assurance
Action
status
Indicator
Indicator Type
Workforce capacity
W1
Establishment WTE
Local / GM
W2
Staff in Post WTE
Local / GM
W3
Vacancy WTE
Local / GM
W4
Vacancy %
Local
W5
Temporary Staffing WTE
Local / GM
W6
Temporary Staffing Cost
Local / GM
W7
Bank % of Pay bill YTD
Local / GM
W8
Agency % of Pay bill YTD
Local / GM
W9
Price Cap Compliance
Local / GM
W10
Off Framework
Local / GM
Looking after our
people
W11
Single Month Sickness Absence %
Local
W12
Rolling 12 Month Sickness Absence %
Local / GM
W13
Call Back & Return to Work Compliance %
Local
Key Oversight Performance Metrics
Focus
Ref
Status
Variation
Assurance
Action
status
Indicator
Indicator Type
W14
Level 1 Mandatory Compliance %
Local / GM
W15
Level 2 & 3 Mandatory Compliance %
Local / GM
W16
Appraisal
– Non Medical Compliance %
Local
W17
Appraisal
– Medical Compliance %
Local
Belonging
W18
Oliver McGowan compliance %
Local
W19
Staff Engagement Score
Local
W20
Friends and Family Recommend to Work
Local
W21
Friends and Family Recommend to receive Care /
Treatment
Local
W22
% of BME in Medical and Dental pay scales
Local
W23
% BME in band 8a and above roles
Local
W24
% BME in band 7 and below
Local
W25
% Disability in Medical and Dental pay scales
Local
W26
% Disability in band 8a and above roles
Local
Workforce
page 137
Trust IPR Metric Assurance Summary
Key Oversight Performance Metrics
Focus
Ref
Status
Variation
Assurance
Action
status
Indicator
Indicator Type
Belongi
ng
W27
% Disability in Band 7 and below
Local
Future Focus
W28
Turnover %
Local / GM
W29
Retention / Stability %
Local
W30
Time to Hire
Local / GM
Workforce
page 138
Executive summary
Off Framework
Level 1 Compliance %
Appraisal Medical Compliance %
% BME in Medical & Dental Payscales
% BME in band 7 and below roles
Turnover %
Retention %
SM Sickness %
R12m Sickness %
Level 2 & 3 Compliance %
% BME in band 8a and above roles
Oliver McGowan Compliance %
Appraisal – Non medical Compliance %
Temporary Staffing WTE
Price Cap Compliance
Call Back & Return to Work Compliance %
Mandatory training compliance has shown a
steady improvement over the past 12
months. In July, Level 1 compliance met the
target at 95.0%, reflecting positive progress.
However, Levels 2 and 3 remain below the
target at 89.1%, despite continued
improvement since the start of the year. A
review of the mandatory training programme
is ongoing, with a focus on identifying quick
wins to boost engagement, as well as more
substantive changes. These include
reviewing training categorisation and content
length to ensure time spent is proportionate
to the value and outcomes achieved.
As of July 2025, the Trust’s rolling 12-month
sickness absence rate stands at 6.0%,
remaining above pre-pandemic levels. This
continues to reflect the wider operational
pressures facing the organisation. The
2025/26 operating plan is based on reducing
this rate to 5.8% by the end of the financial
year. To support this, a comprehensive,
Trust-wide programme has been launched to
improve attendance and reduce absence.
Each Clinical Group has been set a tailored
target and plan to drive local action. The
programme takes a holistic, data-driven
approach—addressing cultural, procedural,
environmental, and operational factors—to
ensure meaningful and measurable
improvement at pace
Variation
Assurance
Achieving Target Inconsistently Achieving Target Not Achieving Target
Special Cause
Improvement
Common
Cause
Special
Cause
Concern
Workforce
page 139
Benchmarking of National Oversight Framework (NOF) Indicators
Single Month Sickness – March 2025
Staff Recommend Care – Q3 24/25
Staff Turnover – May 2025
MFT
5.6%
MFT
9.4%
MFT
66%
Source
Public View Health
The metrics below are benchmarked against NHS organisations in the North West (Blue).
Staff Engagement - 2024
MFT
6.8
Workforce
page 140
Establishment WTE
Establishment WTE
July-25 Target
30,647.2 -
Clinical & Corporate Group Overview
Updates since previous month
At the start of the 2025/26 financial year, the
establishment was reduced in line with a budget
reset, to align staffing and resources with revised
financial priorities and operational goals.
Key dependencies
Establishment levels are influenced by several key
dependencies, including budget availability,
workforce planning strategies, service demand,
and organisational restructuring.
Current issues
Future actions
The establishment is regularly reviewed
throughout the financial year to ensure
efficiency, compliance, and continuous
improvement.
Compliance
Variance
Assurance
Actions
W1 metric
Advise Source
General Ledger (Trial Balance Report)
Note: GL Staff Groups
30,400
30,500
30,600
30,700
30,800
30,900
31,000
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean
4252.4
5042.0
2568.9
5148.4
6656.5
3070.3
2264.5
762.5
881.6
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Staff Group Overview
1761.3
783.0
1726.5
87.3
4.0
1257.2
4173.4
1432.6
9768.2
158.5
2877.2
4113.0
959.6
1545.3
Allied Health
Professionals
Career Grade Doctor
Consultant
Dental Staff
Dental Support
Healthcare Scientists
Infrastructure Support
Other Scientific and
Theraputi
Registered Nursing
Midwifery
Support to AHPs
Support to Clinical
Support to Nursing
Support to STT HCS
Trainee Grade Doctors
Workforce
page 141
Contracted (Staff in Post) WTE
Contracted WTE
July-25 Target
28,304.0 28,405.4
Clinical & Corporate Group Overview
Updates since previous month
Contracted WTE has reduced this financial year
by 202.2 WTE which aligns with the reduction in
establishment.
Key dependencies
Delivery of the new organisation model and
vacancy control restrictions have had an impact
on contracted WTE as planned.
Current issues
The Workforce Annual Plan for 2025/26 is
predicated on a reduction of 324.8 contracted
(Substantive) WTE of the 753 WTE (inc. Bank and
Agency) planned for the end of the financial year.
Future actions
Contracted WTE is monitored monthly in
collaboration with the ICB through the Provider
Workforce Return.
Compliance
Variance
Assurance
Actions
W2 metric Source
General Ledger (Trial Balance
Report)
Note: GL Staff Groups
4042.9
4559.8
2273.5
5041.6
6125.6
2833.5
1932.9
691.3
802.8
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Assure
27,600
27,800
28,000
28,200
28,400
28,600
28,800
29,000
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
Staff Group Overview
1726.2
758.4
1574.7
83.2
4.0
1218.7
3593.7
1295.4
9478.8
152.3
2425.9
3561.5
1020.8
1410.4
Allied Health
Professionals
Career Grade Doctor
Consultant
Dental Staff
Dental Support
Healthcare Scientists
Infrastructure Support
Other Scientific and
Theraputi
Registered Nursing
Midwifery
Support to AHPs
Support to Clinical
Support to Nursing
Support to STT HCS
Trainee Grade Doctors
Workforce
page 142
Vacancies WTE
Vacancies WTE
July-25 Target
2,343.2 -
Clinical & Corporate Group Overview
Updates since previous month
The reported number of vacancies at the Trust
has been relatively stable for the last 7 months
even though there has been fluctuating staffing
and establishment changes.
Key dependencies
Anticipating a vacancy adjustment as part of VfP
once savings work has been transacted in line
with establishment control.
Current issues
Enhanced scrutiny and assurance is being
implemented via vacancy control panels to
rigorously oversee and manage staffing
vacancies. Current review of re-deployment
process being undertaken
Future actions
The Trust vacancy control panel will directly
impact time to hire and the number of vacancies
in TRAC.
Compliance
Variance
Assurance
Actions
W3 metric
Advise Source
General Ledger (Trial Balance Report)
Note: GL Staff Groups
1,900
2,000
2,100
2,200
2,300
2,400
2,500
2,600
2,700
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean
209.5
482.1
295.4
106.8
531.0
236.8
331.6
71.3
78.8
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Staff Group Overview
35.1
24.7
151.8
4.1
0.0
38.4
579.7
137.2
289.5
6.2
451.3
551.5
134.9
Allied Health
Professionals
Career Grade Doctor
Consultant
Dental Staff
Dental Support
Healthcare Scientists
Infrastructure Support
Other Scientific and
Theraputi
Registered Nursing
Midwifery
Support to AHPs
Support to Clinical
Support to Nursing
Support to STT HCS
Trainee Grade Doctors
Workforce
page 143
Vacancy %
Vacancy %
July-25 Target
7.6% -
Clinical & Corporate Group Overview
Updates since previous month
The vacancy percentage has decreased by 0.5%
over the rolling 12-month period, primarily due
to reductions in establishment and an increase
in contracted WTE.
Key dependencies
Anticipating a vacancy % adjustment as part of
VfP once savings work has been transacted.
Current issues
Corporate is showing to have the largest
percentage of vacancies followed by NMGH.
Future actions
The Trust vacancy control panel will directly
impact time to hire and the number of vacancies
in TRAC.
Compliance
Variance
Assurance
Actions
W4 metric
Advise Source
General Ledger (Trial Balance Report)
Note: GL Staff Groups
6.5%
6.7%
6.9%
7.1%
7.3%
7.5%
7.7%
7.9%
8.1%
8.3%
8.5%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean
4.9%
9.6%
11.5%
2.1%
8.0%
7.7%
14.6%
9.3%
8.9%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Staff Group Overview
2.0%
3.2%
8.8%
4.7%
0.0%
3.1%
13.9%
9.6%
3.0%
3.9%
15.7%
13.4%
8.7%
Allied Health Professionals
Career Grade Doctor
Consultant
Dental Staff
Dental Support
Healthcare Scientists
Infrastructure Support
Other Scientific and
Theraputi
Registered Nursing
Midwifery
Support to AHPs
Support to Clinical
Support to Nursing
Support to STT HCS
Trainee Grade Doctors
Workforce
page 144
Temporary Staffing WTE
Temporary Staffing WTE
July-25 Target
1,611.1 1,506.2
Clinical & Corporate Group Overview
Updates since previous month
Temporary Staffing WTE continues to show less
variation month on month compared to the
previous years. For M04 2025/26 Temporary
Staffing increased by 132.7 WTE (all staff groups).
Key dependencies
Attendance, Roster Efficiencies , Job Planning
and Off Platform Activity all impact Temporary
Staffing.
Current issues
Despite reducing trend and reduction from the
same reporting period last year the Trust is still
failing to achieve plan.
Future actions
Continued work across Clinical Groups and
Corporate on initiatives to reduce the reliance on
bank and agency across 2025/26 and
progression of initiatives to control pay growth.
Compliance
Variance
Assurance
Actions
W5 metricAlert Source
General Ledger (Trial Balance Report)
Note: GL Staff Groups
353.1
295.7
286.8
139.3
344.6
72.6
64.4
2.7
52.0
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
1,000
1,200
1,400
1,600
1,800
2,000
2,200
2,400
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
Staff Group Overview
21.4
43.2
63.1
0.0
0.0
27.3
21.4
16.3
413.8
0.2
205.1
588.8
31.8
178.8
Allied Health
Professionals
Career Grade Doctor
Consultant
Dental Staff
Dental Support
Healthcare Scientists
Infrastructure Support
Other Scientific and
Theraputi
Registered Nursing
Midwifery
Support to AHPs
Support to Clinical
Support to Nursing
Support to STT HCS
Trainee Grade Doctors
Workforce
page 145
Temporary Staffing Cost
Temporary Staffing Cost
July-25 Target
£10,081,514
£8,894,317
Clinical & Corporate Group Overview
Updates since previous month
Temporary staffing costs in month M04 of 2025/26
were the highest in the past year, highlighting
continued workforce challenges and an ongoing
reliance on temporary staff.
Key dependencies
Attendance, Roster Efficiencies , Job Planning and
Off Platform Activity all impact Temporary Staffing.
Current issues
Temporary Staffing expenditure was slightly higher
than in the same reporting period last year, which
may reflect the increases in average staff costs
between financial years.
Future actions
Pay controls implemented and continue to be
monitored, this includes agency/bank protocols.
Compliance
Variance
Assurance
Actions
W6 metric Source
General Ledger (Trial
Balance Report) & Global
Monitoring Sheet
Note: Target is the Budget
shown in Global Monitoring
Sheet
Alert
£1,942,776
£1,836,484
£2,058,671
£1,056,334
£2,341,036
£337,067
£268,457
£25,904
£210,618
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
0
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
16,000,000
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
Workforce
page 146
Bank % of Pay bill YTD
Bank % of Pay bill
July-25 Target
5.6% 5.5%
Clinical & Corporate Group Overview
Updates since previous month
The Bank % of Paybill YTD has reduced by 0.1%
in M04 2025/26.
Key dependencies
Attendance, Roster Efficiencies , Job Planning
and Off Platform Activity all impact Temporary
Staffing.
Current issues
The Trust has a 5.5% financial target for Bank %
of Pay bill which it is close to achieving.
Future actions
As part of the Annual Planning round there will be
expected further reductions to the usage of Bank
staff in 2025/26.
Compliance
Variance
Assurance
Actions
W7 metric Source
General Ledger (Trial Balance
Report) & Global Monitoring Sheet
Note: GL Staff Groups
7.9%
6.9%
14.7%
2.9%
6.2%
2.4%
2.4%
0.7%
5.6%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
Advise
Staff Group Overview
0.8%
4.5%
3.1%
0.0%
0.0%
2.5%
0.4%
1.2%
4.4%
0.0%
0.0%
19.3%
4.1%
18.9%
Allied Health
Professionals
Career Grade Doctor
Consultant
Dental Staff
Dental Support
Healthcare Scientists
Infrastructure Support
Other Scientific and
Theraputi
Registered Nursing
Midwifery
Support to AHPs
Support to Clinical
Support to Nursing
Support to STT HCS
Trainee Grade Doctors
Workforce
page 147
Agency % of Pay bill YTD
Agency % of Pay bill
July-25 Target
0.8% 0.5%
Clinical & Corporate Group Overview
Updates since previous month
Agency usage is mainly due to Medical and
Dental roles shown in the staff group analysis.
Key dependencies
Attendance, Roster Efficiencies , Job Planning
and Off Platform Activity all impact Temporary
Staffing.
Current issues
The Trust has set an internal target for reducing its
Agency % of Pay bill to 0.5%.
Future actions
Compliance
Variance
Assurance
Actions
W8 metric Source
General Ledger (Trial Balance
Report) & Global Monitoring Sheet
Note: GL Staff Groups
1.1%
0.8%
2.4%
0.9%
0.6%
0.0%
0.6%
0.0%
1.6%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Advise
0.4%
0.5%
0.6%
0.7%
0.8%
0.9%
1.0%
1.1%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
Staff Group Overview
1.9%
3.4%
1.6%
0.0%
0.0%
0.6%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
2.0%
Allied Health
Professionals
Career Grade Doctor
Consultant
Dental Staff
Dental Support
Healthcare Scientists
Infrastructure Support
Other Scientific and
Theraputi
Registered Nursing
Midwifery
Support to AHPs
Support to Clinical
Support to Nursing
Support to STT HCS
Trainee Grade Doctors
Workforce
page 148
Price Cap Compliance
Price Cap Compliance
June-25 Target
63.1% 80.0%
Clinical Group Overview
Updates since previous month
GM changed the Price Cap compliance metric from
all staff group compliance to AfC compliance in
April 2025. Work being undertaken targeting high
cost agency to achieve 80% target.
Key dependencies
With the Trust reducing its Agency spend this year it
has been left with hard to fill roles which have a
premium cost to them and has led to a lower price
cap compliance score.
Current issues
There are three Trusts in GM not meeting the current
80% target; MFT, Bolton and NCA.
Future actions
Focus on enhancing monitoring mechanisms,
improving cost efficiency, and aligning with updated
regulatory guidelines within the NHS.
Compliance
Variance
Assurance
Actions
W9 metricAlert Source
GM Temporary Staffing
Dashboard
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
IN
DEVELOPMENT
0%
20%
40%
60%
80%
100%
120%
140%
160%
Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25
Mean Target
Workforce
page 149
Off Framework
Off Framework
July-25 Target
£0 £0
Clinical & Corporate Group Overview
Updates since previous month
MFT has ‘zero’ Off Framework spend since January
2024.
Key dependencies
There should be zero off framework agency use from
July 2024 following The Chancellor’s announcement
in the Spring Budget 2024.
Current issues
Future actions
The Trust will continue to monitor Off Framework
spend to be compliant with the ‘zero’ spend target.
Compliance
Variance
Assurance
Actions
W10 metricAssure Source
GM Temporary Staffing
Dashboard
£0
£0
£0
£0
£0
£0
£0
£0
£0
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
£0
£10
£20
£30
£40
£50
£60
£70
£80
£90
£100
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
Workforce
page 150
Single Month & Rolling 12 Month Sickness Absence %
SM & R12M Sickness Absence %
July-25 Target
SM 5.9% 5.9%
R12M 6.0% 6.0%
Clinical & Corporate Group Overview
(SM)
Updates since previous month
A comprehensive programme approach to absence
prevention and attendance management is underway.
Each Clinical Group has a bespoke target and plan to
drive local actions.
Key dependencies
The 2025/26 Workforce Annual Plan is predicated on a
targeted reduction in sickness absence, recognizing its
critical impact on staff wellbeing, operational
efficiency, and overall service delivery.
Current issues
Ambition to push further in sickness absence to
support movement from NOF 3 to NOF 2.
Future actions
Integrating operational sickness reports with case
management data to enhance insights and drive
targeted interventions for improved employee health
outcomes.
Compliance
Variance
Assurance
Actions
W11 metricAssure
Source
ESR (Electronic Staff Records)
5.9%
5.9%
6.2%
6.6%
6.2%
6.6%
6.4%
6.1%
5.9%
5.7%
5.6%
5.9%
6.2%
6.1%
5.9%
6.4%
6.5%
6.9%
6.9%
6.3%
5.7%
5.5%
5.5%
5.7%
5.9%
6.4%
6.4%
6.4%
6.3%
6.2%
6.1%
6.1%
6.1%
6.1%
6.0%
6.1%
6.1%
6.1%
6.1%
6.2%
6.0%
6.1%
6.1%
6.1%
6.1%
6.1%
6.1%
6.1%
6.0%
6.0%
4.0%
4.5%
5.0%
5.5%
6.0%
6.5%
7.0%
7.5%
Jul-23
Aug-23
Sep-23
Oct-23
Nov-23
Dec-23
Jan-24
Feb-24
Mar-24
Apr-24
May-24
Jun-24
Jul-24
Aug-24
Sep-24
Oct-24
Nov-24
Dec-24
Jan-25
Feb-25
Mar-25
Apr-25
May-25
Jun-25
Jul-25
Absence %
Sickness Absence (Single Month & Rolling 12 Months)
SM Sickness R12m Sickness Annual Workforce Plan (R12m Predicted)
Assure W12 metric
SMR12M
Clinical & Corporate Group
Overview (R12M)
6.4%
6.7%
5.3%
5.1%
6.0%
5.9%
5.1%
4.1%
6.6%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
6.8%
6.4%
6.1%
5.3%
5.8%
6.5%
4.9%
5.1%
7.5%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Workforce
NOF metric
Score = 3.44
page 151
Callback & Return to Work Compliance %
Callback & Return to Work Compliance %
July-25 Target
57.0% 80.0%
Clinical & Corporate Group Overview
Updates since previous month
Call back & Return to Work compliance has
remained stable between 54 to 58%.
Key dependencies
Training and management tools are provided to
managers to support with call back and return to
work compliance.
Current issues
Workforce is currently undertaking a review of the
Call Back and Return to Work Compliance KPI to
evaluate its effectiveness as a performance
measure.
Future actions
Work to include the new Clinical group structure in
Absence Manager for ease of reporting at this level.
Compliance
Variance
Assurance
Actions
W13 metricAlert Source
Absence Manager,
Empactis
51.0%
56.0%
61.0%
66.0%
71.0%
76.0%
81.0%
86.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
54.7%
70.6%
41.8%
53.0%
49.9%
52.7%
59.7%
64.4%
71.2%
57.1%
62.8%
65.1%
MRI
WTWA
NMGH
CSS
- RMCH
- SMH
- REH
Specialist
- LCO
- UDH
LCO & UDH
Corporate
Research
Facilities
Workforce
page 152
Level 1 Mandatory Compliance %
Level 1 Mandatory Compliance %
July-25 Target
95.6% 90.0%
Clinical & Corporate Group Overview
Updates since previous month
All Clinical Groups are meeting the 90% target and
the Trust continually meets this target.
Compliance is currently 5.6% above the target.
Key dependencies
Adherence to national guidelines and legal
requirements, such as those set by the Care Quality
Commission (CQC) and Health and Safety Executive
(HSE).
Current issues
Undertaking a review of mandatory training in line
with new national guidance in terms of frequency
and allocation to staff groups.
Future actions
Compliance driven locally, with assurance via
the IPR process. Directors of Workforce & OD
leading local compliance improvement plans.
Compliance
Variance
Assurance
Actions
W14 metricAssure Source
ESR (Electronic Staff Records)
Note: ESR Staff Groups
89.0%
90.0%
91.0%
92.0%
93.0%
94.0%
95.0%
96.0%
97.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
95.8%
94.1%
96.2%
95.3%
95.7%
96.6%
97.1%
95.5%
96.2%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Staff Group Overview
97.7%
96.0%
96.3%
97.1%
95.9%
96.3%
88.1%
96.7%
96.4%
Add Prof Scientific &
Technical
Additional Clinical
services
Admin & Clerical
Allied Health
Professionals
Estates and Ancillary
Healthcare Scientists
Medical and Dental
Nursing and
Midwifery Registered
Students
Workforce
page 153
Level 2 & 3 Mandatory Compliance %
Level 2 & 3 Mandatory Compliance %
July-25 Target
89.1% 90.0%
Clinical & Corporate Group Overview
Updates since previous month
There has been a steady improvement in Level 2
& 3 Mandatory training compliance in the rolling
12 month period. The Trust is close to reaching
the 90% target.
Key dependencies
Adherence to national guidelines and legal
requirements, such as those set by the Care Quality
Commission (CQC) and Health and Safety Executive
(HSE).
Current issues
Enhance compliance with Estates, Medical &
Dental and Admin & Clerical as these are showing
as an outlier.
Future actions
Compliance driven locally, with assurance via the
IPR process. Directors of Workforce & OD leading
local compliance improvement plans.
Compliance
Variance
Assurance
Actions
W15 metric
Advise Source
ESR (Electronic Staff Records)
Note: ESR Staff Groups
83.0%
84.0%
85.0%
86.0%
87.0%
88.0%
89.0%
90.0%
91.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
89.5%
86.3%
88.9%
87.7%
89.0%
91.1%
89.6%
92.6%
92.9%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Staff Group Overview
92.0%
91.2%
75.6%
91.2%
61.5%
89.2%
75.1%
91.7%
89.0%
Add Prof Scientific
& Technical
Additional Clinical
services
Admin & Clerical
Allied Health
Professionals
Estates and
Ancillary
Healthcare
Scientists
Medical and
Dental
Nursing and
Midwifery
Registered
Students
Workforce
page 154
Appraisal – Agenda for Change Compliance %
Appraisal – AfC Compliance %
July-25 Target
82.6% 90.0%
Clinical & Corporate Group Overview
Updates since previous month
Currently none of the Clinical Groups are
meeting the 90%. Further work being
undertaken to drive compliance with managers.
Key dependencies
Sufficient time set aside for both appraisers and
employees to prepare for and conduct
appraisals without disrupting service delivery.
Current issues
Admin and Clerical compliance is showing as an
outlier at just 72.0% compliance.
Future actions
Compliance driven locally, with assurance via the
IPR process. Directors of Workforce & OD leading
local compliance improvement plans.
Compliance
Variance
Assurance
Actions
W16 metricAlert Source
ESR (Electronic Staff Records)
Note: ESR Staff Groups
75.0%
77.0%
79.0%
81.0%
83.0%
85.0%
87.0%
89.0%
91.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
82.8%
82.1%
88.4%
82.9%
83.2%
88.1%
69.1%
70.8%
79.7%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Staff Group Overview
80.7%
86.0%
72.0%
86.0%
85.0%
82.3%
85.6%
82.6%
Add Prof Scientific &
Technical
Additional Clinical
services
Admin & Clerical
Allied Health
Professionals
Estates and Ancillary
Healthcare Scientists
Medical and Dental
Nursing and Midwifery
Registered
Students
Workforce
page 155
Appraisal – Medical Compliance %
Appraisal - Medical Compliance %
July-25 Target
92.2% 90.0%
Clinical & Corporate Group Overview
Updates since previous month
All Clinical Groups apart from WTWA have met the
90% target and the Trust continues to exceed the
target for this metric.
Key dependencies
Sufficient time set aside for both appraisers and
employees to prepare for and conduct appraisals
without disrupting service delivery.
Current issues
Future actions
Compliance driven locally, with assurance via the
IPR process. Directors of Workforce & OD leading
local compliance improvement plans.
Compliance
Variance
Assurance
Actions
W17 metricAssure Source
ESR (Electronic Staff
Records)
85.0%
86.0%
87.0%
88.0%
89.0%
90.0%
91.0%
92.0%
93.0%
94.0%
95.0%
96.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
94.6%
89.2%
92.7%
93.2%
93.8%
93.0%
93.8%
100.0%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Workforce
page 156
Oliver McGowan Compliance % - Part 1 (eLearning)
Oliver McGowan Compliance %
July-25 Target
83.6% 90.0%
Clinical & Corporate Group Overview
Updates since previous month
The Trust compliance score has improved
throughout the financial year but is still 6.4%
below target.
Key dependencies
Adherence to national guidelines and legal
requirements, such as those set by the Care
Quality Commission (CQC) and Health and Safety
Executive (HSE).
Current issues
Future actions
Compliance driven locally, with assurance via the
IPR process. Directors of Workforce & OD leading
local compliance improvement plans.
Compliance
Variance
Assurance
Actions
W18 metric
Advise Source
ESR (Electronic Staff Records)
Note: ESR Staff Groups
88.3%
82.9%
90.0%
74.3%
84.0%
87.6%
77.4%
95.3%
90.5%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
Staff Group Overview
85.8%
88.8%
80.5%
81.1%
90.9%
71.7%
62.8%
90.0%
83.6%
Add Prof
Scientific &
Technical
Additional
Clinical services
Admin & Clerical
Allied Health
Professionals
Estates and
Ancillary
Healthcare
Scientists
Medical and
Dental
Nursing and
Midwifery
Registered
Students
Workforce
page 157
Staff Engagement Score
Staff Engagement Score
July-25 Target
6.8 6.8
Clinical & Corporate Group Overview
Updates since previous month
The Staff Engagement score is taken from the Staff
Survey. The Trust has met the 6.8 staff engagement
target.
Key dependencies
Staff participation in the Staff Survey remains
critical with the Trust encouraging high responses
through incentives and clear communication.
Current issues
Data for the Staff Survey was taken before the
change to Clinical Groups which may hinder
reporting in the new format for future months.
Future actions
Active backing from leadership to promote the
survey/pulse check and emphasize its importance to
staff.
Compliance
Variance
Assurance
Actions
W19 metric Source
Staff Survey
Assure
6.9
6.8
6.9
6.6
6.8
6.7
6.8
7.1
6.6
MRI
WTWA
NMGH
CSS
- RMCH
- SMH
- REH
Specialist
- LCO
- UDH
LCO & UDH
6.70
6.72
6.74
6.76
6.78
6.80
6.82
6.84
6.86
Q2 24/25 Q3 24/25 Q4 24/25 Q1 25/26 Q2 25/26
Mean Target
Workforce
NOF metric
Score = 2.92
page 158
Friends and Family Test – Recommend Work
FFT – Recommend Work
July-25 Target
60% -
Clinical & Corporate Group Overview
Updates since previous month
The FFT 'Recommend as a Place to Work' score for
month M04 2024/25 was 60% from the Staff Survey.
Key dependencies
The FFT is most useful when it's part of a broader
continuous improvement cycle where feedback is
regularly reviewed, analysed, and acted upon.
Current issues
This information is to be used with other data to
create a cultural dashboard to help drive
improvement.
Future actions
Using FFT alongside other surveys or quality
improvement systems to create a fuller picture of
performance and satisfaction.
Compliance
Variance
Assurance
Actions
W20 metric
Advise Source
Staff Survey
48%
48%
48%
51%
51%
52%
60%
56%
40%
MRI
WTWA
NMGH
CSS
- RMCH
- SMH
- REH
Specialist
- LCO
- UDH
LCO & UDH
50.0%
52.0%
54.0%
56.0%
58.0%
60.0%
62.0%
64.0%
Q2 24/25 Q3 24/25 Q4 24/25 Q1 25/26 Q2 25/26
Mean
Workforce
page 159
Friends and Family Test – Recommend Care
FFT – Recommend Care
July-25 Target
66% -
Clinical & Corporate Group Overview
Updates since previous month
The FFT 'Recommend as a Place for Care' score for
month M04 2024/25 was 66% from the Staff Survey.
Key dependencies
The FFT is most useful when it's part of a broader
continuous improvement cycle where feedback is
regularly reviewed, analysed, and acted upon.
Current issues
This information is to be used with other data to
create a cultural dashboard to help drive
improvement.
Future actions
Using FFT alongside other surveys or quality
improvement systems to create a fuller picture of
performance and satisfaction.
Compliance
Variance
Assurance
Actions
W21 metric
Advise Source
Staff Survey
64%
63%
57%
60%
61%
67%
72%
72%
73%
MRI
WTWA
NMGH
CSS
- RMCH
- SMH
- REH
Specialist
- LCO
- UDH
LCO & UDH
60.0%
61.0%
62.0%
63.0%
64.0%
65.0%
66.0%
67.0%
68.0%
69.0%
Q2 24/25 Q3 24/25 Q4 24/25 Q1 25/26 Q2 25/26
Mean
Workforce
page 160
Representative Workforce - % BME
% BME in pay scales
July-25 Target
M&D 48.7%, B8a+
11.9%, B7- 31.0% 23.6%
M&D Clinical & Corporate Group
Overview Updates since previous month
The Trust continues to have high representation
of BME staff in Medical & Dental roles and Band
7 and Below. It has less representation in Band
8a and above.
Key dependencies
Well-defined policies regarding visa sponsorship
and the employment of international staff,
including compliance with UK immigration laws.
Current issues
In all three of these metrics there have been an
upward trajectory in the number of BME staff but
Band 8a and above is still below target.
Future actions
Compliance
Variance
Assurance
Actions
W22 metric
Assure
Source
ESR (Electronic Staff Records)
Advise W23 metric
Assure W24 metric
M&D
8a+B7-
50.3%
48.4%
52.3%
48.3%
48.3%
38.0%
36.4%
50.0%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Band 8a and above Clinical &
Corporate Group Overview
Band 7 and below Clinical &
Corporate Group Overview
14.6%
9.8%
9.3%
15.3%
9.2%
13.3%
11.3%
12.9%
3.0%
MRI
WTWA
NMGH
CSS
Specia…
LCO &…
Corpor…
Resear…
Facilities
44.2%
32.2%
39.2%
36.0%
24.5%
21.7%
26.8%
38.0%
26.2%
MRI
WTWA
NMGH
CSS
Specia…
LCO &…
Corpor…
Resear…
Facilities
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
M&D B8a+ B7- Target
Workforce
page 161
Representative Workforce - % disability
% Disability in pay scales
July-25 Target
M&D 1.9%, B8a+
4.9%, B7- 6.2% -
M&D Clinical & Corporate Group
Overview Updates since previous month
The Trust is seeing an improvement in this metric
month on month.
Key dependencies
Develop and implement recruitment policies that
prioritise the inclusion of disabled candidates,
ensuring job postings reach diverse communities.
Current issues
Currently underreporting on this metric due to a
number of staff not having declared their disability
status on ESR.
Future actions
Work undertaken by the ED&I team to improve the
data collection of Disability status through
Employee Self Service on ESR.
Compliance
Variance
Assurance
Actions
W25 metric
Source
ESR (Electronic Staff Records)
Advise W26 metric
W27 metric
M&D
8a+B7-
Band 8a and above Clinical &
Corporate Group Overview
Band 7 and below Clinical &
Corporate Group Overview
Advise
Advise
2.1%
1.3%
1.9%
1.6%
2.5%
2.3%
0.0%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Facilities
2.2%
4.4%
6.5%
2.8%
4.1%
5.8%
8.8%
8.3%
4.6%
MRI
WTWA
NMGH
CSS
Specia…
LCO &…
Corpor…
Resear…
Facilities
4.6%
4.3%
5.6%
6.5%
7.1%
7.9%
8.0%
6.0%
6.6%
MRI
WTWA
NMGH
CSS
Specia…
LCO &…
Corpor…
Resear…
Facilities
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
M&D B8a+ B7-
Workforce
page 162
Turnover %
Turnover %
July-25 Target
9.5% 11.0%
Clinical & Corporate Group Overview
Updates since previous month
All Clinical Groups are meeting the 11.0% target for
this metric.
Key dependencies
High levels of engagement and job satisfaction
among staff are crucial for reducing turnover.
Current issues
Future actions
The Trust has set a target of keeping below 11%
Turnover as part of the Workforce Plan to the NHSE/I
which it has done.
Compliance
Variance
Assurance
Actions
W28 metricAssure Source
ESR (Electronic Staff
Records)
8.0%
8.5%
9.0%
9.5%
10.0%
10.5%
11.0%
11.5%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
8.9%
9.5%
8.4%
9.6%
8.5%
11.0%
9.5%
5.6%
10.5%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Workforce
page 163
Retention / Stability %
Retention / Stability %
July-25 Target
90.3% 89.0%
Clinical & Corporate Group Overview
Updates since previous month
The Trust is currently exceeding the 89% target for
this metric.
Key dependencies
A high stability metric can indicate a positive work
environment, effective management, and employee
satisfaction.
Current issues
Future actions
MFT People Plan will be reviewed in 2025/26 and will
include a range of new measures under the people
promise including retention.
Compliance
Variance
Assurance
Actions
W29 metricAssure Source
ESR (Electronic Staff
Records)
87.5%
88.0%
88.5%
89.0%
89.5%
90.0%
90.5%
91.0%
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
87.3%
85.2%
88.7%
88.2%
88.6%
87.4%
88.6%
90.2%
88.3%
MRI
WTWA
NMGH
CSS
Specialist
LCO & UDH
Corporate
Research
Facilities
Workforce
page 164
Time to Hire
Time to Hire
July-25 Target
66.5 55.0
Clinical & Corporate Group Overview
Updates since previous month
The Trust has recently started reporting the Time to
Hire through the Provider Workforce Return (PWR).
Key dependencies
Capacity within the resourcing team has been
realigned to VCP and redeployment. Digital ID has
been implemented and will be fully rolled out by the
1st September.
Current issues
Peak season for recruitment which is creating
additional pressure on a reduced resourcing
capacity.
Future actions
NHS England are pulling together a reporting
platform for all GM Trusts so we can benchmark this
metric across different Trusts and Staff Groups.
Compliance
Variance
Assurance
Actions
W30 metric Source
TRAC e-recruitment system
Alert
40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
80.00
Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Mean Target
73.3
58.6
59.5
68.6
74.1
70.1
83.8
64.6
101.8
MRI
WTWA
NMGH
CSS
- RMCH
- SMH
- REH
Specialist
- LCO
- UDH
LCO & UDH
Workforce
page 165
Ensure value for our
patients and communities
by making the best use of
our resources
page 166
Trust IPR Metric Assurance Summary
Focus
Compliance
Variation
Assurance
Action
status
Indicator
Indicator
Type
Income and Expenditure Surplus /
(Deficit) vs Plan YTD
National
Agency expenditure as a proportion of
Total Pay expenditure YTD
National
Total VfP delivered as a proportion of
Plan YTD
Local
Non recurrent VfP as a proportion of
Total VfP YTD
National
BPPC performance vs target YTD National
Capital expenditure vs Plan YTD National
Cash balances above the level where a
working capital loan would be required
National
Key Oversight Performance Metrics
Financial performance
page 167
Measuring our performance
Escalating performance concerns
Using the four SPC rules and outcomes of our benchmarking , we use an Alert, Advise and Assure model to ensure that both risks and improvements associated with performance are escalated
appropriately using the Trust’s risk escalation framework, through the Trust’s Governance Infrastructure. Risks identified through the assessment of and assurance associated with any element of
performance that may have an impact on the delivery of the Trust’s Strategic Objectives are reflected within the Trust’s Board Assurance framework.
Compliance Variation
Target being met Target not met For information, no target
set or target not due
Common cause – no
significant change
Special cause of
concerning nature or
higher pressure due to
(H)igher or (L)ower
values
Special cause of improving
nature or lower pressure
due to (H)igher or (L)ower
values
Assurance
Variation indicates
Inconsistently
passing and falling
short of
the target
Variation indicates
consistently
(P)assing the target
Variation indicates
Consistently
(F)alling short of the
target
Action Status
Active
surveillance –
continue to
observe in order
to better
understand the
current position
Improvement –
continue actions
to support
improvement
until steady
state achieved
Deterioration or
maintained
underperformance –
instigate or review
actions to ensure
drivers of current
position are
mitigated
Steady state – continue
to monitor achievement
of level of performance
which is satisfactory,
and which requires no
intervention to maintain
Financial performance
page 168
Trust IPR Metric Assurance Summary
Focus
Compliance
Variation
Assurance
Action
status
Indicator
Indicator
Type
Income and Expenditure Surplus /
(Deficit) vs Plan YTD
National
Agency expenditure as a proportion of
Total Pay expenditure YTD
National
Total VfP delivered as a proportion of
Plan YTD
Local
Non recurrent VfP as a proportion of
Total VfP YTD
National
BPPC performance vs target YTD National
Capital expenditure vs Plan YTD National
Cash balances above the level where a
working capital loan would be required
National
Key Oversight Performance Metrics
page 169
Executive summary
Consistent assurance can be provided
on:
•BPPC compliance for invoices paid by
value consistently above the 95%
target
•YTD delivery of VfP
Alerts for:
•YTD I&E performance
•Cash balance, £18.8m lower than plan
•Delivery of VfP through non recurrent
schemes
•Capital spend which is marginally
behind plan in M4
•Reduction in agency expenditure
compared to 2024/25 (although note
MFT’s expenditure as a % of overall
pay expenditure is one of the lowest
in the country)
Variation
Assurance
Achieving Target Inconsistently Achieving Target Not Achieving Target
Special Cause
Improvement
Common
Cause
Special
Cause
Concern
•Non-recurrent VfP as a
proportion of Total VfP
•Better Payment Practice
Compliance
•Capital Expenditure
•Cash balance
•Total VfP delivered as a
proportion of Planned VfP
•30% reduction in agency
expenditure compared to
2024/25.
•I&E Performance – Surplus /
(deficit) vs Plan
Financial performance
page 170
Financial Performance – Year to Date
Income & Expenditure Surplus / (Deficit) vs Plan YTD (£m)
July-25 Target
£5.3m £0m
Clinical Group Overview
Updates since previous month
Adverse variance in M4 driven by costs/income loss from
Industrial Action (£2.7m)
Premium pay costs covering vacancies
Non pay pressures relating to inflationary pressures and
costs to deliver activity
Key dependencies
VfP programme
Cash
Current issues
Under delivery of VfP across CGs
Inflationary pressures on non-pay expenditure.
Premium pay (primarily bank costs and ECLs).
Financial impact of IA
Future actions
Recovery plans developed across all areas.
Extended additional capacity to support VfP development and
implementation
Target VfP support to areas with capacity constraints
Compliance
Variance
Assurance
Actions
Alert
Rank Clinical Group YTD Value
£m
1 WTWA 1.2
2 Spec. Hospitals 0.1
3 LCO & Dental (0.6)
4 CSS (2.4)
5 NMGH (4.2)
6 MRI (5.6)
Financial performance
NOF metric
Score = 1
page 171
Agency - % of total staffing costs
Agency Expenditure as a proportion of Total Pay Expenditure YTD
July-25 Target
0.8% 0.5%
Clinical Group Overview
Updates since previous month
National guidance requires a reduction of 30% of
agency costs in 2025/26.
MFT has one of the lowest agency usage nationally
in proportion to total staffing costs
Key dependencies
Total pay costs
Current issues
There are still some challenges to resolve relating
to a reduction in the use of off-
platform agency for
difficult to recruit posts.
Future actions
Identification and implementation plans of
alternatives to off-platform agency as part of
recovery plans.
Compliance
Variance
Assurance
Actions
Rank Clinical Group YTD Value
%
1 LCO & Dental 0.0%
2 Spec. Hospitals 0.4%
3 WTWA 0.6%
4 MRI 0.9%
5 CSS 1.1%
6 NMGH 2.5%
Financial performance
page 172
Value for Patients delivered YTD
Total VfP delivered YTD (from Wave)
July-25 Target
115% 100%
Clinical Group Overview
Updates since previous month
The £25.4m YTD VfP performance is £4.9m above
the M4 YTD target but has been delivered through
predominantly non recurrent Central schemes
which have been brought forward to delivery earlier
than planned.
Key dependencies
I&E performance
Impact on cash
Current issues
The level of non-recurrent delivery in 24/25 has impacted on
the underlying financial position coming into 25/26.
Future actions
External support extended to provide support
Targeted support in areas with capacity constraints
Executive focus through fortnightly Trust Recovery Board
Compliance
Variance
Assurance
Actions
Rank Clinical Group YTD Value
%
1 LCO & Dental 135%
2 Spec. Hospitals 120%
3 NMGH 99%
4 WTWA 98%
5 CSS 79%
6 MRI 47%
Year to Date Target Actual
Variance
to target
Target Actual
Variance
to target
Target Actual
Variance
to target
Actual v
Target
Delivered
NR
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 % %
CSS 3,166 2,850 (316) 1,055 501 (555) 4,222 3,351 (871) 79% 15%
LCO & Dental 1,265 690 (575) 422 1,583 1,162 1,686 2,273 587 135% 70%
MRI 2,840 978 (1,863) 947 794 (153) 3,787 1,772 (2,015) 47% 45%
NMGH 1,260 1,469 209 420 191 (229) 1,680 1,660 (20) 99% 11%
Specialist Hospitals 4,045 1,629 (2,416) 1,348 4,836 3,488 5,393 6,465 1,072 120% 75%
WTWA 2,721 1,537 (1,185) 907 2,034 1,126 3,629 3,570 (58) 98% 57%
0
Total - Clinical Sites 15,298 9,152 (6,146) 5,099 9,939 4,840 20,398 19,092 (1,306) 94% 52%
Corporate exc Informatics 874 1,776 901 291 93 (199) 1,166 1,868 702 160% 5%
Informatics 690 877 187 230 543 313 920 1,420 500 154% 38%
Estates & Facilities 962 28 (933) 321 423 103 1,282 452 (831) 35% 94%
0
Total - Support Services 2,526 2,680 155 842 1,059 217 3,367 3,740 372 111% 28%
Trust 1,242 0 (1,242) 414 7,500 7,086 1,656 7,500 5,844 453% 100%
Grand Total 19,066 11,833 (7,233) 6,355 18,498 12,143 25,421 30,331 4,910 119% 61%
Recurrent
Non Recurrent
Total
Financial performance
page 173
Non -recurrent Value for Patients delivered YTD
Non-recurrent VfP delivered as a proportion of Total VfP delivered YTD (from Wave)
July-25 Target
61% 25%
Clinical Group Overview
Updates since previous month
The Non recurrent delivery of VfP continues to be
higher than planned due to central non recurrent.
VfP schemes being brought forward to offset under-
delivery in the Clinical Groups.
Key dependencies
I&E performance
Impact on cash
Current issues
Any non recurrent delivery will impact on the Trust’s underlying financial
position.
Future actions
Focus on development of recurrent schemes including FYE of 25/26
schemes.
Work ongoing to develop a rolling VfP programme.
Compliance
Variance
Assurance
Actions
Alert
Rank Clinical Group YTD Value
%
1 NMGH 11%
2 CSS 15%
3 MRI 45%
4 WTWA 57%
5 LCO & Dental 70%
6 Spec. Hospitals 75%
Financial performance
page 174
BPPC performance vs Target
BPPC performance (Invoices Paid by Value) vs Target %
July-25 Target
98% 95%
Updates since previous month
A consistent level of c97% of all bills paid within
target.
Key dependencies
BPPC performance vs target for invoices paid by
number (not shown on the chart).
Impact on cash
Current issues
The Trust is falling short on NHS invoices paid within target at 94.7%.
Performance against invoices paid by number (not shown) is 95.0% with
NHS invoices just 67.6%.
Future actions
Although the overall target is being met for the primary driver of invoices paid
by value, targeted work is ongoing to increase the number of NHS invoices
paid in line with the target. However, this will need to be managed in line
with maximising the organisations cash.
Compliance
Variance
Assurance
Actions
Assure
Financial performance
page 175
Capital Expenditure YTD
Capital Expenditure vs Plan (to meet the Trust’s Capital Resource Limit) YTD
July-25 YTD Target
£31.1m £29.4m
Updates since previous month
Overspent against plan due to a timing difference of an
anticipated CDEL credit as a result of securing more
favourable lease terms but anticipating to be back on
plan by the middle of Q2.
Key dependencies
Cash
Current issues
Trust capital requirements exceed CDEL limit.
If the cash position falls to a level where revenue
cash support is required, this will impact on the
affordability of the capital programme and it would
need to be slowed down/reduced.
Future actions
Application for any national funding made available
for capital schemes
Work ongoing to identify alternative funding
mechanisms for capital requirements
Compliance
Variance
Assurance
Actions
Financial performance
page 176
Cash Balance
Cash Balance vs Plan (Target to remain above level where a Working Capital Loan would be required)
July-25 Plan
£38.4m £57.2m
Updates since previous month
The cash position continues to be challenged due to
delivery of the financial position by non cash
releasing means and planned deficit for the first
quarter of the year.
Key dependencies
I&E deficit
Capital underspends
Delivery of VfP target
Current issues
Risk of requiring national revenue cash support if monthly
expenditure is not reduced in line with the profiled plan and through
cash releasing transactions.
Future actions
Weekly cash meetings to monitor and maximise Trust cash position
CFO chaired fortnightly Cash Management Board
Senior sign off for all supplier payment runs
Focus on development and implementation of cash releasing VfP
schemes.
Compliance
Variance
Assurance
Actions
Alert
Financial performance
page 177
Digital Services
page 178
YTD
Compliance
Assurance
Variance
Actions
High Severity Incidents (HSIs) Performance
HSIs Resolved Within 6 Hours in Manage Engine Each Month
June
-
25
Monthly
Target
YTD
Target YTD
6<=6
10 of 12
Months
To be
Achieved
3 of 3
Months
Achieved
Headlines
There was a total of six High Severity Incidents raised in June 2025,
two of which breached the 6
-hour SLA. The breakdown of the
incidents which exceeded the SLA are as follows:
Issue 1
– The incident was related to an issue with network
connection for a community site.
Issue 2
– Incident occurred on a system supported outside of Digital
Services and directly managed by operational Services.
Performance has been stable since the start of the calendar year and
following resolution of key Network issues at ORC.
Digital Services Operational Performance
Current issues
There are no known significant issues we are currently aware of that
may be at risk of causing an increase in High Severity incidents in July
2025.
Key dependencies
Continued support and investment in key Digital Infrastructure will be
needed mitigate against an increase in High Severity Incidents.
Future actions
Performance in July is expected to be maintained with no significant
risks forecasted.
The Digital Director has also shared key areas for future investment to
support mitigatation of key issues.
0
2
4
6
8
10
12
14
16
18
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Jun 25
Number of HSIs Resolved
Digital Services Operational Performance
page 179
Compliance
Assurance
Variance
Actions
Subject Access Requests (SARs)
Percentage of SARs resolved within the statutory deadline
June-25 Target
63.70 60%
(to be achieved
in month of June,
90% by March 26)
Headlines
Performance in June 2025 was reported at 64%, with a total of 1,055
requests resolved, of which 672 were completed within the statutory
timeline. This reflects a 5% improvement compared to May 2025.
Additionally, the Trust achieved a significant reduction in backlog, with a
decrease of 611 cases, despite an increase in the number of Subject
Access Requests (SARs) received during the month.
The Q1 KPI target of >=60% has been achieved, supported by contractor
staffing to assist with SARs processing. Additionally, the adoption of the
new 'Backlog and Day Forward' approach has contributed positively to
overall performance and efficiency in the period.
Digital Services Operational Performance
Current issues
Contractors are currently being used to cover existing vacancies within
the team. In parallel, work is underway to explore automation options
aimed at supporting the team in working more efficiently and improving
overall productivity.
Key dependencies
Continued utilisation of agency provision alongside the temporary
assignment of staff from wider resource pools to maintain service
continuity and address capacity challenges until all recruitment to
substantive positions are completed.
Future actions
The team will continue to work with the Robotic Process
Automation
(RPA) team to develop automation options and explore other areas
for
automation or streamlining of processes.
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Jan-23
Feb-23
Mar-23
Apr-23
May-23
Jun-23
Jul-23
Aug-23
Sep-23
Oct-23
Nov-23
Dec-23
Jan-24
Feb-24
Mar-24
Apr-24
May-24
Jun-24
Jul-24
Aug-24
Sep-24
Oct-24
Nov-24
Dec-24
Jan-25
Feb-25
Mar-25
Apr-25
May-25
Jun-25
SARs % Completed In Time
Digital Services Operational Performance
page 180
Compliance
Assurance
Variance
Actions
Freedom of Information Requests (FOIs)
Percentage of FOIs resolved and responded to <= 20 working days
June-25 YTD Target
59.84
62.92%
50%
(Q1 target,
Quarterly step
change to 90% in
Q4)
Headlines
Of the 127 FOIs sent out in June 2025, 76 were within the 20
-day
legislative window, achieving 59.8% compliance for all FOIs responded to
in month.
This reflects a month-on-month decline in performance
when compared to the 76.9% compliance achieved in May 2025.
138 FOIs remain in progress at the end of June, of which 62 FOI requests
are over 20 working days. A 42.7% breached FOIs, approximately same
percentage as May 2025.
There were 120 FOIs where the 20
-day response deadline was in June
2025, 71 were responded to achieving a 59.2% compliance rate for
‘current’ FOIs
Digital Services Operational Performance
Current issues
The backlog of open FOIs over 20
-
days remains a significant factor for the
Trust.
Quality of responses to FOIs from Clinical groups and corporate teams can
be of low quality, leading to the IG team requesting clarification/additional
detail; IG team currently return circa 30% of all responses.
Key dependencies
Timely and accurate FOI responses from clinical group and corporate
Teams.
Timely onboarding of two new starters within the IG team.
Executive
authorisation to recruit into additional gapped positions in the
IG team (2 x WTE).
Future actions
Nominated Single Point of Contacts will facilitate closer working with the
FOI team, including training and sharing of best practice for response
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Jan-25
Feb-25
Mar-25
Apr-25
May-25
Jun-25
% FOIs Sent In 20 Working Days
Digital Services Operational Performance
page 181
Deliver world-class research &
innovation that improves
peoples lives
page 182
Research & Innovation
Measuring our performance
Escalating performance concerns
Using the four SPC rules and outcomes of our benchmarking , we use an Alert, Advise and Assure model to ensure that both risks and improvements associated with performance are escalated appropriately
using the Trust’s risk escalation framework, through the Trust’s Governance Infrastructure. Risks identified through the assessment of and assurance associated with any element of performance that may have
an impact on the delivery of the Trust’s Strategic Objectives are reflected within the Trust’s Board Assurance framework.
Compliance Variation
Target being met Target not met For information, no target set
or target not due
Common cause – no
significant change
Special cause of concerning
nature or higher pressure
due to (H)igher or (L)ower
values
Special cause of improving
nature or lower pressure due
to (H)igher or (L)ower values
Assurance
Variation indicates
Inconsistently passing
and falling short of
the target
Variation indicates
consistently (P)assing
the target
Variation indicates
Consistently (F)alling
short of the target
Action Status
Active
surveillance –
continue to
observe in order
to better
understand the
current position
Improvement –
continue actions
to support
improvement
until steady state
achieved
Deterioration or
maintained
underperformance –
instigate or review
actions to ensure
drivers of current
position are mitigated
Steady state – continue to
monitor achievement of
level of performance
which is satisfactory, and
which requires no
intervention to maintain
page 183
Research & Innovation
IPR Metric Assurance Summary
KPI Latest month Measure Target
Variation
Assurance
Mean
Lower process
limit
Upper process
limit
All research studies Open to Recruitment or in Follow
- Up May 25 1156 1091 1067 1116
Percentage of all research studies approved within 40 day target
May 25 60% 80% 74% 27% 100%
Monthly participants recruited to NIHR Portfolio
-adopted research studies May 25 1272 1584 1615 1034 2196
MFT
-sponsored, NIHR Portfolio-adopted research studies on track for
recruitment to time and target
May 25 49% 80% 51% 39% 63%
UKCRD Commercial Metric 1 Under Construction
May 25 457 60 380 70 689
UKCRD Commercial Metric 2 Under Construction
May 25 132 30 200 -131 531
page 184
Research & Innovation
Metric Summary
All research studies Open to Recruitment or in Follow- Up Percentage of all research studies approved within 40 day target
Monthly participants recruited to NIHR Portfolio-adopted studies MFT-sponsored, RDN Portfolio studies on target
900
950
1,000
1,050
1,100
1,150
1,200
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
800
1,000
1,200
1,400
1,600
1,800
2,000
2,200
2,400
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
0%
20%
40%
60%
80%
100%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
page 185
Research & Innovation
Metric Summary
UKCRD Commercial Metric 1 Under Construction UKCRD Commercial Metric 2 Under Construction
0
100
200
300
400
500
600
700
800
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
0
100
200
300
400
500
600
700
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
page 186
Research & Innovation
All active studies number
Compliance
Variance
Assurance
Actions
May-25 Target
1179 -
Updates since previous month
N/A - First report
Current issues
Growth in all research studies especially driven by growth in non-commercially
sponsored studies. Especially evident since proportionate review introduced for
lower risk/complexity studies enabling faster set up.
All research studies Open to Recruitment or in Follow- Up
Key dependencies
Indicator of overall capacity to support research
Future actions
None required
Status
Assure
900
950
1,000
1,050
1,100
1,150
1,200
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
page 187
Research & Innovation
All studies approval time
Compliance
Variance
Assurance
Actions
May-25 Target
60% 80%
Updates since previous month
N/A - First report
Current issues
Research Office staffing levels have been impacted by turnover and extended
vacancy periods, although being addressed and set to improve across second half of
2025. Imaging capacity remains a long-term issue on which CSS and R&I are
focussed.
Percentage of all research studies approved within 40 day target
Key dependencies
Full staffing of key and relatively small Research Office team
supporting approvals essential. Also indicates capacity of
Clinical Trial Pharmacy team and Imaging teams in CSS to
support new studies.
Future actions
Maintain Research Office and research critical service staffing levels. Continue
efforts to addressing staffing arrangements for paediatric MR scanning for research
studies and overall MR capacity for research.
Status
Advise
page 188
Research & Innovation
Portfolio studies recruitment number
Compliance
Variance
Assurance
Actions
May-25 Target
1272 1584
Updates since previous month
N/A - First report
Current issues
Recruitment lower in 2024/25 due to large number of vacancies and extended times
to recruit reducing delivery staff capacity. Note that whilst overall increase in
number of participants is important, a great deal of early phase experimental
medicine studies involve very small numbers of patients.
Monthly participants recruited to NIHR Portfolio-adopted research studies
Key dependencies
Related to number of research studies and recruitment
targets of those studies. Impacted by staff availability to
recruit, especially Clinical Research Nurse capacity.
Future actions
Maintain full staffing of research delivery staff to enable recruitment of eligible
patients.
Status
800
1,000
1,200
1,400
1,600
1,800
2,000
2,200
2,400
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Advise
page 189
Research & Innovation
Sponsored studies recruitment performance
Compliance
Variance
Assurance
Actions
May-25 Target
86% 80%
Updates since previous month
N/A - First report
Current issues
Data presented here is currently incomplete and actual performance is at 86%. This
is work in progress involving external data provider to be completed by end August.
MFT-sponsored, NIHR Portfolio-adopted research studies on track for recruitment to time and target
Key dependencies
This is a nationally set target by the NIHR which MFT must
meet to ensure infrastructure awards (e.g., BRC, CRF) are
paid in full. Failing the target will reduce such award income.
Future actions
Maintain focus on realistic research study methodologies, recruitment strategies
and staff capacity to quickly identify and consent participants, and monitoring
performance at senior levels in R&I.
Status
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Assure
page 190
Research & Innovation
Commercial studies approval time
Compliance
Variance
Assurance
Actions
May-25 Target
457 60
Updates since previous month
N/A - First report
Current issues
This is a nationally set metric by NIHR which is publicly available for use by
commercial sponsors and contract research organisations so they can see how sites
perform. It has only started this year and with only three months of reports (one
month in arrears) there is insufficient actual data for an SPC chart.
UKCRD Commercial Metric 1 Under Construction
Key dependencies
This metric is about approval speed for commercially
sponsored clinical trials approved at MFT each month.
Future actions
For this report: identifying and extracting accurate data from national reporting
website and constructing a hypothecated SPC chart until sufficient months of data
in place. To speed up approval: external review of set up processes took place in
May. Awaiting report recommendations to inform revisions.
Status
0
100
200
300
400
500
600
700
800
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Alert
page 191
Research & Innovation
Commercial studies first patient recruitment time
Compliance
Variance
Assurance
Actions
May-25 Target
132 30
Updates since previous month
N/A - First report
Current issues
This is a nationally set metric by NIHR which is publicly available for use by
commercial sponsors and contract research organisations so they can see how sites
perform. It has only started this year and with only three months of reports (one
month in arrears) there is insufficient actual data for an SPC chart.
UKCRD Commercial Metric 2 Under Construction
Key dependencies
This metric is about speed of recruitment of first participant
to commercially sponsored clinical trials at MFT.
Future actions
For this report: identifying and extracting accurate data from national reporting
website and constructing a hypothecated SPC chart until sufficient months of data
in place. To speed up recruitment: external review of set up processes took place in
May. Awaiting report recommendations to inform revisions.
Status
0
100
200
300
400
500
600
700
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Assure
page 192
Agenda Item 10.1
Escalation and Assurance Report
Research Innovation and Population Health Board Committee
(RIPHBC)
Report to: Board of Directors
Report from: Ashley Blom, Trust Non-Executive Director and Chair of the Committee
Date of meeting: 10/09/25
Key escalation and discussion points from the meeting
Alert
The Committee discussed a letter from NHS England received by Trusts in May 2025. The letter references
the role of research in the NHS to drive patient benefit and generate income and requests Board-level
reporting of research activity and income. New metrics have been included in the IPR since the July Board
meeting to reflect this requirement.
Advise:
The Committee received an update on the development of Population Health-related metrics for inclusion
in the IPR with work ongoing with the Digital team to collate the pertinent data. The first cut of the data
being presented at the next Committee meeting. The metrics will be:
•Missed appointments (DNAs) - Gap metrics for ethnicity and deprivation
•18 week and 40 week performance - Gap metrics for ethnicity and deprivation
•Admissions for ambulatory care sensitive conditions - Gap metrics for ethnicity and deprivation
The Committee discussed other indicators which could be monitored in order to evidence MFT’s ‘shift’ from
treatment to prevention in line with the NHS 10-year plan. The importance of including data regarding
children and young people was emphasised.
The Committee received a detailed update on delivery of the Green Plan following approval of the ‘Green
Plan 2 Net Zero 2025-30’ at the Board in May. The Green Plan Oversight Group (GPOG) continues to
develop. The Chief Executive of WTWA Clinical Group is chairing the GPOG and has appointed leads for
the 10 thematic areas of the plan. A number of grant-funded schemes were highlighted at the committee
including:
•Trafford General Hospital Decarbonisation Scheme, replacing the aged steam infrastructure, due
for completion by April 2026. included within the scheme are additional Solar PV arrays and
improved building insulation.
•Altrincham Hospital decarbonisation by April 2027 which will see the existing heating system
converted to an electrically led Air Source Heat Pump while retaining some of the existing gas
infrastructure for resilience only.
•Great British Energy Solar PV schemes at the Oxford Road Campus and the Wythenshawe Hospital
site.
•NEEF funded Solar PV arrays at North Manchester General Hospital, Cobbett House and off-
campus properties.
•Further EV charging points across the Trust estate.
page 1
The Committee noted the value of the existing staff network for sustainability (c.200 members) and asked
for further information regarding projected spend up until 2038 at a future meeting, alongside what can be
achieved without capital spend.
The Joint Chief Medical Officer updated the Committee on the ongoing engagement with GPs in
Manchester and Trafford to support population health programmes and the shift of activity from hospitals
to the community.
Two colleagues from Research and Innovation team joined the meeting to provide updates on the
Healthtech Research Centre (HRC) and the Greater Manchester Commercial Research Delivery Centre
(GM CRDC). The HRC currently has 55 projects ongoing and the Committee discussed the opportunities
to build capacity through apprenticeships, potential links to MFT’s commercial development work. The GM
CRDC was launched on the 1/4/25 with partners from primary and secondary care. The Committee
discussed links with the GM Prevention Demonstrator an emphasised the need to plan the infrastructure
required for R & I activity based on projected activity.
Assure:
Report approved by: Ashley Blom, Chair of the Committee
Agenda
Research, Innovation and Population Health Board Committee
Date: 10th September 2025
Time: 2:00-4:00pm
Location: Main Boardroom Agenda
Item
Purpose
Lead
Time
1.
Apologies for absence & confirmation of quoracy
(verbal)
Meeting admin
Chair
2.
Declaration of interest (verbal)
Meeting admin
Chair
3.
Minutes of the previous meeting (22nd May 2025) (Verbal)
Meeting admin
Chair
4.
Action Log
Discussion
Chair
5.
Matters Arising
Discussion
Chair
page 2
6.
Assurance Reporting
6.1
Strategic and Corporate Risk
Discussion
SM
7.1
Strategic aim 1: Work with partners to help people live longer, healthier lives
7.1
Population Health metrics
Discussion
SM
7.2
Progress on working with GPs and in neighbourhoods
Verbal
SM
7.3
MFT Green Plan 2025-28 updates
Discussion
RJ
8.
Strategic aim 5: Deliver world class research and innovation that improves people’s lives
8.1
NIHR HealthTech Research Centre + Commercial
Research Delivery Centre
Discussion
TF/CC
8.2
NHSE R & I reporting metrics and requirements
Discussion
IM
Committee business
9.
Escalation report
Approval
Chair
10.
Workplan Review
Meeting admin
Chair
11.
Any Other Business (verbal)
Discussion
12.
Meeting Evaluation (verbal)
Meeting admin
Chair
Date of next meeting: Wednesday 3rd December at 10:00am
page 3
page 4
Public Board of Directors
Wednesday 1 October 2025
Paper title:
Strategic Development Update
Agenda
Item
10.2
Presented by:
Tom Rafferty, Acting Chief Strategy Officer
Prepared by:
Caroline Davidson, Director of Strategy
Meetings where content has
been discussed previously
Service Strategy and Planning Management Committee
Purpose of the paper
Please check one box only:
☐ For approval
☒ For discussion
☐ For support
Executive summary / key messages for the meeting to consider
This paper outlines the following strategic developments:
• At a national level:
- Assessing Provider Capability: Guidance for NHS trust boards
- Annual Planning
• At a regional and local level:
- GMCA Strategy - Together we are Greater Manchester
- GM ICB Single Improvement Plan (SIP)
- GM Trust Provider Collaborative Priorities
- Major Trauma Centre Provision within Greater Manchester
• At MFT:
- Integrated Neighbourhood Teams
- Genomic Medicine Service Tender
- Laboratory Medicine – partnership working with Northern Care Alliance
- Community Gynaecology Service
- Respiratory Pathway Transformation Bid
Recommendation(s)
The Board of Directors is asked to:
• Note the updates in relation to strategic developments nationally, regionally and across
MFT
page 1
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐Yes (please set out in your report what action
has been taken to address this)
☒No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☐
LHL objective 2
☐
HQSC objective 1
☐
HQSC objective 2
☐
HQSC objective 3
☐
PEW objective 1
☐
PEW objective 2
☐
VfP objective 1
☐
VfP objective 2
☐
R&I objective 1
☐
R&I objective 2
☐
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks:
•
Care Quality Commission
domains
Please check all that apply
☐Safe
☐Effective
☐Responsive
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
•
Main report
1. Introduction
The purpose of this paper is to update the Board of Directors in relation to strategic issues of
relevance to MFT.
2. National Developments
2.1 Assessing Provider Capability: Guidance for NHS trust boards
NHS England has published updated guidance to support NHS trust boards in assessing their
organisational capability. This forms part of the NHS Oversight Framework (NOF) and is
aligned with expectations for integrated care systems. Trusts are asked to complete a self-
assessment and submit supporting evidence to their regional NHS England teams by 21
October 2025.
page 2
The guidance sets out six domains that NHS trust boards should use to assess their
organisational capability. These domains reflect those included in the Insightful Provider Board
guidance published in December 2024:
• strategy, leadership and planning
• quality of care
• people and culture
• access and delivery of services
• productivity and value for money
• financial performance and oversight
Each domain includes criteria that boards are expected to consider when determining whether
they can confidently self-certify. Trust Boards are encouraged to see this, not as a tick box
exercise, but as an opportunity to promote self-awareness and transparency regarding the
organisation’s capabilities, strengths, weaknesses and the challenges they face.
NHSE oversight teams will review the self-assessment and triangulate this with other
information to develop a holistic view of capability and assign a capability rating to the trust.
Possible ratings include
• Rating: Green High confidence in management.
• Rating: Amber–green Some concerns or areas that need addressing.
• Rating: Amber–red Material issue needs addressing or failure to address major issues over
time.
• Rating: Red Significant concerns arising from poor delivery, governance and other issues.
The outputs of these assessments may influence the segment to which a trust is allocated
through the NOF.
2.2 Annual Planning
NHS England has published a framework for the 2026/27 Annual Planning round. It describes
a different model of planning shifting the focus towards a rolling five-year planning horizon. As
a result, planning becoming a continuous iterative process that supports transformational
change, delivering the three shifts set out in the 10 Year Plan and taking full advantage of
breakthroughs in science and technology.
The planning process this year is split into two phases. Phase 1 runs to the end of September
is a preparatory phase establishing roles and responsibilities and undertaking the groundwork
such as capacity and demand analysis. Phase 2 runs from October to December. During this
period providers are required to develop integrated plans. These must be based on credible
assumptions and targets, deliverable within the available resources and operating environment
and align with available funding and budgetary limits.
NHS England, through their regional teams, will assure the plans during January and February
prior to implementation in April.
The intention to bring forward the planning round had been well signalled by NHS England and
preparatory work, in-line with Phase 1, has therefore been underway across MFT for some
time.
page 3
3 Regional and Local Developments
3.1 Greater Manchester Strategy 2025–35: Together we are Greater Manchester
A renewed Greater Manchester strategy ‘Together we are Greater Manchester’ was launched
in July, with a focus on growing the economy and making sure people can live well. The vision
is for a thriving city region where everyone can live a good life.
It recognises that economic and social progress go hand in hand and that Greater Manchester
is only successful if every part of the city region is successful. It aims to create the conditions
for people and businesses to succeed thus unlocking a new form of inclusive economic growth
where no one is left behind.
The plans for growing the economy and making sure everyone can live well are intended to
address wider determinants of health such as shelter, safety, mobility, opportunity and support.
The strategy sets out are seven workstreams:
• Healthy homes for all - increasing the housing supply, improving housing standards, and
addressing the challenges people face in finding and keeping a home of their own
• Safe and strong communities - consistently high performing police and fire services, cutting
crime and antisocial behaviour, tackling the underlying causes of violence by working with
young people; and Vision Zero, the strategy to eliminate deaths and life-changing injuries
on our roads by 2040.
• A transport system for a global city region - delivering the first fully integrated seamless
transport system outside London and developing a new railway linking Liverpool and
Manchester
• A clear line of sight to high-quality jobs - a transformed technical education system via the
Greater Manchester Baccalaureate (MBacc) will give young people a clear line of sight to
high-quality jobs and building people’s confidence and basic skills to enable more people to
consider moving into work, and helping residents to enter, sustain and progress in work.
• Everyday support in every neighbourhood - a network of welcoming and empowering Live
Well centres, community spaces and support offers will provide everyday support in every
neighbourhood around jobs, health, housing, debt, food, family and social support and
connection. This is the Prevention Demonstrator referred to in the NHS 10 Year Plan.
• A great place to do business - delivering homes, jobs and innovation, supporting existing
and attracting new industries. Investment will be targeted at six growth locations –
nationally significant sites with land earmarked and shovel-ready.
• Digitally connected places and people - Greater Manchester will be a fully digitally enabled
region, helping more people to get online and working to remove barriers like connectivity,
confidence, skills, affordability and accessibility and ramping up responsible AI adoption,
working with Government, industry and academia to be the place to come to test and grow
AI businesses.
The GM strategy is one of the key documents against which the MFT strategy has been tested
as part of the strategy refresh process.
3.2 GM Trust Provider Collaborative Priorities
Earlier this year the Greater Manchester Trust Provider Collaborative (TPC) agreed a revised
set of 8 priorities to be delivered over the next 3 years. They are:
page 4
Transform corporate services
• Transforming people services (1): deliver digitally enabled people services at the level
where they will benefit the most from scale and have the greatest impact, focusing on
recruitment, occupational health, implementation of chatbots and a consistent approach to
the electronic staff record.
• Transforming financial transactional services (Ledger (2) and Procurement (3)): Deliver a
single ledger system and service across all GM Trusts. Establish an integrated service
delivery model for procurement via a phased implementation approach to service integration
• Transforming other transactional corporate services (4): deliver collaborative approaches on
cluster and GM levels as appropriate in areas such as: BI, legal, governance and risk,
estates & facilities
Innovation to support delivery of clinical services
• Pathology (5): Single collaborative model, delivered from appropriate number of sites across
GM relating to demand with a residual service at all sites to support urgent requirements
• Single queue approaches (6): GM wide approach to scaling up the implementation of single
queue diagnostics
• Digital convergence and interoperability (7): deliver digital convergence and enhanced intra
operability across GM and at cluster level
• Aseptics hub (8): Single service operating as a hub and spoke model for the whole of GM.
Trusts have been asked to ensure that these priorities are reflected in their local plans and
there are mechanisms in place to oversee progress. The TPC priorities have been reflected in
the refreshed actions in the MFT strategy.
3.3 GM ICB Single Improvement Plan (SIP)
In July 2024 Greater Manchester ICB formally accepted undertakings agreed with NHS
England. The ICB developed a Single Improvement Plan (SIP) that addressed all of the issues
highlighted in the undertakings.
In March 25 the ICB reported that they had achieved compliance with 28 of the 36
undertakings and were making progress against the remaining eight. In July it was reported
that compliance had been achieved against two more undertakings. They are as follows:
• Leadership and governance: Following the independent Carnall Farrar review, NHS GM
implemented system-wide improvements that NHS England has now formally signed off as
compliant.
• Financial planning: NHS England has accepted GM Integrated Care Partnership's financial
plan submission for 2025/26, which has achieved £335m of savings reducing the
overspend to £200m.
The focus will now turn to four remaining undertakings and a further review will be carried out
regarding progress against these at the end of Quarter 2:
• Delivering the 2025/26 NHS Greater Manchester financial plan
• Developing the medium-term financial plan with the aim of ensuring NHS GM enters
2026/27 in a “break-even” position
• Continuing to resolve outstanding historical commissioning arrangements
• Sustaining improvements in patient wait times.
page 5
3.1 Major Trauma Centre Provision within Greater Manchester
Work continues with GM Integrated Care Board (ICB) and Northern Care Alliance NHS
Foundation Trust (NCA) colleagues to ensure the optimal provision of major trauma services
across GM. The ICB wishes to undertake further work on wider financial impacts of the options,
clinical outcomes, other systems’ approaches to compliance with the national service
specification and wider consequences of any service change. A revised timetable for this work
means that a decision is expected in November 2025.
4 MFT Strategic Developments
4.1 Integrated Neighbourhood Teams
The development of Integrated Neighbourhood teams is an area in which Greater Manchester
has historically led nationally, and a key part of the 10 Year Plan. Integrated Neighbourhood
Teams have been established across Manchester and Trafford, but in different ways.
In Trafford a pilot in the Central locality pilot has undergone initial evaluation and identified
opportunities for greater primary care and mental health involvement. A timetable for roll out
across the other three Trafford localities will be agreed in October.
In Manchester the plans for the further development of the way in which the LCO works are to
be shared across the partners in September to jointly agree how they should be taken forward.
Applications to the National Neighbourhood Improvement Programme were made with partners
in both Manchester and Trafford but were not successful. The work of partners over many years
mean that the Local Care Organisations and our wider neighbourhood working is recognised
nationally and work with continue as a system to further develop our neighbourhood models in
Manchester and Trafford.
4.2 Genomic Medicine Service Tender
NHS England has launched a tender process to establish regional Genomic Medicine Services
across the country. These regional services will bring together and replace the current regional
Genomic Laboratory Hubs and Genomic Medicine Service Alliances and play a key role in
mainstreaming genomic medicine across the NHS, as signalled in the 10 Year Plan.
MFT is actively engaging with NHS England through this process. A decision on contract award
is expected later this year with the new services established from April 2026.
4.3 Laboratory Medicine – partnership working with Northern Care Alliance
A collaborative approach to pathology services has been identified as a priority within the
Greater Manchester Trust Provider Collaborative. Together with colleagues from NCA a
proposal is being developed to set out how, by working more closely together, we can improve
laboratory services, enhance efficiency and quality and achieve greater financial and workforce
sustainability.
Outline proposals for the next phases of development for the consolidation have been
developed. The focus is on delivering changes that will deliver benefits in the short-term whilst
continuing to build the case for a broader consolidation of services.
page 6
4.4 Community Gynaecology Service
The ICB has, in principle, approved funding for a community gynaecology service across
Manchester and Trafford. MFT teams are working closely with GP colleagues to agree the design
and implementation of the service which will help to reduce waiting times for services across
MFT. This initiative is not only a key enabler in delivery of our plan for 25/26, it is also a good
example of the ‘shift’ of care into the community through partnership working.
4.5 Respiratory Pathway Transformation Bid
The MFT Respiratory team and local primary care partners have been successful in a bid to a
national innovation programme to transform end-to-end respiratory pathways. The proposed
model is designed to shift care from hospital to community settings. Key features include early
identification of respiratory conditions using digital tools, strengthening community-based
multidisciplinary teams, and establishing one-stop clinics in primary care to support admission
avoidance and discharge planning. The plan will see new services established this winter to
help people to stay healthy in the community.
5 Recommendations
The Board of Directors is asked to note the updates in relation to strategic developments
nationally and regionally and the key MFT strategic programmes of work.
page 7
Public Board of Directors
Wednesday 1st October 2025
Paper title:
MFT Strategy Review
Agenda
Item
10.3
Presented by:
Tom Rafferty, Acting Chief Strategy Officer
Prepared by:
Caroline Davidson, Director of Strategy
Meetings where content has
been discussed previously
n/a
Purpose of the paper
Please check one box only:
☒ For approval
☐ For discussion
☐ For support
Executive summary / key messages for the meeting to consider
Following the approval of the MFT Trust Strategy Where Excellence Meets Compassion in March 2024, a
full refresh of the strategy has been brought forward to align with the newly published 10-Year Health
Plan, the Life Sciences Sector Plan and the recent 10-year Greater Manchester Strategy. This ensures
MFT’s 2026/27 operational and multi-year strategic plans reflect national priorities and system-level
expectations.
In line with the national planning framework to deliver the NHS 10YP, the MFT strategy refresh process
was expedited and delivered in three phases:
1. Engagement (July–August 2025): Broad input was gathered via workshops, executive meetings,
questionnaires, and a Council of Governors session.
2. Consultation (September 2025): Strategy reference groups and wider teams reviewed proposed
changes.
3. Approvals (from 19 September 2025): Final proposals presented to TLTC and Board of Directors
for support.
MFT’s current strategy aligns well with these national directions, particularly in areas such as community
care, genomics, digital innovation, and research. However, feedback from internal and external
stakeholders highlighted opportunities to strengthen focus on prevention, digital transformation, and
patient experience.
The Board of Directors are asked to support the proposed changes to the strategy, initially in draft form.
This can then feed into the MFT internal planning guidance and support detailed planning required to
submit a 26/27 operational plan in December 2025. It is proposed that a final version of the refreshed
strategy is presented to the Board in January.
page 1
The key proposed changes to the strategy are outlined in full in this paper, and in Appendix B. In
summary, these include:
•Mission and Aims: No change.
•Objectives: Three updates under Aim 1 and Aim 5 to emphasise neighbourhood-level care,
system-wide collaboration, and the opportunity to lead the way in digital improvements.
•Strategic Actions: Reduced from 87 to 61, with 22 retained, 39 amended, and 24 removed.
Updates reflect new programmes such as GM Prevention Demonstrator and Care on Time, and
increased emphasis on digital, research, and innovation.
In addition, draft priorities for 2026/27 are presented to the Board for support. Each year, a smaller
number of priorities are identified, with a particular focus on their delivery over the coming 12 months. 16
priorities are proposed for 26/27 with new priorities including AI adoption, digital solutions for community
services, and enhanced patient experience frameworks.
Recommendations:
The Board of Directors is asked to:
a. Consider the proposed changes to the strategy
b. Consider the proposed changes to the MFT priorities for 26/27 and agree that they should be
used as the basis for annual planning for 26/27
c. Note that a final version of a refreshed strategy and priorities for 26/27 will be brought to the
Board in January for approval alongside the 26/27 Annual Plan.
Do the recommendations in this paper have
any impact upon the requirements of the
protected groups identified by the Equality Act?
☐Yes (please set out in your report what action has
been taken to address this)
☒No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic objectives (see
key overleaf)
LHL objective 1
☐
LHL objective 2
☐
HQSC objective 1
☐
HQSC objective 2
☐
HQSC objective 3
☐
PEW objective 1
☐
PEW objective 2
☐
VfP objective 1
☐
VfP objective 2
☐
R&I objective 1
☐
page 2
R&I objective 2
☐
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following strategic,
corporate or operational risks:
•
Care Quality Commission
domains
Please check all that apply
☐ Safe
☐ Effective
☐ Responsive
☐ Caring
☒ Well-Led
Compliance & regulatory
implications
The following compliance and regulatory implications have been
identified as a result of the work outlined in this report:
• n/a
Main report
1. Introduction and background
The MFT Trust strategy Where Excellence Meets Compassion was approved by the Board of Directors in
March 2024, following an extensive development and engagement process. The strategy outlines the
mission, aims and objectives for the Trust for the next five years, as well as identifying the key strategic
actions to deliver these aims and objectives.
The strategy outlines that the strategic actions will be reviewed each year as part of the annual planning
process and formally refreshed after two years so that our strategy remains up to date and relevant.
However, following the launch of the NHS 10-year plan (10YP) and the Life Sciences Sector plan in July
2025, it was decided to bring the full refresh forward slightly to ensure that our 2026/27 operational plan and
multi-year strategic plan are in line with national direction.
1.1. NHS 10 Year plan
The NHS 10 year plan: Fit for the Future was published in July 2025 and outlines national ambitions for
healthcare services in over the next decade. The plan seizes the opportunities provided by new
technologies, medicines, and innovations to deliver better care for all patients – wherever they live and
whatever they earn – and better value for taxpayers.
The plan identifies three big shifts to how the NHS works:
• From hospital to community: more care will be available on people’s doorsteps and in their homes
• From analogue to digital: new technology will liberate staff from admin and allow people to
manage their care as easily as they bank or shop online
• From sickness to prevention: we’ll reach patients earlier and make the healthy choice the easy
choice
page 3
It also describes a range of other changes that will underpin these shifts:
• A new operating model
• Greater transparency
• A new workforce model with staff aligned with the future direction of reform
• A reshaped innovation strategy
• A different approach to NHS finances.
1.2. Life Sciences Sector plan
The Life Sciences Sector Plan was also published in July 2025, developed alongside the 10 Year Health
Plan and Industrial Strategy, the plan positions life sciences as central to the UK’s approach to modernising
healthcare and delivering sustainable economic growth.
The Life Sciences Sector Plan is built around three strategic pillars:
• Enabling world-class research and development, strengthening the UK’s global leadership in
science and discovery.
• Making the UK the best place to start, scale and invest, supporting domestic companies and
attracting international capital.
• Driving health innovation and NHS reform, embedding innovation into the NHS to improve
outcomes, reduce pressure, and cut waiting times.
To achieve these pillars, six key actions backed by over £2 billion in government funding during this
Spending Review period have been announced:
• Health data infrastructure, up to £600 million to establish the Health Data Research Service,
enabling secure, efficient use of health data to support research and innovation.
• Clinical trials reform, cutting unnecessary bureaucracy to improve trial access, accelerate
approvals, and embed research more effectively in the NHS.
• Manufacturing investment, up to £520 million to scale up UK-based manufacturing of medicines
and medical technologies, supporting security of supply and job creation.
• Regulatory reform, strengthening the capacity of the MHRA to support faster approvals and help
clinicians access proven, safe innovations sooner.
• Adoption pathways, launching a new NHS ‘innovator passport’ to enable earlier, system-wide
rollout of effective tools, such as AI diagnostics and digital health devices.
• Support for scaling companies, targeted support to help high-potential firms grow and remain in
the UK, with a commitment to securing at least one major partnership each year.
page 4
1.3. Greater Manchester Strategy 2025-2035
A renewed Greater Manchester strategy ‘Together we are Greater Manchester’ was launched over the
summer, with a focus on growing the local economy and supporting people to live well, recognising that
economic and social progress go hand-in-hand. The strategy aims to create the conditions for people
and businesses to succeed, unlocking a new form of inclusive economic growth. The strategy has a
particular focus on housing, community safety, employment, transport, health and wellbeing.
The GM Live Well programme is an important part of the strategy which pledges to provide people with
access to one-stop-shops providing practical help on housing and debt, for example. This is part of a
commitment to reduce inequalities which features alongside pledges to reduce smoking, increase
activity and deliver year-on-year improvements in NHS waiting time standards.
• The strategy prioritises shifting from crisis response to prevention, investing in the “foundations
of life” such as good homes, safe communities, mobility, opportunity, and everyday support.
• There is a strong commitment to tackling health inequalities, with a focus on early intervention,
community-led health and care, and supporting people to live well at every stage of life.
• The “Live Well” model will embed everyday support in every neighbourhood, combining public
services with voluntary and community organisations to provide wraparound help on health,
housing, employment, and wellbeing.
• The is a commitment to delivering key NHS waiting time standards.
• There is a focus on healthy homes (including retrofitting for energy efficiency), safe and inclusive
neighbourhoods, and access to green spaces, all recognised as key determinants of health.
• The strategy also commits to supporting children and young people’s wellbeing, improving
mental health, and ensuring older people can age well.
As a provider of health and care, a large employer and contributor to the life sciences sector, MFT has
an important contribution to make in supporting the delivery of the GM strategy.
1.4. Alignment with the MFT strategy
There is already good alignment with the MFT strategy and these two core national strategies. There is
explicit alignment in our ambitions to:
• Support people in the community
• Target the causes of ill health
• Provide excellent patient experience
• Lead the way in relation to expansion of genomics and precision medicine
• Support and develop our staff
• Improve productivity, performance and value for money
• Develop our digital infrastructure and investing in digital leadership and innovation
• Apply research and innovation to improve the people’s health
page 5
However, there are areas where our strategy could go further to deliver these national strategies:
• Delivering more services in the community and in people’s own homes
• Increasing our prevention work
• Increasing the prominence of our digital innovation and development work
• Enhancing the way we capture and use patient experience, engagement and feedback
1.5. National multi-year planning framework
The national planning framework that accompanies the NHS 10YP was published in August 2025 and
outlines a requirement for NHS provider Trusts to develop deliverable, credible, integrated five-year plans
which demonstrate financial stability in the medium term as well as delivering national priorities, and aligned
to system level plans.
MFT’s multiyear plan will be submitted in December 2025, and therefore there was a need to develop an
expedited process to review and refresh the Trust strategy by October 2025 to allow strategic guidance to
be developed which will support detailed operational delivery plans.
The purpose of this paper is to provide an overview of the process taken to refresh the strategy and sets out
proposed changes to our MFT strategy and annual planning priorities for 26/27
2. Process
The process to review and refresh the strategy has been undertaken in three phases.
Due to planning timescales, we need to have defined any changes to our strategy by October 2025 to
inform the detailed operational plans to deliver our strategy. Due to these tight timescales the development
and engagement process could not mirror the extensive engagement undertaken to develop the strategy
initially, and some phases have had to be delivered concurrently. Despite this, the limited engagement has
still provided valuable insights to support the refresh.
• Engagement: The first phase (July-August 2025) involved seeking views from as wide a range of
people as possible on what the 10YP and Life Sciences Sector plan means for MFT and how we
should respond. We used various mechanisms which included internal MFT workshops using the
TLTC and STAG meetings, 1-2-1 meetings with Executives, Clinical Group Chief Executives and
Trust leaders, and questionnaires to engage with staff and members. A bespoke session was also
held for the Council of Governors. This phase completed on 30th August 25. Based on the feedback
Phase 1 - Engagement
July- August 2025
Phase 2 - Consutlation
September 2025
Phase 3 - Approvals
September- October 2025
page 6
that we received we have developed of a set of proposed changes to the strategy and suggested
priorities for 2026/27.
• Consultation: The second phase commenced on 3rd September 2025. During this phase we have
consulting on proposed changes. We have re-established the strategy reference groups to consult
with staff, clinical and academic stakeholders, patient representative groups and external system
partners. Recognising the tight timescales, Clinical Groups and Corporate teams have also asked to
seek feedback from the wider teams through existing forums and mechanisms.
• Approvals: This third and final phase commenced on 19th September 2025. The strategy refresh
proposals have been presented to TLTC and StAG. The final set of proposed changes are outlined
in this paper, seeking formal approval. This will then inform the Trust’s developing multi-year plan
submission 2026-2031.
It should be noted that we will continue to work with the Board of Directors to review the strategy, beyond
October, but agreement on the proposed changes is needed now to provide direction for detailed 26/27
operational planning.
2.1. Summary of feedback from the staff and member survey
The view that MFT’s strategy is already well aligned to the NHS 10YP was reinforced by the feedback from
the phase one engagement exercises.
Specific feedback was that the key themes that MFT needs to address are:
• Focusing on preventing illness
• Bringing care closer to home
• Making systems work together
The members feedback also supported greater involvement of patients in service design and the staff
feedback prioritised training, particularly in the use of new technology.
2.2. Summary of feedback from reference group meetings
Further feedback from the three meetings of the reference groups, who reviewed our proposed changes,
suggested that we should:
• Ensure that 26/27 priorities capture our digital, research, and innovation ambition in line with the
specialist expertise, opportunities and resources that exist at MFT, and enable staff capacity and
skills relating to this – recognising MFT’s role as a teaching hospital
• System partnerships are key to realising our strategy and therefore our aims, objectives and
priorities must align to wider system plans, including the Live Well programme.
• Consider the language in our strategy aims and objectives, being clear about MFT’s role in
delivering system wide ambitions or facilitating delivery.
page 7
• Carefully consider how we will engage with patients and public to ensure it is inclusive and effective,
including dispersed and marginalised communities.
• Ensure that our objectives for prevention and moving services into the community are positively
framed in relation to patient outcomes and benefits, such as living well rather than preventing ill
health.
3. Proposed changes to our MFT strategy
The section below summarises the proposed changes to the objectives and actions in our strategy.
3.1. Mission statement and Aims
There are no proposed changes to our mission statement or five strategic aims. All the major themes in the
10YP and Life Sciences Sector plan are broadly covered by our five aims. Additionally, continuing with the
existing aims helps consistency of messaging and supporting our staff and partners to engage with the
strategy.
3.2. Objectives
There are two proposed changes to our objectives, specifically those relating to Aim 1 and Aim 5:
Current objective
Proposed objective
2. We will improve the experience
of children and adults with long-
term conditions, joining up primary
care, community and hospital
services so people are cared for in
the most appropriate place
2. We will work with partners to
redesign services so that more care is
delivered in people’s homes and
neighbourhoods.
page 8
11. We will apply research and
innovation including digital
technology and artificial intelligence,
to improve people’s health and the
services we provide.
11. We will apply research and
innovation, building on our position as
a digital leader and embracing new
technology such as artificial intelligence,
to improve people’s health and
transform the services we provide.
Taken together with Aim 1, the focus of which is on prevention, this better reflects the ‘shifts’ from the 10
Year Plan and is explicit about delivering more care at a neighbourhood level and working as part of the
wider GM system to support delivery of these aims – two significant themes from our engagement and
consultation process.
Additionally, the update to objective eleven emphasizes the opportunity that MFT has to maximise digital
innovation due to the level of maturity and expertise already within the Trust.
It is proposed that the other nine objectives remain as they are currently, as the wider feedback is well
reflected in the existing wording:
We will work with partners to target the biggest causes of illness and inequalities,
supporting people to live well from birth through to the end of their lives, reducing their
need for healthcare services.
We will provide safe, integrated, local services, diagnosing and treating people quickly,
giving people an excellent experience wherever they are treated.
We will strengthen our specialised services and support the adoption of genomics and
precision medicine.
We will continue to deliver the benefits that come with our breadth and scale, using our
unique range of services to improve outcomes, address inequalities and deliver value for
money.
We will make sure that our staff feel valued and supported by listening well and responding
to their feedback. We will improve the experience of all our staff experience by embracing
diversity and fairness.
We will offer new ways for people to start their career in healthcare. Everyone at MFT will
have opportunities to develop new skills and build their careers here.
We will achieve financial sustainability, increasing our productivity through continuous
improvement and the effective management of public money.
We will deliver value through our estate and digital infrastructure, developing existing and
new strategic partnerships.
We will strengthen our delivery of world-class research and innovation by developing our
infrastructure and supporting staff, patients and our communities to take part.
3.3. Strategic Actions
page 9
Much of the feedback received through the engagement and consultation phases was aimed at the
specifics of how we deliver our strategy – as such, our 87 strategic actions have been through a review with
the lead executive director. This review has reduced our actions down to 64. The review determined
whether actions should:
A. Remain unchanged where work is ongoing and remains relevant. In total, 22 actions remain
unchanged, examples of this include:
• Maintain our regional centres, providing leadership and support across Greater Manchester
and beyond in areas such as Children’s, Ophthalmology and Respiratory services.
• Improve patient outcomes and reduce the burden of antimicrobial resistance by promoting
the prompt switching of intravenous to oral antibiotics and reducing the use of 'watch and
reserve' antimicrobials across MFT
• Help to create protected time for people across the organisation to pursue external
funding opportunities and carry out research and innovation activities.
B. Be amended/renewed, to better reflect the 10 Year Health Plan or to reflect programmes of work
established since the strategy was originally approved. 40 actions have been amended/renewed,
examples of this include:
• Support the delivery of the GM Prevention Demonstrator programme. Increase number
of public health interventions that we deliver across MFT to both address the three major
lifestyle drivers of illness - smoking, poor diet and lack of activity - and wider social
determinants of health by supporting access to services for housing, debt, benefits,
employment etc
• Deliver the Care on Time programme. Transform our outpatient services, elective and
diagnostic pathways, supported by digital innovation. Reduce waiting times and ensure that -
when people are waiting - they are waiting safely
• Build a patient experience framework to improve delivery of person-centred services,
strengthening the way we obtain feedback and our approaches to co-production. Build on
our relationships with external groups, including through our VCSE leaders forum, to ensure
broader community involvement.
• Deliver our Digital Strategic Delivery Plan, ensuring that MFT is a digitally connected,
data-driven organisation. Support the public and staff to use digital innovations to improve
their health and working lives.
C. Be removed, primarily where work has been completed or is expected to be complete by year-end,
or where a renewed action now captures it. 25 actions have been removed, for example:
• Increase the number of patient safety representatives attending key meetings, and the
number of safety champions we have in post across the organisation (due to complete in
25/26)
page 10
• Develop an infrastructure plan for community services, covering both estates and digital.
(estates and digital plans developed during 24/25)
• Carry out post-implementation reviews on all major projects and investments to ensure that
the benefits forecast in business cases are delivered. (process now in place through
Finance and Commercial Management Committee)
• Formalise our approach to identifying and adopting proven innovations that will help us to
address the challenges faced by our communities and our organisation. (Innovative
Technology Adoption Pipeline (iTAP) launched)
D. 2 new actions have been added:
• Implement a robust quality system that integrates safety, patient experience, and
outcomes to drive continuous improvement.
• Refresh the Trust’s medium term financial and capital plans to support our strategic
ambitions, actively responding to new financial flows and payment mechanisms in support of
the Trusts clinical and population health strategies.
The full list of the proposed changes to the actions on our strategy can be found in Appendix B.
It should be noted that there is an ongoing piece of work within R&I to develop plans for future growth.
Further changes to R&I actions are anticipated following the conclusion of this work in the coming months.
3.4. Critical enablers
Through the engagement, colleagues fed back that there were some important themes that did not come
through strongly enough in our aims and objectives, in particular our need to work with partners and our
ambition around digital innovation. This may be because these – and other themes – are spread across a
number of our objectives and actions and therefore lack prominence.
It is therefore proposed that the following are added to our strategy as critical enablers:
Equity
We will seek to address inequalities in all that we do, working with partners to
close inequalities in our communities, improving equity of access and outcomes in
our services and research, and treating the people who work and learn at MFT
equitably.
Digital Innovation
We will capitalise on our leading digital capabilities, and continue to develop our
digital infrastructure, to transform the way we deliver services, grow our research
and innovation activities and make better use of our resources.
Improvement
We will embed an approach to continuous improvement across the organisation
ensuring that everyone has the skills and data that they need to improve our
services.
page 11
Partnership and
collaboration
We cannot deliver our strategy on our own, and we have an important role to play
in delivering wider system plans. We will work together with our communities and
the people that use our services; with primary care, Local Authorities, the VCSFE
sector and colleagues across health and care; with the people who work and train
at MFT and their representatives; with partner organisations and industry.
4. MFT Priorities for 26/27
The Trust priorities for 26/27 have been informed by the engagement and consultation exercise and
represent the key strategic priorities for next year. Some priorities have been carried over from 25/26, or
amended to reflect the current phase in a programme - Appendix C provides a comparator for reference.
The below table outlines the proposed priorities:
Support delivery of the GM Live Well programme. Increase public health interventions
delivered across MFT to address both the major lifestyle drivers of illness and social
determinants of health.
Increase the range of integrated services offered to people of all ages in the community,
transforming outpatient services and moving care out of a hospital setting where possible.
Deliver our integrated neighbourhood health plans – and develop the role of the Local Care
Organisations – through place-based partnerships in Trafford and Manchester.
Strengthen our culture of patient safety by empowering and supporting staff with human
factors training, encouraging psychological safety and compassionate leadership.
Build a patient and carer experience framework to improve delivery of person-centred
services, strengthening the way we obtain feedback and our approaches to co-production
Continue to reduce waiting times – for adults and children – in a way that is safe and
equitable.
Continue the development of Genomic Medicine across MFT and beyond, mainstreaming
Genomics and building on our position as a national leader.
Embed our new, clinically-led operating model, building an inclusive, engaged organisation
where everyone has a sense of value and belonging.
Enable people to develop the skills needed to deliver high quality care in the future, including
digital and improvement skills. Ensure we are data-driven, providing people with the
information they need to improve their services.
Enable teams to create workplaces where people feel safe and well.
Improve our productivity and increase commercial income to deliver our financial plan.
Take forward plans to implement a digital solution for community services and to support
digital integration with the wider system.
Progress plans to redevelop the NMGH campus, delivering a refreshed Outline Business
Case whilst making best use of existing estate across MFT.
Make it easier for people to take part in research and innovation, growing the volume and
value of our R&I activity.
Improve the strategic alignment between MFT and our academic and industry partners.
page 12
Develop our digital infrastructure and embrace technology, including AI and wearables, to
drive new models of care, improve quality and productivity across the organisation.
These new priorities reflect the feedback from the engagement and consultation process, particularly
around:
• delivery of neighbourhood health plans and the work to develop our LCOs.
• the development of digital skill among staff, in-line with staff feedback and the Digital strategic
delivery plan (SDP).
• the use of AI and automation to reflect planned work in this space and the Digital SDP
The net result is an increase in the number of priorities for next year from 14 to 16. It is proposed that these
are adopted as the basis for planning for 2026/27.
5. Next Steps
This paper sets out the proposed changes to our strategic aims, objectives and actions as well as the
proposed priorities for 26/27.
The Board of Directors are asked to support these changes to inform detailed internal MFT annual planning
guidance for 26/27, providing direction to Clinical Groups SLTS and Corporate Teams. This will also
support ongoing board approval processes as the Trust level plan develops.
If supported, further engagement is planned to complement the limited engagement achieved in this
expedited process, which may result in further changes – notably further engagement with the Board and
also with system partners as they develop their own multiyear plans over the coming months.
A further iteration of the proposed changes following wider engagement will be presented to the Board of
Directors in January 2026, along with our 26/27 annual plan for approval.
6. Actions/recommendations
The Board of Directors is asked to:
a. Support the proposed changes to the MFT priorities for 26/27 and agree that they should be used as
the basis for annual planning for 26/27.
b. Note that a refreshed strategy and priorities for 26/27 will be presented to the Board for approval
alongside the 26/27 Annual Plan in January 2026.
page 13
Appendix A – List of actions
Strategic Aim
Objective
Original Action
Revised Action
1. Work with partners to
help people live longer,
healthier lives
1. We will work with
partners to target the
biggest causes of
illness and inequalities,
supporting people to
live well from birth
through to the end of
their lives, reducing
their need for
healthcare services.
Improve equity, access and the quality of care in our
maternity services by developing personal care pathways
for women and families who we know have poorer
outcomes. For example, black and Asian women, those
from other minority ethnic backgrounds and from more
deprived areas.
Develop personalised maternity care pathways to
improve equity, access, and outcomes for women at
higher risk, including those from minority ethnic
backgrounds and deprived areas.
Play a leading role in delivering joined-up physical and
mental health services for families, children and young
people, working with Local Authority partners to develop
and deliver integrated plans.
Work with partners across Manchester and Trafford -
including primary care and Local Authorities and VCSFE
colleagues - to further develop all-age neighbourhood
health services through our Local Care Organisations,
delivering more services in the community with a focus
on prevention. Support the GM Live Well Programme.
Address health inequalities by working with under-served
communities to improve things like bowel cancer
screening, hypertension and diabetes services, fully
embedding our Integrated Neighbourhood Teams and
their work with primary care, Local Authority and VCSE
colleagues. Extend this approach to asthma in children
and young people, and to other screening and
immunisation programmes.
Address health inequalities by working with under-served
communities to improve things like oral health, bowel
cancer screening, hypertension and diabetes services.
Extend this approach to asthma in children and young
people, and to other screening and immunisation
programmes.
Support earlier detection and better outcomes by
improving the uptake of our screening programmes –
such as Targeted Lung Health Checks – in an equitable
way. Ensure that the right diagnostic and treatment
capacity is in place to support people who need
subsequent care.
Deliver our Cancer Strategic Delivery Plan. Develop our
services and pathways to deliver equitable access and
outcomes and personalised care.
Increase the number of public health interventions that
we deliver across MFT, such as referrals to smoking
cessation and other preventative services, making every
contact count.
Increase number of public health interventions that we
deliver across MFT to both address the three major
lifestyle drivers of illness - smoking, poor diet and lack of
activity - and wider social determinants of health by
supporting access to services for housing, debt, benefits,
employment etc.
Improve the identification of people with frailty through
better links with Neighbourhood Teams so that we can
improve the support we provide. Support older people
accessing our services to live a full and healthy life by
offering improved information and educational resources.
Deliver the Care Closer to Home programme. Support
patients in the most appropriate care setting, improving
the way that people move through community and
hospital services, reducing days away from home.
Make sure that people who tend to experience poorer
outcomes are appropriately prioritised on our waiting lists,
using public health intelligence to inform clinical
prioritisation.
Improve the way in which we collect and use
demographic data, and data on inequalities, to inform our
planning, decision-making and service improvement.
Embed the Green Plan among the MFT workforce,
continuing to reduce the carbon footprint per patient
contact through the full decommissioning of nitrous oxide
manifolds at our main hospital sites, and engage 10% of
the workforce through sustainability communications and
training.
Embed the Green Plan among the MFT workforce,
continuing to reduce the carbon footprint per patient
contact through the full decommissioning of nitrous oxide
manifolds at our main hospital sites, and engage 10% of
the workforce through sustainability communications and
training.
2. We will improve the
experience of children
and adults with long-
term conditions, joining-
up primary care,
community and hospital
services so that people
are cared for in the
most appropriate place.
Work with commissioners and locality partners to roll out
our Hospital@Home services for adults and children, and
to demonstrate how these services can improve care and
reduce demand on local services by delivering care and
support in people's own homes.
Improve the identification of patients with multiple long-
term conditions so that we can better co-ordinate
appointments and care across multiple specialties,
providing a more personalised experience.
Improve the care of patients with long term conditions,
such as cardiovascular, respiratory, diabetes, ensuring
the right services and support is available for people in
the right place and from the right professionals.
Work with colleagues in primary care to develop and
implement plans to improve the interface with MFT
services, improving the experience for patients and
reducing steps that may contribute to delays.
Work with colleagues in primary care, social care and the
VCSFE to develop and implement plans to improve the
interface with MFT services, improving the experience for
patients and reducing steps that may contribute to
delays.
Work with commissioners and locality partners to ensure
that access to services across our communities is
consistent, whilst being tailored to local need, embedding
a core community health offer that fits with wider
community services.
Work with commissioners and locality partners to ensure
that access to services across our communities is
consistent, whilst being tailored to local need.
page 14
Strategic Aim
Objective
Original Action
Revised Action
Offer a greater range of tests and pathways to people
closer to their home by fully establishing our Community
Diagnostic Centres.
Build on the establishment of our Community Diagnostic
Centres to support the transformation of pathways and
support the delivery of more care at a neighbourhood
level.
Build on research and innovation work to implement
wearable and implanted devices to monitor patients with
long-term conditions such as mental health, respiratory,
heart disease and diabetes.
Develop a programme for the adoption of wearable
technology to support the adoption of new models of
care.
2. Provide high quality,
safe care with excellent
outcomes and
experience
3. We will provide safe,
integrated, local
services, diagnosing
and treating people
quickly, giving people
an excellent experience
wherever they are
treated.
Improve the way that we routinely involve people with
decisions about how we plan and deliver our services by
establishing a network of patient and communities groups
across the organisation. Build on our relationships with
external groups, including through our VCSE leaders
forum, to ensure broader community involvement.
Build a patient experience framework to improve delivery
of person-centred services, strengthening the way we
obtain feedback and our approaches to co-production.
Build on our relationships with external groups, including
through our VCSE leaders forum, to ensure broader
community involvement.
Increase the number of patient safety representatives
attending key meetings, and the number of safety
champions we have in post across the organisation.
Improve patient experience through a focus on better
communication, food and hydration and pain relief.
Ensure that every patient-facing team at MFT has a
process through which they analyse feedback from
people that use our services and make changes to
improve the service they offer.
Ensure that every patient-facing team at MFT has a
process through which they analyse real-time feedback
from people that use our services and make changes to
improve the service they offer.
Reduce episodes of avoidable harm in our hospitals
through a focus on preventing pressure ulcers, falls and
missed doses of critical medicines.
Reduce episodes of avoidable harm in our hospitals
through a focus on preventing pressure ulcers, falls and
missed doses of critical medicines.
Improve patient outcomes and reduce the burden of
antimicrobial resistance by promoting the prompt
switching of intravenous to oral antibiotics and reducing
the use of 'watch and reserve' antimicrobials across MFT.
Improve patient outcomes and reduce the burden of
antimicrobial resistance by promoting the prompt
switching of intravenous to oral antibiotics and reducing
the use of 'watch and reserve' antimicrobials across MFT.
Continue to review harm to patients waiting for planned
care and use the learning to identify and appropriately
prioritise patients on our waiting lists with known risk
factors.
Reduce the time that people wait for diagnostic tests and
for these tests to be reviewed by a clinician by better
balancing our capacity with demand across MFT,
improving our booking and scheduling processes and the
use of technology.
Make the best use of our outpatient capacity by
supporting attendance, and maximising advice and
guidance services, virtual clinics and patient-initiated
follow-up.
Reduce waiting times for planned treatment through
improved utilisation and productivity of our theatre lists,
allowing us to treat more patients within MFT. Complete
the establishment of the Trafford Elective Hub and roll-
out good practice on patient pathways across other MFT
sites and beyond.
Deliver the Care on Time programme. Transform our
outpatient services, elective and diagnostic pathways,
supported by digital innovation. Reduce waiting times
equitably and ensure that - when people are waiting -
they are waiting safely.
Reduce the amount of time people stay in our hospitals
and waiting times for urgent care, working with partners
on key programmes to improve flow through hospital and
community services.
n/a
Implement a robust quality system that integrates safety,
patient experience, and outcomes to drive continuous
improvement.
4. We will strengthen
our specialised services
and support the
adoption of genomics
and precision medicine.
Help to deliver high quality, sustainable regional services
by centralising care in some areas, for example, in
Cardiac Surgery and Vascular Surgery.
Help to deliver high quality, sustainable regional services
by centralising care in some areas, for example, in
Cardiac Surgery and Vascular Surgery.
Use the range and scale of services that we offer to
develop high quality specialised services, for example, in
Cancer Surgery and Transplant services.
Use the range and scale of services that we offer to
develop high quality specialised services, for example, in
Cancer Surgery and Transplant services.
Maintain our regional centres, providing leadership and
support across Greater Manchester and beyond in areas
such as Children’s, Ophthalmology and Respiratory
services.
Maintain our regional centres, providing leadership and
support across Greater Manchester and beyond in areas
such as Children’s, Ophthalmology and Respiratory
services.
page 15
Strategic Aim
Objective
Original Action
Revised Action
Increase adoption of genomic medicine across
specialties at MFT, bringing genomic testing earlier in
patient pathways and applying pharmacogenomics.
Support wider regional adoption through hosting the
North West Genomic Medicine Service Alliance.
Mainstream genomic medicine across specialties at MFT
and the wider system through the new Regional Genomic
Medicine Service, bringing genomic testing earlier in care
pathways and applying pharmacogenomics.
Build on our position as being at the forefront of genomic
testing nationally by developing new services such as
circulating tumour DNA testing and leading work on
pharmacogenomics. Develop plans in other advanced
diagnostic disciplines such as metabolomics, proteomics
and integrative diagnostics.
Build on our position as being at the forefront of genomic
testing nationally by developing services such as
circulating tumour DNA testing, pharmacogenomics and
in population health. Develop plans in other advanced
diagnostic disciplines such as metabolomics, proteomics
and integrative diagnostics.
Continue to be a leading provider nationally of cell and
gene therapies, and other advanced therapies, in both
service and research. Develop a long-term plan to
consider our future capacity and potential strategic
partnerships.
Continue to be a leading provider nationally of cell and
gene therapies, and other advanced therapies, in both
service and research. Develop a long-term plan to
consider our future capacity and potential strategic
partnerships.
Develop our strategy for robotic assisted surgery across
MFT and deliver a viable short-term plan to maximise the
use of our existing surgical robots and grow our robotic
capacity in the future.
Develop and deliver our strategic delivery plan for robotic
assisted surgery across MFT
5. We will continue to
deliver the benefits that
come with our breadth
and scale, using our
unique range of
services to improve
outcomes, address
inequalities and deliver
value for money.
Ensure equitable access and outcomes for patients
across MFT by establishing networked or single services
in key specialties. Finalise the integration of services at
North Manchester General Hospital, delivering models of
care that meet people’s needs, address inequalities and
are financially sustainable.
Ensure equitable access and outcomes for patients
across MFT by establishing networked or single services
in key specialties, delivering models of care that meet
people’s needs, address inequalities and are financially
sustainable.
Work together with other providers, the Trust Provider
Collaborative and other partners to help make sure that
services across Greater Manchester are sustainable.
Work together with GM providers to deliver the Trust
Provider Collaborative priorities, including the GM
pathology and procurement collaborations, single queue
diagnostics and corporate services projects.
Maximise clinical effectiveness and efficiency, whilst
ensuring local access wherever possible, by agreeing
and implementing our plans for which services will be
delivered from which MFT sites.
Develop an effective operating model for MFT that will
help us to deliver the benefits that come with our size and
scale.
3. Be the place where
people enjoy working,
learning and building
career
6. We will make sure
that our staff feel valued
and supported by
listening well and
responding to their
feedback. We will
improve the experience
of all our staff
experience by
embracing diversity and
fairness.
Ensure that every team has effective ways of engaging
and involving all staff in decisions which affect them, to
listen to their ideas and learn from their experience, so
that we can improve services for patients and their
families and the working lives of staff.
Ensure effective engagement with colleagues at all
levels, including strong engagement with Staff Networks,
students and trainees, Trade Unions and professional
associations. Work with ED&I leads and with Change
Agents to support this.
Respond to issues raised in staff surveys, workforce
equality standards, and listening events by co-producing
MFT-wide improvement plans, with an initial focus on
food provision, car parking, flexible working, health and
wellbeing, support for managers and career
development.
Listen and respond to what staff and students tell us
through surveys and other routes. Co-create plans to
deliver improvements.
Update priorities and plans within the MFT Equality,
Diversity and Inclusion (ED&I) strategy Diversity
Matters, ensuring that everyone has a personal objective
on ED&I appropriate to their role, creating a working
environment where everyone has a sense of value and
belonging.
Monitor and deliver on the Trust-wide Equality, Diversity
and Inclusion (ED&I) plan to create an organisation
where all staff feel a sense of value and belonging, and
are treated fairly.
Implement plans to reduce pay gaps with respect to race,
disability and gender, fulfilling and, where possible,
exceeding obligations for all staff with protected
characteristics.
Promote a safe, open and transparent working
environment which encourages staff to raise concerns
directly within their team, whilst ensuring that other routes
are available for staff to raise concerns where necessary.
Promote a safe, open and transparent working
environment which encourages staff to raise concerns
directly within their team, whilst ensuring that other routes
are available for staff to raise concerns where necessary.
page 16
Strategic Aim
Objective
Original Action
Revised Action
Embed our values and behaviours across the
organisation so that they are understood and role-
modelled by all staff, promoting compassionate
leadership and teamwork in all areas through the Civility
Saves Lives programme.
Embed our values and behaviours through values-based
recruitment, leadership development programmes, and
implementation of the management and leadership
framework. Ensure that our values are role modelled and
understood, encouraging colleagues to challenge
inappropriate behaviour.
Deliver our ongoing culture change programme, working
with our team of Change Agents on three-year cycles of
cultural improvement.
Make MFT a place that people enjoy working and
learning through our culture change programme, working
with our team of Change Agents on three-year cycles of
cultural improvement.
Implement, monitor and enhance compliance against our
Violence Response and Sexual Conduct Charters,
ensuring colleagues receive the training and support
required, including our approach to trauma informed care.
Implement, monitor and enhance our response to violent,
abuse and sexual safety concerns. Ensure that people
see that concerns regarding their safety and wellbeing
are taken seriously and acted on.
Support healthy living, address health inequalities and
improve attendance by promoting staff health and
wellbeing services through initiatives such as Health and
Wellbeing Champions and the Colleague Community
initiative. Increase the range of preventative services
available to staff such as on-site cancer screening.
Support healthy living and address health inequalities by
promoting staff health and wellbeing services and
initiatives such as Health and Wellbeing Champions.
Deliver a step change in how we support attendance by
addressing long term inequities and policy gaps.
7. We will offer new
ways for people to start
their career in
healthcare. Everyone at
MFT will have
opportunities to develop
new skills and build
their careers here.
Develop a workforce planning framework and associated
skills to help predict our future workforce needs to deliver
high quality care now and, in the future, aligned to MFT
strategy and annual plans.
Work with colleagues to build a People Plan aligned to
the goals of the 10 Year Health Plan, developing a
workforce that is fit for the future, with an individualised
development plan for every employee.
Co-design a workforce, education and training plan which
ensures we have the appropriate mix of skills within
teams (utilising apprentice, assistant, advanced and
associate practitioner roles), making best use of the
apprenticeship levy to improve development opportunities
and career pathways for our current and future
employees.
Co-design an education and training plan, supporting
new roles and ways of working, improving access to roles
and maximising apprenticeship opportunities.
Build a supportive environment for our students and
professionals-in-training, responding to feedback and
developing innovative ways to increase capacity for
supervision.
Work with local schools and colleges to promote careers
in health and care, continuing to build an inclusive
community-based approach to recruitment, on-boarding
and induction.
Strengthen our widening participation initiatives, working
with job centres, schools and local communities. Ensure
recruitment, onboarding and career development
practices are inclusive and accessible.
Embed fair and inclusive recruitment practices that
promote diversity at all levels, target under-represented
groups, and ensure that careers in healthcare are open to
all. Improve representation of people from an ethnic
minority background at senior levels.
Work with managers to ensure proactive and efficient
processes are in place for recruitment, onboarding and
induction, so that all vacancies are filled as swiftly as
possible. Develop a tailored approach for colleagues
joining from overseas.
Invest in collective and compassionate leadership and
team development models so that our managers at all
levels are confident in demonstrating the knowledge,
skills and behaviours expected of them and can be the
best versions of themselves in their jobs.
Improve our understanding of avoidable staff turnover to
help find ways keep retain the people and skills that we
need.
Increase the number of people that we employ through
our Widening Participation Charter, encouraging greater
recruitment from our local population with improved
engagement on career opportunities.
Continue to recognise the brilliant work of our people and
our teams through staff recognition and awards
programmes.
Continue to recognise the brilliant work of our people and
our teams through staff recognition and awards
programmes.
Publicise the work of our teams externally so that people
get the recognition that they deserve nationally and
internationally.
Publicise the work of our teams externally so that people
get the recognition that they deserve nationally and
internationally.
page 17
Strategic Aim
Objective
Original Action
Revised Action
4. Ensure value for our
patients and
communities by making
the best use of our
resources
8. We will achieve
financial sustainability,
increasing our
productivity through
continuous
improvement and the
effective management
of public money.
Use our new Hive EPR system to help get the best value
for patients from our clinical activity, for example,
ensuring that the diagnostic tests that we provide have a
strong evidence base and will help in clinical decision-
making.
Work with partners across the system to make the best
use of all the resource available, for example, by
supporting work to improve prescribing and the use of
medicines within in hospitals, community services and
primary care.
Standardise policies and practice across MFT where this
can help to deliver value. Identify opportunities to use our
scale to deliver better value on products that we buy with
an initial focus on theatres, urgent care and maternity
services.
Standardise our operational policies and practice across
MFT to eliminate unwarranted variation and deliver better
value.
Deliver a programme of engagement for staff so that
everyone understands the part they can play and is
engaged in making the best use of our resource.
Deliver a programme of engagement for staff so that
everyone understands the part they can play and is
engaged in making the best use of our resource.
Carry out post-implementation reviews on all major
projects and investments to ensure that the benefits
forecast in business cases are delivered.
Continue to develop strategic partnerships with suppliers
through our Procurement Partners Programme and
exploring ways that these partnerships can deliver
additional value.
Maximise the value and income delivered by our MFT
Charities, learning from approaches taken elsewhere, to
strengthen the brands of our hospitals and Local Care
Organisations, and improve our services.
Maximise the value and income delivered by our MFT
Charities, learning from approaches taken elsewhere, to
strengthen the brands of our hospitals and Local Care
Organisations, and improve our services.
Develop and deliver plans to increase commercial
income for MFT to support the delivery of our services,
including the development of a commercial estates plan.
Develop and deliver plans to increase commercial
activities for MFT in support of the Trust's financial
sustainability, innovation and partnerships.
n/a
Refresh the Trusts medium term financial and capital
plans to support our strategic ambitions, actively
responding to new financial flows and payment
mechanisms in support of the Trusts clinical and
population health strategies.
9. We will deliver value
through our estate and
digital infrastructure,
developing existing and
new strategic
partnerships.
Deliver the Hive benefits case around clinical quality,
patient experience, productivity and research and
innovation, supporting staff the get the most out of the
system. Maximise the use of the MyMFT app to improve
engagement with communities, information sharing about
our services and healthy living, and the involvement of
individuals with their care, whilst mitigating the risk of
digital exclusion.
Maximise the use of the MyMFT app to improve
engagement with communities, information sharing about
our services and healthy living, and the involvement of
individuals with their care, whilst mitigating the risk of
digital exclusion.
Develop an infrastructure plan for community services,
covering both estates and digital.
Complete the redevelopment of North Manchester
General Hospital as part of the New Hospitals
Programme, and the wider campus as part of the North
Manchester Strategy.
Complete the redevelopment of North Manchester
General Hospital as part of the New Hospitals
Programme, and the wider campus, as part of the North
Manchester Strategy.
Work with national and local partners to identify
alternative sources of capital funding to support the
development of our estate and facilities, for example, our
plans for the development of Wythenshawe Hospital and
the surrounding area.
Work with national and local partners to identify
alternative sources of capital funding to support the
development of our estate and facilities. Progress our
plans for the development of Wythenshawe Hospital and
the surrounding area.
Develop and deliver plans to reduce our overall estates
footprint by making best use of the facilities that we have.
Put in place the right governance and oversight
arrangements to deliver this.
Develop and implement an estates plan that is aligned to
the MFT strategy, delivers our major capital programmes
and ensures that our estate meets the required
standards.
Continue to invest in, maintain and develop our estate,
making the best use of the capital funding that is
available to us.
page 18
Strategic Aim
Objective
Original Action
Revised Action
5. Deliver world-class
research and innovation
that improves people’s
lives
10. We will strengthen
our delivery of world-
class research and
innovation by
developing our
infrastructure and
supporting staff,
patients and our
communities to take
part.
Help to create protected time for people across the
organisation to pursue external funding opportunities and
carry out research and innovation activity.
Help to create protected time for people across the
organisation to pursue external funding opportunities and
carry out research and innovation activity.
Make research and innovation more accessible to staff
through leaner, more proportionate administrative
processes.
Make research and innovation more accessible to staff
through leaner, more proportionate administrative
processes.
Support people to develop the skills to deliver world-class
research and innovation by creating a careers framework
that supports people at all levels to become involved and
succeed in research. Work closely with universities to
identify areas of joint interest in which clinical academic
roles can be created.
Support people to develop the skills to deliver world-class
research and innovation by creating a careers framework
that supports people at all levels to become involved and
succeed in research. Work closely with universities to
identify areas of joint interest in which clinical academic
roles can be created.
Develop and deliver plans to improve access for research
studies to services such imaging, pharmacy and
laboratory medicine.
Develop and deliver plans to improve access for research
studies to services such imaging, pharmacy and
laboratory medicine.
Fully integrate research and innovation into the annual
planning process so that we can better plan for
sustainable growth.
Prioritise the delivery of research programmes and the
strategic themes that are part of our NIHR hosted
infrastructure, supporting them to meet and surpass the
required outputs.
Prioritise the delivery of research programmes and the
strategic themes that are part of our NIHR hosted
infrastructure, supporting them to meet and surpass the
required outputs.
Look for opportunities to further develop our research and
innovation infrastructure, helping to drive forward
research and innovation in new areas – such as children
and young people, social care, primary and community
care and health inequalities.
Look for opportunities to further develop our research and
innovation infrastructure and to maximise commercial
opportunities. Drive forward research and innovation in
new areas – such as children and young people,
neighbourhood health services, long-term conditions and
health inequalities .
Develop strong relationships with our communities so
that we can work together on research and innovation
which addresses the issues that matter most to people
and improve the diversity of people participating. Co-
create our engagement strategy to ensure research
remains relevant and more accessible.
Develop strong relationships with our communities so
that we can work together on research and innovation
which addresses the issues that matter most to people
and improve the diversity of people participating. Co-
create our engagement strategy to ensure research
remains relevant and more accessible.
Develop strong links with clinical and operational teams
across MFT, and partners such as Health Innovation
Manchester, to make sure that our research and
innovation work addresses the challenges and
opportunities within the organisation.
Make sure that our research and innovation work
addresses the challenges and opportunities for the
organisation, supported by our iTAP programme,
Innovation Ambassadors and system partners.
Use digital channels, including Hive and MyMFT, to
identify opportunities for patients and our communities to
get involved in research and innovation, and to make it
easier for people to stay involved with research once they
are recruited.
Use digital channels, including Hive and MyMFT, to
identify opportunities for patients and our communities to
get involved in research and innovation, and to make it
easier for people to stay involved with research once they
are recruited.
11. We will apply
research and
innovation, including
digital technology and
artificial intelligence, to
improve people’s health
and the services we
provide.
Develop the MFT secure data environment and its
interfaces with other datasets, ensuring that the data we
hold is secure and is curated and structured in such a
way that it can be harnessed to improve services for
patients and power cutting-edge medical research.
Build on the development of the MFT trusted research
environment so that it can be harnessed to improve
services for patients and power cutting-edge medical and
commercial research.
Develop a framework to support the appropriate adoption
of safe and effective AI solutions for clinical and
operational use in healthcare. Explore the opportunity to
appoint at least one strategic partner to help us prepare
for more widespread adoption.
Explore the opportunity to appoint at least one strategic
partner to help us adopt safe and effective AI solutions
for clinical and operational use at scale.
Understand and exploit opportunities to evaluate and
apply new technologies that will improve the efficiency
and quality of the services and care that we provide,
whilst mitigating any risk of digital exclusion.
Increase the number of impactful, formalised industry
partnerships year-on-year to generate new research and
innovation activities and new income streams as
appropriate.
Increase the number of impactful, formalised industry
partnerships year-on-year to generate new research and
innovation activities and new income streams as
appropriate.
Formalise our approach to identifying and adopting
proven innovations that will help us to address the
challenges faced by our communities and our
organisation.
Work with higher education institutions (e.g. universities)
to explore the opportunities for bespoke collaboration
which strategically matches MFT’s ambition with
individual partners’ expertise.
Work with higher education institutions (e.g. universities)
to explore the opportunities for bespoke collaboration
which strategically matches MFT’s ambition with
individual partners’ expertise.
page 19
Strategic Aim
Objective
Original Action
Revised Action
Deliver a data strategy which makes better use of our
data to improve patient care and, with appropriate
safeguards, supports innovation and commercial
partnerships. Strengthen our cybersecurity to make sure
our data and the patient data we hold is safe.
Deliver our Digital Strategic Delivery Plan and develop
our digital infrastructure, ensuring that MFT is a digitally
connected, data-driven organisation. Support the
adoption of digital innovations to transform our services,
improve people's health and working lives.
page 20
Appendix C – 25/26 – 26/27 priorities comparator
25/26
26/27 (new wording highlighted in blue)
Increase Secondary prevention activity across the Trust to improve health inequalities
Support delivery of the GM Live Well programme. Increase public health interventions delivered
across MFT to address both the major lifestyle drivers of illness and social determinants of health.
Increase the range of integrated services offered to people in the community, moving care out of a
hospital setting where possible to help address health inequalities
Increase the range of integrated services offered to people of all ages in the community, transforming
outpatient services and moving care out of a hospital setting where possible.
Deliver our integrated neighbourhood health plans – and develop the role of the Local Care
Organisations – through place-based partnerships in Trafford and Manchester.
Embed the safety framework, empowering and training colleagues with the skills to improve safety.
Strengthen our culture of patient safety by empowering and supporting staff with human factors
training, encouraging psychological safety and compassionate leadership.
Improve the way we involve patients and public in how we plan and deliver our services
Build a patient and carer experience framework to improve delivery of person-centred services,
strengthening the way we obtain feedback and our approaches to co-production
Continue to reduce waiting times
Continue to reduce waiting times – for adults and children – in a way that is safe and equitable.
Continue the development of Genomic Medicine across MFT and beyond, mainstreaming Genomics
and building on our position as a national leader
Continue the development of Genomic Medicine across MFT and beyond, mainstreaming Genomics
and building on our position as a national leader.
Deliver an improved operating model for the trust through the OneMFT programme
Embed our new, clinically-led operating model, continuing to build an inclusive, engaged organisation
where everyone has a sense of value and belonging.
Deliver our culture change programme, building inclusive organisation where everyone has a sense of
value and belonging
Implement plans to ensure we are a data driven organisation
Enable people to develop the skills needed to deliver high quality care in the future, including digital
and improvement skills. Ensure we are data-driven, providing people with the information they need to
improve their services.
Enable teams to create workplaces where people feel safe and well.
Improve our productivity and increase commercial income to deliver our financial plan.
Improve our productivity and increase commercial income to deliver our financial plan.
Level up digital maturity in the LCOs and community services
Take forward plans to implement a digital solution for community services and to support digital
integration with the wider system.
Progress plans to redevelop the NMGH campus, delivering a refreshed Outline Business Case whilst
making best use of existing estate across MFT.
Progress plans to redevelop the NMGH campus, delivering a refreshed Outline Business Case whilst
making best use of existing estate across MFT.
Grow the volume and value of our research and innovation activity.
Make it easier for people to take part in research and innovation, growing the volume and value of our
R&I activity.
Improve the strategic alignment between MFT and our university partners
Improve the strategic alignment between MFT and our academic and industry partners.
Develop our digital infrastructure and embrace technology, including AI and wearables, to drive new
models of care, improve quality and productivity across the organisation.
page 21
Agenda Item 11.1
Escalation and Assurance Report
Quality, Safety and Performance Board Committee
Report to: Board of Directors
Report of: Mark Gifford, Non-Executive Director
Date of meeting: 03/09/25
Key escalation and discussion points from the meeting
Alert
Two further never events (NEs) have occurred since the last Committee meeting, totalling eight NEs in this
financial year. No patient harm was caused by the incidents however the potential distress and reduced
patient experience to the patient was recognised by the Committee. An Oversight Group has been formed
to consider the themes across all the incidents and to identify and monitor delivery of the improvement
actions. The Trust has offered to test NHS England’s new Never Events Framework when it is finalised.
Never Events will return as a substantive item to the October QSPBC meeting.
Clinicians from Saint Mary’s joined the meeting to explain the adoption of a local variation to the national
Maternity Early Warning Scores (MEWS) as it is linked to the Trust’s Adult Early Warning Score and is
therefore more aligned with patient safety requirements – e.g the triggering of hypertension alerts at a lower
level. The Committee discussed the risk of non-compliance with national requirements and recognised the
benefits to patient safety from the local approach. This agenda item is being further considered at the
Quality and Safety Management Committee.
Advise:
The Committee received an update on current and future service developments. The Committee discussed
the risks associated with potential changes to major trauma provision in Greater Manchester, how service
developments are prioritised from a strategic perspective, and considered how assurance can be received
that services remain safe and effective, and planned benefits are realised, after transformation. The
potential of the IPR to provide this assurance was noted.
The Committee received the Q1 Infection Prevention and Controls report. CDI cases are under the quarterly
threshold, MRSA bacteraemia (3 cases) is above the national standard of zero cases, and gram negative
blood stream infections are above the quarterly threshold by 11 cases. Improvement plans are in place to
address underperformance and will continue to be monitored by the Committee. The Committee also
discussed the role of MFT supporting the reduction of the recent increases of measles presentations by
children.
The Committee received the Biannual Mortuary Services report which confirmed that the MFT service
remains complaint with all the recommendations from the Phase 1 Fuller report. The Human Tissue
Authority carried out an inspection on the 7/8/25 and the report has not yet been received. The Committee
discussed current risks to the service including environment/estates issues.
Saint Mary’s Director of Nursing and Midwifery (DoM) presented the latest Maternity Safety Update
including the actions being taken to address issues with consistent delivery of Safety Actions 1, 7 and 8.
the DoM was joined by clinicians from Saint Mary’s to provide an update on progress made following the
page 1
adoption of the Manchester Maternity Assessment Triaging Tool. Performance has improved with the 30
minute national triage standard met in 95% of cases. Self-discharge rates remain at 3% with work ongoing
to improve this.
The Committee discussed the current position at MFT, and across Greater Manchester, with regard to Anti-
Microbial prescribing. Progress has been demonstrated against several indicators, however point
prevalence audit results for the duration of antibiotic treatment require improvement. Findings have been
communicated to the relevant clinical groups to inform the development of targeted action plans aimed at
improvement. Guidelines are being strengthened to reduce the prescribing of co-amoxiclav and other broad
spectrum antibiotics.
The Medicines Optimisation Annual Report for 2024/25 was discussed and the Committee noted the
successes over the year, including the development of a safety improvement plan and the achievement of
£1.5m savings, and asked for future reports to include benchmarking against other similar Trusts.
The Committee received an update on the successful implementation of the four new da Vinci Robotic
Assisted Surgery (RAS) systems, the da Vinci Xi, following business case approval in November 2024, and
welcomed the planned oversight of delivery of benefits. The Committee discussed the need for ensure that
our workforce was suitably trained in the future and heard that Robotic fellowships were being planned.
NHS England have now produced a Quality Impact Assessment process for Trust undertaking efficiency
programmes. The existing MFT process is being reviewed against it to identify if any changes are required.
The Committee discussed the value in seeing proposals which have failed to pass the assessment.
The Committee received the EPRR Core standards submission prior to approval by the Board on the 1st
October. The submission shows a 2% improvement from last year’s submission (95% compared to 93%).
The Committee also supported the EPRR and Business Continuity policies which will also be presented to
the Board for approval. Reassurance was provided regarding the testing of the policies through regular
EPRR exercises.
Assure:
The Committee received the Integrated Performance Report for July/August 2025 and noted:
•The progress made in meeting a number of key indicators.
•The plateauing of the recent improvement in VTE compliance and the work to introduce a change
within Hive to prevent prescribing if a VTE assessment has not been undertaken.
•Substantive reports on stroke and fractured neck of femur performance are scheduled at the next
QSPBC meeting
•An increase being seen in waiting times for non-RTT reportable waits.
•The links between performance against certain metrics and the Trust’s position in the National
Oversight Framework and the potential for the Committee to receive more up to date information
in the future.
The Committee received a report detailing the results of the 2024 Cancer Patient Experience Survey
which have shown a positive improvement in key areas. The Trust’s Cancer Collaborative are addressing
areas where improvement is required.
The Committee received an update following an internal audit report on waiting list management processes.
All identified actions have been implemented with improvements in performance noted.
Risks discussed at the meeting
The Committee considered the strategic and corporate risks aligned to the Committee. A new strategic
risk related to achievement of the Mental Health Strategy was noted and the risk owner was asked to
consider whether the description of the risk was correct and whether the target rating was in line with the
Trust’s risk appetite. The Committee welcomed the review of all strategic and corporate risks by the new
page 2
Deputy Director of Clinical Governance and Risk to ensure target ratings and dates are achievable and in
accordance with risk appetite.
Report approved by: Mark Gifford, Non-Executive Director
Quality, Safety and Performance Board Committee
Date: Wednesday 3rd September 2025
Time: 10:00am – 1:00pm
Location: Medical Boardroom, ORC
Agenda
Item
Purpose
Lead
Time
1.
Apologies for absence & confirmation of quoracy
(verbal)
Meeting
admin
Chair
10:00am
2.
Declaration of interest (verbal)
Meeting
admin
Chair
10:00am
3.
Minutes of the previous meeting (25th June 2025)
Meeting
admin
Chair
10:00am
4.
Action Log
Discussion
Chair
10:00am
5.
Matters Arising
Discussion
Chair
10:00am
6.
Assurance Reporting
6.1
Strategic and Corporate Risks
Discussion
Executive
Directors
10:05am
6.2
Integrated Performance Report
Discussion
Executive
Directors /
Director of
Nursing and
Midwifery
10:15am
7.
Strategic aim 2: Provide high quality, safe care with excellent outcomes and experience
7.1
Update report on service developments (strategic
objectives 4 and 5)
Discussion
Acting Chief
Strategy
Officer
10:30am
7.2
Q1 Infection Prevention and Control (IPC) Report
Discussion
Interim Deputy
Chief
Executive /
Chief Nursing
Officer
10.40am
7.3
Mortuary Update
Discussion
Interim Deputy
Chief
Executive /
10:50am
page 3
Chief Nursing
Officer
7.4
Maternity Safety update (including MEOWS, MMATT,
and response to ‘No delays’ internal audit report)
Discussion
Director of
Nursing and
Midwifery
11:00am
7.5
Annual Cancer Survey Report
Discussion
Interim Deputy
Chief
Executive /
Chief Nursing
Officer
11:10am
7.6
Medicine Optimisation report 2024/2025
Discussion
Chief
Pharmacist
11:20am
7.7
Update on Anti-microbial prescribing
Discussion
Chief
Pharmacist
11:30am
7.8
Annual report on Medicine Incident Themes
Discussion
Chief
Pharmacist
11:40am
7.9
Robotic-assisted surgery
Discussion
Joint Chief
Medical Officer
11:50am
7.10
Cancer Strategic Delivery Plan
Discussion
Chief Delivery
Officer
12:00pm
7.11
Waiting list management progress update
Discussion
Chief Delivery
Officer
12:10pm
7.12
QIAs for VfP Programme
Discussion
Chief Delivery
Officer
12:20pm
7.13
EPRR Core Standards statement of compliance
• MFT Business Continuity Policy
• EPRR policy
Approval
Chief Delivery
Officer
12:35pm
Committee business
8.
Escalation report
Approval
Chair
12:45pm
9.
Workplan Review
Meeting
admin
Chair
12:50pm
10.
Any Other Business (verbal)
Discussion
Chair
12:55pm
11.
Meeting Evaluation (verbal)
Meeting
admin
Chair
12:55pm
Date of next meeting: Wednesday 22nd October 2025 at 10:00am, Medical Boardroom
page 4
page 5
Public Board of Directors
Wednesday 1st October 2025
Paper title:
Trust Bi-Annual Mortuary Services Report
Agenda
Item
11.2
Presented by:
Kimberley Salmon-Jamieson, Trust Interim Deputy Chief
Executive and Chief Nursing Officer
Prepared by:
Kristopher Bailey, Deputy Director of Nursing, Clinical and
Scientific Services
Sarah Ingleby, Director of Nursing and Healthcare
Professionals, Clinical and Scientific Services
Input received from Department of Laboratory Medicine,
Mortuary Senior Team.
Meetings where content has
been discussed previously
Clinical and Scientific Services Clinical Group Management
Board
Clinical and Scientific Services Quality and Safety
Subgroup
Quality, Safety and Performance Board Committee
September 2025
Purpose of the paper
Please check one box only:
☐ For approval
☐ For discussion
☒ For support
Executive summary / key messages for the meeting to consider
The Board of Directors are asked to receive this paper which provides oversight and assurance of the
required regulatory compliance and demonstrates the high-quality safe care that is provided within the
Trust Mortuaries.
The Trust's mortuaries, licensed by the Human Tissue Authority, have undergone inspections during 2022
& 2023, with most findings satisfactorily resolved at the time. Most recently, 7th August 2025 there was an
unannounced inspection at Wythenshawe Hospital. Preliminary feedback is contained in the content of
this report whilst the formal inspection report is awaited. Quality management practices, including audits
and incident submissions, are in place and themes monitored to maintain high standards.
In response to the Independent Inquiry following the David Fuller case, the Trust's Executive Leadership
sought assurances that all policies and procedures associated with MFT mortuary services meet quality
assurance measures, follow appropriate lines of governance, and meet statutory requirements to ensure
the service is managed safely and maintains high standards of care for deceased patients.
This paper provides an update on the comprehensive action plan that was developed (appendix 2) to
address Phase 1 of the Fuller recommendations within the mortuary sites. Following publication of the
Phase 2 report of the Fuller Inquiry, 15th July 2025, a gap analysis is currently being completed with an
associated action plan due by the end of September 2025.
Regular visits to all mortuary sites continue, supported by senior colleagues from the Division of
Laboratory Medicine (DLM), Clinical & Scientific Services, and Trust Executive teams to ensure policy
page 1
adherence, staff competency, to highlight any new estate issues but also to ensure mortuary colleagues
have a forum to raise any concerns with senior leaders within the organisation.
The Trust has made notable progress against the action plan in place and continues to work towards
delivering high-quality care of deceased patients.
Recommendation(s)
The Board of Directors is asked to:
•Receive for review, the content of this Trust Mortuary services report and the ongoing work to
deliver high quality care in line with the regulatory key lines of enquiry and the Trust strategic aims.
•Review and confirm the progress made against the action plan developed in line with the Fuller
Independent Inquiry to further improve provision of services across all MFT sites.
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐Yes (please set out in your report what action
has been taken to address this)
☒No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☐
LHL objective 2
☒
HQSC objective 1
☒
HQSC objective 2
☐
HQSC objective 3
☐
PEW objective 1
☒
PEW objective 2
☒
VfP objective 1
☐
VfP objective 2
☐
R&I objective 1
☐
R&I objective 2
☐
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following strategic,
corporate or operational risks:
•MFT/007200: Monitoring and auditing of restricted access to
mortuaries (all sites)
•MFT/006686: Training of mortuary staff (all sites)
•MFT/002791, MFT/006455: Estates & IPC (all sites)
•MFT/007115: Requirements for the renewal of the Manchester
City Coroners Contract
•MFT/004039, MFT/002813, MFT/000073: Care of the deceased
capacity (all sites). Freezer capacity (all sites). Fridge design
(TGH)
•MFT/002469: Prolonged length of stay implications (all sites)
•MFT/008011: Delays in PM reporting due to reduced consultant
capacity
•MFT/008022: Requirement for robust security at all mortuary and
body store sites.
•MFT/00279: Condition of flooring in Wythenshawe and ORC
mortuaries.
page 2
Care Quality Commission
domains
Please check all that apply
☒ Safe
☒ Effective
☒ Responsive
Compliance & regulatory
implications
The following compliance and regulatory implications have been
identified as a result of the work outlined in this report:
• HTA licence 12554 (Adult and Paediatric Mortuaries and the TGH
body store. Postmortem procedures)
• HTA licence 12203 (Wythenshawe Mortuary)
• BSI ISO 9001:2015 accreditation
Main report
1 Introduction
1.1 Manchester University NHS Foundation Trust (MFT) has 5 mortuary facilities across 4 hospital sites.
- Adult and Paediatric Mortuary services at Oxford Road Campus (ORC, Manchester Royal
Infirmary and Royal Manchester Children’s Hospital respectively).
- A body store at Wythenshawe Hospital.
- A body store at Trafford General Hospital.
- A body store at North Manchester General Hospital.
1.2 Across all mortuary sites the capacity is:
- 314 standard fridge spaces.
- 36 Bariatric spaces, including 3 super bariatric spaces.
- 10 Standard freezer spaces.
- 14 Bariatric freezer spaces.
1.3 In line with regulatory guidance, the Trust mortuaries are maintained under 2 Human Tissue
Authority (HTA) licenses.
- License number 12554 serves the ORC Adult and Paediatric mortuaries and Trafford General
Hospital body store. This license also covers postmortem procedures undertaken at both mortuary
sites.
- License number 12203 serves Wythenshawe body store. This license has been updated to reflect
the transfer of postmortem services to ORC (adult mortuary) in 2024. The license covers storage
of a body and relevant material along with storage of material whilst part of an active Coronial
case.
- There is no requirement for a HTA license at NMGH as this site provides a body store only which
is not covered under the HTA requirements.
1.4 During 2024/25 MFT Mortuary services cared for 4544 deceased patients compared to 4749 during
2023-24.
1.5 This paper services to inform Board of Directors (BoD) of the regulatory compliance achieved and
the governance in place to safeguard the deceased following admission to any of the Trust mortuary
facilities. This Mortuary service update will be received through BoD on a bi-annual basis.
2 Regulation
2.1 HTA Oxford Road and Trafford Licence 12554.
ORC (Adult Mortuary), Trafford and Paediatric Mortuaries were inspected by the HTA in April 2023.
- Where the HTA determines that a licensing standard is not met, they refer to this as a shortfall
which is classified as ‘Critical’, Major’ or ’Minor’.
page 3
- The HTA found the Designated Individual and the Licence Holder to be suitable in accordance
with the requirements of the legislation.
- Although the HTA found ORC, Trafford and Paediatrics to have met the majority of the HTA
standards, there were 4 major shortfalls and 2 minor shortfalls. These were found against
standards for Consent, Governance and quality systems, Traceability and Premises, facilities and
equipment.
- Corrective and preventative actions were put in place and based on the information provided to
the HTA, they were satisfied from this correspondence that the Trust had completed the agreed
actions in the action plan and in doing so addressed all the shortfalls that were highlighted.
- The HTA requested to be kept updated with the additional long-term storage (increased freezer
capacity – risk register MFT/002813), and the access to records in support of the security audit.
Security audits were included in the 12-month schedule, these are now scheduled monthly and
can be found on the mortuary quality management system (Qpulse). These are available to
demonstrate compliance to the HTA as required.
2.2 HTA Wythenshawe Licence 12203
Wythenshawe was inspected by the HTA on 7th August 2025. This was an unannounced
inspection. The HTA inspection report has yet to be released, with interim feedback as described
below:
- The inspection focused on security concerns and the extent of the access control audits. The
inspectors stated that the scope of the access audits must be increased. The sample size has
increased from one 24-hour period per month to 15 separate dates and times across the month.
- The scheduled 15 monthly dates and times audits are to be carried out where attendance is out
of working hours or a lot of activity within that time. This has commenced, working closely with the
Clinical Groups where any breaches have occurred.
- The HTA inspectors advised the Mortuary Manager must review the CCTV footage and not the
security manager.
- Mortuary management and security management have met to discuss the findings and arrange
implementation of corrective action.
Further feedback received during the inspection closing meeting included;
• Concern over a staff balcony overlooking the funeral directors’ entrance, an unlocked door
between the family visiting area and mortuary staff room (completed).
• Notification of death form required signature from both attending porters (completed).
• Further monitoring of patient sheet changes (actions commenced).
• Monitoring of deceased patients with the same or similar names (actions commenced).
• Monitoring of cleaning of fridge doors and seals. (actions commenced).
- To ensure the above actions are completed, without activity impact, additional support is confirmed
at Wythenshawe. An extra member of staff to attend Wythenshawe 3 times a week to ensure
actions are addressed.
- CSS SLT have oversight of theses immediate actions. The actions are being tracked within
Cellular Pathology Quality & Safety (Q&S), DLM Q&S through to CSS Safety Summit and CSS
Q&S as a subcommittee of the CSS Clinical Group Management Board.
- Replacement of the Wythenshawe mortuary flooring needs to be completed given the erosion of
the surface and Health & Safety risks. This is a known risk and previous HTA finding. Remedial
action was taken at the time but has eroded since. Works have been costed and a solution must
be completed within the maintenance programme. CSS SLT and E&F leadership are reviewing to
agree next steps. Oversight will continue through CSS Q&S until resolution is complete.
- Key mortuary staff were interviewed and further documents requested by the HTA, which were
submitted on 14th August 2025.
- A paper has been presented to Quality Compliance Group on the 29th August 2025 to capture the
initial outcome of the inspection and progress with the actions. The actions will be monitored
within in Cellular pathology Q&S Group and overseen in DLM Q&S and assurance given to CSS
page 4
Q&S. The Mortuary Manager will provide updates in the DLM Quality and Safety monthly meeting
which is then escalated by the DLM Governance Lead and CSS Q&S monthly.
- A final action plan will be established once the full HTA inspection report is received.
2.3 HTA inspection reports can be found at:
- https://www.hta.gov.uk/guidance-professionals/latest-inspection-reports
2.4 There has been two HTA reportable HTARI incidents during 2025, which were investigated with
implementation of appropriate actions to prevent reoccurrence. These are within appendix 1.
2.5 Designated Individual
- The designated individual (DI) for ORC license 12554 is: Dr Mohsin Mazhari, Speciality Doctor
Adult Histopathology.
- The DI for Wythenshawe license 12203 is: Mr Daniel Shingleton, Senior Biomedical Scientist.
- A DI report is presented on a yearly basis to the Division of Laboratory Medicine Management
Board which is a subgroup of the Clinical and Scientific Services Clinical Group Management
Board. HTA committee meetings for all DI’s across all sectors is held twice yearly.
- The DI report provides the Divisional and Clinical Group Management Boards with oversight of all
HTA reportable incidents, themes and actions in place to mitigate associated themes, key risks,
overview of inspection status and assurance of regulatory compliance.
- Formal visits to the Trust mortuaries have been established, with recommendations from these
visits forming part of an overall mortuary action plan.
- Visits take place weekly and are performed by the DLM Senior Management Team following which
an audit is completed for assurance.
- Criteria assessed during the assurance visits have been updated to take into account the recent
HTA and clinical accreditation inspections.
- Recent audits have highlighted the potential requirement to use additional temporary storage at
ORC site. A risk identifying mortuary capacity issues is in place with controls in place with bi-
monthly reviews at divisional risk committee (MFT/002813).
- All sites were visited in June and July 2025.
- Observations noted during these visits are recorded and findings are discussed with the mortuary
senior leadership team at DLM Q&S, escalated to CSS Q&S and Clinical Group Quality & Safety
Subcommittee. Going forward the actions from the HTA assessments will be utilised to ensure
readiness for subsequent inspections.
2.6 British Standards Institute 9001 Inspections (ISO9001:2015)
- British Standards Institute 9001 (BSI ISO9001:2015) is a European standard for assessment of
Quality Management systems.
- The BSI audit the service against 7 quality management principles:
o Customer focus
o Leadership
o Engagement of People
o Process approach
o Improvement
o Evidence based decision making
o Relationship management
- The last inspection took place in May 2025 across all Trust mortuary sites. The inspection
confirmed the Trust mortuary services met the standards for accreditation of ISO 9001:2015
standards.
- Only one minor finding was noted, involving oversight of staff refresher training at NMGH mortuary.
Remedial actions have been completed.
- The BSI inspection report can be found in full below:
- https://www.bsigroup.com/en-GB/products-and-services/bsi-connect/connect-portal/
2.7 Internal Quality Assurance review
page 5
- To provide additional assurance of quality, safety and care of the deceased, Mortuary services
have been added to the Trust Quality Assurance schedule.
- The Quality Assurance benchmarks are based on three domains which include:
o Care of the Deceased
o Safety and Security,
o Clinical Effectiveness.
- The domains have been benchmarked against the HTA requirements and the Fuller
recommendations, to achieve compliance with licensing.
- The first visits took place on 28th and 29th July 2025, involving all sites. The mortuary was
awarded silver. The minor shortfalls identified during the visit have been addressed.
2.8 KPMG
- KPMG will be undertaking their review in November 2025. Terms of reference have been agreed
and will include a view of confirm our governance processes across MFT Mortuary services.
3 Fuller Inquiry
3.1 Following Phase 1 a gap analysis was completed for all MFT mortuaries. Based on the
recommendations of phase 1 an action plan to achieve full compliance was developed and is
monitored through Clinical and Scientific Services Clinical Group Quality and Safety Subcommittee
(Appendix 2).
3.2 The Phase 2 recommendations were released on 15th July. An update paper is being prepared
along with a gap analysis of the recommendations. This is expected to be complete by the end of
September 2025.
4 Mortuary Action plan
4.1 The mortuary action plan was initially produced to ensure compliance against the 17
recommendations published in Phase 1 of the Fuller Inquiry report.
4.2 MFT can report full compliance with all 17 of the recommendations.
4.3 The action plan developed further to include actions identified for improvement during formal visits
from the Trust Executive and Senior Leadership Teams.
4.4 7 further actions were added to the action plan. All actions are within their review date with target
dates for achieving compliance.
4.5 The full action plan is tracked through DLM Quality and Safety Subcommittee.
5 Audits
5.1 The Division of Laboratory Medicine have a robust monthly audit schedule capturing the activity on
all Trust mortuary sites. The audits review the quality of services provided against set standards
engaging all staff in the process. These audits include the HTA standards and Fuller
recommendations. Findings from the audits are submitted for clinical review and discussion at
divisional governance meetings with any escalations occurring to Clinical Group Clinical
Effectiveness Committee as required.
5.2 Monthly security audits are scheduled. Access data (swipe cards) and recorded CCTV footage is
reviewed together to ensure all access attempts into the Trust mortuaries are for legitimate purposes
only and by appropriately trained colleagues.
5.3 The security audits have highlighted the following issues over the last 6 months.
- A nurse accessed the Paediatric mortuary at ORC using a colleague ID badge. CCTV footage
showed the staff member accessing mortuary paper records.
page 6
- A porter used a colleagues ID badge at NMGH to access the mortuary for the transfer of a patient
from the ward.
5.4 A Trust wide audit of Care of the Deceased was completed between 9th – 27th September 2024
across ORC, Wythenshawe, North Manchester, and Trafford. The audit was led by the Trust
Palliative and End of Life Care team. The audit reviewed the documentation and care provided to
patients at ward level after death.
5.5 The report of findings has been completed and is to be presented to the Trust End of Life Steering
group and onward at DLM Quality and Safety Subcommittees with actions to be discussed and
appointed to appropriate areas for completion and oversight.
5.6 The next Care of the Deceased audit will take place in September 2025.
6 Risk
6.1 Currently there are 15 mortuary/body store risks on the risk register.
6.2 Of the 15 risks 11 remain open/active with mitigations and a further 4 are open/ accepted with
monitoring of the risk.
6.3 All risks are within review date with reviews taking place at Histopathology Quality and Governance
meeting with oversight at Clinical Group Risk Committee. The details of the risks are within appendix
3
7 Incidents
- February to July 2025 there were 27 incidents raised for mortuary services
o 11 were for ORC (Adults).
o 9 for the paediatric mortuary.
o 0 for North Manchester.
o 3 for Trafford.
o 4 for Wythenshawe mortuary.
The themes and incident categories are detailed within Appendix 4.
7.1 Each incident has a calculated level of severity.
o 14 of the incidents were categorised as Level 1 no harm.
o 12 were categorised as Level 2 slight harm.
o One incident was validated as level 3 harm. 2607135. A HILA was completed and the
incident was reported to HTA.
o To note, any incident categorised as Level 3 or above must have full investigation and may
be HTA reportable.
7.2 The HTA require establishments licensed in the postmortem sector to notify them within 5 working
days of the incident occurring or being discovered, of serious incidents and near miss incidents that
may affect the dignity of the deceased and damage public confidence.
7.3 2638758 – The incident involves delayed cases related to organ and tissue samples (mainly
histopathology blocks and slides) taken during postmortems from both adult and paediatric
deceased patients. Families had requested either the return or disposal of these samples.
• 1 organ from a deceased paediatric patient was authorised for return – returned to family.
• 33 tissue samples from deceased paediatric patients authorised for return.
• 31 tissue samples from deceased paediatric patients authorised for disposal – sensitively disposed
of.
• 9 tissue samples from deceased adult patients authorised for return.
• 51 tissue samples from deceased adult patients authorised for disposal - sensitively disposed of.
page 7
Governance actions are ongoing. Families are being contacted by phone by the paediatric and adult
bereavement teams, followed by personalised apology letters, starting 20th August 2025.
8 Training and Development
8.1 Vocational Training
- To gain full qualification as an Anatomical Pathology Technician, both level 3 and level 4 Diplomas
must be achieved.
- Currently 5/12 staff have successfully completed both level 3 and level 4 Diplomas
- Two additional staff have recently completed their level 3 diploma and aim to enrol on a level 4
diploma in February 2026.
- Two staff are due to submit their portfolio and take practical exam late summer for Level 3 Diploma
- One staff member is currently progressing with their level 4 diploma.
8.2 Competencies
- Internal staff training and competency documents are produced with completion requirements for
staff to complete every 2 years. Tables 3 and 4 shows a list of all staff competency documents.
- Staff competencies are 100% compliant across all sites.
A full list of competencies for all mortuary staff is detailed within appendix 5
8.3 Mandatory training
- The mortuary department Core Level 1 mandatory training compliance is 68%.
- Staff members whose mandatory training is overdue have been offered protected time. Target
date for completion is the end of August 2025.
- To ensure safeguarding of patients transferring to the mortuary services, all staff complete both
Child and Adult Level 1 Safeguarding. In addition, Band 6 staff also complete Levels 2 and Band
7 and above complete Level 3.
- The Mortuary Safeguarding Champion completes Safeguarding levels 1,2 and 3 and acts as a
resource for other staff within the service.
- Current Safeguarding training compliance is 86.3% for level 1 and 100% for level 2. Compliance
is monitored through CSS Safeguarding subcommittee.
- Porter training competencies, in relation to care of the deceased patient, are shared with the
Mortuary Management Team.
9 Conclusion
This bi-annual mortuary services report provides a comprehensive overview of the current licensing and
inspection status.
It demonstrates that quality management practices, including audits and incident reporting, are in place
to maintain high standards. In response to the independent inquiry following the David Fuller case, a
comprehensive gap analysis of Phase 1 was undertaken and an action plan developed to address areas
for improvement, including security improvements and regular visits implemented which are well
supported by senior colleagues.
The Trust has taken significant steps against the action plan to ensure the quality and safety of the
deceased is continuously maintained with visible oversight and assurance provided through robust Quality
and Safety processes.
Following the publication of the Fuller Inquiry Phase 2 a further gap analysis will be completed in
September 2025 with further steps actioned to be taken in providing assurance the Mortuary Service
remains compliant, and the quality and safety of deceased patients is maintained, in line with regulatory
requirements and the Trust strategic aims.
page 8
10 Appendix 1
HTA Reportable Incidents (HTARI) - 2025
CAS-74928-
Y5F6
Accidental damage to body
During the 21day check (where patients are examined for signs of
deterioration/decomposition and if freezing is required escalated to Senior
APT/Manager) an injury had occurred to the patient’s skin when removing
the sheet.
CAS-76154-
M2N8
Cases have been identified
dating back to postmortems
held in 2015 where tissue
samples (block and slides) and
1 organ removed should have
been either returned to the
family or disposed depending
upon the option chosen by the
family.
-Notify the HTA of a reportable incident - COMPLETED
-Return the retained organ as per protocol with support for RMCH family
support team - COMPLETED
-Agree the procedure for return of materials to families acknowledging
delays - COMPLETED
-Return the material from outstanding cases in a structured and sensitive
manner – start 19.8.25
-Ensure metrics on management of postmortem retention data is included
in reports to the Mortuary Management team meetings for escalation
through the relevant governance channels if required
-Provide updates on the completion of actions into the DLM Q&S meetings
for oversight and escalation as required
-Add the Designated Individual role to the existing risk around staffing and
service resilience, ensuring this risk is visible to CSS colleagues.
page 9
11 Appendix 2 Mortuary Action Plan
Action Plan (Grey – Completed)
Action
number
Action
Target date
Owner
Progress
1
Implement a cross-site, fully aligned
induction procedure to ensure non-
mortuary staff and contractors (including
security and maintenance staff) are given
training on the requirement to be
accompanied by another member of staff,
preferably mortuary staff, at all times whilst
on mortuary premises. (recommendation
1)
28.03.2024
Kerry
Anne
Wheat
Complete
2
Undertake a documented gap analysis to
support alignment CCTV coverage at all
MFT Mortuary and body store sites to meet
the requirements of the recommendations
of the Fuller Inquiry phase 1 report
(recommendation 9)
01.05.2024
Sharon
McMinn
Gap analysis completed. Business case submitted for
additional CCTV. Funding for CCTV has been confirmed.
CCTV fully installed – Wythenshawe & NMGH
3
Monitor the outcome of business case
submission through to procurement and
installation of the required CCTV.
(Recommendation 9)
01.09.2024
Sharon
McMinn
Work completed 31st July 2024.
Business case approved. Work to commenced as below:
NMGH – Work completed 15th July – 22nd July.
Wyth – Work completed 15th July.
4
Escalate risk MFT/007200 from 12 to 16
(recommendation 10)
01.07.2024
Nicky
Fagan
Complete
page 10
5
Confirm whether a care of the deceased
policy exists for paediatrics and consider
drafting if not already in place.
14.06.2024
Clare
Ryan
Complete. Death of a child or young person policy in
circulation available on trust intranet.
6
Review of the proximity card reader on the
paediatric mortuary entrance point
accessible via the Sodexo facilities
Management corridor
01.07.2024
Sharon
McMinn
Complete.
Mortuary senior team liaising with trust E&F team to
review. This door is not used, it is one of 3 access points
and has a Digi lock to secure it whilst the plan is made in
terms of replacement/repair.
Magnet was broken - now repaired. Card reader is active
and digi lock in place as back up.
7
Completion of first MFT wide Care of the
Deceased audit. Review of outcome and
sharing of learning.
01.11.2024
Paula
Parr
Audit completed 19th September 2024
Audit provides additional assurances for
recommendation 16 & 17.
8
Review of requirement to access data from
third party Schneider to ensure process for
undertaking quarterly audits is robust
(Recommendation 10)
01.07.2024
Sharon
McMinn /
KerryAnn
Wheat
CCTV/Access audits increased to twice monthly (from
quarterly) for all mortuary sites.
page 11
Wider Trust Action Plan (Grey – Completed)
Action
number
Action
Target date
Owner
Progress
1
Review of the pre-employment checks
performed on staff that attend the mortuary
that are not employed by MFT but by
Sodexo contractors, i.e. Portering, E&F
01/07/2024
Zara Pain
All Sodexo employees are subject to the same pre-
employment checks as MFT staff. This applies to
Sodexo directly employed staff or those staff on MFT
contacts of employment seconded to Sodexo. All
contractors are subject to a permit to work process
and cannot work on MFT sites without these being
issued. This process confirms the staff attending on
behalf of approved contractors carry the correct DBS
status or a permit cannot be issued.
2
To consider the introduction of an audit to
demonstrate compliance with MFT policy
on DBS checks for staff (Recommendation
3)
01/07/2024
Zara Pain
The MFT policy position with regards to DBS checks
is set out within our Recruitment & Selection Policy
and follows the NHS Employers Criminal Record
Check Standard.
DBS checks are completed when an individual joins
the Trust based on the eligibility of their role with the
Trust.
Staff will be re-checked if they undergo a formal
recruitment process and either.
a)  the DBS requirements of the new role are different
from their current role - in such cases a new check
will be undertaken
b)  their last DBS check was undertaken more than
three years ago – in such cases a new check will be
undertaken.
page 12
MFT actively promote the DBS Update Service,
however it is not mandated.
If a situation occurs where an individual is required to
start in post prior to DBS clearance, a risk
assessment is completed setting our appropriate
mitigation i.e., full supervision when working in clinical
areas and restricted duties. All risk assessments
require Executive level approval.
A standalone DBS policy has been drafted which
provides further clarity on the different types of DBS
check, eligibility, positive disclosures, and record
retention as per the NHS Employers Check
Standard.
Compliance with our Recruitment Policy is subject to
audit by our internal audit team. A full audit of
Recruitment check compliance was undertaken in
2018, and a further audit regarding the compliance for
Nursing & Midwifery roles was undertaken in 2023.
The audit did not raise any concerns in relation to
DBS check compliance.
In light of the Fuller Enquiry, it is suggested that DBS
check compliance is added to the internal audit
schedule for 24/25.
Considering the Fuller Enquiry DBS check
compliance has been added to the internal audit
schedule for 24/25 with KPMG.
page 13
3
To review the requirement for DBS re-
checks and consider if this should apply at
fixed intervals for specific groups of staff
01/07/2024
Zara Pain
MFT does not currently undertake periodic DBS re-
checks, apart from when an individual goes through
a formal internal recruitment process. Re-checks are
also undertaken for specific roles where this is a
requirement of a wider governance framework, for
example where a role is subject to Ofsted governance
such as those working in an educational setting.
This DBS policy position was agreed by the MFT
board in 2018. It is in line with the NHS Employer
Criminal Records Check Standard which states that:
5.1 Introducing periodic checks.
5.1.1   Although not a legal requirement, employers
may choose to introduce periodic checks. The
frequency by which employers require periodic
checks should be decided at a local level. Employers
may choose to apply requirements to certain
professions or more widely to all roles that are eligible
for a DBS check. All requirements to recheck
members of staff should be proportionate to risk.
It should be noted that Staff are contractually obliged
to notify the Trust if they become subject to any
convictions, police cautions, conditional cautions, or
other similar offences, at any point during their term
of appointment. Similarly, staff who are professionally
registered are also required to notify their
page 14
professional body of any changes to their criminal
record status.
In light of the Fuller Enquiry, it is suggested that an
Options Appraisal is completed to review whether
MFT should change its recheck position, noting that
there will be a cost and resource implication if a
periodic re-check process is adopted. Options would
include:
Periodic rechecks for all eligible staff.
Periodic rechecks for specific staff groups deemed
high risk.
An audit of all those with swipe card access to MFT
mortuaries is being undertaken to check their DBS
status upon hire. A further step of updating those DBS
checks is under immediate consideration.
page 15
4
To review the process for proactive sharing
of the HTA reports with CQC and other
governing bodies as part of the inspection
process and good practice
(Recommendation 11)
01/07/2024
Beverley
Fearnley
Complete.
Agreement has been made with the CQC that HTA
reports will be a standing item for information on
MFT/CQC formal engagement meetings. These will
be discussed by exception. Meetings for the
remainder of the financial year are scheduled for 27th
August 27th November 2024 and 24th February 2025.
HTA reports will also be a standing item for
information on the Trusts formal NHS Greater
Manchester Quality and Safety Assurance Group
meeting with the ICB. These will be discussed by
exception. This meeting is currently being established
but will be a monthly meeting and will report to the
Manchester System Quality Group and NHS GM
Contract Review Meetings.
5
Security to review processes in place in
order to agree that these meet the required
robust standards (Recommendation 8)
01/07/2024
Rob
Jepson
Complete
6
Further reports to be added to Group
Quality, Scrutiny and Performance
Committee bi-annually (October and April)
which will form part of the annual cycle for
Trust Board of Directors (May and
November)
01/07/2024
Nick
Gomm
Added to work programme
page 16
Actions taken from Chief Nurse and Trust Executive visits (Grey – Completed)
Action
number
Action
Target
date
Owner
Progress
1
Review of the visiting area
environment at North Manchester
General Hospital
14.06.2024
Sharon McMinn
Redecorating has taken place throughout all patient and
visitor facing areas within NMGH Mortuary. The team
are now looking into sourcing additional resources for
the visitor’s room in terms of wall pictures and a memory
tree.
Further improvement in terms of environment is noted to
be required at NMGH. However, the overall
improvement forms part of the wider new hospital
build. Planters have been installed.
Review of Wythenshawe visiting rooms is ongoing in
collaboration with WTWA, CSS and E&F colleagues.
2
Bariatric fridge space at NMGH
10.05.2024
Sharon McMinn
There is a robust process in place for managing transfer
of bariatric patients to ensure appropriate storage of
bariatric patients as required.
3
Review of long length of stay
procedures across all Mortuaries
01.11.2025
Sharon McMinn/
Clare Ryan
Adult long length of stay policy in operation and utilised
across all Adult Mortuaries – completed.
Paediatric long length of stay policy is going to RMCH
End of Life Group for signoff September 2025. This will
then go to RMCH Q&S for final ratification October 2025.
Legal team have been involved in the development of
this pathway.
page 17
4
Contact Medical Illustrations for 2 x
Butterfly stickers to be placed on
the two electronic doors leading into
CSB1 for families visiting the Adult
Mortuary ORC – way finding
29.11.2024
Sharon McMinn
To improve way finding for families visiting the adult
mortuary.
Completed. Stickers now in situ.
5
New signage at Wythenshawe
Mortuary – Funeral Directors
entrance doors
29.11.2024
Sharon
McMinn /Kerry
Ann Wheat
Signage previously read ‘Rose Cottage’
Replacement signage approved and installed Jan 2025.
6
New signage at North Mortuary
01.08.2024
Sharon McMinn
Previously no signage on mortuary or directions to the
mortuary at North for families/visitors and Funeral
Directors
Signs are now in place since May 2025 on:
• Mortuary main building
• Funeral Directors entrance
• Visitors entrance
• Trust sign at the top of the road leading to the
mortuary
• 2 x car parking spaces close to the mortuary
building.
7
Intruder Alarms
01.12.2025
Sharon
McMinn /Rhys
Jones
15/08/25 Adult ORC and Wythenshawe now have an
intruder alarm.
The ORC security team are reviewing the practicalities
of installing an intruder alarm in Paediatric mortuary.
8
Panic Alarms
01.12.2025
Sharon
McMinn /Rhys
Jones
Submit a variation of works to request for Security
Control Room panic alarm monitoring, the current
infrastructure does not support active monitoring at
ORC adult mortuary. Due to the nature of the work
page 18
required and the cost implication the completion date
has been recorded to reflect this. Panic alarms are not
a recommendation from the Fuller Enquiry or HTA. This
has been placed on the risk register. Procedures are in
place to mitigate the risk.
9
Panic Alarms – North Manchester
Mortuary
31.12.2024
Sharon
McMinn /Jay
Carney
Panic alarms have been installed at North mortuary. A
fibre cable is now installed and linked to security so
when activated security are alerted and can attend for
support.
10
Risk Register – Panic alarms and
Intruder alarms
01.10.2024
Sharon
McMinn /Emily
Moore
A risk is now on the risk register highlighting the lack of
panic alarms and intruder alarms at ORC,
Wythenshawe and Paediatrics
The associated risk is live on Ulysees.
11
CCTV to be installed to ensure
winter pressures capacity is visible
01.12.2025
Kerry-Ann Wheat
All mortuaries have full CCTV coverage and monitors.
One further camera to be installed at Wythenshawe.
Review underway relating to the technical ability to
install one further camera to be installed at ORC.
page 19
12. Appendix 3
Risks held within Mortuary identifies the breakdown of scoring.
Total
Number of
Risks
Risk Score
2
16
2
12
5
9
1
8
4
6
1
4
The table below shows the two risks scored at 16
MFT/007200
Risk score: 16
Monitoring and Auditing of access to
Restricted Areas in within MFT
Mortuaries (all sites)
Actions: being updated in light of the
recent HTA audit
Inability to access CCTV and access data prevents
proper auditing of out-of-hours mortuary access,
risking non-compliance with HTA licensing. This
could lead to loss of the licence, suspension of
mortuary services, reputational damage to the
Trust, and increased public complaints.
MFT/008011
Risk score: 16
Insufficient Consultant Capacity for
paediatric, adult and Coroners post-
mortem services
Actions: SMART actions in place and
up to date
Insufficient consultant capacity to manage
paediatric and adult postmortem workloads risks
reduced or withdrawn service provision. This could
lead to reputational damage, loss of coronial
contracts, reporting delays, postmortem backlogs,
accreditation risks, increased complaints, a
deterioration in professional relationships, and
financial losses through failure to meet
requirements of existing contracts.
page 20
13. Appendix 4
The table below shows the themes/incident categories from our mortuary incidents
Number of
incidents
Cause group
3
Infrastructure – Facilities, Utilities
5
Patient care, monitoring, review
1
Health and safety/General accident
3
Security
2
Clinical assessment-Diagnosis, tests
1
Access, Admission, Transfer, Discharge
3
Communication and consent
6
Medical Device, Equipment
1
Documentation and Information Governance
0
Fire
page 21
14 Appendix 5 – Full list of competencies required for mortuary staff
Adults
AMORPRO30
Conducting an Adult PM - Pre-Examination
AMORPRO18
Conducting an Adult PM Examination
MORPRO12
CNS Autopsy Saw
MORPRO28
Rules Concerning Retention of organs/Tissues
MORPRO2
Procedure for Mortuaries Stacking Trolley
MORPRO15
Postmortem Admin
AMORPRO5
Release of a Deceased out of Hours
AMORPRO4
Release of a Deceased in Hours
AMORPRO6
Receipt of Deceased Adult Patient
MORPRO24
Transfer of Deceased Patient between sites
AMORPRO8
Management of Deceased Patients in Adult
Mortuaries
MORPRO27
General Cleaning and Schedules in the
Mortuaries
AMORPRO22
Viewing of a Deceased Adult
AMORPRO12
Kelsius Monitoring Systems
AMORPRO31
Use of Departmental Camera
Paediatrics
MORPRO2
Using the Mortuaries Stacking Trolley
MORPRO27
General Cleaning in the Mortuaries
MORPRO12
CSN3 Autopsy Saw with Extraction
PMORPRO48
accepting Patients transferred from other hospitals
to RMCH
PMORPRO30
Release of Patients in Working Hours
PMORPRO28
Postmortem Examination and Procedure
PMORPRO52
Delivery of Patients from RMCH & St Marys
PMORPRO24
Transfer of Patients to X-Ray Department for
Imaging
PMORPRO27
Viewings & IDs of Patients Within the Paediatric
Mortuary
PMORPRO44
Arranging the End of Month Service
PMORPRO25
Release of infants & POC's for EOMS
PMORPRO26
Booking in & Boxing up of infants for EOMS/Private
Burial
PMORPRO50
Booking in & Boxing up of POC's for EOMS /Private
Burial
page 22
PMORPRO29
Release of Patients Outside of Working Hours
PMORPRO31
Taking of Mementos
PMORPRO23
out of hours Forensic postmortem
PMORPRO32
Operating the PathVision X-Ray Machine
PMORPRO54
Booking in deceased patients on HIVE
page 23
Public Board of Directors
Wednesday 1st October 2025
Paper title:
Medical Appraisal and Revalidation and Annual Statement
of Compliance
Agenda
Item
11.3
Presented by:
Professor Matt Makin – Interim JCMO
Dr Emma Hurley – ACMO Revalidation and Appraisal
Prepared by:
Cameron Chandler – Head of CMO Programmes
Meetings where content has
been discussed previously
People Board Committee 3 September 2025
Purpose of the paper
Please check one box only:
☒For approval
☐For discussion
☐For support
Executive summary / key messages for the meeting to consider
Revalidation is the process by which all licensed doctors are required to demonstrate, on a
regular basis, that they are up to date and fit to practise in their chosen field and able to
provide an appropriate standard of care. The process of revalidation seeks to give extra
confidence to patients, the public and the profession that doctor is being regularly checked by
both their employer and the General Medical Council (GMC). Licensed doctors must revalidate
usually every five years, part of which is the requirement to have an annual appraisal based on
the GMC’s Good Medical Practice framework. The revalidation process is based on a
recommendation from the Responsible Officer to the GMC, the regulator making the final
decision about revalidating a doctor. As part of the revalidation process, all doctors must
ensure that they undergo appraisal within each financial year and are responsible for the
continuous collection of their portfolio of evidence covering their full scope of practice.
Continued engagement with appraisal by GMC registered clinicians is necessary over the
course of the five-year revalidation cycle.
Summary of key points:
•at the end of the last appraisal year (31 March 2025), MFT had 2,757 doctors with a
prescribed connection plus an additional 81 dentists requiring an MFT appraisal
•96.4% of connected doctors had an appraisal for the 2024-2025 appraisal year
•appraisers were rated as Very Good or Good by 98.1% of appraisees who submitted
feedback
•the process for allocating appraisers by Clinical Groups require significant improvement in
ownership and timeliness
•the Trust has been instructed to submit a signed Statement of Compliance to NHS England
for 2024-2025
page 1
Recommendation(s)
The Board of Directors is asked to:
• note the contents of this paper, progress made to date and the challenges to be faced in
the coming year.
• approve submission of the Annual Statement of Compliance with The Medical
Professional (Responsible Officers) Regulations 2010 (as amended in 2013), signed on
behalf of the designated body by the Trust Chief Executive Officer.
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐ Yes (please set out in your report what action
has been taken to address this)
☒ No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☐
LHL objective 2
☐
HQSC objective 1
☐
HQSC objective 2
☐
HQSC objective 3
☐
PEW objective 1
☒
PEW objective 2
☒
VfP objective 1
☐
VfP objective 2
☐
R&I objective 1
☐
R&I objective 2
☐
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks:
•
Care Quality Commission
domains
Please check all that apply
☐ Safe
☐ Effective
☐ Responsive
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
•
Main report
Revalidation was formally launched in the UK in January 2013 and is the process by which all
licensed doctors are required to demonstrate, on a regular basis, that they are up to date and
fit to practise in their chosen field and able to provide an appropriate standard of care. The
process of revalidation seeks to give extra confidence to patients, the public and the profession
that doctor is being regularly checked by both their employer and the General Medical Council
(GMC). Licensed doctors must revalidate usually every five years, part of which is the
page 2
requirement to have an annual appraisal based on the GMC’s Good Medical Practice
framework1. The Trust’s appraisal and revalidation process is managed operationally by the
team of the Responsible Officer (RO); a role established in statutory legislation2 and currently
undertaken by Professor Bernard Clarke, taking over from Dr Toli Onon from 4 August 2025.
The RO’s role is supported by Dr Emma Hurley, Associate CMO for Appraisal and Revalidation,
in addition to the Deputy ACMO, Chief of Staff, Head of Programmes, and the revalidation
admin team.
The revalidation process is based on a recommendation from the RO to the GMC, the regulator
making the final decision about revalidating a doctor. In order to make this recommendation,
the RO must be assured that:
▪ the doctor has a track record of engagement with annual appraisals consistent with the
guidance on strengthened medical appraisal and has been appraised on the full scope of
their practice (including in the independent sector) at a single appraisal meeting
▪ any concerns about the doctor raised through the appraisal have been brought to the
attention of the relevant medical line manager and successfully addressed
▪ the doctor has undertaken a multisource feedback evaluation of their work and professional
behaviour, including feedback from both colleagues and patients, and that this has been
discussed with their appraiser (one formal multisource feedback per five-year revalidation
cycle)
▪ there are no outstanding concerns about the doctor’s performance or professional conduct
known to the Trust
Options available to the RO are to recommend revalidation, defer the recommendation for a
period of up to 12 months (either due to insufficient information for a positive recommendation
or because the doctor is subject to an ongoing process), or to notify the GMC of the doctor’s
non-engagement with the process.
Designated body
Manchester University NHS Foundation Trust is a designated body, as established in the
Responsible Officer regulations; this also determines which doctors should be connected to
the Trust for appraisal and revalidation. At 31 March 2025 (the end of the appraisal year), 2,757
doctors were connected; 1,666 Consultants, 139 SAS grade doctors, 940 temporary and short-
term contract holders (including clinical fellows and bank doctors), and 12 other doctors (such
as clinical trial physicians). There was an increase on the previous year of 160, primarily
consisting of Consultants, Clinical Fellows and Bank Doctors.
Doctors who work jointly within the Trust and the University of Manchester in an academic
position are required to undergo a joint appraisal under the Follett Principles. These doctors
connect to the Trust for revalidation. Additional doctors who work for the Trust, who are not
connected for appraisal and revalidation, include GPs (who connect to one of the NHS England
local teams), and doctors who undertake work at MFT but also with another NHS organisation,
who is their main employer and designated body. Despite not connecting directly with these
doctors, the Trust still has an obligation to monitor their fitness to practise and report any
1 http://www.gmc-uk.org/static/documents/content/GMP_.pdf
2 The Medical Profession (Responsible Officers) Regulations 2010, amended 2013
page 3
concerns to the doctor’s RO. Doctors in a training grade are appraised and revalidated
separately by NHSE Education.
Revalidation
For the appraisal year 1 April 2024 – 31 March 2025, 570 doctors were due to be revalidated.
Of the doctors due, 495 doctors were recommended for revalidation and a further 27 were
deferred and subsequently revalidated; 48 doctors were deferred with a future revalidation date
after 31 March. Of the 48 deferrals, 46 were due to insufficient information (on which to make
a recommendation) and two due to involvement in an ongoing process; two doctors from the
period are on hold from the revalidation process due to ongoing GMC investigations. No
submissions of non-engagement were made for the period. All MFT recommendations
regarding revalidation have been approved by the GMC. For the year April 2025 – March 2026,
193 doctors are due for revalidation.
Revalidations by Submission Approved Date (01/04/24 – 31/03/25)
Designated Body
Total
Submissions
Revalidated
Deferred
Non-
Engagement
Late
Submissions
All DBs (England)
63,295
87.2%
12.7%
0.1%
2.1%
All NHS Acute Trusts
22,058
84.4%
15.5%
0.1%
3.0%
MFT
593
87.7%
12.3%
0.0%
0.3%
There two late submissions, one was due to allow a process to be commenced before
submitting the recommendation; the other doctor connected to MFT after their due date had
passed.
For those deferred due to lack of sufficient information, the primary reason for this remains to the
absence of patient feedback; however, this has significantly reduced compared to previous years.
Reasons for Deferral
No. of Deferrals
Patient feedback
34
Appraisal activity
30
Colleague feedback
27
Interruption to practice
16
CPD
10
QIA
10
Compliments and complaints
5
Significant events
5
Appraisal
All doctors must ensure that they undergo appraisal within each financial year and are
responsible for the continuous collection of their portfolio of evidence covering their full scope of
practice. For medical staff who are registered with the GMC as well as the General Dental
Council (GDC), continued engagement with appraisal is necessary over the course of the five-
year revalidation cycle (the GDC has no equivalent revalidation process).
page 4
At 31 March 2025, 2,757 connected doctors were due to have an appraisal within year (1 April
– 31 March). The appraisal rate for the 2024-25 appraisal year is as follows (table 1):
Group
Connected
Completed
appraisal
Approved
incomplete or
missed
appraisal
Unapproved
incomplete or
missed
appraisal
Consultants
1,666
1,631
97.9%
34
2.0%
1
0.1%
SAS
139
133
95.7%
6
4.3%
0
0%
Temporary or short-
term contract holders
940
882
93.8%
58
6.2%
0
0%
Other
12
11
91.7%
1
8.3%
0
0%
Total
2,757
2,657
96.4%
99
3.6%
1
0.04%
Whilst the majority of appraisals have been completed, it should be noted that a large number
of these were held late; the importance of maintaining a regular appraisal month each year is
communicated to those undertaking a late appraisal as it allows for appraisals to be held
evenly throughout the year and prevent over run after the end of March. Overdue appraisals
are being more proactively managed this year with formal escalation process in place.
Appraisers
The Trust has a responsibility to support appraisers in the maintenance and development of
their skills, to assure the quality of medical appraisals, and to ensure that appropriate
resources are available to support this. Those who undertake medical appraisals for the Trust
must be adequately trained in this role. Refresher training should be undertaken every three
years, with these sessions held virtually facilitated by the ACMO. At 1 August 2024, 762 of the
783 appraisers are currently in date with training. The 21 not currently compliant have been
contacted to confirm if they wish to book on to a training session or come off the appraiser list if
they don’t want to refresh their training; if no reply or training is declined then they will be
removed as an appraiser.
Appraiser Training Feedback (April 2024 to March 2025)
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
The objectives were clearly defined
73%
27%
1%
0%
0%
Participation and interaction were
encouraged
67%
31%
2%
0%
0%
The topics covered were relevant
78%
21%
0%
0%
0%
The content was organised and easy to
follow
71%
26%
3%
0%
0%
page 5
This training will be useful in my work
77%
21%
2%
0%
0%
The trainer was knowledgeable about the
training topics
90%
10%
0%
0%
0%
The trainer was well prepared
87%
13%
0%
0%
0%
The training objectives were met
75%
24%
0%
0%
0%
The time allotted for the training was
sufficient
63%
31%
4%
3%
0%
Appraisee feedback
Following each completed appraisal, appraisees are asked to submit feedback regarding their
appraisal, appraiser, and the overall process. For the last appraisal year, a total of 2,098
feedback responses were received which saw an increase in positive feedback across all
metrics. Individual reports for each appraiser are collated and added to their appraisal
portfolios for discussion at their own appraisal. Of the responses received:
• 90.7% rated their appraiser overall as Very Good and a further 7.4% as Good
• 76.1% Strongly Agreed that their appraisal discussion was important in their professional
development and a further 19.9% Agreed
• 71.3% Strongly Agreed that the overall administration of their appraisal had been
satisfactory and 26.0% Agreed
Quality assurance
The need for a robust Quality Assurance process for appraisal as part of the Medical
Revalidation process is self-evident, but also explicitly expected by both NHS England, as the
Senior Responsible Owner of the revalidation process, and the GMC. A need for oversight of
both appraisers and appraisal outputs is necessary to ensure a consistent, effective and
constructive appraisal system, benefiting both the doctor’s development and the Trust
assurance processes.
Appraisers are responsible for ensuring the quality of the appraisal outputs for the appraisals
they undertake. They must ensure that both the appraisal summary and the Personal
Development Plan (PDP) adhere to the required standards. Feedback is requested from
doctors following an appraisal; this information is collated and used to assist appraisers with
their development and gives an indication of how the process is progressing.
An appraisal quality tool ASPAT3 (Appraisal Summary and PDP Audit Tool) developed by NHS
England has been incorporated within SARD so that randomised samples of appraisals can be
audited online to assess the quality of the appraisal process. The process for this has been
trialled and is being increased to allow for 10% of all appraisal outputs to be audited. Initial
findings from this appear to indicate that whilst good appraisal discussions appear to be taking
place, these are not necessarily being documented sufficiently. The findings from ASPAT are
being fed back into appraiser training to highlight required improvements and, where
necessary, discussed with individual appraisers.
Future challenges
A key challenge for medical appraisal is the timely allocation of appraisers; appraisers are not
required to be linked to management structure and also need to change after three consecutive
years. This can lead to a delay in allocation of appraisers, as well as those for new starters,
which can subsequently delay appraisals being held. It is currently Trust policy and NHSE
3 https://www.england.nhs.uk/professional-standards/medical-revalidation/appraisers/aspat-notes/
page 6
guidance that appraisers are allocated rather than self-selected, helping to prevent bias in the
system and doctors being unable to find an appraiser.
The process of allocating appraisers by Clinical Groups still needs embedding and the onus is
often still being pushed back to individual appraisees. Where possible, appraisers should be
allocated ahead of the appraisal year, ideally linking in with the job planning process to ensure
appraisee and SPA time allocation equates. Lists are sent out by the revalidation team each
year before April to enable this process, but this is not routinely undertaken by sites. For any
new positions being recruited to, an appraiser should be allocated in advance prior to the role
commencing to prevent any delay, especially for any staff new to the UK who will require an
appraisal within their first three months. Allocation is required only for consultant and SAS
grade clinicians; appraisers for clinical fellows and other short-term staff should be undertaken
by their Educational Supervisor. Appraisers for ACMOs and Clinical Group Medical Directors
are assigned centrally to prevent any potential conflicts of interest or appearance of
management influence. The RO is allocated an external appraiser by their Higher-Level
Responsible Officer (currently the Regional Medical Director).
Work has been taken in conjunction with Medical Education to closer align the work of
Educational Supervisors and the revalidation team achieving a significant increase in appraisal
rates, bringing them in line with other medic groups. Further work is required on this however,
to universally recognise that appraisal is part of the job of an Educational Supervisor and is
included within the SPA allocation for this role.
page 7
Appendix A
2024-2025 Annual Submission to
NHS England North West:
Framework for Quality Assurance and
Improvement
This completed document is required to be submitted
electronically to NHS England North West at
england.nw.hlro@nhs.net by 31st October 2025.
As this is a national deadline, failure to submit by this
date will result in a missed submission being recorded.
We are unable to grant any extensions.
page 8
2024-2025 Annual Submission to NHS England North West:
Appraisal, Revalidation and Medical Governance
Please complete the tables below:
Name of Organisation:
Manchester University NHS Foundation Trust
What type of services does your
organisation provide?
Acute NHS Trust providing local hospital care,
specialised services and community care
Name
Contact Information
Responsible Officer
Prof Bernard Clarke
bernard.clarke@mft.nhs.uk
Medical Director (Joint)
Dr Sohail Munshi
Prof Matt Makin (interim)
sohail.munshi@mft.nhs.uk
matthew.makin@mft.nhs.uk
Medical Appraisal Lead
Dr Emma Hurley
emma.hurley@mft.nhs.uk
Appraisal and Revalidation Manager
Cameron Chandler
cameron.chandler@mft.nhs.uk
Additional Useful Contacts
Andrea Johnson
Revalidation Manager)
andrea.roberts@mft.nhs.uk
Yvonne Jenkinson
(Revalidation Administrator)
yvonne.jenkinson@mft.nhs.uk
Service Level Agreement
Do you have a service level agreement for Responsible Officer services?
No
If yes, who is this with?
Organisation: N/A
Please describe arrangements for Responsible Officer to report to the Board:
Date of last Responsible Officer Report to the Board:
Action from last year:
page 9
Annex A
Illustrative Designated Body Annual Board Report and Statement of Compliance
This template sets out the information and metrics that a designated body is expected to report upwards, through their
Higher Level Responsible Officer, to assure their compliance with the regulations and commitment to continual quality
improvement in the delivery of professional standards.
Section 1 – Qualitative/narrative
Section 2 – Metrics
Section 3 - Summary and conclusion
Section 4 - Statement of compliance
Section 1 Qualitative/narrative
All statements in this section require yes/no answers, however the intent is to prompt a reflection of the state of the item
in question, any actions by the organisation to improve it, and any further plans to move it forward. You are encouraged
therefore to provide concise narrative responses
Reporting period 1 April 2024 – 31 March 2025
1A – General
The board/executive management team of: Manchester University NHS Foundation Trust
can confirm that:
1A(i) An appropriately trained licensed medical practitioner is nominated or appointed as a responsible officer.
Y/N
Yes
Action from last year:
None
Comments:
Professor Bernard Clarke assumed the role from 4 August 2025
Action for next year:
None
1A(ii) Our organisation provides sufficient funds, capacity and other resources for the responsible officer to carry out the
responsibilities of the role.
Y/N
Yes
Action from last year:
None
Comments:
None
Action for next year:
None
1A(iii)An accurate record of all licensed medical practitioners with a prescribed connection to our responsible officer is always
maintained.
Y/N
Yes
Action from last year:
None
page 10
Comments:
Revalidation Management System (SARD), ESR, regular auditing
Action for next year:
None
1A(iv) All policies in place to support medical revalidation are actively monitored and regularly reviewed.
Y/N
Yes
Action from last year:
Ensure policy is ratified and distributed accordingly
Comments:
Latest policy has been reviewed and is with the Joint Local Negotiating
Committee for consideration
Action for next year
Ensure policy is ratified and distributed accordingly
1A(v) A peer review has been undertaken (where possible) of our organisation’s appraisal and revalidation processes.
Y/N
No
Action from last year:
Finalise peer review arrangements
Comments:
Similar sized organisations are being approached to undertake this exercise;
currently one has agreed and a third is required to prevent this being reciprocal.
An internal of all appraisal processes (medical and non-medical) was undertaken
by KPMG in 2021 which had an outcome of significant assurance with minor
improvement opportunities.
Action for next year:
Finalise peer review arrangements
1A(vi) A process is in place to ensure locum or short-term placement doctors working in our organisation, including those with a
prescribed connection to another organisation, are supported in their induction, continuing professional development, appraisal,
revalidation, and governance.
Y/N
Yes
Action from last year:
None
Comments:
Appointment of educational supervisors; role of dedicated Associate Director of
Medical Education for Locally Employed Doctors and International Medical
Graduates. Access to same appraisal system and guidance as consultants;
tailored portfolios and guidance on system specific to cohort of doctors.
Action for next year
None
page 11
1B – Appraisal
1B(i) Doctors in our organisation have an annual appraisal that covers a doctor’s whole practice for which they require a GMC
licence to practise, which takes account of all relevant information relating to the doctor’s fitness to practice (for their work carried
out in the organisation and for work carried out for any other body in the appraisal period), including information about complaints,
significant events and outlying clinical outcomes.
Y/N
Yes
Action from last year:
None
Comments:
Portfolio template built into SARD based on previous MAG Form and contains
the above specified criteria to ensure all relevant information included.
Action for next year:
None
1B(ii) Where in Question 1B(i) this does not occur, there is full understanding of the reasons why and suitable action is taken.
Y/N
Yes
Action from last year:
None
Comments:
Records are kept on the SARD appraisal system as to why appraisals are
deferred or marked as exempt for a particular year. Any deferment request
from a clinician is required to be submitted via a standardised proforma for
approval or rejection as appropriate by the Revalidation Team. Escalation
process in place for appraisal non-compliance, concluding with the RO and
then the GMC.
Action for next year:
None
1B(iii) There is a medical appraisal policy in place that is compliant with national policy and has received the Board’s approval (or by
an equivalent governance or executive group).
Y/N
Yes
Action from last year:
None
Comments:
Policy ratified by Medical Education and Workforce Committee, reporting to
the Board of Directors
Action for next year:
None
1B(iv) Our organisation has the necessary number of trained appraisers4 to carry out timely annual medical appraisals for all its
licensed medical practitioners.
4 While there is no regulatory stipulation on appraiser/doctor ratios, a useful working benchmark is that an appraiser will
undertake between 5 and 20 appraisals per year. This strikes a sensible balance between doing sufficient to maintain
proficiency and not doing so many as to unbalance the appraiser’s scope of work.
page 12
Y/N
Yes
Action from last year:
Ensure SPA allocation across the trust is sufficient for number of appraisals that
are required.
Comments:
At year end there were 793 trained appraisers giving an approximate ratio of
1:4 for appraisers:appraisee. Per the policy appraisers are expected to carry
out between 3 and 12 appraisals annually. (Includes GDC only appraisals).
Action for next year:
None
1B(v) Medical appraisers participate in ongoing performance review and training/ development activities, to include attendance at
appraisal network/development events, peer review and calibration of professional judgements (Quality Assurance of Medical
Appraisers or equivalent).
Y/N
Yes
Action from last year:
None
Comments:
Appraisers are expected to undergo refresher training every three years.
Modified ASPAT form has been incorporated into appraisal software to audit a
representative sample. Appraisee feedback forms completed after each
appraisal.
Action for next year:
None
1B(vi) The appraisal system in place for the doctors in our organisation is subject to a quality assurance process and the findings are
reported to the Board or equivalent governance group.
Y/N
Yes
Action from last year:
Increased number of ASPAT reviews carried out and results fed back into the
appraiser training process
Comments:
Modified ASPAT form has been incorporated into appraisal software to audit a
representative sample; the number carried out has been increased to allow for
10% of appraisal outputs to be assessed. This will be included in the annual
reports to the Board and the Workforce Scrutiny committee
Action for next year:
None
1C – Recommendations to the GMC
page 13
1C(i) Recommendations are made to the GMC about the fitness to practise of all doctors with a prescribed connection to our
responsible officer, in accordance with the GMC requirements and responsible officer protocol, within the expected timescales, or
where this does not occur, the reasons are recorded and understood.
Y/N
Yes
Action from last year:
Ensure all recommendations are carried out on time and deferrals are
requested earlier if necessary
Comments:
Two submissions were made late for the 2024-25 year; one was already
overdue when connected to MFT. The other was one day late due to additional
checks due to an ongoing process. Recommendations are now being made one
month ahead of the due date to avoid last minute and overdue submissions.
Action for next year:
None
1C(ii) Revalidation recommendations made to the GMC are confirmed promptly to the doctor and the reasons for the
recommendations, particularly if the recommendation is one of deferral or non-engagement, are discussed with the doctor before
the recommendation is submitted, or where this does not happen, the reasons are recorded and understood.
Y/N
Yes
Action from last year:
None
Comments:
Doctors are emailed following a positive recommendation for revalidation to
confirm this; if a deferral is being submitted, the doctor is notified of this in
advance when possible. Additionally, an action plan template is completed and
submitted to the doctor outlining the steps required to be undertaken before
the new recommendation due date, and an agreement to this is asked for from
the doctor.
Action for next year:
None
1D – Medical governance
1D(i) Our organisation creates an environment which delivers effective clinical governance for doctors.
Y/N
Yes
Action from last year:
None
Comments:
Sub-committees which report to the Board, and are chaired by non-executive
directors, include the Quality, Safety & Performance Board Committee and
People Board Committee. Data on complaints, incident reporting, appraisals,
management of concerns, patient experience and outcomes, and clinical
indicators are presented at Board sub-committees and reported to the Board.
The RO and Joint Chief Medical Officers attend Trust Board and provide input
on matters relating to clinical governance for doctors. A culture of honesty,
openness, learning, and improvement is promoted throughout the trust
including a duty of candour encouraging staff to report adverse incidents and
near misses, give honest and open feedback on their colleagues, and be open
and honest with patients if something goes wrong with their care.
page 14
Action for next year:
None
1D(ii) Effective systems are in place for monitoring the conduct and performance of all doctors working in our organisation.
Y/N
Yes
Action from last year:
None
Comments:
Quarterly Medical Professional Matters Oversight Group (MPMOG) meetings
between RO, Associate CMOs (Appraisal and Revalidation, Professional
Matters) and Clinical Group Medical Directors and HR Directors to discuss
medical professional matters and concerns.
Action for next year:
None
1D(iii) All relevant information is provided for doctors in a convenient format to include at their appraisal.
Y/N
Yes
Action from last year:
None
Comments:
Incidents above an agreed outcome level attached to a specified consultant are
automatically uploaded into portfolios. Appraisee feedback reports are
automatically added. Data is available from the HIVE EPR system and clinicians
are being encouraged to sign-up to NCIP (National Consultant Information
Programme) with portfolio sections being added for this.
Action for next year:
None
1D(iv) There is a process established for responding to concerns about a medical practitioner’s fitness to practise, which is
supported by an approved responding to concerns policy that includes arrangements for investigation and intervention for
capability, conduct, health and fitness to practise concerns.
Y/N
Yes
Action from last year:
None
Comments:
Handling Concerns about Medical Staff (MHPS) Policy
Action for next year:
None
page 15
1D(v) The system for responding to concerns about a doctor in our organisation is subject to a quality assurance process and the
findings are reported to the Board or equivalent governance group. Analysis includes numbers, type and outcome of concerns, as
well as aspects such as consideration of protected characteristics of the doctors and country of primary medical qualification.
Y/N
Yes
Action from last year:
None
Comments:
Register of MPMOG data maintained for each meeting. Overview of MHPS
exclusions provided to Board of Directors.
Action for next year:
None
1D(vi) There is a process for transferring information and concerns quickly and effectively between the responsible officer in our
organisation and other responsible officers (or persons with appropriate governance responsibility) about a) doctors connected to
our organisation and who also work in other places, and b) doctors connected elsewhere but who also work in our organisation.
Y/N
Yes
Action from last year:
None
Comments:
Transfer of information process within NHS is managed by Revalidation
Manager. Sharing of information with two main private providers in locality is
managed by RO and CMOs for professional matters. Quarterly assurance
meetings are held with two main private providers to discuss any issues.
Action for next year:
None
1D(vii) Safeguards are in place to ensure clinical governance arrangements for doctors including processes for responding to
concerns about a doctor’s practice, are fair and free from bias and discrimination (Ref GMC governance handbook).
Y/N
Yes
Action from last year:
None
Comments:
All polices at MFT undergo an Equality Impact Assessment prior to being
ratified and policies a reviewed on a rolling basis including review by staff side
representatives at Joint Local Negotiating and Consultation Committee
(JLNCC). The Equality and Diversity Team advise, guide and support MFT on
Equality, Diversity and Human Rights issues and work to deliver the Equality,
Diversity and Inclusion Strategy, Diversity Matters.
Action for next year:
None
page 16
1D(viii) Systems are in place to capture development requirements and opportunities in relation to governance from the wider
system, e.g. from national reviews, reports and enquiries, and integrate these into the organisation’s policies, procedures and
culture. (Give example(s) where possible.)
Y/N
Yes
Action from last year:
None
Comments:
Information from wider governance system cascaded to Trust and Clinical
Group leadership teams to be discussed at the relevant Patient Experience /
Quality and Safety committees and recommendations and actions fed up to
the Quality, Safety & Performance Board Committee.
Action for next year:
None
1D(ix) Systems are in place to review professional standards arrangements for all healthcare professionals with actions to make
these as consistent as possible (Ref Messenger review).
Action from last year:
None
Comments:
Action for next year:
None
1E – Employment Checks
1E(i) A system is in place to ensure the appropriate pre-employment background checks are undertaken to confirm all doctors,
including locum and short-term doctors, have qualifications and are suitably skilled and knowledgeable to undertake their
professional duties.
Y/N
Yes
Action from last year:
None
Comments:
Pre-employment checks undertaken as part of the Trac system checklist
including identity, criminal record, work health, professional registration and
qualification, right to work, and employment history and references.
Additionally, ESR-IAT occurs where they have previously been employed within
the NHS; we also request and review previous appraisals on appointment. All
overseas doctors undergo an induction appraisal within the first three months
which enables learning and development requirements to be assessed.
Action for next year:
None
1F – Organisational Culture
1F(i) A system is in place to ensure that professional standards activities support an appropriate organisational culture, generating
an environment in which excellence in clinical care will flourish, and be continually enhanced.
Y/N
Yes
Action from last year:
None
page 17
Comments:
Right to be accompanied for all clinicians attending formal meetings;
signposting of self-help services to employees; ability for clinicians to ask a
member of staff to provide pastoral care, mentorship and personal staff who
will be support. All managers and directors who are involved in undertaking
investigations or sitting on disciplinary/capability panels or appeals panels shall
have undertaken formal equal opportunities training prior to undertaking such
duties. Case Managers, Case Investigators and Panel Members should be
trained in the operation of the conduct, capability and ill health procedures.
Training update in both is required every 3 years.
Action for next year:
None
1F(ii) A system is in place to ensure compassion, fairness, respect, diversity and inclusivity are proactively promoted within the
organisation at all levels.
Y/N
Yes
Action from last year:
None
Comments:
Work is currently being undertaken to assess the medical workforce in line
with the protected characteristics of doctors involved in an ongoing process
and GMC referrals, and those who have deferral recommendations made to
the GMC. Work will shortly commence to reduce the number of unknown and
not declared ethnicity information held on ESR to allow for more meaningful
figures.
Action for next year:
None
1F(iii) A system is in place to ensure that the values and behaviours around openness, transparency, freedom to speak up (including
safeguarding of whistleblowers) and a learning culture exist and are continually enhanced within the organisation at all levels.
Y/N
Yes
Action from last year:
None
Comments:
MFT has a Freedom to Speak Up Guardian and a Deputy Guardian, to provide
confidential, impartial support and advice to staff, students or volunteers who
need to speak up. Additionally, there is a network of over 100 Freedom to
Speak Up Champions supporting the Guardians. These are staff members who
have volunteered to help individuals raise concerns routinely and effectively
using existing routes, processes, and leadership structures. This is alongside
their usual role at MFT and help to raise awareness of Freedom to Speak Up by
being visible and accessible to staff. A programme of training exists for all
levels of staff to support this: ‘Speak Up’ - Core Training for all Workers
Action for next year:
None
1F(iv) Mechanisms exist that support feedback about the organisation’ professional standards processes by its connected doctors
(including the existence of a formal complaints procedure).
page 18
Y/N
Yes
Action from last year:
None
Comments:
MHPS policy ratified by staff representatives at JLNCC. Policy contains appeals
processes. Grievance policy in place to raise any concerns. Regular meeting
with GMC ELA to discuss cases and ensure these are handled consistently.
Action for next year:
None
1F(v) Our organisation assesses the level of parity between doctors involved in concerns and disciplinary processes in terms of
country of primary medical qualification and protected characteristics as defined by the Equality Act.
Y/N
Yes
Action from last year:
Undertake Medical Workforce Race Equality Standard (MWRES) analysis
Comments:
Work is currently being undertaken to assess the medical workforce in line
with the protected characteristics of doctors involved in an ongoing process
and GMC referrals, and those who have deferral recommendations made to
the GMC. Work will shortly commence to reduce the number of unknown and
not declared ethnicity information held on ESR to allow for more meaningful
figures.
Action for next year:
None
1G – Calibration and networking
1G(i) The designated body takes steps to ensure its professional standards processes are consistent with other organisations
through means such as, but not restricted to, attending network meetings, engaging with higher-level responsible officer
quality review processes, engaging with peer review programmes.
Y/N
Yes
Action from last year:
None
Comments:
RO Networks attended by RO, Associate CMOs for Appraisal and Professional
Matters, and the Head of CMO Programmes. Quarterly assurance meetings are
held with two main private providers to discuss any issues.
Action for next year:
None
page 19
Section 2 – metrics
Year covered by this report and statement: 1 April 2024 – 31 March 2025 .
All data points are in reference to this period unless stated otherwise.
The number of doctors with a prescribed connection to the designated body on the last day
of the year under review
2,676
Total number of appraisals completed
2,657
Total number of appraisals approved missed
99
Total number of unapproved missed
1
The total number of revalidation recommendations submitted to the GMC (including
decisions to revalidate, defer and deny revalidation) made since the start of the current
appraisal cycle
570
Total number of late recommendations
2
Total number of positive recommendations
522
Total number of deferrals made
48
Total number of non-engagement referrals
0
Total number of doctors who did not revalidate
0
Total number of trained case investigators
98
Total number of trained case managers
6
Total number of concerns received by the Responsible Officer5
35
Total number of concerns processes completed
13
Longest duration of concerns process of those open on 31 March (working days)
13,500
Median duration of concerns processes closed (working days)6
170
Total number of doctors excluded/suspended during the period
4
Total number of doctors referred to GMC
1
Total number of appeals against the designated body’s professional standards processes
made by doctors
0
Total number of these appeals that were upheld
0
Total number of new doctors joining the organisation
589
Total number of new employment checks completed before commencement of employment
3,534
Total number claims made to employment tribunals by doctors
0 new
3 open
Total number of these claims that were not upheld7
0
Section 3 – Summary and overall commentary
This comments box can be used to provide detail on the headings listed and/or any other detail not included elsewhere in this
report.
General review of actions since last Board report
The following actions from last year have been completed:
• Ensure SPA allocation across the trust is sufficient for number of appraisals that are required
• Increased number of ASPAT reviews carried out and results fed back into the appraiser training process
• Ensure all recommendations are carried out on time and deferrals are requested earlier if necessary
5 Designated bodies' own policies should define a concern. It may be helpful to observe https://www.england.nhs.uk/publication/a-practical-guide-for-
responding-to-concerns-about-medical-practice/, which states: Where the behaviour of a doctor causes, or has the potential to cause, harm to a patient
or other member of the public, staff or the organisation; or where the doctor develops a pattern of repeating mistakes, or appears to behave persistently
in a manner inconsistent with the standards described in Good Medical Practice.
6 Arrange data points from lowest to highest. If the number of data points is odd, the median is the middle number. If the number of data points is even,
take an average of the two middle points.
7 Please note that this is a change from last year's FQAI question, from number of claims upheld to number of claims not
upheld".
page 20
• Undertake MWRES analysis
Actions still outstanding
• Ensure Appraisal and Revalidation policy is ratified and distributed accordingly
• Finalise peer review arrangements
Current issues
A key challenge for medical appraisal is the timely allocation of appraisers; this can lead to a delay in appraisals
being held. It is currently Trust policy and NHSE guidance that appraisers are allocated rather than self-selected,
helping to prevent bias in the system and doctors being unable to find an appraiser. The process of allocating
appraisers by Clinical Groups still needs embedding and the onus is often still being pushed back to individuals
Actions for next year (replicate list of ‘Actions for next year’ identified in Section 1):
• Ensure Appraisal and Revalidation policy is ratified and distributed accordingly
• Finalise peer review arrangements
Overall concluding comments (consider setting these out in the context of the organisation’s achievements,
challenges and aspirations for the coming year):
Summary of key points:
• At the end of the last appraisal year (31 March 2025), MFT had 2,757 doctors with a prescribed
connection plus an additional 81 dentists requiring an MFT appraisal
• 96.4% of connected doctors had an appraisal for the 2024-2025 appraisal year
• appraisers were rated as Very Good or Good by 98.1% of appraisees who submitted feedback
• the process for allocating appraisers by Clinical Groups require significant improvement in ownership and
timeliness
page 21
Section 4 – Statement of Compliance
The Board/executive management team have reviewed the content of this report and can confirm the organisation is compliant
with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013).
Signed on behalf of the designated body
[(Chief executive or chairman (or executive if no board exists)]
Official name of the
designated body:
Manchester University NHS Foundation Trust
Name:
Mark Cubbon
Role:
Chief Executive
Signed:
Date:
Name of the person
completing this form:
Cameron Chandler
Email address:
cameron.chandler@mft.nhs.uk
page 22
Public Board of Directors
Wednesday 1st October 2025
Paper title:
Learning from Deaths and Mortality Indicators
Agenda
Item
11.4
Presented by:
Dr Sohail Munshi, Joint Chief Medical Officer
Prepared by:
Dr Dare Seriki, Associate Chief Medical Officer, Q&S
Meetings where content has
been discussed previously
Quality & Safety Management Committee
TLTC
Purpose of the paper
Please check one box only:
☐ For approval
☒ For discussion
☐ For support
Executive summary / key messages for the meeting to consider
In 2024/2025, there were 3,187 inpatient deaths, from 348,736 qualifying superspells. (A superspell
refers to a period of continuous care for a patient within a hospital setting. This includes all the time a
patient spends in the hospital, from admission to discharge.) This data helps in calculating the crude
mortality rate and understanding the overall performance and quality of care provided by the hospital
There were 4,991 deaths for patients who died during an inpatient stay or within 30 days of discharge.
This represents a crude mortality rate of 0.9%. In 2023/2024, the crude mortality rate was 1.0%, there
were 3,188 deaths from 331,102 superspells. In 2022/2023, the crude mortality rate was 1.2%, there were
3,424 deaths from 284,612 superspells. (See Figure 1)
Figure 1 – In-hospital mortality
The Summary Hospital-level Mortality Indicatory (SHMI) is a measure used to assess hospital mortality
rates. It includes deaths that occur during an inpatient stay or within 30 days of discharge. The SHMI
does not adjust for patient deprivation or frailty, which distinguishes it from other mortality measures like
the Hospital Standardised Mortality Ratio (HSMR)
page 1
Currently the SHMI for MFT is within normal limits at 1.05. However, the SHMI for NMGH is at the
upper limit of normal at 1.17
There are robust plans to harmonise the Learning from Deaths processes across MFT to maximise and
share learning
Recommendation(s)
The Board of Directors is asked to note:
•currently the MFT SHMI is within normal limits 1.05. The SHMI for all three sites (MRI, NMGH and
Wythenshawe hospital) is within normal expected confidence levels however the SHMI for NMGH is
at the upper limit of normal at 1.17
•development and upgrades to the Mortality Portal to allow better review of Mortality and SJR data
•roll out Telstra Dr Foster Training to Clinical Groups to allow better interrogation and review of
Mortality Data
•there are robust plans to harmonise the Learning from Deaths processes across MFT to maximise
and share learning
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐Yes (please set out in your report what action
has been taken to address this)
☒No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☒
LHL objective 2
☒
HQSC objective 1
☒
HQSC objective 2
☐
HQSC objective 3
☒
PEW objective 1
☐
PEW objective 2
☐
VfP objective 1
☒
VfP objective 2
☐
R&I objective 1
☐
R&I objective 2
☐
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks: n/a
Care Quality Commission
domains
Please check all that apply
☒Safe
☒Effective
☒Responsive
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
n/a
page 2
Main report
1. Introduction
Learning from Deaths processes are important for hospitals because they help identify avoidable
factors in patient care, improve safety and prevent future harm. They foster accountability, support
transparency and drive continuous quality improvement in clinical practice
A CQC review in December 2016 Learning, candour and accountability: a review of the way trusts
review and investigate the deaths of patients in England found some providers were not giving
learning from deaths sufficient priority and so were missing valuable opportunities to identify and
make improvements in quality of care
In March 2017, the National Quality Board (NQB) introduced new guidance for NHS providers on
how they should learn from the deaths of people in their care
The MFT Learning from Deaths Group (LfD Group) has reviewed its Terms of Reference and
developed a sub group to support the harmonisation and standardisation of LfD across Clinical
Groups and MFT as a whole
The main aims of the LfD are
1. deliver harmonised LfD process for MFT
2. improve how the different Clinical Groups and MFT engage with and support bereaved
families/carers
3. improve the learning from deaths of service users with learning disabilities or serious mental
illness
4. improve the recording of information about patient deaths and sharing of this between different
Clinical Groups, hospital sites and divisions to learn from review of the care provided to patients
who die
5. improve the quality and consistency of investigations into patient deaths
2. Current mortality indices
There are multiple indices that can be used to analyse mortality in a healthcare organisation
o Summary Hospital-level Mortality Indicatory (SHMI) analysis
o Hospital Standardised Mortality Ratio (HSMR)
o Crude and expected mortality -v- peers
o Charlson coding depth by diagnosis group, MCS and site – the Charlson coding depth refers to
the number of secondary diagnosis codes recorded for each patient in the hospital data
o Elixhauser Bottle Comorbidity score – this is a clinically validated tool used to evaluate the
overall burden of a patient’s comorbid conditions derived from diagnostic codes
o Comorbidity trend
o Prevalence of R codes as a primary diagnosis group, MCS and site
o Demographics and coding trends of deceased patients
o Cumulative Sum Control Chart (CUSUM) – a statistical method used to monitor change over
time. It tracks performance by accumulating small deviations from an expected average such as
expected mortality rates
2.1. Summary Hospital-level Mortality Indicatory (SHMI)
Currently, the MFT SHMI is within normal limits 1.05. The SHMI for all three sites (MRI, NMGH
and Wythenshawe Hospital) is within normal expected confidence levels however, the SHMI for
NMGH is at the upper limit of normal at 1.17 (Figure 2)
page 3
Figure 2 MFT SHMI January – December 2024
North Manchester General Hospital currently reports the highest expected mortality rate, crude
mortality rate, and relative risk within MFT. These figures are influenced by the high levels of
deprivation and patient frailty in the North Manchester population – factors that are not adjusted
for within the SHMI model. North Manchester also provides a greater provision of in-hospital
palliative care, which is also not included in the risk calculation for patients. See Figure 3 for
site comparison
Figure 3a Site Comparison – NMGH records the highest expected mortality
page 4
Figure 3b Site Comparison – NMGH records the highest crude rate within the HSMR
Figure 3c Site Comparison – NMGH records the highest relative risk of the three sites
The higher SHMI, crude mortality rates, and relative risk at NMGH are likely driven by a greater
proportion of patients on palliative care pathways, higher levels of comorbidity and increased
admissions from the most deprived areas. NMGH reports a lower proportion of spells in the
‘Symptoms and Signs’ chapter comparted to MFT and regional peers. Additionally, it records a
slightly higher proportion of spells with an Elixhauser-Bottle comorbidity score of 0 or less than
MFT, though this remains above regional and national averages
page 5
An Elixhauser-Bottle comorbidity score of 0 or less indicates a relatively low comorbidity
burden. The Elixhauser comorbidity index, developed by Elixhauser et al., is a system for
measuring the overall severity of a patient's comorbidities. A score of 0 suggests the absence or
minimal presence of the 30 comorbidities included in the index. A negative score, while less
common, indicates an even lower comorbidity burden compared to a score of 0. See 2.6
Conversely, NMGH shows a significantly higher proportion of spells with a score of 20+, as well
as a greater proportion of superspells (patients aged 75+) with recorded frailty, compared to
both regional and national benchmarks. See Figure 4
Figure 4 Coding and case mix at NMGH
NMGH is completing a Deep Dive into their deaths to ensure there are no unseen reasons
accounting for the increased SHMI and HSMR. This will be complete by end of October 2025
2.2. Hospital Standardised Mortality Ratio (HSMR)
The HSMR for MFT continues to be within expected limits and had demonstrated a high degree
of consistency over the last 12 months. The HSMR is currently at 80.8, varying between 80.8
and 83.4 over the past two years. The relative risk for NMGH is higher than other sites,
currently 84, varying between 84 and 89.8 over the past two years. The relative risk for MRI is
currently 78.9, varying between 78.6 and 81.6. Wythenshawe is currently 80.5, varying
between 80.5 and 84.8 (Figure 5)
page 6
Figure 5 MFT HSMR
2.3. Standardised Mortality ratio trend
The HSMR and SMR are consistently below 1.0, this is reassuring and MFT has the third lowest
HSMR in the North west
Figure 6a – Trust level comparison. MFT reports a HSMR which is significantly ‘lower than
expected’. In the regional peer group, MFT records the third lowest relative risk
page 7
Figure 6b – Regional average. MFT have followed a similar trajectory as the regional average
in relative risk. The Trust however has reported a significantly lower relative risk compared to
the regional average
SHMI and HSMR
HSMR (Hospital Standardised Mortality Ratio) and SHMI (Summary Hospital-level Mortality
Indicator) are both measures of hospital mortality but differ in scope and methodology.
HSMR captures only in-hospital deaths, while SHMI includes deaths within 30 days of
discharge. SHMI also lags behind HSMR due to the time required for data linkage with the
Office for National Statistics. A key distinction is that SHMI does not adjust for patient
deprivation or patient frailty, whereas HSMR incorporates both as part of its risk adjustment
model
Scope: HSMR measures in-hospital deaths only, while SHMI includes deaths within 30 days
of discharge
Methodology: HSMR uses 80% of diagnosis groups, while SHMI uses 100%. SHMI also
does not adjust for deprivation or patient frailty, whereas the HSMR does
In essence, SHMI is a broader metric, while HSMR focuses solely on in-hospital mortality
2.4. Crude mortality analysis
Crude mortality rate is the number of deaths occurring in hospital in any given year compared to
the number of people admitted for care in the same time period. The crude mortality rate can
then be described as the number of deaths for every 100 patients admitted. MFT’s crude
mortality is consistently low compared to regional peers (Figure 3) and published performance
tracks below the expected number of deaths for almost all the period between April 2021 and
page 8
March 2024 – the exception being the period September 2022 to February 2023 which coincides
with a similar rise in the Northwest
MFT crude mortality is the lowest of all Acute Trusts in the Northwest at 0.9%.
For Acute admissions MFT crude mortality is 2.0% (expected 2.3%) which is the third lowest in
the Northwest (See Figure 7a). For Elective admissions the crude mortality is 0.1% (expected
0.1%) which is the fourth lowest in the Northwest (See Figure 7b). The MFT 2.0% crude
mortality rate is the joint fourth lowest with Newcastle in the Shelford Group (Figure 8)
Figure 7a Crude mortality by NW Trust – Acute/Non-Elective admissions
page 9
Figure 7b Crude mortality by NW Trust – Elective admissions
Figure 8 Crude mortality rate Shelford Group
2.5. Charlson coding depth by diagnosis group
'Depth of coding' is defined as the number of secondary diagnosis codes for each record in the
data. A higher mean depth of coding may indicate a higher proportion of patients with multiple
conditions and/or comorbidities but may also be due to differences in coding practice between
trusts
Since Hive implementation Charlson coding depth has improved across the majority of MFT
sites and services. Virtually every diagnosis group exhibits the same trends; Charlson coding
has increased steadily since Hive implementation. As stated, the month of December 2022
page 10
had a high crude mortality rate. The overlap of low coding depth and high mortality rate in
December 2022 has negatively impacted the rolling SHMI score
Charlson depth has increased in all diagnosis groups since Hive implementation, apart from
injuries/fractures, and perinatal, where the Charlson depth has fallen in recent months
(comorbidity coding in neonates differs and the Charlson indicators do not include neonatal
comorbidities). However, there are only a small number of observed deaths in these diagnosis
groups, meaning that their recent coding decline may have little impact on the overall SMHI
score
2.6. Comorbidity trend
This analysis examines the percentage of all patients recorded with a complex Charlson
comorbidity score between 20 and 49. It confirms a general upward trend in the percentage of
patients in this most complex comorbidity band from September 2022 to August 2023. Before
this period, the Trust showed a general downward trend coinciding with the implementation of
Hive, likely due to the transition to a new system and the time needed to familiarise and
integrate the system. The current data suggests that MFT’s capture of complex comorbidities
is once again at its peak
Figure 9 – the chart examines the percentage of all activity with a 20+ Elixhauser Bottle
Comorbidity
2.7. Prevalence of R codes as the primary diagnosis
R codes indicate symptoms, signs, and abnormal clinical and laboratory findings, not
elsewhere classified, designated as ‘ill-defined’ or ‘unknown aetiology’ therefore, if the primary
diagnosis is classified under an R code, the SHMI score will assign a lower risk of death. A
patient who has an R code as a primary diagnosis and subsequently dies is therefore a low
risk of death in the SHMI and HSMR methodologies. As a result, the smaller the proportion of
patients with an R code as a primary diagnosis, the more likely the SHMI and HSMR scores
will improve
The proportion of R codes has decreased since Hive implementation, across each site. This
should have a positive impact on the SHMI score (Figure 10)
page 11
Figure 10 – the trend analysis shows a decline in the percentage of patients with a primary
diagnosis in the signs or symptoms chapter
2.8. Demographics and coding trends of deceased patients
Charlson depth and average score per deceased patient declined immediately after Hive
implementation, due to the change in methodology, but they have been increasing consistently
since Hive implementation. Higher Charlson scores contribute to a greater likelihood of
expected death in the SMHI score. Observing an increase in Charlson scores in deceased
patients is therefore likely to have a positive impact on the SHMI score, by bringing expected
deaths and actual deaths in line with each other
Age is a factor contributing to the SHMI score, such that older patients are assigned a higher
likelihood of death. There is no consistent rend in the average age of deceased patients since
Hive implementation, meaning we can rule out this factor as negatively impacting the SHMI
2.9. CUSUM
There were no CUSUM alerts for the Trust’s HSMR or SMR, though alerts were reported for
lower respiratory disease and investigated further by the WTWA mortality review group
3. MFT Mortality Portal
The Hogan score is a measure used to assess the avoidability of deaths in a hospital setting. It
ranges from 1 to 6, with each score representing a different level of avoidability:
• Score 6: Definitely not avoidable
• Score 5: Slight evidence of avoidability
• Score 4: Possibly avoidable but not very likely (less than 50:50)
• Score 3: Probably avoidable (more than 50:50)
• Score 2: Strong evidence of avoidability
• Score 1: Definitely avoidable
Currently the mortality portal is not fit for purpose, but plans are in place with the Data Engineering
Team to upgrade the portal and allow appropriate interrogation of metrics to slice and dice the data.
This is key to moving things forward for the Trust
page 12
3.1. Performance assessment data – April 2024 – March 2025
Hogan Score
Score 6
80.5 % of deaths reviewed were found definitely not avoidable.
Score 5
13.3% of deaths reviewed had slight evidence of avoidability.
Score 4
4.1% of deaths reviewed were found to be possibly avoidable.
Score 3
1.3% of deaths reviewed were found to be probably avoidable
Score 2
2 deaths reviewed were found to have strong evidence of avoidability
Score 1
2 deaths reviewed were found to be definitely avoidable
3.2. Paediatric deaths
There were 82 paediatric deaths, and 53 mortality reviews were completed.
Key themes were:
o lack of guidelines for Complex burns patients and management of orbital compartment
syndromes.
o communication between colleagues, consultant to consultant discussion and Consultant
oversight
o delays in attempting intraosseous access and transfer to critical care
o challenges in resolving conflicts between clinical staff and parents
o ECG interpretation
o advance Care Planning
3.3. Gynaecology deaths
There were twelve patients who died whilst receiving care from the Division of Gynaecology.
However, in two patient deaths the patients were receiving shared care and mortality reviews
were completed by the principal speciality. A further death occurred at home and was an
expected death from progression of disease
4. Conclusion and next steps
o Detailed analysis of mortality indices has confirmed that the Summary Hospital-level Mortality
Indicator (SHMI) has remained in the ‘as expected’ range since April 2016; the SHMI is at the
upper limit of normal for NMGH. A Deep Dive is being undertaken
o The crude mortality and relative risk are higher for NMGH than other sites and regional
peers. This appears to be due to more patients with complex comorbidities, a higher number
of patients over 75 and frail patients and significantly higher levels of deprivation amongst the
North Manchester patient cohort, which is not accounted for in the SHMI methodology
page 13
Public Board of Directors
Wednesday 1st October 2025
Paper title:
Management of Never Events
Agenda
Item
11.5
Presented by:
Professor Kimberley Salmon-Jamieson, Interim Deputy
Chief Executive and Chief Nursing Officer
Dr Sohail Munshi, Joint Chief Medical Officer
Prepared by:
Dr Beverley Fearnley, Director of Clinical Governance
Meetings where content has
been discussed previously
N/A
Purpose of the paper
Please check one box only:
☐For approval
☐For discussion
☒For support
Executive summary / key messages for the meeting to consider
Since April 2025, the Trust has reported eight Never Events
•NMGH: Trafford Trauma and Orthopaedics: Left-sided femoral component inserted into the
right limb (wrong implant/prothesis)
•CSS Anaesthetics: Central line guidewire retained post-surgery (retained foreign object)
•CSS Anaesthetics: Wythenshawe Pain Clinic: Wrong side block in pain clinic (wrong site
surgery)
•CSS Anaesthetics: MRI Theatres: Wrong side block during elbow replacement (wrong site
surgery)
•CSS Critical Care: MRI ICU: Wrong side drain insertion (wrong site surgery)1
•WTWA: Cardiology Cath Lab at MRI: Wrong size stent inserted (wrong implant/prothesis)
Two additional Never Events were reported in August 2025
•SHCG Maternity (ORC): Retained surgical tampon (retained foreign object)
•RMCH: North Manchester Paediatric Ward: Misplaced nasogastric tube (misplaced
naso/orogastric tube)
Given the additional incidents in the past month, an enhanced response plan has been
developed. This builds on
1. initial safety actions taken as an immediate response to the Never Events
2. additional Trust wide actions that can be taken to enhance our overall response
3. incident-specific recommendations that are flowing out of the PSIIs relating to the Never
Events – many of these are currently under development and will be updated as the PSII
recommendations are responded to
1 There is ongoing discussion about whether this classifies as a Never Event due to the prime causal factor being a
‘flipped’ x-ray
page 1
Those actions that will take us ‘further faster’ are centred around a number of key themes
which were discussed in depth at the first Task and Finish Group meeting, including
• the need to understand our incident profiles (specifically relating to Never Events or
incidents that align to the Never Event categories without meeting the threshold for
reporting) and therefore where to target interventions to have the greatest impact outside of
the specific incidents being reviewed
• anecdotal reports from senior consultants, senior nurses and AHPs in a number of different
forums that would indicate that awareness of recent Never Events across clinical teams is
variable and therefore lessons are not being shared consistently which may prevent future
occurrences
• anecdotal reports that checklists do not always support workflow in practice and are seen as
a barrier rather than a supportive measure – this highlighted the need to move ‘further
faster’ in ensuring that procedural checklists within HIVE are procedure specific and have
been created with the relevant clinical team
• anecdotal reports that there is variability in safety culture across sites, services and teams
with instances of lack of leadership by senior clinicians in relation to safety processes, lack
of leadership by senior clinicians in relation to safety processes, lack of perceived ability to
speak up and lack of engagement with safety processes all being cited as examples of
where the safety culture is not as strong as we would wish; as part of the response to this,
the Task and Finish Group purposes to undertake a baseline survey and targeted
observations to understand where the greatest opportunities to influence this are
Governance and oversight of the plan is via a newly established Invasive Procedures Safety
Oversight Task and Finish Group which will report into Quality and Safety Management
Committee
The Trust is working with NHS England who have confirmed that they are satisfied with the
robustness and appropriateness of our plan, and we are actively seeking out opportunities to
collaborate further in this area, in anticipation of the potential publication of new Never Event
guidance in the coming weeks
Recommendation(s)
The Board of Directors is asked to:
• take assurance from the proposed enhanced Never Event response plan and associated
governance arrangements
• take assurance from ongoing engagement with the central NHSE Patient Safety team
• be aware of future plans to partner with the NHSE Patient Safety team to test embedding of
any new approach to Never Events post-publication of the refreshed framework
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐ Yes (please set out in your report what action
has been taken to address this)
☒ No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
page 2
LHL objective 1
☐
LHL objective 2
☐
HQSC objective 1
☐
HQSC objective 2
☒
HQSC objective 3
☐
PEW objective 1
☐
PEW objective 2
☐
VfP objective 1
☐
VfP objective 2
☐
R&I objective 1
☐
R&I objective 2
☐
Good Governance
☐
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks: n/a
Care Quality Commission
domains
Please check all that apply
☒ Safe
☒ Effective
☒ Responsive
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
• Regulation 17
Main report
1. Background and context
Since April 2025, the Trust has reported eight Never Events, of which the following have
previously been reported to TLTC
o NMGH: Trafford Trauma and Orthopaedics: Left-sided femoral component inserted
into the right limb (wrong implant/prothesis)
o CSS Anaesthetics: Central line guidewire retained post-surgery (retained foreign
object)
o CSS Anaesthetics: Wythenshawe Pain Clinic: Wrong side block in pain clinic (wrong
site surgery)
o CSS Anaesthetics: MRI Theatres: Wrong side drain insertion (wrong site surgery)2
o WTWA: Cardiology Cath Lab at MRI: Wrong size stent inserted (wrong
implant/prothesis)
Two additional Never Events were reported in August
o SHCG Maternity (ORC): Retained surgical tampon (retained foreign object)
o RMCH: North Manchester Paediatric Ward: Misplaced nasogastric tube (misplaced
naso/orogastric tube)
Details of the Never Events and immediate actions can be found in Appendix A
In all cases, there was no patient harm and patients and families were appropriately and
compassionately engaged through provision of apologies, explanations and ongoing
engagement in the development and conduct of investigations. At the same time,
colleagues who are also impacted have been provided with support following the incidents
2 There is ongoing discussion about whether this classifies as a Never Event due to the prime causal factor being a
‘flipped’ x-ray
page 3
In all cases, a full Patient Safety Incident Investigation (PSII) has been commissioned as
there is the potential for significant learning. This is in line with the national criteria as Never
Events are classified as a national priority
Whilst assurance can be taken that there are no areas which have seen repeated events
and that no harm has come from any of these events to date, there is risk associated with
this continued relatively high level of occurrence, namely
Safety/quality risk – if we do not address the underlying causes on the increase in the
occurrences of similar incidents, then we miss the opportunity to develop stronger safety
barriers, change practice, systems and processes resulting in a continued likelihood of
incidents occurring, potentially including those that may cause a higher degree of patient
harm
Regulatory risk - if NHSE and the CQC are not assured that MFT has robust arrangements
for the prevention of avoidable incidents then they may take additional regulatory steps to
seek assurance, resulting in impacts on SOF 3 exit criteria and enhanced oversight from the
CQC
Reputational risk – if the ongoing occurrence of Never Events contributes to heightened
public awareness of potential safety concerns at MFT then there may be adverse publicity
resulting in decreased partner, patient and staff confidence
Workforce risk – if the Trust’s approach to understanding and mitigating the future
likelihood of further similar incidents is incongruent with messaging about compassionate
engagement and learning then staff will not feel safe to continue to report such incidents
and will not feel empowered to act to reduce their likelihood, resulting in decreased staff
morale and reduced engagement in future safety initiatives
2. Risk mitigation and enhanced response
In response to the increase in reported Never Events, a number of steps have been taken
as described below. These aim to ensure that there is a robust, proportionate and
responsive approach to reducing the likelihood of future similar occurrences
2.1. Establish an Invasive Procedures Safety Oversight Task and Finish Group
This Task and Finish Group will provide high level direction and focused oversight to the
Never Event response plan. The group met first on 27 August. It met weekly initially,
moving to a reduced frequency of once a fortnight once the plan was fully developed
and enacted. Once the plan is firmly embedded, oversight will move back to the Patient
Safety Group. The outcomes from this group will report into the Quality and Safety
Management Committee
Membership of the group includes multidisciplinary representation including medical,
AHP and nursing leadership as well as specialist input from the Director of Quality and
Safety, our Trust Patient Safety Specialist and our Digital teams
2.2. Develop links with the NHS England Patient Safety team and with other Trusts to
identify learning
A number of discussions have been held since 11 August with members of the NHS
England Patient Safety team. These discussions have focused on exploration of MFT’s
page 4
approach to Never Events, check and challenge of MFT’s plans, insight into national
profiles and approaches and opportunities to work collaboratively to continue to improve
our response to Never Events
The outcome of these discussions has been that NHSE have provided us with
confirmation that they are assured that the approach we are taking to managing our
Never Events is robust and in line with their expectations. This has been escalated
through their own governance structures/reporting lines. They have agreed to stay
connected with the Invasive Procedures Safety Oversight Task and Finish Group as it
develops and implements its plans, and as the outcomes of the Patient Safety Incident
Investigations (PSIIs) are identified, providing the Trust with independent check and
challenge of what we are doing
There is also an opportunity, should the new Never Event Framework be published as
planned in the near future, to work in partnership with NHS England to test the new
approaches the framework describes
The Director of Quality and Safety has connected with Barts Health NHS Trust to
understand the work they have been doing in the 12 months following their own recent
run of Never Events. This feedback will be used to check and challenge the Never
Event response plan being put in place
2.3. Learning from previous Never Events and near misses – both internally and
nationally
A thematic review of National published data on Never Events has demonstrated that
the types of Never Events MFT is currently seeing, and has seen over the past five
years, is in line with the national picture of Never Event profiles. This profile indicates
that the majority of incidents reported as Never Events fit into categories where it is
acknowledged nationally that safety processes used to prevent these incidents do not
meet the national definition of ‘strong systemic barriers3’ and therefore the
implementation of these processes still leaves opportunity for errors and mistakes to
happen leading to such incidents occurring. This has been explored in previous papers
including the Never Event Annual report received by Quality, Safety and Performance
Board Committee in June 2025 and is fundamental to NHSE’s evolving approach
around the response to Never Events
In terms of MFT’s near miss profile, over the past three years the majority of near
misses that are recorded in categories associated with Never Events relate to issues
with completion of surgical checklists. This means that when considering which actions
may make the most impact, how we ensure that our safety barriers, including checklists,
are being used reliably and effectively is a key area of focus
A review of previous MFT Never Event investigations and action plans is also currently
underway. This has highlighted a number of key areas for consideration. The review
recognised the limitations of pre-PSIRF approaches which depended on Root Cause
Analysis rather than looking at systems, environments, and processes, and identified
that new ways of conducting investigation following the PSII methodologies will support
us in identifying solutions that apply to both specific areas and teams, and also where
3 The national definition of Never Events, defines ‘strong systemic barriers’ as barriers that are successful, reliable and
comprehensive safeguards or remedies – for example, a uniquely designed connector that stops a medicine being given
by the wrong route
page 5
the learning can be amplified and used to create an action plan that looks at key areas
of improvement Trust wide as part of the Trust Quality and Safety Delivery Plan
2.4. Going further, faster
The Invasive Procedures Safety Oversight Task and Finish Group has developed a plan
which builds on the following
o initial safety actions taken as an immediate response to the Never Events
o additional Trust wide actions that can be taken to enhance our overall response
o incident specific recommendations that are flowing out of the PSIIs relating to the
Never Events – many of these are currently under development and will be updated
as the PSII recommendations are responded to
Those actions that will take us ‘further, faster’ are centred around a number of key
themes which have been discussed in depth at the Task and Finish Group meeting.
These are largely based on anecdotal evidence as the PSIIs that will provide in depth
evidence are at different stages of completion, however they provide opportunities to
enhance our initial safety actions in anticipation of the more targeted recommendations
coming from the PSIIs. The themes that have been identified as providing opportunities
for us to enhance our response further include
o the need to understand our incident profiles (specifically relating to Never Events or
incidents that align to the Never Event categories without meeting the threshold for
reporting) and therefore where to target interventions to have the greatest impact
outside of the specific incidents being reviewed
o anecdotal reports from senior consultants, senior nurses and AHPs in a number of
different forums that would indicate that awareness of recent Never Events across
clinical teams is variable and therefore lessons are not being shared consistently
which may prevent future occurrences
o anecdotal reports that checklists do not always support workflow in practice and are
seen as a barrier rather than a supportive measure – this highlighted the need to
move ‘further, faster’ in ensuring that procedural checklists within HIVE are
procedure specific and have been created with the relevant clinical team
o anecdotal reports that there is variability in safety culture across sites, services and
teams; as part of the response to this, the Task and Finish Group is undertaking a
baseline survey and targeted observations to understand where the greatest
opportunities to influence this are
Actions are assigned to each of these drivers and allocated to an action horizon of
immediate/short term (one – three months); medium term (four – nine months) or longer
terms (10+ months). The plan will be overseen initially by the Task and Finish Group,
reporting into Quality and Safety Management Committee, with the intent of transferring
this to the Patient Safety Group for business-as-usual oversight in due course
page 6
Background to Never Event performance
Position
Since the start of April 2025, the Trust has reported 8 Never Events. This is significant in the context of the previous year’s
performance where we only reported 3 for the entire year.
Appendix A
page 7
Never event update
Never event 1 – wrong implant / prothesis
Definition: Placement of an implant/prosthesis different from that specified in the procedural plan, either before or during the procedure. The incident is detected any time after the
implant/prosthesis is placed in the patient
On Friday, 11th April 2025, the North Manchester General Hospital Medical Director was emailed by a consultant employed within the Trauma and Orthopaedics (T&O) Managed
Single Service, advising that they had completed a right knee total replacement on 9th April 2025 at the Trafford Elective Surgical Hub. The consultant noted that a left-sided
femoral component had been inserted into the right limb. This error became apparent upon reviewing the post operative imaging. An incident was logged the same day, and
professional duty of candour was completed by the treating consultant. The patient is reported to be recovering well, and it has been agreed that there will be no changes to the
rehabilitation plan at this stage although this will continue to be reviewed in the consultant’s follow up clinic.
Draft recommendations - the draft response is currently going through Quality Assurance and Approvals
1. Review and standardise Trust-wide processes for conducting local safety checks in theatres, clearly outlining individual responsibilities and ensuring consistency across sites
2. Develop and implement a formalised “pause moment” protocol to be conducted between the surgeon and scrub nurse prior to implant insertion, with clear guidance on timing
and responsibility
3. Review and implement a standard layout for implant storage areas, ensuring left and right implants are separated on distinct levels and supported by colour-coded labelling to
reduce selection errors (Complete)
4. Include a dedicated section on implants in the theatre induction book, enhancing staff familiarity with implant types, storage protocols, and procedural workflows. This should
serve as a reference guide for new and existing staff
5. Ensure that theatre teams have access to clear documentation methods for noting implant requirements during surgery to reduce reliance on memory (Complete)
6. Define a cross-site surgical planning approach that considers familiarity with implant processes as part of case allocation decisions
7. Implement system enhancements within HIVE to actively flag implant mismatches when scanned against a patient’s record
8. Ensure continued alignment of HIVE with NatSSIPs2 standards, maintaining momentum on current workstreams and increasing focus on integrating national safety
guidelines
9. Continue to review MFT Safe Surgery and Procedures policy is updated and formally ratified before May 2026, incorporating current best practices, NatSSIPs2 guidance,
and standard processes across site
10. Review the feasibility of implementing a rotation system for theatre teams
page 8
Never Event 2 – retained foreign object post procedure
Definition: Retention of a foreign object in a patient after a surgical/invasive procedure.
On the 28th April 2025, a 68-year-old male underwent a laparoscopic liver resection. A
left-sided central venous line was inserted by the anaesthetic consultant under anaesthesia as is routine for this surgery. In the recovery room a
chest x-ray was performed as is routine following central venous line insertion. It was immediately identified that the guidewire was retained within
the line, still in the patient. The Consultant anaesthetist was informed and removed the wire and line in the recovery room.
The patient was informed in the recovery room by the consultant anaesthetist and apologies given. The has been no patient harm identified as a
result of this incident.
Immediate areas for further exploration included distractions during the procedure, use of checklists (including auto population) and use of a new
central line pack – recommendations currently being finalised.
Immediate safety actions undertaken
1. Shared at Trust-wide ACE Day on 30th April 2025 across the Anaesthetic team.
2. Support given to consultant anaesthetist involved
3. Share event with theatre teams via safety huddles across all sites
4. Shared at ODP meeting on 30th April 2025
5. Asked Hive Pathway Council to consider additional ‘wire removed’ prompt on central and arterial lines in Hive and remove the auto-population of
the wire removed box
6. Theatre team education around ‘sterile cockpit’ via practice based educators and safety huddles
Never event update
page 9
Never Event 3 - wrong implant/prosthesis
Definition: Placement of an implant/prosthesis different from that specified in the procedural
plan, either before or during the procedure. The incident is detected any time after
the implant/prosthesis is placed in the patient.
On the 4th May 2025, a patient was admitted to the MRI cardiology lab. As part of the procedure, a size 3x28mm stent was requested. The stent was inserted but only partially
inflated as appeared larger than requested. The stent was checked and identified that it was a 5x28mm stent.
As the stent was only partially inflated, there was no damage from this. Duty of Candour has been completed with the patient and no patient harm has been identified.
Draft recommendations - the draft response is currently going through Quality Assurance and Approvals
1. Storage: - Consideration to be given as to how the design of the storage can be used to help staff select the correct device in catheterisation labs. The storage of stents,
balloons and guidewires needs to be standardised across both catheterisation labs
2. Pause before implant: - Catheterisation labs should agree and introduce a pause before the implant (and balloon/guidewire) as a critical safety step when implants are
passed into the sterile field, as recommended in NatSSIPs2. This will require the buy-in and support of senior medical and nursing leadership to ensure best practice is
role-modelled and justified.
3. Implant verification: - To agree and standardise the checking process of implants (and balloons and stents) in both catheterisation labs, ensuring a clear expectation of
what is checked and by whom. This includes standardising training, role-modelling by senior staff, and regularly auditing checks to ensure compliance.
4. Storage: - The organisation needs to implement a process to identify high-risk items with a high consequence of selection errors. The risk reduction would include ways to
separate or remove similar-looking high-risk devices and how storage design can be used to help staff select the correct item
5. Pause before implant: - There is an ongoing risk at MFT that areas using implants have not included the specific implant verification steps as described in NatSSIPS2,
including the pause before implant. The organisation needs to address this risk while awaiting the completion and signing off of the current policy review
6. On-call working and fatigue: - There should be a trust-wide risk-based approach to the use of on-call working, which promotes ways to reduce fatigue as much as possible.
Insight from the actual activity levels in clinical areas should be used to identify areas with chronic high activity levels during on-calls and to allow an informed risk
assessment of the impact of staff fatigue on patient safety and staff well-being
Never event update
page 10
Never Event 4 - wrong side block
Definition: An invasive procedure performed on the wrong patient or at the wrong site (eg wrong knee, eye, limb). The incident is
detected at any time after the start of the procedure.
Includes: Wrong site block (including blocks for pain relief),
On the 6th of June 2025 an 80-year-old patient was admitted for elective surgery for a left total elbow replacement. The
consultant anaesthetist, anaesthetic trainee and anaesthetic practitioner performed the prep check block (stop before you block)
prior to the block. The correct site and mark were confirmed as the left elbow. The consultant anaesthetist administered the
peripheral block whilst the anaesthetic practitioner was completing the documentation on HIVE. The error was identified during
the positioning of the patient. The consultant escalated to colleagues for advice and the decision was made not to administer a
block to the correct site of surgery, but to administer multimodal analgesia. The surgery proceeded and went ahead with no
complications.
Immediate areas for further exploration include distractions in the theatre setting and use of LOCSIPs – recommendations
currently being finalised.
Immediate safety actions undertaken:
1. Supportive discussions taken place with staff members involved
2. Anaesthetic practitioners informed of incident and reminded of Prep Stop Block checks including requirement to visualise the
side of surgery mark and confirm this is the correct side to be blocked
Never event update
page 11
Never Event 5 wrong side block
Definition: An invasive procedure performed on the wrong patient or at the wrong site (eg wrong knee, eye, limb). The incident is
detected at any time after the start of the procedure.
Includes: Wrong site block (including blocks for pain relief),
The patient attended the Baguley Suite at Wythenshawe Hospital on 28th May 2025 for right side medial branch block diagnostic
injection at 3 lumbar vertebral levels (L3/4, L4/5, L5/S1). Team brief was completed at the start of the list at the same time as the
patient sign in. At the same time the theatre board was updated. The patient was then transferred to theatre. A read out loud time
out was completed, however this was not completed immediately before needle to skin. Lidocaine was administered to the skin
and then the 22G spinal needle was inserted to the left side L5/S1 level. The bupivacaine was then administered to the left
medial branch. At this point, the team notified the Anaesthetic Consultant of the incorrect site. An apology was offered to the
patient and the correct site procedure was subsequently completed as planned.
Immediate areas for further exploration include distractions in theatre and the importance of the timing and concentration of
individuals during safety checks – recommendations currently being finalised.
Immediate safety actions undertaken
1. Review and update the Safe Surgery Checklist
2. Supportive discussions taken place with staff members involved
Never event update
page 12
Never Event 6 chest drain inserted on the wrong side
Definition: An invasive procedure performed on the wrong patient or at the wrong site (eg wrong knee, eye, limb). The incident is detected at any
time after the start of the procedure.
91 year old patient had an emergency tracheostomy whilst an inpatient at the MRI. The patient had an x-ray following Nasogastric (NG) tube placement confirming position.
This x-ray demonstrated the NG tube was misplaced, and it was subsequently removed. The NGT had not been used. The patient then had a second nasogastric (NG) tube
inserted. The NG tube was again X rayed as per normal process. This x-ray showed what appeared to be a left sided pneumothorax (and correctly placed NGT). A chest
drain was inserted on the left side with the use of ultrasound to confirm laterality. The post drain insertion x-ray to confirm chest drain position showed that the drain was
placed in the left side, but the pneumothorax was now showing on the right side. Following a review of the images, the second chest x-ray, post NG tube insertion had been
inverted and was the incorrect way around (right to left).
Duty of candour has been completed with the patient and her family. No concerns raised by patient and family at this stage. Staff involved in Critical care are being supported
with a plan in place to support imaging colleagues on their return to work.
Immediate areas for further learning include; X-ray post NG tube insertion had been inverted and labelled L for left side. Discussion around the availability of the function
to “flip” Images as usually used mainly when reporting. Radiographer has to put on an anatomical marker, either at the time of image acquisition, or at the time of image
processing. The incorrect side not identified by the Artificial Intelligence (AI) system used in Imaging, Annalise. – recommendations currently being finalised.
Immediate safety actions undertaken
1. Support for staff in critical care and imaging provided
2. Trust communication sent out 15/8/25:
Not to touch mobile X-ray machines
Not to review films on the mobile X-ray machines
Always review X-rays on computer with GM PACS
Systematically review all chest X-rays - use Annalise Clinical Decision Support
Document X-ray interpretation in the patients notes in HIVE.
Never event update
page 13
Never Event 7 retained surgical tampon
Definition: Retention of a foreign object in a patient after a surgical/invasive procedure
Patient X gave birth to her daughter at Saint Mary’s ORC on 10th July 2025. This was an uncomplicated vaginal birth, however she experienced
perineal trauma and required suturing. This took place in the delivery room by a Tier 2 resident doctor and in line with Local Safety Standards for
Invasive Procedures (LocSSIP) and perineal suturing guidance, the swab count, inclusive of surgical tampon, was documented as checked and
correct by both the midwife and the doctor following the procedure. There is no documentation to suggest that a tampon was intentionally left in.
On 8th August, at 29 days post birth of her first baby, Patient X attended maternity triage following being seen by her GP with a concern of a vaginal
prolapse and protrusion. On review by a senior obstetrician following arrival in maternity triage, a surgical tampon was removed from her vagina.
Duty of candour has been completed with the patient. Support has been provided to Patient X, who is clinically well, had no signs of infection/sepsis
on review and has been discharged home with prophylactic antibiotics.
Immediate areas for further learning include; understanding of the use of safety processes in a non-theatre space; roles and responsibilities – the
Terrms of Reference were approved W/C 25th August 2025
Immediate safety actions undertaken
1. Supportive conversations with all staff involved
2. Snap shot audit of 3 months safer surgery checklist underway within maternity
3. Meeting with theatre matrons to support fresh eyes review of WHO checklist
4. Increased awareness (via safety huddles) of invasive procedures outside of theatre and role and responsibilities of all clinicians has been
shared across SM MCS divisions
5. Review of guidelines, training and audit
Never event update
page 14
Never Event 8: Misplaced naso-gastric tube
Definition: Misplacement of a naso- or oro-gastric tube in the pleura or respiratory tract that is
not detected before starting a feed, flush or medication administration.
Patient S is 10 years old. Admitted with chronic constipation, non compliance with oral medication. Has had surgical intervention for her constipation which was not
successful therefore, oral treatment was recommenced. S has LDA and sensory needs. On 17th August an NG tube was repassed after the original tube was vomited out
(days prior not immediately before) the procedure was challenging due to LDA and sensory needs. Tube was reportedly passed easily however, reported as some trauma on
insertion as S was so distressed, secured at 38cm, but initial aspirate could not be obtained. Doctors reviewed X-ray (no real-time reporting available); advised to advance
tube by 2cm, but tube could not be advanced further due to looping. Nurse flushed tube with up to 20mls water as 'was told in was in the stomach'. S coughed and flush was
stopped. Night staff attempted to secure tube, still unable to get pH <7, decided to let Summer rest due to distress. On 18th August, retesting revealed frank blood; repeat X-
ray showed tube in left main bronchus, not stomach, and tube was removed.
Duty of candour has been completed with the patient’s family. Observations showed no respiratory distress, only low-grade temperature since theatre.
Immediate areas for further learning include; Training for all clinical staff involved, understanding of existing processes and protocols, impact of environment on decision
making – the Terrms of Reference were approved W/C 25th August 2025
Immediate safety actions undertaken
1. The updated Policy has been uploaded to the policy hub and the link sent out to all staff.
2. Key safety messages regarding NG tube processes have been added to core huddles
3. A meeting has taken place with all senior nursing staff, to review local monitoring/ assurance processes.
4. A review of all actions relating to misplaced nasogastric tubes undertaken since 2019 with associated assurance
5. NG tube audit report analysis has been expedited and the senior nursing team are supporting the development of the actions.
6. E-learning for health e-learning training re x-ray interpretation is being shared with all medical staff - view to look at making mandatory for Paeds
7. Safety shout out in development to share widely.
8. Inclusion of NG tube safety as main subject of safety workstreams for national patient safety day in September
Never event update
page 15
Public Board of Directors
Wednesday 1st October 2025
Paper title:
MFT Core Standards Statement of Compliance
Agenda
Item
11.6
Presented by:
Vanessa Gardener, Chief Delivery Officer
Prepared by:
Nicky Shaw, EPRR Head of Service
Meetings where content has
been discussed previously
Purpose of the paper
Please check one box only:
☒ For approval
☐ For discussion
☐ For support
Executive summary / key messages for the meeting to consider
The minimum requirements that NHS-funded organisations must meet are set out in the Core
Standards. These standards are in accordance with the CCA 2004, the 2005 Regulations the
NHS Act 2006, the Health and Care Act 2022 and the Cabinet Office national resilience
standards.
Under the Civil Contingencies Act (CCA) 2004, Acute Providers are designated as
Category 1 Responders and underpinned legislation above. Levels of compliance are
measured set out in the table below. Last year the Trust achieved 93% building on the
previous year of 79%.
Full
Substantial
Partial
Non-Compliant
Compliant with all
standards
The organisation is 89-
99% compliant
The organisation is 77-
88% compliant
The organisation is
compliant with 76% or
less
Annual EPRR assurance is a statutory requirement requiring Board level sign off, and must
include:
• A formal Statement of Compliance
• An EPRR Action Plan (inc. Policies)
• The EPRR Core Standards Self-Assessment Spreadsheet with RAG ratings and
supporting evidence (Report)
This year our submission is on track to remain substantially compliant with a 2% increase to
95%.
page 1
Recommendation(s)
The Board of Directors are asked to:
•Note that Quality Safety Performance Board Committee have reviewed
the progress to
date and the on-going work to ensure MFT achieve substantial compliance by September
2025.
•Acknowledge the contents of the EPRR Policy and the Business Continuity Policy that
requires sign off by the Board. Included in the Policy, the Board agree the resources in
place, ensure full discharge of EPRR duties.
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐Yes (please set out in your report what action
has been taken to address this)
☒
No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☐
LHL objective 2
☐
HQSC objective 1
☒
HQSC objective 2
☐
HQSC objective 3
☐
PEW objective 1
☒
PEW objective 2
☐
VfP objective 1
☐
VfP objective 2
☐
R&I objective 1
☐
R&I objective 2
☐
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks:
•MFT/008229 – Corporate Risk – Risk of non-compliance
with the Civil Contingencies Act 2004
Care Quality Commission
domains
Please check all that apply
☒Safe
☒
Effective
☒Responsive
☐Caring
☒
Well-Led
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
•Civil Contingencies Act 2004
•NHS Core Standards for EPRR
•MFT Incident Response Plan v4.0
•NHSE EPRR Framework 2022
Main report
Progress Update on the Two-Year EPRR Improvement Programme (2024–2026)
page 2
The Trust EPRR work is currently midway through a two-year improvement programme (2024–
2026), as outlined in the previous Board submission. The annual Statement of Compliance
builds on last year’s progress, noting that the Trust remains on track to deliver the outcomes
agreed as part of the EPRR work Plan 2025.
Significant work has taken place to address historical data gaps and discrepancies in the
training records for on-call commanders. A renewed focus has been placed on ensuring all
individuals receive the required training and formal induction before joining the on-call rota. This
directly supports operational readiness and ensures alignment with national guidance.
In line with the minimum national occupational standards for Emergency Preparedness,
Resilience and Response (EPRR), EPRR is working to ensure that all incident response
personnel – including on call commanders and supporting roles meet the required competency
thresholds. This initiative is strongly aligned with the recommendations of the Manchester
Arena Inquiry, promoting a culture of continuous professional development and demonstrable
learning across the system.
To support this, the EPRR and Learning and Development teams have developed Personal
Development Portfolios (PDPs) for staff undertaking EPRR roles. The structure and process for
PDPs is nearing completion, with a formal launch and accompanying training scheduled for
November. This proposal was presented to the EPRR Group on 15 July 2025.
Since January 2025, the Trust has delivered over 21 exercises testing business continuity
plans, Trust-wide plans, and regional exercises. These include a variety of statutory and
assurance exercises, such as Exercise Polar Bear (Command Post), Exercise Gift (CBRN),
Exercise Leaf (Major Incident call cascade), Exercise Tempest (Winter Preparedness), and
Exercise Flashover (Live Trust-wide incident exercise).
Training has also been delivered to Tactical and Strategic Commanders, Functional Officers.
EPRR command post awareness sessions for Trustees, Estates and Facilities staff, and the
Digital team as well as over 16 new Loggists have been successfully trained and onboarded.
A full review of the Trust’s Business Continuity Management System (BCMS) commenced in
April 2025. This work is aimed at transforming current arrangements and delivering a more
robust approach to business continuity. Following a successful procurement process, the Trust
is implementing Continuity 2 (C2), a digital BCMS platform aligned to ISO 22301. This will
significantly strengthen organisational resilience and ensure that business continuity practices
meet national standards.
In summary, the Trust remains firmly on track with its improvement trajectory and is actively
addressing areas of partial compliance. Board support is now requested to endorse the annual
Statement of Compliance and approve this year’s submission.
The table overleaf summarises progress made against the Core Standards. Three standards
remain partially compliant, although significant progress has been made. These areas are now
rated as ‘amber – in progress’ with detailed work plans in place:
• Evacuation and Shelter (Standard 16)
• Business Continuity (Standards 46 and 47)
Domain Name Acute Core Standards (62) Fully Compliant
Governance
1, 2, 3, 4, 5, 6
6
Duty to Risk Assess
7, 8
2
page 3
Duty to Maintain Plans 9, 10, 11, 12, 13, 14, 15, 16, 17, 18,
19 10
Command and control 20, 21 2
Training and Exercise 22, 23, 24, 25 4
Response
26, 27, 28, 29, 30, 31,3 2
7
Warning and informing 33, 34, 35, 36 4
Cooperation
37, 38, 39, 43
4
Business Continuity 44, 45, 46, 47, 48, 49, 50, 51, 52, 53 8
Hazmat/CBRN 55, 56, 57, 58, 59, 60, 61, 62, 63, 64,
65, 66 12
The organisation is
89-99%
compliant
MFT Compliance Total for 2025 59 (95%)
2025 EPRR Submission Update
There will be no Deep Dive component included in this year’s EPRR assurance process.
However, it is important to note that the absence of a Deep Dive does not contribute to the
overall score and, therefore, will not impact the Trust’s compliance level.
The self-assessment and accompanying Statement of Compliance must be submitted by 30th
September 2025. The Trust Board is scheduled to review and approve the submission on 1st
October 2025, and this date will be formally recorded within the Statement. Appendix 1
provides governance requiring sign off by the Board.
The assurance process will follow the same format as in 2024, including a scheduled visit to the
Trust to support inspection discussions and review the submitted evidence. Following the
completion of all provider visits, the Integrated Care Board (ICB) will meet with Accountable
Emergency Officers (AEOs) at the Local Health Resilience Partnership (LHRP) on 24th
November 2025 to finalise and sign off the regional submission to NHS England.
Board sign off pathway:
Meeting Date Papers
EPRR Group – 15/07/2025 MFT EPRR Policy
MFT Business Continuity Policy
Core Standards Statement of Compliance
Includes:
EPRR Policy Statement (inc. Policy)
EPRR board report
EPRR work programme (inc. Policy)
EPRR Resource (inc. Policy)
Continuous improvement (inc. Policy)
Delivery Oversight Group – 24/07/2025
TLTC – 30/07/2025
QPSCB - 03/09/2025
Trust Board of Directors – 01/10/2025
page 4
page 5
Appendix 1 – Areas of compliance related to board sign off
2
Governance
EPRR Policy
Statement
The organisation has an overarching
EPRR policy or statement of intent.
This should take into account the
organisation’s:
• Business objectives and processes
• Key suppliers and contractual
arrangements
• Risk assessment(s)
• Functions and / or organisation,
structural and staff changes.
The policy should:
• Have a review schedule and version
control
• Use unambiguous terminology
• Identify those responsible for ensuring
policies and arrangements are updated,
distributed and regularly tested and
exercised
• Include references to other sources of
information and supporting documentation.
Evidence
Up to date EPRR policy or statement of
intent that includes:
• Resourcing commitment
• Access to funds
• Commitment to Emergency Planning,
Business Continuity, Training, Exercising
etc.
3
Governance
EPRR board
reports
The Chief Executive Officer ensures
that the Accountable Emergency
Officer discharges their responsibilities
to provide EPRR reports to the Board,
no less than annually.
The organisation publicly states its
readiness and preparedness activities
in annual reports within the
organisation's own regulatory
reporting requirements
These reports should be taken to a public
board, and as a minimum, include an
overview on:
• training and exercises undertaken by the
organisation
• summary of any business continuity,
critical incidents and major incidents
experienced by the organisation
• lessons identified and learning undertaken
from incidents and exercises
• the organisation's compliance position in
relation to the latest NHS England EPRR
assurance process.
Evidence
• Public Board meeting minutes
• Evidence of presenting the results of the
annual EPRR assurance process to the
Public Board
• For those organisations that do not have a
public board, a public statement of
readiness and preparedness activities.
4
Governance
EPRR work
programme
The organisation has an annual EPRR
work programme, informed by:
• current guidance and good practice
• lessons identified from incidents and
exercises
• identified risks
• outcomes of any assurance and
audit processes
The work programme should be
regularly reported upon and shared
with partners where appropriate.
Evidence
• Reporting process explicitly described
within the EPRR policy statement
• Annual work plan
page 6
5
Governance
EPRR
Resource
The Board / Governing Body is
satisfied that the organisation has
sufficient and appropriate resource to
ensure it can fully discharge its EPRR
duties.
Evidence
• EPRR Policy identifies resources required
to fulfil EPRR function; policy has been
signed off by the organisation's Board
• Assessment of role / resources
• Role description of EPRR Staff/ staff who
undertake the EPRR responsibilities
• Organisation structure chart
• Internal Governance process chart
including EPRR group
6
Governance
Continuous
improvement
The organisation has clearly defined
processes for capturing learning from
incidents and exercises to inform the
review and embed into EPRR
arrangements.
Evidence
• Process explicitly described within the
EPRR policy statement
• Reporting those lessons to the Board/
governing body and where the
improvements to plans were made
• participation within a regional process for
sharing lessons with partner organisations
page 7
Greater Manchester Local Health Resilience Partnership (LHRP)
Emergency Preparedness, Resilience and Response (EPRR) assurance 2025-2026
STATEMENT OF COMPLIANCE
Manchester Foundation Trust has undertaken a self-assessment against required areas of the
EPRR Core standards self-assessment tool.
Where areas require further action, Manchester Foundation Trust will meet with the LHRP to
review the attached core standards, associated improvement plan and to agree a process
ensuring non-compliant standards are regularly monitored until an agreed level of compliance is
reached.
Following self-assessment, the organisation has declared an EPRR assurance rating of
Substantial (from the four options in the table below) against the core standards.
I confirm that the above level of compliance with the core standards has been agreed by the
organisation’s board / governing body along with the enclosed action plan.
_______________________________________________________________
Signed by the organisation’s Accountable Emergency Officer
Click here to enter a date.
Date signed
Click here to enter a date.
Click here to enter a date.
Click here to enter a date.
Date of Board/governing body
meeting
Date presented at Public Board
Date published in organisation’s
Annual Report
page 8
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V4.1
Emergency Preparedness, Resilience and
Response (EPRR) Policy
Did you print this document yourself?
MFT can only guarantee that the document on the Trust website is the most
up-to-date version. Departments who have hard copies will be notified of any
changes so these copies can be updated. If, for exceptional reasons, you
need to print a policy off for personal use, it is your responsibility to ensure it is
the most recent version before use
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Document Title EPRR Policy
Version Number V4.1
Sensitivity External
Document Hierarchy Policy
Ratified by MFT BOD
Ratification Date PRN
Review Date Annually
Authors Nicky Shaw
Owner/s MFT EPRR
Accountable Emergency
Officer (AEO)
Vanessa Gardener
Chief Delivery Officer
Applicable to MFT
EqIA Registration
Number EPRR02
Location of Hard Copies MFT Intranet
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Collaborative Planning
NHSE EPRR Core Standard 9 (Domian 3, Duty to Maintain Plans)
Plans and arrangements have been developed in collaboration with relevant
stakeholders including emergency services and health partners to enhance joint
working arrangements and to ensure the whole patient pathway is considered.
Partner organisations collaborated with as part of the planning process are in
planning arrangements. Consultation process in place for plans and arrangements,
changes to arrangements as a result of consultation are recorded.
Version Date Contributor Change/s
New Template and previous version log starts from 2024 (contact EPRR for previous version)
4.0
01.06.2024
Nicky Shaw, Head of EPRR
Updated to align to NHSE
Core Standards
4.0
08.07.2024
Vanessa Gardener AEO
Policy Board sign off
4.1
15.07.2025
Nicky Shaw, Head of EPRR
Reviewed to align with
NHSE EPRR Framework
4.1
01.10/2025
Vanessa Gardener AEO
Policy Board sign off.
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Associated Internal Documents
Title Owner Location
Document Handling Procedure EPRR Team MFT Intranet
Please note: Responsibility for verifying the content and safety of all external links embedded in this document
lies with the reader. MFT and the EPRR team do not assume any responsibility for external sources linked
contained in this document.
Document Approval
Document to be approved by the Accountable Emergency Officer, MFT Chief Executive Officer and Board of
Directors Chair.
_____________________________________________________________
Signed by the organisation’s Chairman
________________________________________________________________
Signed by the organisation’s Chief Executive
__________________________________________
Signed by the organisation’s Accountable Emergency Officer
3rd September 2025
01st October 2025
Date presented to
Board/Governing Body
meeting
Date presented at Public
Board
Date published in
organisation’s Annual Report
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Table of Contents
Collaborative Planning _______________________________________________________________________ 3
Associated Internal Documents ________________________________________________________________ 4
Document Approval _________________________________________________________________________ 4
Table of Contents ___________________________________________________________________________ 5
MFT values: ______________________________________________________________________________ 7
Document Purpose, Objectives and Scope _______________________________________________________ 7
Policy Purpose ____________________________________________________________________________ 7
Policy Objectives __________________________________________________________________________ 7
Policy Scope _____________________________________________________________________________ 8
Statutory Requirements for EPRR ______________________________________________________________ 8
Applicable legislation and guidance ________________________________________________________ 8
NHS England EPRR Framework and Core Standards ______________________________________________ 8
Organisational Duties ________________________________________________________________________ 9
MFT Duties ______________________________________________________________________________ 9
Greater Manchester Local Health Resilience Partnership (GM LHRP) ________________________________ 9
Greater Manchester Resilience Forum (GMRF). _________________________________________________ 9
Compliance ______________________________________________________________________________ 9
Health Emergency Planning Group (HEPG) _____________________________________________________ 9
Roles and Responsibilities ___________________________________________________________________ 10
Accountable Emergency Officer (AEO) _______________________________________________________ 11
Key responsibilities of the AEO include: _______________________________________________________ 11
Non-Executive Directors (NEDs) _____________________________________________________________ 11
EPRR __________________________________________________________________________________ 12
Clinical Group ___________________________________________________________________________ 12
Assurance ______________________________________________________________________________ 12
EPRR Governance Process ___________________________________________________________________ 12
EPRR Forums ____________________________________________________________________________ 12
EPRR Forum Work Plan ___________________________________________________________________ 13
Internal Governance Structure: _____________________________________________________________ 15
External Strategic and Operational Partnerships: _______________________________________________ 15
NHS England Core Standards for EPRR Compliance _______________________________________________ 15
Domain 1 – Governance _____________________________________________________________________ 15
Domain 2 – Duty to risk assess _______________________________________________________________ 16
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Domain 3 – Duty to maintain plans ____________________________________________________________ 17
Plans __________________________________________________________________________________ 17
Document Check List _____________________________________________________________________ 17
Coordination of plan review processes _______________________________________________________ 18
Sign off and distribution ___________________________________________________________________ 18
Domain 4 - Command and control ____________________________________________________________ 19
Cascade ________________________________________________________________________________ 19
_________________________________________________________________________________________ 20
Domain 5 – Training and exercising ___________________________________________________________ 20
Training ________________________________________________________________________________ 20
Minimum Occupational Standards for EPRR ___________________________________________________ 21
Domain 6 – Response _______________________________________________________________________ 22
Domain 7 – Warning and informing ___________________________________________________________ 22
Domain 8 – Cooperation ____________________________________________________________________ 23
Domain 9 – Business Continuity ______________________________________________________________ 23
Business Continuity Policy _______________________________________________________________ 23
Business Continuity Management System (BCMS) _________________________________________ 24
Validation and monitoring _________________________________________________________________ 25
Business Continuity Audit __________________________________________________________________ 25
Domain 10 – Chemical, biological, radiological and nuclear (CBRN) and hazardous materials (HAZMAT) ___ 26
CBRN–HAZMAT Preparedness ______________________________________________________________ 26
CBRN–HAZMAT Training and Equipment Maintenance SOP ______________________________________ 26
Mutual Aid and Record Keeping ______________________________________________________________ 26
MFT Intranet and EPRR Toolkit _______________________________________________________________ 27
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MFT strategy
MFT is made up of ten hospitals and two Local Care Organisations organised into
six Clinical Groups. Together, they provide a wide range of hospital and community
services to the people of Greater Manchester and beyond.
The MFT strategy confirms our mission to work together to improve the health and
quality of life of our diverse communities.
MFT values:
• We are compassionate
• We are collaborative
• We are open and honest
• We are inclusive
• We are curious
We have used these values to inform the aims, objectives and values that make up
our strategy.
Document Purpose, Objectives and Scope
Policy Purpose
The purpose of this document is to provide the framework for MFT to meet the
statutory requirements of the Civil Contingencies Act (CCA) (2004), NHS Act 2006
(as amended by the Health and Social Care Act 2012), NHS Standard Contract and
NHS England EPRR Framework. This document seeks to describe how the
organisation will go about its duty to be appropriately prepared for dealing with
emergencies.
Policy Objectives
The objectives of the Trust’s EPRR Policy are:
To enable the organisation to prepare for the common consequences of
emergencies rather than for every individual emergency scenario.
• To enable the organisation to have flexible arrangements for responding to
emergencies, which can be scalable and adaptable to work in a wide range of
specific scenarios.
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• To supplement arrangements with specific planning and capability building for
the most concerning risks in the Community Risk Register (CRR) and the
National Risk Register (NRR).
• To ensure that plans are in place to recover from incidents and to provide
appropriate support to those affected.
• To outline how MFT will demonstrate compliance with the Core Standards for
EPRR as provided by NHS England.
• To provide a dedicated structure to maintain the delivery of EPRR functions
regardless of organisational structure and staffing changes.
• To outline how the Trust will work with key suppliers and contractors with
regard to EPRR functions.
Policy Scope
This policy is a Trust-wide document and applies equally to all members of staff,
either permanent or temporary and to those working within, or for, the trust under
contracted services.
Statutory Requirements for EPRR
Applicable legislation and guidance
MFT is an acute provider of medical services and is designated as a Category 1
responder under the Civil Contingencies Act (2004). As such, it is subject to a range
of statutory and strategic guidance including Civil Contingencies Act (2004);
Emergency Preparedness and Emergency Response and Recovery guidance; NHS
Act 2006; Health and Social Care Act 2012; NHS Constitution; NHS Core Standards
for EPRR; ISO 22301:2019; and the NHS England EPRR Framework (2022).
NHS England EPRR Framework and Core Standards
The NHS England EPRR Framework outlines national principles and responsibilities
for EPRR across NHS-funded organisations. The NHS Core Standards for EPRR
underpin the annual assurance process required of all providers and commissioners
of NHS-funded services. Compliance is assessed via self-assessment and validated
by NHS England and Integrated Care Boards (ICBs).
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Organisational Duties
MFT Duties
As a Category 1 responder, MFT must assess risks, develop emergency and
business continuity plans, warn and inform the public, and collaborate with local
responders. These duties align with the statutory requirements of the Civil
Contingencies Act (2004).
Greater Manchester Local Health Resilience Partnership (GM LHRP)
MFT participates in GM LHRP to coordinate regional planning and ensure NHS
representation in Greater Manchester Resilience Forum (GMRF) structures. GM
LHRP receives and confirms NHS organisational assurance against Core Standards.
The strategic nature of GM LHRP means it can provide a forum for consideration of
system wide EPRR risks and arrangements that affect NHS organisations. GM
LHRP may also serve as a link to regional governance structures for NHS EPRR.
The chair of GM LHRP will determine the need for any specific subgroups or projects
groups to reflect locally identified risks and to ensure that effective tactical and
operation planning/response arrangements are developed and maintained.
Greater Manchester Resilience Forum (GMRF).
GM LHRP is a strategic forum with a focus on joint EPRR planning across the
Greater Manchester integrated care system. GM LHRP also supports the health
sector’s contribution to multi-agency planning through Greater Manchester
Resilience Forum (GMRF).
Compliance
The GM LHRP will annually confirm the assurance declared by NHS organisations
against the NHS England EPRR Core Standards. This will include receiving a report
on the overall level of GM compliance against the Core Standards and confirmation
that any action plans arising from the assurance process are appropriate and
achievable
Health Emergency Planning Group (HEPG)
The Health Emergency Planning Group (HEPG) is a tactical forum with
representation from EPRR leads for GM NHS organisations will support GM LHRP to
achieve this purpose.
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Figure 1: GM LHRP Structure
Roles and Responsibilities
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Accountable Emergency Officer (AEO)
Under the NHS Act 2006, there is a statutory requirement for relevant service
providers (as defined in Section 8.2) to appoint an individual responsible for
discharging duties under Section 252A(9). This individual is referred to as the
Accountable Emergency Officer (AEO).
The AEO is a Board-level Executive accountable for ensuring that the organisation
complies with all EPRR statutory duties. At MFT the role of AEO is held by the Chief
Delivery Officer.
Key responsibilities of the AEO include:
Ensuring that effective EPRR arrangements and plans are in place, adequately
resourced, and regularly tested.
Providing assurance to the Trust Board regarding EPRR compliance and
organisational readiness.
Approving key strategic documents, including the Trust’s Business Continuity and
Incident Response Policies.
In the AEO’s absence, their duties are assumed by the designated Executive On-
Call to maintain continuity of oversight and compliance. In cases of prolonged
absence, the Chief Executive may appoint a temporary AEO to fulfil these
responsibilities.
For acute providers such as MFT, the AEO also holds responsibility for signing off
the organisation’s mass casualty distribution figures. At MFT, this duty is fulfilled in
accordance with the Greater Manchester Mass Casualty Dispersal Framework, as
referenced in the Trust’s Incident Response Plan (IRP).
Non-Executive Directors (NEDs)
The independence that (NEDs) bring is essential to being able to hold the AEO to
account, but responsibility for EPRR sits with the whole board and all NEDs should
assure themselves that requirements are being met.
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Therefore, EPRR should be included on appropriate Committee Groups forward
plans and EPRR board reports, including EPRR annual assurance, should be taken
to the board annually.
EPRR
The EPRR team is resourced via the Chief Deliver Officer Directorate(CDO).
Strategic and functional officer roles are resourced centrally. Tactical, operational
and loggist roles are resourced via clinical groups. Resources used to carry out
preparatory and response EPRR functions are overseen by corporate, clinical group
or stakeholder governance structures, with overall responsibility and oversight
provided by the AEO.
Clinical Group
Chief Executives and senior leadership are responsible for embedding and
approving an EPRR Work Plan through their clinical governance structures (e.g.
Senior Leadership Team), ensuring compliant Business Continuity Plans (BCP) are
in place and maintained, identifying and managing relevant risks, overseeing
appropriate training and resourcing, and reporting into the EPRR Forum for
escalation to the Trust-wide EPRR Group.
Assurance
The EPRR Team coordinates Trust-wide EPRR activity under the leadership of the
Chief Delivery Officer. Site-specific EPRR Forums feed into the overarching Trust-
wide EPRR Group, which provides assurance to the Board. This assurance is
delivered through the implementation of the EPRR Policy, Business Continuity
Policy, and EPRR work plan, designed to ensure an effective response in the event
of an incident. The Board remains fully aware of its legal obligations to ensure
organisational preparedness, safeguard public protection, and support a coordinated
NHS response.
EPRR Governance Process
EPRR Forums
• Manchester Royal Infirmary (MRI)
• Wythenshawe, Trafford, Withington and Altrincham Hospitals (WTWA)
• North Manchester General Hospital (NMGH)
• Clinical and Scientific Services (CSS)
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• Specialist Hospitals Clinical Group
• Local Care Organisation & University Dental Hospital (LCO/UDH)
• Digital Services (including Cyber Security and HIVE)
• Estates and Facilities (including Telephony and Security)
The EPRR Team coordinates preparedness activity across the Trust through site-
specific EPRR Forums, which meet every four to six weeks. Each Forum is chaired
locally and ensures the effective coordination of emergency preparedness and the
integration of risk management for Business Continuity Plans.
Every forum operates under a standardised Terms of Reference that outlines its
purpose, scope, and membership, and is supported by a designated EPRR Lead.
These governance arrangements provide consistency across sites and enable
alignment with Trust-wide assurance processes.
EPRR Forum Work Plan
EPRR Forums are tasked with delivering and monitoring an annual EPRR Work Plan
that supports compliance with statutory and regulatory requirements, strengthens
organisational resilience, and addresses any areas of partial or non-compliance. A
key responsibility of the Forums is to ensure that adequate resources are identified
and made available to support preparedness and response activity. This includes the
appointment and ongoing training of a sufficient number of trained Loggists to
support incident coordination, ensuring operational readiness across all sites.
Forums are expected to monitor the presence and capability of trained Business
Continuity Service Leads (BCSLs) within each service area. These individuals are
responsible for overseeing the development, maintenance, and review schedules of
Business Continuity Plans (BCPs). To ensure accountability and consistent
governance, all BCPs must be formally signed off either at director level or through a
structure agreed by the relevant Senior Leadership Team (SLT).
Each Forum must also undertake a Training Needs Analysis (TNA) to ensure that
staff receive appropriate and proportionate training, with participation in exercises
routinely monitored and records maintained in line with EPRR and audit
requirements. Where CBRNe arrangements apply, Forums are responsible for
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appointing a designated CBRNe Lead and supporting the coordination of associated
training, equipment maintenance, and exercise delivery.
Forums are required to actively manage the risks allocated to them, ensuring regular
review with risk owners, updating associated actions, and escalating risks scored
above 15 in accordance with Trust risk management procedures. Progress must be
reported to the Trust EPRR Group to support integrated oversight and assurance.
Following incidents or exercises, Forums should request support from the EPRR
Team to facilitate structured debriefs. Directors of Performance & Operations are
responsible for tracking, implementing, and closing any identified actions to ensure
that lessons are embedded and continuous improvement is achieved.
Each Forum must be chaired with appropriate and consistent senior representation,
demonstrating active engagement in meetings, exercises, and the delivery of EPRR
objectives. Assurance is provided through regular AAA reporting, which includes
evidence of BCP compliance, workforce capability, and the status of core
preparedness activity across all areas of responsibility. Reporting Structure:
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Internal Governance Structure:
• EPRR Group
• Delivery Oversight Management Committee
• Trust Leadership Team Committee (TLTC)
• Quality, Safety and Performance Board Committee (QSPBC)
• Board of Directors
External Strategic and Operational Partnerships:
• Manchester Health Protection Board (HPB)
• Local Health Resilience Partnership (LHRP)
• Health Emergency Planning Group (HEPG)
• Shelford Group
• Security Advisory Groups (SAGs)
• Integrated Care Board (ICB) and NHS England (NHSE) – Regional and
National Exercises.
NHS England Core Standards for EPRR Compliance
There are 62 Core Standards divided across 10 domains. MFT measures
compliance using thresholds ranging from ‘fully compliant’ to ‘non-compliant’.
Evidence is captured via reports submitted to the EPRR Group and Trust Board.
• Fully compliant: 100% of relevant standards met
• Substantially compliant: 89-99% of relevant standards met
• Partially compliant: 77-88% of relevant standards met
• Non-compliant: up to 76% of relevant standards met
Domain 1 – Governance
Organisations must have an appointed accountable emergency officer (AEO) who is
a board-level director and responsible for EPRR in their organisation.
The AEO must provide reports to the public board on EPRR activity no less
frequently than annually and must publicly state readiness and preparedness
activities in annual reports within the organisation’s own regulatory reporting
requirements.
Board reports will include:
• Training and exercising compliance
• Declared incidents by the Trust
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• Lessons identified
• Compliance with NHS England Core Standards
Domain 2 – Duty to risk assess
Organisations should have provision in place to regularly assess the risks to the
population they serve. This process should consider the community and national risk
registers. At an operational level, EPRR related risks are managed using a seven-
step process below:
A supporting risk management system must be in place to ensure a robust method
of reporting, recording, monitoring, communicating and escalating EPRR risks
internally and externally with partners.
MFT will take steps to identify health sector risks relevant to the Trust. Risk
identification will be informed by the National Risk Register, Greater Manchester
Community Risk Register, the MFT Risk Register and risks identified by the GM
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Integrated Care Service and NHS England North West. The Trust has in place a
Risk Management Strategy and Framework. EPRR works within this structure to
define EPRR risks as those that impact compliance with the NHS Core Standards for
EPRR. Where appropriate, such risks may also inform MFT’s EPRR compliance.
Domain 3 – Duty to maintain plans
Organisations must have in place appropriate and up-to-date plans setting out how
the organisation plans for, responds to and recovers from Major Incidents, Critical
Incidents and Business Continuity Incidents. These should be developed in
collaboration with partners and service providers to ensure the whole patient
pathway is considered. All EPRR plans must demonstrate a cycle of preparedness:
All Plan and policies must be ratified via the EPRR Group with assurance from the
EPRR Clinical Lead and identified stakeholders. Policies must also be ratified by the
MFT Trust Board.
Plans
All plans must clearly record any changes made, with accurate dates, version
numbers, and supporting information to ensure alignment with due governance
processes. A document control checklist has been developed to ensure all plans are
complete, accurate, and compliant at the point of release.
Document Check List
Confirm
Yes/No/Comment
All dates are correct throughout the document
Headers and Footer is in date and correct.
No.
Plans
1
Incident Response
2
Adverse Weather
3
Infectious disease
4
New and emerging pandemics
5
Countermeasures
6
Mass Casualty
7
Evacuation and shelter
8
Lockdown
9
Protected individuals
10
Excess fatalities
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Contents page is correct
Hyperlinks work and are in date and correct
Page numbers are correct and match the contents page
All formatting is correct, and font is Arial 12
Consultation and contributors have been dated and recorded
EqIA Registration Number
Coordination of plan review processes
The EPRR Team will coordinate the review process, ensuring a standardised
process aligned to NHS Core Standards and EPRR best practice. The EPRR Team
will track and monitor progress via internal trackers, and coordinate internal and
external coordination where applicable, as well as coordinating testing and
exercising of plans.
Sign off and distribution
The EPRR Team coordinate the review process, ensuring a standardised process
aligned to NHS Core Standards and EPRR best practice.
The EPRR Team track and monitor progress via internal trackers, and coordinate
internal and external coordination where applicable, as well as coordinating testing
and exercising of plans.
Summaries of reviews and activities are shared with relevant EPRR Forums and
reported to the EPRR Group, with activity and amendments communicated widely
and via Forums, Group minutes.
A record of consultations, changes and decisions must be recorded alongside
individual document control information within the plans and policies.
Only Trust-level full plan re-writes require Delivery Oversight Management
Committee (DOMC) level sign-off; site-level plans and other plan reviews do not
require DOMC level sign-off. Policies must also be ratified by the MFT Trust Board.
All plans will be stored in the first instance in the following places:
MFT intranet/MFT Incident Management Toolkit (SharePoint) and Incident
Coordination Centres (ICC) (hard copy)
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Domain 4 - Command and control
A robust and dedicated EPRR on-call mechanism should be in place to receive
notifications relating to EPRR. This facility should be 24 hours a day, seven days a
week, and provide the ability to respond or escalate notifications to executive level.
Personnel performing the on-call function should be appropriately trained in major
incident, critical incident and business continuity response. The below diagrams
outline the overall arrangements for incident notification and escalation within MFT,
and the Command and Control.
Cascade
The EPRR Team, in coordination with MFT Switchboard, will manage and maintain
the incident notification cascade list, and provide training to Switchboard staff in rder
to ensure effective notification of incidents takes place.
Extract from MFT Incident call out cascade
MFT COMMAND AND CONTROL STRUCTURE
Strategic Commander
Strategic Commander on call provides overall leadership and
strategic direcon during an incident, ensuring that the Trust
response aligns with organisaonal priories, paent safety, and
mul-agency coordinaon where applicable.They do this
through a Strategic Coordinaon Group (SCG) meeng.
Clinical Group (CG) Operational structure
An Operaonal Commander is responsible for the frontline
execuon of response plans, ensuring acons are carried out
effecvely at the incident site or within their designated area.
They do this through the Incident Command Center (ICC).
Tactical Coordinator/Commander
CG Tactical Commander for each clinical group (6) who is
responsible for the overall coordination and management of
their site. They translate the strategic direction ensuring that
plans are implemented eectively.They do this through a
Tactical Coordination Group (TCG) meeting chairedd by the
Tactical Coordinator.
24/7 - 365
Clinical Group Operational Commanders (Bronze)
Clinical Group Tactical Commanders
(Silver)
Strategic Commander
(Gold)
a wL
í Çí ! [/ h
Ü5 I a
b a DI / {{
wa / I
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a w9 I
Tactical Coordinator
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Following formal declaration of an incident the trust will alert the ICB using the agreed
process below:
Domain 5 – Training and exercising
Delivery of EPRR training and exercising is coordinated by the EPRR Team and
summarised in the annual Training and Exercising Schedule. This schedule outlines
the required frequency and compliance expectations to ensure the Trust maintains
its capability to respond confidently and effectively to incidents. The schedule is
reviewed and formally signed off each year.
Training
All training is informed by an annual Training Needs Analysis (TNA), coordinated by
the EPRR Team. Training is delivered either via the Kallidus platform or directly
facilitated by the EPRR Team. This approach supports the effective capture, tracking,
and assessment of trained personnel across the Trust.
Training activity is recorded on the MFT Learning Hub. Outputs from training
sessions—including risks identified, capability gaps, and lessons learned—are
reported through the EPRR Forums and submitted to the EPRR Group as part of
formal governance. Training opportunities are also promoted through EPRR Forums
and other internal communication channels.
NHS ICB Regional and National Escalation Framework
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In accordance with the MFT EPRR Policy, the Trust is required to exercise its
emergency response and business continuity plans regularly to test their
effectiveness. The EPRR Team manages these exercises as part of the wider
training programme, ensuring that all learning contributes to assurance reporting and
continuous improvement.
To support oversight and ensure compliance, EPRR Forum Chairs will be provided
with access to relevant training records.
Minimum Occupational Standards for EPRR
The Minimum Occupational Standards for EPRR sets out the minimum national
occupational standards that health commanders, managers and staff responding to
incidents as part of an incident management team and other staff involved in EPRR
must achieve in order to be competent and effectively undertake their roles. The
EPRR Team is responsible for establishing the structures and providing guidance
required by staff to allow submission of evidence, which can be used for Personal
Development Portfolios (PDP).
Exercising
MFT are required to exercise response plans in-line with minimum national
requirements, as detailed below:
Live Exercise Every 3 years
Tabletop Exercise
Every 12 months
Communications Exercise
Every 6 months
Command Post Exercise
Every 3 years
ICC equipment test
Quarterly
Roles within plans, not individuals, will be exercised to ensure they are fit for purpose
and encapsulate all necessary functions and actions to be carried out in an incident.
MFT will consider exercising with partner agencies and contracted services where
the identified risks and the involvement of partner organisations is appropriate.
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The EPRR Team will provide guidance and support to colleagues across the Trust in
planning, undertaking and learning from exercises, in line with best practice and
statutory requirements as outlined below.
Domain 6 – Response
The EPRR Team will produce and support the production of plans, policies and
procedures required to ensure that MFT can undertake its duties as outlined in the
Civil Contingencies Act (2004) and associated guidance.
Operational detail for these arrangements is contained in the MFT Incident
Response Plan (IRP) and all other Trust-wide and Site-specific incident response
plans, a full list of plans maintained or supported by the EPRR Team is available.
Domain 7 – Warning and informing
As outlined in the Civil Contingencies Act (2004) and associated guidance, all
Category 1 responders have a duty to warn and inform. MFT incident response plans
contain operational detail on how to carry out effective warning and informing, and
the MFT Communications plan provides further detail.
The EPRR Team will support the production and validation of appropriate plans, with
submission to the EPRR Group for ratification. The EPRR Team will also support the
Figure 10: Incident and Emergency Management Learning
Cycle (adapted from NHSE EPRR Framework 2022)
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coordination of communications exercises as mandated nationally via the NHS
EPRR Framework.
Domain 8 – Cooperation
As outlined in the Civil Contingencies Act (2004) and associated guidance, all
Category 1 responders have a duty to cooperate.
MFT primarily fulfils this requirement via attendance at and participation in the GM
HEPG and LHRP.
Where relevant and in-line with plan review processes, the EPRR Team will identify
and engage with external and internal stakeholders to participate in training,
exercising and plan reviews.
Additionally, in order to support the continuous improvement of the organisation, the
EPRR Team will support cooperative working with internal and external stakeholders
to identify, share and embed lessons. Activity for this will be recorded and reported
through the EPRR Forums and Groups escalation reports.
Domain 9 – Business Continuity
Business Continuity Policy
The EPRR Team is responsible for the development and maintenance of the Trust’s
Business Continuity Policy, which is submitted to the EPRR Group and subsequently
to the MFT Trust Board for review, approval, and ratification.
This policy sets out the framework for implementing an effective Business Continuity
Management System (BCMS), aligned with ISO 22301:2019, the internationally
recognised standard for business continuity. It also ensures compliance with NHS
England’s Emergency Preparedness, Resilience and Response (EPRR) Core
Standards and the requirements of the Civil Contingencies Act 2004.
The primary aim of the policy is to ensure that MFT can maintain critical service
provision and deliver a coordinated response in the event of disruption. It promotes a
proactive approach to risk management, encourages adaptability and flexibility in
planning, and supports the embedding of resilience as a cultural norm across the
organisation. The policy further aims to raise awareness of continuity responsibilities
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at all levels, ensuring that plans and supporting structures are understood and
accessible.
The objectives of the policy are to ensure that resilience is embedded as a golden
thread throughout all clinical and corporate services, with continuity planning,
preparedness, and response fully integrated into daily operations.
The policy commits the Trust to maintaining up-to-date Business Continuity Plans
(BCPs), delivering annual Business Impact Analyses (BIAs), and ensuring a
sufficient level of staff training, exercising, and assurance activity to meet statutory
and regulatory obligations.
Business Continuity Management System (BCMS)
The Business Continuity Management System (BCMS) at MFT is a Trust-wide
framework designed to ensure organisational resilience and the continuation of
critical services during periods of disruption.
A core component of the BCMS is the Business Impact Analysis (BIA) process.
Supported by the EPRR Team, services and directorates assess and categorise
their functions by priority: Essential, High Priority, Medium Priority, and Low Priority.
This classification provides clarity on recovery time objectives (RTOs) and resource
dependencies, forming the basis for effective continuity planning and prioritisation
during incidents.
Business Continuity Plans (BCPs) outline strategies and actions to address potential
disruptions to people and staffing, premises, digital systems and infrastructure,
estates, information and data, and external suppliers. Plans are reviewed annually
and are subject to director-level approval or sign-off via an agreed governance
structure.
To support delivery, the Trust has procured a secure, digital continuity platform – C2
BCMS – which enables the development, management, and testing of plans in a
consistent and centralised manner.
The C2 system also supports the creation of audit-ready reports and dashboards,
providing performance oversight and assurance to internal governance groups and
external regulators.
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Validation and monitoring
The effectiveness of the Business Continuity Policy is measured through a set of key
performance indicators. These KPIs provide assurance that resilience measures are
embedded and maintained:
1. 100% completion of annual business continuity mapping.
2. 90–100% of services maintain up-to-date BIAs.
3. Achievement of Recovery Time Objectives (RTOs) and Recovery Point
Objectives (RPOs) as defined in the Business Continuity Plan.
4. Annual delivery of business continuity exercises with a minimum 65%
participation rate.
5. Accurate and timely recording of training and exercising activity on the MFT
Learning Hub.
Performance against these KPIs is monitored by Site-level EPRR Forums. Any
deviations, risks, or concerns are escalated to the EPRR Group for further review
and action, ensuring timely intervention and continuous improvement.
Business Continuity Audit
Internal audits of the BCMS are conducted annually, following a structured cycle of
self-assessment, quality assurance reviews, and evaluations of supplier resilience.
External audits are undertaken every three years to provide independent assurance
of BCMS effectiveness and compliance with ISO 22301.
Audit findings—along with recommended actions—are reported through the EPRR
Forums and EPRR Group, with escalation to the Trust Board as required. To
strengthen oversight, the Trust has a formal arrangement with KPMG to
independently review the quality of emergency plans and the robustness of business
continuity arrangements and records.
Lessons identified through audits, reviews, and exercises are shared across the
organisation to inform continuous improvement and reinforce Trust-wide resilience.
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Domain 10 – Chemical, biological, radiological and nuclear
(CBRN) and hazardous materials (HAZMAT)
CBRN–HAZMAT Preparedness
MFT maintains a comprehensive CBRN–HAZMAT Plan and an associated Standard
Operating Procedure (SOP), which set out the Trust’s responsibilities, training
requirements, and arrangements for the maintenance of specialist response
equipment.
These documents provide guidance to Trust personnel on the management of
CBRN- HAZMAT incidents, with a particular focus on the acute setting. They include
background information based on incident types and offer detailed planning and
preparedness guidance.
Supported by the EPRR team, clinical groups are responsible for ensuring the
Trust’s compliance with CBRN-HAZMAT requirements, supporting operational
readiness through internal exercises and external audit, including assurance
activities led by North West Ambulance Service (NWAS).
CBRN–HAZMAT Training and Equipment Maintenance SOP
The CBRN–HAZMAT Training and Equipment Maintenance SOP outlines a
structured process for the routine inspection, testing, and upkeep of CBRN/HAZMAT
response equipment. It also defines the requirements for training staff in the correct
use and handling of this equipment, ensuring that training records are accurately
maintained and easily auditable. This SOP underpins the Trust’s ongoing assurance
that both equipment and personnel are prepared to respond effectively to a CBRN–
HAZMAT incident.
Mutual Aid and Record Keeping
Mutual aid agreements are embedded into incident response plans. All incidents
require trained loggists to maintain auditable records. The EPRR Team supports
training and document retention via the Trust’s policies.
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MFT Intranet and EPRR Toolkit
MFT hosted internet the Incident Management Toolkit SharePoint provide access to
EPRR plans, SOPs, guidance and supporting documentation across the Trust.
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V2.2
Business Continuity Policy
Did you print this document yourself?
MFT can only guarantee that the document on the Trust website is the most
up-to-date version. Departments who have hard copies will be notified of any
changes so these copies can be updated. If, for exceptional reasons, you
need to print a policy off for personal use, it is your responsibility to ensure it is
the most recent version before use
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Document Title Business Continuity Policy
Version Number V2.2
Sensitivity External
Document Hierarchy Policy
Ratified by MFT BOD
Ratification Date PRN
Review Date Annually
Authors Nicky Shaw
Owner/s MFT EPRR
Accountable Emergency
Officer (AEO)
Vanessa Gardener
Chief Delivery Officer
Applicable to MFT
EqIA Registration
Number TBC
Location of Hard Copies MFT Intranet
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Collaborative Planning
NHSE EPRR Core Standard 9 (Domian 9, Business Continuity)
Version Date Contributor Change/s
New Template and previous version log starts from 2024 (contact EPRR for previous version)
2.2
15.07.2025
Dominic Sagar, EPRR
Manager
Updated to align to NHSE
Core Standards
2.2
01.10.2025
Vanessa Gardener, AEO
Policy Board sign off
2.2
15.07.2026
Nicky Shaw, Head of EPRR
Reviewed to align with
NHSE EPRR Framework
2.3
01.10.2026
Vanessa Gardener, AEO
Policy Board sign off.
Associated Internal Documents
Title Owner Location
Document Handling
Procedure
EPRR Team MFT hosted internet the Incident Management
Toolkit, SharePoint provide access to all EPRR
documents, plans, SOPs etc.
Please note: Responsibility for verifying the content and safety of all external links embedded in this document
lies with the reader. MFT and the EPRR team do not assume any responsibility for external sources linked
contained in this document.
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Document Approval
Document to be approved by the Accountable Emergency Officer, MFT Chief Executive Officer and Board of
Directors Chair.
_____________________________________________________________
Signed by the organisation’s Chairman
________________________________________________________________
Signed by the organisation’s Chief Executive
__________________________________________
Signed by the organisation’s Accountable Emergency Officer
3rd September 2025
01st October 2025
Date presented to
Board/Governing Body
meeting
Date presented at Public
Board
Date published in
organisation’s Annual Report
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Table of Contents
Collaborative Planning _______________________________________________________________________ 3
Associated Internal Documents ________________________________________________________________ 3
Document Approval _________________________________________________________________________ 4
Table of Contents ___________________________________________________________________________ 5
MFT values: ______________________________________________________________________________ 6
Document Purpose, Objectives and Scope _______________________________________________________ 6
Policy Purpose ____________________________________________________________________________ 6
Policy Objectives __________________________________________________________________________ 7
Policy Scope _____________________________________________________________________________ 7
Statutory Requirements for EPRR ______________________________________________________________ 7
Applicable legislation and guidance ________________________________________________________ 7
NHS England EPRR Framework and Core Standards ______________________________________________ 7
Organisational Duties ________________________________________________________________________ 8
MFT Duties ______________________________________________________________________________ 8
EPRR Governance Process ____________________________________________________________________ 8
EPRR Forums _____________________________________________________________________________ 8
EPRR Work Plan __________________________________________________________________________ 8
Definition _________________________________________________________________________________ 9
Business Impact Analysis (BIA) _______________________________________________________________ 9
Business Continuity Plans (BCPs) ____________________________________________________________ 10
Incident Threshold _______________________________________________________________________ 10
NHSE EPRR Core Standards __________________________________________________________________ 11
Business Continuity Management System (BCMS) _______________________________________________ 12
C2 - BCMS ______________________________________________________________________________ 12
C2 Implementation _______________________________________________________________________ 13
Business Continuity Audit __________________________________________________________________ 13
Validation and monitoring (KPIs) ____________________________________________________________ 14
Supplier Performance _______________________________________________________________________ 14
Governance _______________________________________________________________________________ 14
Business Continuity Lexicon__________________________________________________________________ 15
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MFT strategy
MFT is made up of ten hospitals and two Local Care Organisations which are
organised into six clinical groups. Together, they provide a wide range of hospital
and community services to the people of Greater Manchester and beyond.
The MFT strategy confirms our mission to work together to improve the health and
quality of life of our diverse communities.
MFT values:
• We are compassionate
• We are collaborative
• We are open and honest
• We are inclusive
• We are curious
We have used these values to inform the aims, objectives and values that make up
our strategy.
Document Purpose, Objectives and Scope
Policy Purpose
Manchester University NHS Foundation Trust (MFT) is committed to ensuring the
continuity of its critical services in the face of disruptions. This policy sets out the
framework through which the Trust meets its statutory and contractual obligations,
aligning with the Civil Contingencies Act 2004, the NHS Act 2006 (as amended by
the Health and Social Care Act 2012), the NHS Standard Contract, and NHS
England’s Emergency Preparedness, Resilience and Response (EPRR) Framework.
Furthermore, the policy supports compliance with the NHS EPRR Core Standards
and the international standard ISO 22301 for Business Continuity Management
Systems (BCMS). Its purpose is to outline how MFT will discharge its responsibilities
to ensure appropriate preparedness for, response to, and recovery from, emergency
situations.
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Policy Objectives
The objectives of the Business Continuity Policy at MFT are to implement a Business
Continuity Management System (BCMS) aligned with ISO 22301 and to deliver a
scalable, Trust-wide Business Continuity Plan.
The policy aims to ensure that all services are incorporated into service-level
Business Continuity Plans and that effective response capabilities are in place,
supported by increased organisational awareness.
Plans will be maintained and regularly reviewed in line with NHS EPRR guidance
and standards. The Trust is committed to top-level management oversight, continual
improvement of the BCMS, and fostering a culture where all staff embrace and
embed business continuity into day-to-day operations.
Additionally, the policy supports the development and integration of the newly
commissioned C2 software, which will serve as the Trust’s central BCMS platform.
Policy Scope
This policy is a Trust-wide document and applies equally to all members of staff,
either permanent or temporary and to those working within, or for, the trust under
contracted services.
Statutory Requirements for EPRR
Applicable legislation and guidance
MFT is an acute provider of medical services and is designated as a Category 1
responder under the Civil Contingencies Act (2004). As such, it is subject to a range
of statutory and strategic guidance including Civil Contingencies Act (2004);
Emergency Preparedness and Emergency Response and Recovery guidance; NHS
Act 2006; Health and Social Care Act 2012; NHS Constitution; NHS Core Standards
for EPRR; ISO 22301:2019; and the NHS England EPRR Framework (2022).
NHS England EPRR Framework and Core Standards
The NHS England EPRR Framework outlines national principles and responsibilities
for EPRR across NHS-funded organisations.
The NHS Core Standards for EPRR underpin the annual assurance process
required of all providers and commissioners of NHS-funded services. Compliance is
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assessed via self-assessment and validated by NHS England and Integrated Care
Boards (ICBs).
Organisational Duties
MFT Duties
As a Category 1 responder, MFT must assess risks, develop emergency and
business continuity plans, warn and inform the public, and collaborate with local
responders. These duties align with the statutory requirements of the Civil
Contingencies Act (2004).
EPRR Governance Process
EPRR Forums
• Manchester Royal Infirmary (MRI)
• Wythenshawe, Trafford, Withington and Altrincham Hospitals (WTWA)
• North Manchester General Hospital (NMGH)
• Clinical and Scientific Services (CSS)
• Specialist Hospitals Clinical Group
• Local Care Organisation & University Dental Hospital (LCO/UDH)
• Digital Services (including Cyber Security and HIVE)
• Estates and Facilities (including Telephony and Security)
The EPRR Team coordinates preparedness activity across the Trust through site-
specific EPRR Forums, which meet every four to six weeks. Each Forum is chaired
locally and ensures the effective coordination of emergency preparedness and the
integration of risk management for Business Continuity Plans.
Every Forum operates under a standardised Terms of Reference that outlines its
purpose, scope, and membership, and is supported by a designated EPRR Lead.
These governance arrangements provide consistency across sites and enable
alignment with Trust-wide assurance processes.
EPRR Work Plan
The Trust’s EPRR Forums are responsible for ensuring that robust business
continuity arrangements are in place, actively maintained, and implemented across
all relevant services.
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Each Forum is expected to oversee the maintenance of appropriate records by
Clinical Groups and corporate stakeholders to support audit trails, regulatory
assurance, and the annual NHS England Core Standards submission.
A key function of the Forums are to deliver and monitor an annual EPRR Work Plan
that drives compliance, strengthens organisational resilience, and addresses areas
of partial or non-compliance.
Assurance is provided through regular AAA reporting, including evidence of
Business Continuity Plan (BCP) compliance. This includes ensuring that up-to-date
BCPs are in place and that a trained and identified Business Continuity Service Lead
(BCSL) is assigned to every service area, with oversight of planning and review
schedules.
All business continuity plans must be signed off either at director level or through a
governance structure agreed by the relevant Senior Leadership Team (SLT),
providing clear accountability and assurance across One MFT.
Definition
Business Impact Analysis (BIA)
A Business Impact Analysis (BIA) is the process of analysing business functions and
the effect that a business disruption might have upon them.
It involves identifying and evaluating the potential impacts of an interruption to critical
business operations as a result of a disaster, accident, or emergency. This process
identifies service criticality and categorises activities into four tiers: Essential, High
Priority, Medium Priority, and Low Priority. This prioritisation informs the development
and maintenance of effective continuity plans.
“A Business Continuity Incident is an event or occurrence that disrupts (or might
disrupt) an organisation's normal service delivery to below acceptable predefined
levels and would require special arrangements to be implemented until service
delivery can return to an acceptable level.” NHS England EPRR Framework,
2022
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Business Continuity Plans (BCPs)
Business Continuity Plans (BCPs) are developed at both Trust-wide and service-
specific levels to support a coordinated response to Business Continuity incidents,
Critical Incidents, and Major Incidents. These plans are tailored to reflect local risks
and operational priorities, addressing a range of potential disruptions including the
loss or degradation of staffing, information and data, premises, digital and estates
infrastructure, and critical suppliers or contractors.
Each BCP is subject to an annual review and testing process, with oversight from the
EPRR Team to monitor compliance, quality, and alignment with current standards.
This approach ensures that business continuity arrangements are fully embedded
into day-to-day operations and remain responsive to the evolving risk landscape
across One MFT.
Incident Threshold
An example of a Business Continuity Incident could be an Estates issue that causes
a water leak, preventing staff and patients from accessing a facility. This could
disrupt the delivery of care and would require activating alternative arrangements
(such as moving temporarily to a new area, or rescheduling treatments) to maintain
the continuity of the service.
Within MFT: Commanders may receive reports of incidents at any time. If you are
unsure whether an incident meets the definition of Business Continuity Incident,
consider:
• Do the impacts of the event occurring disrupt service delivery?
• Do they have the potential to disrupt service delivery?
• Do you have to put special or different arrangements in place to continue to
deliver your service?
If the answer to any of these questions is “yes”, services should:
• Activate their Service-Level Business Continuity Plans, and
• Escalate to their Tactical Commander.
Commanders should oversee and support this process. Tactical Commanders
should escalate to the Tactical Coordinator who will inform the Strategic
Commander; together the Tactical Coordinator and Strategic Commander should
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make an assessment of whether this is a Business Continuity Incident and the
severity of the incident and take appropriate actions thereafter.
On declaring a Business Continuity Incident the Strategic Commander must alert the
ICB using the agreed process.
Measures outlining the management of Business Continuity Incidents are contained
within the MFT Incident Response Plan.
NHSE EPRR Core Standards
Domain 9 – Business Continuity
Domain 9 of the NHS England Emergency Preparedness, Resilience and Response
(EPRR) Framework outlines nine core standards relating to Business Continuity. The
EPRR Team is responsible for ensuring that these standards are fully implemented,
monitored, and evidenced across the Trust.
The primary aim of the Trust’s Business Continuity Policy is to ensure the
organisation can sustain the delivery of critical services and respond effectively
during periods of disruption. It supports proactive preparedness, promotes regular
testing and exercising of plans, and embeds a culture of resilience across clinical
and corporate services.
The objectives of the policy are to ensure that business continuity is embedded as a
golden thread throughout the organisation, with continuity, preparedness, and
response fully integrated into routine operations. The Trust commits to maintaining
and reviewing Business Continuity Plans (BCPs) in line with national standards,
ensuring the BCMS is understood and used by staff at all levels, and integrating
business continuity into wider governance and assurance frameworks.
The nine NHS England EPRR Core Standards under Domain 9 are:
1. Business Continuity Management Policy Statement – A board-approved policy
statement is in place, demonstrating commitment to business continuity.
2. Business Continuity Governance – Clear governance arrangements are
established to oversee business continuity across the organisation.
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3. Business Impact Analysis (BIA) – A documented BIA process is undertaken
annually to identify critical functions and recovery priorities.
4. Business Continuity Plans (BCPs) – Up-to-date BCPs are in place for all critical
services, aligned to BIA outcomes and service risk assessments.
5. BCP Testing and Exercising – Business Continuity Plans are tested at least
annually through exercises or incident reviews.
6. BCP Maintenance – BCPs are reviewed, maintained, and updated annually or in
response to lessons identified or changes to delivery or service.
7. BCP Training – All staff are responsible for business continuity; training is available
and participation in exercises essential for continued patient safety.
8. Assurance and Audit – Internal and external mechanisms are in place to assess
compliance with national standards.
9. Integration with Risk Management – Business continuity is integrated with the
Trust’s risk management processes and escalations.
Collectively, these standards provide a structured and consistent foundation for
ensuring that business continuity arrangements are effective, auditable, and
embedded across One MFT.
Business Continuity Management System (BCMS)
C2 - BCMS
To strengthen the Trust’s business continuity arrangements and support full
compliance with ISO 22301:2019 standard for Business Continuity Management
Systems, NHS England’s EPRR Core Standards, and the Business Continuity
Institute Good Practice Guidelines (GPG), MFT has procured a three-year licence for
a digital Business Continuity Management System (BCMS). Provided by Continuity2.
(C2) is a secure, web-based platform that enables the Trust to manage all aspects
of business continuity through a single, integrated tool
Business Impact Analyses (BIAs) are embedded within the system and can be
completed at every level of the organisation, ensuring visibility of risk and
prioritisation of essential, high-priority, and time-critical services.
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In the event of disruption, C2 BCMS enables access to live plans, associated
documents, and automated contact trees. This not only strengthens information
governance and cyber resilience but also significantly reduces response time and
eliminates reliance on paper-based documentation.
A fully integrated management information dashboard provides real-time oversight of
the status and currency of BIAs, continuity plans, exercises, and governance
documentation across all sites.
C2 Implementation
The implementation of C2 BCMS began in April 2025 and will be phased over two
years and is essential to maintaining and improving Trust-wide compliance with
statutory duties under the Civil Contingencies Act 2004, the NHS Standard Contract,
and NHS England’s EPRR Framework.
In addition to enabling more consistent and effective delivery of business continuity
arrangements, the system supports continuous improvement of our resilience
capabilities. It also provides a single source of truth for business continuity activity
across One MFT, promoting standardisation, transparency, and reducing duplication
of staff time.
Business Continuity Audit
Internal audits of the BCMS are conducted annually, following a structured cycle of
self-assessment using C2 to demonstrate levels of compliance. Quality assurance
reviews, and evaluations of supplier resilience and external audits are undertaken
every three years to provide independent assurance of BCMS effectiveness and
compliance with ISO 22301.
Audit findings, along with recommended actions are reported through the EPRR
Forums and Group, with escalation to the Trust Board as required.
To strengthen oversight, the Trust has a formal arrangement with KPMG to
independently review the quality of emergency plans and the robustness of business
continuity arrangements and records.
Lessons identified through audits, reviews, and exercises are shared across the
organisation to inform continuous improvement and reinforce Trust-wide resilience.
page 48
Title: Business Continuity Policy Version: 2.3 Page 14 of 16
OFFICIAL
OFFICIAL
Validation and monitoring (KPIs)
The effectiveness of the Business Continuity Policy is measured through a set of key
performance indicators. These KPIs provide assurance that resilience measures are
embedded and maintained:
1. 100% completion of annual business continuity mapping.
2. 90–100% of services maintain up-to-date BIAs.
3. Achievement of Recovery Time Objectives (RTOs) and Recovery Point
Objectives (RPOs) as defined in the Business Continuity Plan.
4. Annual delivery of business continuity exercises with a minimum 65%
participation rate.
5. Accurate and timely recording of training and exercising activity on the MFT
Learning Hub.
Performance against these KPIs is monitored by Site-level EPRR Forums. Any
deviations, risks, or concerns are escalated to the EPRR Group for further review
and action, ensuring timely intervention and continuous improvement.
Supplier Performance
MFT will request one Business Continuity Plan from an external supplier / provider /
contractor per annum to ensure that their business continuity program is reviewed in
line with the MFT BCMS.
Suppliers BCPs must be reviewed as part of the procurement process and not after
the contract is awarded. Acceptable assurance from a provider is subject to
satisfactory submission of a BCP that meets the requirements of the NHS Checklist.
Suppliers, contractors and providers will be invited to participate in joint exercises in
order to validate the effectiveness of their BCP.
Governance
Organisations must have an appointed accountable emergency officer (AEO)
who is a board-level director and responsible for EPRR in their organisation.
page 49
Title: Business Continuity Policy Version: 2.3 Page 15 of 16
OFFICIAL
OFFICIAL
The AEO must provide reports to the public board on EPRR activity no less
frequently than annually and must publicly state readiness and preparedness
activities in annual reports within the organisation’s own regulatory reporting
requirements. Board reports will include:
• Training and exercising reports (including BC).
• Incidents experienced by the Trust.
• Lessons identified and lessons learned.
• Compliance with NHS England Core Standards.
• BC KPI summary.
Business Continuity Lexicon
This table provides commonly used BC abbreviations and their meanings according to ISO
Standard 22301 and the BCI.
Abbreviation
Meaning
BAU
Business As Usual
BC
Business Continuity
BCI
Business Continuity Institute
BCM
Business Continuity Management
BCMS
Business Continuity Management System
BCMT
Business Continuity Management Team
BCP
Business Continuity Plan
BCPDR
Business Continuity Planning and Disaster Recovery
BCR
Business Continuity Requirements
BCRA
Business Continuity Risk Assessment
BCRP
Business Continuity Recovery Plan
BCRS
Business Continuity and Resilience Standards
BCS
Business Continuity Strategy
page 50
Title: Business Continuity Policy Version: 2.3 Page 16 of 16
OFFICIAL
OFFICIAL
Abbreviation
Meaning
BAU
Business As Usual
BIA
Business Impact Analysis
DRP
Disaster Recovery Plan
EPRR
Emergency Preparedness, Resilience, and Response
ISO
International Organisation Standardisation
IT
Information Technology
KPI
Key Performance Indicator
MFT
Manchester University Foundation Trust
MTPD
Maximum Tolerable Period of Disruption
MTTR
Mean Time to Recover
NHS
National Health Service
NHSE
National Health Service England
OEM
Original Equipment Manufacturer
RPO
Recovery Point Objective
RTO
Recovery Time Objective
SLA
Service Level Agreement
SPOF
Single Point of Failure
page 51
Public Board of Directors
Wednesday 1st October 2025
Paper title:
Improve@MFT Strategic Delivery Plan
Agend
a Item
11.7
Presented by:
Vanessa Gardener – Chief Delivery Officer
Prepared by:
Maxine Power – Director of Improvement
Meetings where content has
been discussed previously
N/A
Purpose of the paper
Please check one box only:
☐For approval
☒For discussion
☐For support
Executive summary / key messages for the meeting to consider
This document outlines the proposed MFT Improve@MFT Strategic Delivery Plan.
Anchored in our commitment to our overall aim “we want everyone who uses services or works
at MFT to contribute to our improvement, be excited to explore ‘better is possible’, and have the
skills, time and permission to make improvements”, the plan sets out clear objectives,
governance structures, and delivery mechanisms to accelerate improvement at scale. It
prioritises workforce empowerment, data-driven decision-making, and cross-system collaboration
to enhance patient outcomes, operational efficiency, and staff experience. With measurable
milestones and a robust assurance framework, the plan ensures alignment with national priorities
while remaining responsive to local needs and opportunities for innovation.
Governance for delivery of the Improve@MFT Strategic Delivery Plan will be via the
Improvement Oversight Group reporting to Delivery Oversight Management Committee / Trust
Leadership Team Committee and Quality Safety Performance Board Committee.
Recommendation(s)
The Board of Directors Committee is asked to:
•Note the strategic delivery plan and progress to date in line with the milestones.
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐Yes (please set out in your report what action
has been taken to address this)
☒No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
page 1
LHL objective 1
☒
LHL objective 2
☒
HQSC objective 1
☒
HQSC objective 2
☒
HQSC objective 3
☒
PEW objective 1
☒
PEW objective 2
☒
VfP objective 1
☒
VfP objective 2
☒
R&I objective 1
☒
R&I objective 2
☒
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks:
• If MFT fails to deliver a culture of continuous improvement, then
there may be reduced staff engagement, lower patient satisfaction,
and a decline in service quality, impacting overall organisational
performance, reputation and stakeholder confidence
Care Quality Commission
domains
Please check all that apply
☒ Safe
☒ Effective
☒ Responsive
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
• CQC Well Led Domain compliance
Main report
Excellence and Compassion Powered by Improvement
We would like everyone who uses services or works at MFT to contribute to our improvement, be excited
to explore ‘better is possible’, and have the skills, time and permission to make improvements.
As a result, we will deliver improved performance on key staff survey indicators of engagement including
our primary outcome measure of 70% of staff agreeing that ‘I am able to make Improvements happen in
my area of work’, by 2030.
We will align the improvement work to the right suite of metrics to determine the impact of our
improvement on experience, quality, performance, efficiency, population health, sustainability and health
inequalities.
page 2
Shared Purpose
MFT is signed up to the delivery of our 2024-2029 Strategy “Where Excellence meets Compassion”. We
are ambitious and we want to go further faster. To do this we need a clearly articulated improvement plan.
Our MFT Approach
In 2023, NHS England launched the NHS Impact Programme which aims to mainstream continuous
improvement across the entire NHS to achieve enhanced patient outcomes, increase operational
efficiency and overall excellence in healthcare delivery.
We are committed to the principles of NHS Impact and appreciate that sustained improvement at scale
within healthcare is difficult to achieve. It requires long term commitment and a reframing of roles and
responsibilities for all leaders and staff. Actions to improve are all welcome and clarity on how we are
organising improvement is vital if we are to avoid duplication and redundancy. We therefore need to
articulate who is doing what and how improvement is best delivered by clinical groups and across MFT.
This plan assumes that improvement will happen at three levels:
• Level 3: MFT centrally led (macrosystem)
• Level 2: Clinical group led, with learning across MFT (mesosystem)
• Level 1: Clinical group service (microsystem)
Our MFT Improvement Plan
The plan is split into the following areas (see Appendix 1 for a summary of the Strategic Delivery Plan):
1. Clarity on the MFT improvement approach: We have established the Institute for Health Care’s
(IHI) Model for Improvement as our core method under the brand Improve@MFT. To effectively use
the model for improvement teams are also taught some applied theory that underpins all
improvement:
• the psychology of change (managing people’s reaction to change)
• systems thinking (value stream mapping, process re-design & waste)
• variation (setting aims, statistical process control, understanding variation)
• testing changes (creating logic models and using Plan, Do, Study, Act cycles).
2. A pipeline for ideas: We have an ideas pipeline which currently operates via our value for patients'
team. We will build on this to develop a robust innovation pipeline for incubating patient and staff
suggestions. The Innovation Pipeline will learn from, and be aligned with, the i-Tap programme and
‘pitch for patients’ programmes so that by 2026 we have a single pathway for ideas generation,
incubation, testing and scaling. This will allow us to evaluate impact and grow the confidence of our
workforce that the changes they suggest will be progressed and if the changes do not progress there
will be clear communications about why not. We will use our partnerships to identify ideas with
commercial potential.
3. A clear strategy for scaling improvement:
Investment in training and improvement leadership: We have developed a skills escalator
(novice to expert) and tiered training plan which identifies the number of staff we need to train in
improvement science to reach a ‘tipping point’ (see Appendix 2). Our improvement training is both
‘standalone’ and embedded into leadership training programmes in a complimentary way. Over
the next two years we will be working with the organisational development team and executive
offices on how we can integrate the knowledge and skills for improvement leadership with system
leadership, learning and improvement. Our shared aim will be the development of an MFT
academy for leadership, learning and improvement.
Value Stream Mapping and Process Re-design: Value stream mapping and process redesign
are powerful tools for scaling improvement efforts, especially in healthcare and workforce
page 3
development. Value Stream Mapping (VSM) helps visualize the entire workflow, identifying
inefficiencies and opportunities for streamlining. It focuses on eliminating waste and optimizing the
flow of value to the end user, whether that’s a patient or an employee. Process Redesign builds
on VSM by restructuring workflows to enhance efficiency, reduce bottlenecks, and improve
outcomes. This often involves automation, role redefinition, or integrating new technologies. For
large-scale improvement, combining these methods ensures that changes are systematic,
scalable, and sustainable. During 2025-26 Improve@MFT will support the identification of a total
of three value streams across the clinical groups and complete a series of rapid improvement
events to re-design processes from end to end. By 2026-27 we will have a train the trainer
programme established for value stream mapping and the removal of waste.
The Breakthrough Series collaborative: developed by the Institute for Healthcare Improvement
(IHI), is a structured approach to scaling improvement efforts. It brings together multiple teams
from different organizations to rapidly test and implement changes in a short-term learning system
(typically 6 to 15 months). Organizations learn from each other and from experts in the field.
Teams engage in cycles of testing and refining improvements. Proven methods help spread
successful changes across a system. Includes learning sessions, action periods, and ongoing
measurement. This model has been widely used in healthcare to improve quality, efficiency, and
patient outcomes.
We will use the Breakthrough Series collaborative model to support delivery of three priority
programmes over the next 2 years:
• Access to scheduled care and outpatient services (Care on Time)
• Improving the quality of urgent and emergency care (Care Closer to Home)
• Saving lives and reducing avoidable harm (Harm Free Care).
Clinical communities: Clinical communities are a powerful approach for scaling improvement
across healthcare systems. They bring together professionals with shared expertise and goals to
drive change collaboratively. We will use clinical communities to deliver cancer improvement and
to reduce variation (GIRFT and audit).
Extension agents: Extension agents play a crucial role in scaling improvement efforts,
particularly in fields like healthcare, agriculture, and workforce development. They act as
intermediaries, connecting best practices, research, and innovations to frontline workers or
communities. We will use extension agents to deliver key improvement priorities within and
between clinical groups in combination with collaboratives and process re-design
4. A quality management system: We will bring together quality planning, quality assurance and quality
improvement into a single quality management system. Over the next two years our management
system will be developed by:
• Establishing a learning network of peer organisations and systems
• Convening an advisory faculty and steering group
• Developing our prototype model and testing validity
• Aligning our existing systems and processes to our framework
• Evaluating impact and sustainability.
5. An improvement home and brand: A SharePoint site for Improve@MFT has been developed and is
currently being tested prior to launch in July 2025. A LinkedIn account has been established and
newsletters are also produced. A full communications and networking strategy is planned, aligned with
re-launch of the value for patients’ programme. We will develop the Improve@ MFT recognition and
rewards scheme which will celebrate and recognise Improve@MFT. We will host GM partners at the
‘Improve Manchester’ Conference which will commence in 2026. This will become the ‘engine room’
for collaboration across GM and beyond. We will identify suitable accommodation for co-locating our
improvement teams whilst our academy is under construction. This will help with the hosting
improvement teams and fellowship programmes.
page 4
6. Clinical group plans aligned with MFT wide improvement: Clinical groups will develop their own
improvement plan (aligned to their annual plan) which includes how they will release staff to attend the
capability for improvement development programmes, organise their internal improvement
programmes and participate in each of the three large scale change programmes (see Appendix 1).
They will also be invited to participate in development of the MFT quality management system.
7. A highly skilled improvement team, advisory faculty and academic leadership. The Improvement
Team at MFT were established in October 2024 following Phase 1 of the OneMFT programme, which
covered Clinical Group formation along with strategy and transformation functions. The improvement
workforce operates in an aligned model, with team members aligned to each clinical group and
corporate team, whilst also working in a matrix model to deliver Trust-wide capability building and
large-scale change. They are engaged in a programme of skills development and are specialised in
project management and leadership; however some gaps exist in advanced improvement skills. A
plan will be put in place to develop the team, an advisory faculty and fellowship programme in 2025-
26.
8. Clear Allocation of improvement resources: for MFT to deliver, the improvement resource needs to
align to this plan. There are requirements for staff to be released for training and to lead improvement.
Transitioning the improvement team to support this will potentially leave gaps in delivery. It is our
intention in 2025-26 to review workload allocation for all clinical group improvement teams jointly with
the senior leadership teams to ensure that the historical and reactive workload is value added, reduce
it where possible and release time to focus on improvement training, organising improvement
programmes and coaching teams.
Milestones and Timescales
Deliverable
Rationale
By when
1. Nominated senior lead for each Clinical
Group with responsibility for
improvement plan
Key contact for improvement director
Reports to SLT
Clinical Group representative on MFT
Improvement Oversight Group
June 25
August 25
Sept 25
2. Clarity on top three improvement
priorities
Focus for organisational resource
Clarity on improvement approach for
each priority
July 25
August 25
3. A3 plan for delivery of top three
priorities with SMART aim, driver
diagram, measures, steering group and
delivery team
Clarity of messaging
Focus
Application of improvement method
July 25
4. Identification and release of three teams
(five people per team) to participate in
MFT wide breakthrough series
collaborative (Sept 2025- August 2026) –
care closer to home, care on time and
harm free care.
Building leadership in teams
Learning whilst ‘doing’
Cross organisational learning
Strengthening existing work
August 25
(ongoing)
5. Articulated mechanism for improvement
teams to share their learning with senior
leaders at least monthly eg improvement
team sponsorship, report out, lunch and
learn, Hospital Leadership Forums or
leadership walk rounds
Celebrate success
Unblock barriers
Learning for SMT
Opportunity to close gaps
Sept 25
6. Communications plan for sharing
improvement stories and celebrating
success (aligned to VfP comms and
engagement plan)
CEO blog
Case study for quality account
Poster at nursing and quality
conference
Sept 25
Mar 26
Dec 25
page 5
7. Improvement capability building plan
agreed
Agreement of dosing strategy and
numbers
Identification of future leaders
Alignment with personal
development plans
Sept 25
Jan 26
Mar 26
8. Improvement Leaders network linked to
fellowship programme
Identification of 10 future leaders for
improvement fellowship application
Mar 26
9. Plan for developing improvement skills in
senior management team
SMT development day on Quality
management systems and leading for
quality
Mar 26
10. Review Improvement Resource within
the clinical group and define how this will
be allocated
Improvement SLT lead with
improvement director
Monthly meetings
July 25
Ongoing
All milestones are on track to the timescales stated.
Risks and Interdependencies
Managing risks and interdependencies is crucial to the successful development and realisation of the
Improvement Strategic Delivery Plan. Risk 008234 (Failure to deliver the Improvement Strategic Delivery
Plan) includes a comprehensive risk assessment and management plan. The improvement leadership
team will work proactively and collaboratively across MFT to mitigate and manage these risks and
interdependencies.
page 6
Appendix 1: Improve@MFT – Strategic Delivery Plan
Our Aim
We want everyone
who uses services or
works at MFT to
contribute to our
improvement, be
excited to explore
‘better is possible’,
and have the skills,
time and permission
to make
improvements.
Measured by: 70%
of staff agreeing that
‘‘I am able to make
Improvements
happen in my area of
work’, by 2030.
✓A shared purpose
✓Visible leadership
✓Learning together
✓Learning from others
✓
Partnering for
success
Creating the conditions
for improvement to
thrive
Clarity on the MFT
approach to
improvement
✓Our method
✓Our pipeline
✓Levels of action
✓Skills escalator
A clear plan for taking
improvement to scale
Co-production of a
world class quality
management system
✓Partnerships
✓Faculty
✓Fellows
✓Academy
✓
Clinical &
Operational
✓Improving value,
reducing waste
✓Collaborative
learning
✓
Clinical communities
✓Extension agents
page 7
Appendix 2: Two Year Schedule
2025/26
2026/27
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
Q2
Q3
Q4
Collaborative 1
Harm free care
Prework
Learning
Session 1
Learning
Session 2
Learning
Session 3
Share
Evaluation
Collaborative 2
Prework
Learning
Session 1
Learning
Session 2
Learning
Session 3
Share
Evaluation
Collaborative 3
Prework
Learning
Session 1
Learning
Session 2
Learning
Session 3
Share
Evaluation
Clinical community 1
Cancer
20
20
20
20
20
10
5
20
20
20
20
20
60
50
45
Clinical community 2
TBC
Pre-work
Value stream 1
Prework
RPIW 1
30
60
90
RPIW2
30
60
90
Evaluation
Cycle 2 planning
Value Stream 2
Prework
RPIW 1
30
60
90
RPIW2
30
60
90
Cycle 2
planning
Value Stream 3
Prework
RPIW 1
30
60
90
RPIW2
30
60 90
Cycle 2
planning
Value for patients -
Pitch
10x£10k
10x£10k
10x£10k
Level 1 training
50
50
50
50
50
50
50
50
50
50
50
50
150
150
150
Level 2 training
Co-design
50
50
50
50
50
Recruit
Level 3 training
Pre-work
LS1
LS2
LS3
Share
50
Recruit
Advisory Faculty
Engage
expertise
Academic
partner
Fellows Programme
Co-design
Fellows Programme (4-6)
Evaluation
Clinical Group Plan
Agree 25/26 Plan and transition
Review
Develop & agree 26/27
Plan
Review
Improvement
Conference
Plan
July
page 8
page 9
Public Board of Directors
Wednesday 1st October 2025
Paper title:
MFT / NCA Pathology Consolidation Programme Update
Agenda
Item
11.8
Presented by:
Tom Rafferty, Acting Chief Strategy Officer
Prepared by:
Gareth Adams, Chief Executive Clinical & Scientific Services
Sophie Hargreaves, Director of Strategy
Ian Daniels, Deputy Director of Strategy
Meetings where content has
been discussed previously
Strategy and Planning Management Committee
Trust Leadership Team Committee
Purpose of the paper
Please check one box only:
☐ For approval
☐ For discussion
☒ For support
Executive summary / key messages for the meeting to consider
• This paper provides an update on the strategic collaboration between Manchester
University NHS Foundation Trust (MFT) and Northern Care Alliance NHS Foundation Trust
(NCA) to consolidate pathology services.
• The programme represents an opportunity to align strategic priorities and combine
resources and expertise to develop a consolidated high efficiency, high quality, high
performing pathology service utilising the latest automation, digital and artificial intelligence
technologies. This will unify services currently delivering over 60 million tests annually,
supported by a workforce of 1,700 and a combined budget exceeding £165 million, meeting
national directives to establish pathology networks across Integrated Care Board (ICB)
areas. It also creates a future opportunity for commercial income growth.
• There has been a long-held ambition within GM to consolidate and network pathology
provision. The strategic imperative has gained momentum following national guidance to
improve efficiency, resilience, and cost-effectiveness within pathology networks.
• Given MFT \ NCA services deliver a large proportion of pathology testing activity within GM,
building on the partnership working between pathology services forged during North
Manchester disaggregation and guided by the GM Trust Provider Collaborative identifying
pathology networking as a priority, both Trusts recognise the leadership role they have to
play in driving this agenda.
• Recent key developments include executive-level endorsement from both organisations to
proceed with a Strategic Outline Case (SoC) in January 2025, completion and approval of
the SoC between March and May 2025, and the development of a proposal in August 2025
recommending a phased approach to delivery of consolidation. The SoC identified four
critical success factors: strategic delivery, governance and accountability, implementation
feasibility, and capital efficiency.
• The next stages of development have been defined in a three-phased approach. Phase 1a
focuses on short-term service priorities, tangible improvements through targeted service
collaborative working. Phase 1b involves a comprehensive due diligence exercise to inform
page 1
the development of detailed consolidation options. Phase 2 will develop detailed options for
full consolidation, and Phase 3 will involve executing the chosen consolidation plan.
•A formal programme structure is being established to oversee each phase, supported by
dedicated resources from digital services, estates, HR, finance, and clinical governance.
External expertise will be sought, particularly regarding commercial and ownership models.
Engagement with the Trust Provider Collaborative (TPC) and other partners will be integral
to the programme’s success.
•The establishment of a small, dedicated programme team to support delivery is proposed,
resourced jointly across MFT and the NCA.
Recommendation(s)
The Board of Directors is asked to:
•Note the strategic collaboration between MFT and NCA to consolidate pathology services
and the drivers behind it.
•Note the progress that has been made so far.
•Support the proposed phased approach to the next stage of programme delivery.
•
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐Yes (please set out in your report what action
has been taken to address this)
☒No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☐
LHL objective 2
☒
HQSC objective 1
☒
HQSC objective 2
☒
HQSC objective 3
☒
PEW objective 1
☐
PEW objective 2
☒
VfP objective 1
☒
VfP objective 2
☒
R&I objective 1
☒
R&I objective 2
☒
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks:
•None.
Care Quality Commission
domains
Please check all that apply
☒Safe
☒Effective
☒Responsive
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
page 2
• Maintaining required Laboratory accreditations such as
UKAS will be essential during the delivery of a
consolidation programme.
Main report
Background
• This paper provides an update on the strategic collaboration between Manchester
University NHS Foundation Trust (MFT) and Northern Care Alliance NHS Foundation Trust
(NCA) to consolidate pathology services.
• The programme represents an opportunity to align strategic priorities and combine
resources to develop a consolidated high efficiency, high quality, high performing pathology
service utilising the latest automation, digital and artificial intelligence technologies. This will
unify services currently delivering over 60 million tests annually, supported by a workforce of
1,700 and a combined budget exceeding £165 million, meeting national directives to
establish pathology networks across Integrated Care Board (ICB) areas. It also creates a
future opportunity for commercial income growth.
• There has been a long-held ambition within GM to consolidate and network pathology
provision. The strategic imperative has gained momentum following national guidance to
improve efficiency, resilience, and cost-effectiveness within pathology networks.
• Given MFT \ NCA services deliver a large proportion of pathology testing activity within GM
building on the partnership working between pathology services forged during North
Manchester disaggregation and guided by the GM Trust Provider Collaborative identifying
pathology networking as a priority, both Trusts recognise the leadership role they have to
play in driving this agenda.
• Recent key developments include:
o January 2025: Executive-level endorsement from both organisations to proceed with
a Strategic Outline Case (SoC).
o March–May 2025: Completion and approval of the SoC. This recommended the
pursuit of a strategic consolidation of pathology services into single site operating
models across the two provider organisations and the exploration of potential
commercial partnership opportunities to support and accelerate this.
o August 2025: Proposal developed recommending a phased approach to delivery of
consolidation and the interim pursuit of ‘Fast Track Impacts’ to further strengthen joint
working between the two services to maximise short term benefits.
• The SoC identified four critical success factors:
o Strategic Delivery – Alignment with national strategy and organisational objectives.
o Governance and Accountability – Clear lines of responsibility in a consolidated
delivery model.
o Implementation Feasibility – Realistic delivery timelines.
o Capital Efficiency – Minimising capital investment requirements.
Next Stage
• Following the approval of the SoC, a three phased approach to the next stages of
development has been defined.
page 3
• The phased approach will ensure that immediate improvements are realised while laying the
groundwork for comprehensive consolidation. By combining short-term wins with thorough
due diligence and strategic planning, the programme aims to deliver a resilient, efficient,
and high-quality pathology service for the future.
Phase 1a: Fast Track Impacts
• The initial phase focuses on short-term, tangible improvements through targeted service
collaborative working. Examples include:
o Reviewing and aligning activity with the capacity opportunities across provider
pathology services with a focus on histopathology and microbiology
o Transferring NCA electron microscopy to MFT.
o Launching a joint procurement programme.
o Harmonising job descriptions.
o Implementing shared cost improvement initiatives and value-for-patients
programmes.
• These measures aim to alleviate capacity pressures, reduce outsourcing and agency
spend, improve turnaround times and drive service resilience. Work commences
immediately and is expected to run for three to six months.
Phase 1b: In-Depth Due Diligence
• A comprehensive due diligence exercise will be undertaken to inform the development of
detailed consolidation options. This involves:
o Deep diving into both organisations’ pathology services.
o Developing a full capacity and demand model, including potential Greater
Manchester additions.
o Exploring estates and digital options, considering refurbishment or new build
requirements.
o Identifying organisational limitations and opportunities for commercial partnerships.
o Scoping further service consolidation and joint appointments.
• This phase starts immediately and is anticipated to last three to six months.
Phase 2: Consolidation Detailed Options Development
• Building on the findings from Phase 1b, this phase will develop detailed options for full
consolidation. This includes:
o Defining ownership and service models, site configurations, and workforce
requirements.
o Specifying estate and digital service needs, financial models, and expected
efficiencies.
o Engaging with Greater Manchester partners to identify a preferred solution.
o Creating an implementation plan and seeking approval from both Trust Boards and
support from the Trust Provider Collaborative (TPC).
• This phase will commence after the completion of Phase 1b and is expected to take
approximately six months.
Phase 3: Implementation of Formal Consolidation
page 4
• The final phase involves executing the chosen consolidation plan. Timescales for this phase
will be confirmed during Phase 2. This will mark the full integration of pathology services
across both organisations.
Programme Governance and Support
• A formal programme structure will be positioned to oversee each phase, supported by
dedicated resources from digital services, estates, HR, finance, and clinical governance.
External expertise will be sought, particularly regarding commercial and ownership models.
Engagement with TPC and other partners will be integral to the programme’s success.
• The establishment of a small, dedicated programme team to support delivery is proposed,
resourced jointly across MFT and the NCA.
Success Factors
• The following factors will be important in the successful delivery of the consolidation
programme:
o Strong Programme Governance – Establishment of a formal programme board and
working groups with clear leadership from clinical, scientific, managerial, commercial,
estates, digital, HR, finance, and governance representatives.
o Dedicated Resources and Expertise – Securing dedicated programme management,
administrative support, and subject matter experts, especially in digital services and
estates.
o Effective Stakeholder Engagement – Ongoing engagement with internal teams, the
Greater Manchester Pathology Network (GMPN), Trust Provider Collaborative (TPC),
and external partners.
o Early Delivery of Tangible Benefits – Pursuing fast track impacts such as service
transfers, joint procurement, and harmonisation of job descriptions.
o Robust Due Diligence and Option Appraisal – Comprehensive due diligence
including capacity and demand modelling, estates and digital options, and
organisational red lines.
o Clear Communication and Joint Statement of Intent – A joint statement from
Executive Teams to galvanise focus and foster collaboration.
Programme Risks
• The following risks will have to be monitored and mitigated to ensure the successful delivery
of the programme:
o Resource Constraints – Insufficient programme management, digital, estates, or
external support could delay progress or compromise delivery quality.
o Estate Challenges – Funding to aligning infrastructure with future service models—
requiring phased investment, modernisation of ageing facilities, and reconfiguration
of laboratory environments to support integrated, resilient, and scalable diagnostic
networks.
o Digital Integration Challenges – Difficulties in integrating Laboratory Information
Management Systems (LIMS), clinical records, or laboratory facilities.
o Workforce Alignment and Change Management – Challenges in harmonising job
descriptions, training, and cross-organisational roles may lead to resistance or
disruption.
o Financial and Commercial Uncertainty – Uncertainty around funding or delays in
securing commercial partnerships could impact feasibility or timing.
page 5
o Governance and Accountability Risks – Lack of clarity in governance arrangements
or escalation routes for consolidated services may result in decision-making delays.
o Stakeholder Engagement Risks – Inadequate engagement with key partners or
internal teams could result in misalignment or lack of buy-in.
o Operational Disruption – Service transfer and system integration may cause short-
term disruption to service delivery.
Recommendations
• The Board of Directors is asked to:
o Note the strategic collaboration between MFT and NCA to consolidate pathology
services and the drivers behind it.
o Note the progress that has been made so far.
o Support the proposed phased approach to the next stage of programme delivery.
o
page 6
Agenda Item 12.1
Escalation and Assurance Report
People Board Committee (PBC)
Report to: Board of Directors
Report from: Angela Adimora, Non-Executive Director and Chair of PBC
Date of meeting: 03/09/25
Key escalation and discussion points from the meeting
Alert
The Committee received the annual Medical Appraisal and Revalidation report and noted that Professor
Bernard Clarke is acting Responsible Officer until the new substantive Joint Chief Medical Officer joins the
Trust. At the end of the last appraisal year (31 March 2025), MFT had 2,757 doctors with a prescribed
connection plus an additional 81 dentists requiring an MFT appraisal. 96.4% of connected doctors had an
appraisal for the 2024-2025 appraisal year and appraisers were rated as Very Good or Good by 98.1% of
appraisees who submitted feedback. The Committee supported the Statement of Compliance submission
being presented to the Board for approval at this meeting.
North Manchester General Hospital (NMGH) has faced long-standing challenges in delivering high-quality
training in Obstetrics and Gynaecology, resulting in the imposition of formal conditions by the GMC in June
2025. The Committee received a report describing the short, medium and long term work being undertaken
to address the findings of the GMC. Immediate actions have been implemented to ensure compliance with
GMC requirements. An NHSE-led review is scheduled for October 2025. The NED Chairs of the PBC and
QSPBC have met with the Joint Chief Medical Officer to discuss the issues further and the Committee will
continue to monitor progress being made.
Advise:
The Committee discussed a film presenting the new Digital ID process checking service at the Trust which
will reduce the time between a successful interview and an individual beginning in their new role.
The Committee received the Guardian of Safe Working report for Q1 of 2025/26. 1. A total of 214 exception
reports (ERs) were submitted by 93 doctors in Q1, which is 6 fewer ERs than the number reported in Q4.
72% of ERs were reviewed within 28 days. The new national guidance allowing resident doctors to receive
additional pay instead of time off for additional hours worked was explained. The risks to the health and
wellbeing of resident doctors and the potential financial risk to the Trust from a financial point of view were
noted.
As part of her report, the Chief People Officer highlighted recent leadership changes, at Trust-level and
within Clinical Groups, and described the different aspects of the organisational development programme
which has been developed to support the new leadership arrangements within Clinical Groups.
The Committee received an update on planning and activity in preparation for the 2025 NHS National Staff
Survey. The survey takes place from the 9/9/25 to the 28/11/25. The Committee discussed the importance
in supporting Sodexo staff to complete the survey, due to the impact of their roles on patient experience,
and some of the practical challenges people in those roles have in completing surveys due to the nature of
their roles.
page 1
The Committee received an update on the Trust’s apprenticeship programme. MFT contributes £550,000
a month to the apprenticeship levy and has generated £345,000 funding from the provision of MFT-
delivered apprenticeships due to having ‘Main Provider’ status. Work is underway to increase the uptake
of apprenticeships with three areas of focus: digital, care support workers, and Band 2/3 administrative
staff. The Committee discussed the importance of the work to offer employment opportunities to local
people and to address health inequalities. In the past 12 month, over £500,000 of unused apprenticeship
levy has been gifted to other organisations including NWAS and local GP practices.
The Committee received a report on current employment tribunal activity and the key themes which have
been identified. The Trust’s Employee Relations Oversight Group is reviewing all employee relations’
activity to improve processes and enhance support provided to managers and all staff. The Disabled Staff
Network are supporting an analysis of disability-related tribunals.
The Committee received a detailed summary of medical and NMAHP education provision within the Trust
which identified positive progress and areas where improvement was still required. CPD monies are being
used to focus training and education spend on the Trust’s priorities and the job planning process is being
used to build in time for education.
Assure:
The Committee discussed the workforce-related elements of the Integrated Performance Report for July
2025 and the action in place to address areas of underperformance.
•Of the 30 areas measured within the IPR, eight are not meeting their target.
•More work is being undertaken to support compliance with the price-cap compliance target.
•There has been an in-month improvement in non-medical appraisal rates but the target is not yet
being met.
•Level 2 and 3 mandatory training are very nearly at the target rate of 90% which is a significant
improvement on this time last year.
•Staff absence is currently at 6% and on track to achieve target but work continues to reduce this
further. The Trust Leadership Team Committee is monitoring this on a weekly basis.
•A new indicator will be included in future reports to track the progress towards achieving the target
in relation to overall staff establishment for the Trust.
The Committee received the bi-monthly Safer Staffing reports for Nursing and Midwifery. The nurse
vacancy rate is 2.8% below the national average with a fill rate of 94.96%. Work with universities to attract
graduating student nurses to MFT continues. Maternity services are compliant with the Birthrate+
calculations for recommended establishments and there has been a sustained reduction in midwifery
staffing incidents. A further Birthrate+ exercise has begun and is due to be completed in Q3.
Risks discussed at the meeting
Committee discussed the strategic and corporate risks relevant to the Committee. Since the last
Committee meeting, workforce-related corporate risk have been reviewed and the new risks were
identified within the report. The Committee emphasised the need to ensure that risk rating and target
dates were appropriate – a review of all strategic and corporate risks is being supported by the Deputy
Director of Clinical Governance and Risk.
Report approved by: Angela Adimora, Non-Executive Director and Chair of the PBC.
page 2
Agenda
People Board Committee
Date: Wednesday, 3rd September 2025
Time: 2:00pm – 4:00pm
Location: Main Boardroom, Cobbett House, ORC
Agenda
Item
Purpose
Lead
Time
1.
Apologies for absence & confirmation of quoracy
(verbal)
Meeting
admin
Chair
2:00pm
2.
Declaration of interest (verbal)
Meeting
admin
Chair
2:00pm
3.
Minutes of the previous meeting
(25th June 2025).
Meeting
admin
Chair
2:00pm
4.
Action Log
Discussion
Chair
2:05pm
5.
Matters Arising
Discussion
Chair
2:10pm
6.
Staff story (film)
Discussion
Chief People
Officer
2:15pm
7.
Assurance Reporting:
7.1
Strategic and Corporate Risks
Discussion
Chief People
Officer
2:20pm
7.2
Integrated Performance Report
Discussion
Deputy Chief
People Officer
2:30pm
Strategic aim 3: Be the place where people enjoy working, learning and building a career
8.1
Chief People Officer report
Discussion
Chief People
Officer
2:35pm
8.2
Staff Survey update
Discussion
Chief People
Officer
2:40pm
8.3
Apprenticeship Update
Discussion
Chief People
Officer
2:50pm
page 3
8.4
Employment Tribunal Update
Discussion
Deputy Chief
People Officer
3.00pm
8.5
Trust Education Summary
Discussion
Deputy Chief
People Officer
3:10pm
8.6
Guardian of Safe Working Quarterly report (Q1)
Discussion
Guardian of Safe
Working
3.20pm
8.7
Annual Medical Revalidation report and Annual
Organisational Audit (Statement of Compliance)
Discussion
Interim Joint
Chief Medical
Director
3:30pm
8.8
GMC Conditions on Obstetrics and Gynaecology
Training at NMGH
Discussion
Joint Chief
Medical Officer
3:35pm
8.9
Safer Staffing report (nursing)
Discussion
Interim Deputy
Chief Executive /
Chief Nursing
Officer
3:40pm
8.10
Safer Staffing report (midwifery and newborn
services)
Discussion
Interim Deputy
Chief Executive /
Chief Nursing
Officer
3:50pm
Committee business
9.
Escalation report
Approval
Chair
3:55pm
10.
Workplan review
Meeting
admin
Chair
3:55pm
11.
Any Other Business (verbal)
Discussion
All
3:55pm
12.
Meeting Evaluation (verbal)
Meeting
admin
Chair
4:00pm
Date of next meeting: Wednesday, 22nd October 2025 at 2.00pm in the Main Boardroom, near
Cobbett House.
page 4
page 5
Public Board of Directors
Wednesday 1st October 2025
Paper title:
Bi-monthly Safe Staffing Report (Nursing)
Agenda
Item
12.2
Presented by:
Kimberley Salmon-Jamieson, Interim Deputy Trust Chief
Executive and Chief Nursing Officer
Prepared by:
Mark Keegan, Corporate Director of Nursing for Workforce and
Education; Darren Dunleavy, NMAHP Workforce Programme
Lead; Marie Matthew, NMAHP Workforce Lead Nurse
Meetings where content has been
discussed previously
Trust Workforce and Education Management Committee
NMAHP Workforce and Education Forum, 6th August 2025.
People Board Committee, 3rd September 2025.
Purpose of the paper
Please check one box only:
☐For approval
☒For discussion
☐For support
Executive summary / key messages for the meeting to consider
1. This bi-monthly safe staffing report covers the months of May and June 2025 and provides
assurance that the Trust remains compliant with the national guidance in relation to safer
staffing for nursing in accordance with National Quality Board (NQB) Safer Staffing
Guidance (2016), and the NHS Improvement (NHSI) Developing Workforce Safeguards
(DWS) Guidance (2018). A midwifery safe staffing report is provided separately.
2. The Board of Directors received a report of the bi-annual assessment of the nursing
establishment and skill mix in June 2025, and this report provides assurance of safe nurse
staffing as described in sections 4, 6, 7 and 9.
3. In the previous two months the NMAHP Corporate Workforce team have continued to
support Clinical Groups with several financial control schemes in collaboration with the
NMAHP Workforce leads for each Clinical Group and Clinical Group Directors of Finance
to ensure the financial impact is accurately reported.
4. Nursing establishments are set using a triangulated approach including an evidence-
based acuity and dependency tool, professional judgement and assessment of nursing
sensitive outcomes. The suite of Safer Nursing Care Tool (SNCT) applications,
developed by the Shelford Group and endorsed by the National Institute for Health and
Care Excellence (NICE) are used to support nursing establishment and skill mix
assessments.
5. MFT has maintained licences for all the Safer Nursing Care Tool (SNCT) evidence-based
tools, which are developed by the Shelford Group and endorsed by the National Institute
for Health and Care Excellence (NICE) to support nursing establishment and skill mix
assessments.
page 1
6. The funded establishment in May 2025 was 9,061.8wte for registered nursing roles (band
5 and above) and 3,646.8wte for unregistered staff, with a decrease of 15.8wte in
registered nursing establishment and no change for unregistered establishment since
March 2025.
7. There are 8,883.8wte registered nurses and 3,197.1 unregistered nursing support
colleagues in post, with a vacancy rate of 2.8% for registered nurses (less than the current
national vacancy rate at 6.0%) and 12.2% for unregistered nursing support.
8. Turnover for registered nurses has reduced over the past 12 months and as of May 2025
is 8.0% against a national rate of 7.2%. Sickness rate for registered nurses has seen no
significant variation in recent months and for the past 3 months has reduced below the
mean average of 6.3% at a current rate of 5.8%. Sickness rates for unregistered nursing
support colleagues has reduced down to 9.1% following a seasonal winter peak of 12.5%
in December 2024. There is currently an unbudgeted pressure on nursing workforce due
to maternity leave of 4.4%.
9. Phase 2 of the enhanced rate reduction plan has now concluded, with additional reduction
in rates being implemented in May 2025. Fill rates across all affected areas collectively
reduced from a mean average of 88.3% to 74.4% in the first week of phase 2 reductions.
The fill rates have then remained at c74% since this date.
10. The Trust continues to inform and maintain membership with the national improvement
collaborative sponsored by NHSE with a focus on Enhanced Therapeutic Observations of
Care. A Steering Group has been established, and an improvement plan has been
developed to focus on clinical assessment and decision making, data, workforce
deployment models, temporary staffing escalations and staff training. The overall aim of
the programme is to ensure ETOC is least restrictive, thereby reducing the reliance on 1to1
observation and the use of temporary staffing.
11. The overall shift fill rate across MFT has been maintained between 94 and 96% in the last
6 months, with 58 areas from a reported 120 meeting the fill rate standard of 95.0% or
above in May 2025.
12. The MFT wide average Care Hours Per Patient Day (CHPPD) level is at 9.7 hours per
patient matching the Shelford Group average of 9.7 hours, indicating that the Trust staffing
levels result in a CHPPD level aligned with the Shelford average. CHPPD at MFT is in the
middle of the range when compared to the Shelford Group of NHS Trusts ( 6th out of 10
when ranking highest to lowest CHPPD).
13. The total number of incidents reported directly to staffing levels was 924 for the period
March 2025 to June 2025. The majority of the incidents resulted in no harm and the
appropriate actions were taken at the time following investigation. Of the 4 incidents
resulting in moderate harm, 3 related to corporate services and had no direct impact on
patient care, and one related to low staffing levels on a respiratory ward with high acuity.
14. There were 9 category 3 or 4 attributable pressure ulcers in May 2025. 6 associated to
community and 3 in acute settings (1 WTWA, 1 CSS and 1 MRI). The rate of falls per
10,000 in May 2025 shows a pattern of normal variation. MRI (3 falls) and WTWA (3 fall)
have reported the largest number of level 4 and 5 reported falls and improvement plans
are in place.
page 2
15. The Theatre Workforce forum was reinstated in April 2025 with senior nursing
representation from theatre departments across all Clinical Groups and oversees the
NMAHP workforce plan for Theatres to support the Clinical Groups to deliver the elective
surgery programme and maintain non-elective surgery capacity.
16. Theatre Establishment increased by 18.6wte primarily due to new establishments resulting
in increased vacancy position of 16.6wte in May 2025. Staffing continues to improve with
recruitment of 13 graduate ODP’s due to start by October 2025. Supernumerary period for
registered nursing has been standardised to 12 weeks for registered nursing across all
Clinical Groups.
Recommendation(s)
The Board of Directors is asked to:
• Receive this report and note that MFT remains compliant with the national guidance (NQB
2026; DWS 2018) in relation to safer nurse staffing.
• Note the report was received and discussed at the People Board Committee on 3rd
September 2025.
• Receive assurance of safe nurse staffing as described in sections 4, 6, 7 and 9.
Do the recommendations in this paper have
any impact upon the requirements of the
protected groups identified by the Equality Act?
☐ Yes (please set out in your report what action has
been taken to address this)
☒ No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic objectives (see
key below)
LHL objective 1
☐
LHL objective 2
☐
HQSC objective 1
☒
HQSC objective 2
☐
HQSC objective 3
☐
PEW objective 1
☐
PEW objective 2
☐
VfP objective 1
☒
VfP objective 2
☐
R&I objective 1
☐
R&I objective 2
☐
Good Governance
☒
Links to Trust Risks
The work contained with this report links to the following strategic,
corporate or operational risks:
•
Care Quality Commission
domains
Please check all that apply
☒ Safe
☐ Effective
☐ Responsive
Compliance & regulatory
implications
The following compliance and regulatory implications have been
identified as a result of the work outlined in this report:
page 3
• National Quality Board (NQB) Safer Staffing Guidance for adult
wards (2016)
• CQC’s fundamental standards – staffing; safety; good
governance
• Developing workforce safeguards - Supporting providers to
deliver high quality care through safe and effective staffing;
NHSE; 2018
Main report
1. Introduction
This bi-monthly Safe Staffing report provides the Board of Directors with assurance that MFT
remains compliant with the national guidance in relation to safer staffing for nursing. A midwifery
safe staffing report is provided separately.
2. Background
The National Quality Board (NQB) Safer Staffing Guidance for adult wards (2016), states 3
expectations of the Trust Board of Directors. These are endorsed by the NHS Improvement
(NHSI) Developing Workforce Safeguards (DWS) Guidance (2018).
Expectation 1: Right staff
Boards should ensure there is sufficient and sustainable staffing capacity and capability to
provide safe and effective care to patients at all times, across all care settings in NHS provider
organisations.
Boards should ensure there is an annual strategic staffing review, with evidence that this is
developed using a triangulated approach (ie the use of evidence-based tools, professional
judgement and comparison with peers), which takes account of all healthcare professional
groups and is in line with financial plans. This should be followed with a comprehensive staffing
report to the board after six months to ensure workforce plans are still appropriate. There should
also be a review following any service change or where quality or workforce concerns are
identified.
Expectation 2: Right skills
Boards should ensure clinical leaders and managers are appropriately developed and supported
to deliver high quality, efficient services, and there is a staffing resource that reflects a
multiprofessional team approach. Decisions about staffing should be based on delivering safe,
sustainable and productive services.
Expectation 3: Right place and time
Boards should ensure staff are deployed in ways that ensure patients receive the right care, first
time, in the right setting. This will include effective management and rostering of staff with clear
escalation policies, from local service delivery to reporting at board, if concerns arise.
The Board of Directors receives a bi-annual report of the comprehensive establishment and skill
mix review in June and December respectively.
In between these reports, the Board of Directors will receive a bi-monthly safe staffing report to
provide assurance that the Trust remains compliant with the national guidance in relation to safer
staffing for nursing.
3. Nursing Workforce Productivity
page 4
In the last two months the NMAHP Corporate Workforce team have continued to support Clinical
Groups with several financial control schemes in collaboration with the NMAHP Workforce leads
for each Clinical Group and Clinical Group Directors of Finance to ensure the financial impact is
accurately reported.
Confirm roster and establishment alignment and introduce a process to maintain
alignment.
The roster review standard operating procedure has been revised to include a bi-annual review
of roster and establishment alignment and in-year monitoring. The review in quarter 4 of
2024/25 showed 4 wards/departments where there was misalignment between the
establishment and roster, and this was corrected. Further analysis demonstrated that the
misalignment did not incur any additional staffing spend. The next bi-annual review of will take
place during quarter 2 of 2025/26.
Reduce access to and use of premium overtime and agency.
The cascade to nursing agencies through the NHSP bank stopped in October 2023 and the use
of agency staffing for nursing stopped completely in April 2025 with the last 2 remaining agency
colleagues in LCO Clinical Group converting to NHSP contracts.
Figures 1 shows the reduction in use of nursing overtime across all Clinical Groups, with
colleagues staying after the end of their shift (eg. theatre overruns) accounting for the usage.
Removal of premium overtime for this reason is being addressed through the Theatre
Workforce group.
Figure 1: Premium overtime for nursing across MFT
Pay to shift rather than pay to band.
Monthly audit of NHSP shifts paid by each band is completed to identify any shifts that have
been paid at a higher band than the shift required. The findings are confirmed by the Clinical
Group Director of Nursing/Midwifery at the NMAHP Temporary Staffing Confirm and Challenge
meetings chaired by the Director of Nursing – Workforce and Education.
Figures 2 shows the reduction in shifts booked inappropriately at a higher band since the audits
commenced in October 2024. The audits will continue and will be monitored through the
NMAHP Temporary Staffing Confirm and Challenge meetings
page 5
Figure 2: Shifts inappropriately filled by higher band across MFT
Enhanced Financial Oversight Framework
The Enhanced Financial Oversight Framework for nurse staffing expenditure at ward /
department level has been implemented across all Clinical Groups following a pilot in MRI Clinical
Group. The framework identifies wards / departments that are exceeding the established budget
by 5% or more, and workforce metrics and roster performance are interrogated to tailor
interventions that target the specific causes of overspend. Assessment of the financial impact of
the framework and associated interventions will be reported in the next Safer Staffing report.
Since May 2025, the NMAHP Corporate Workforce team have continued to focus on the
workforce planning improvement programme, with the current priorities as:
• Increase roster approval lead time
• SafeCare System update and training refresh
The Interim Deputy Chief Executive & Chief Nursing Officer set a standard for all Clinical Groups
to ensure all nursing rosters were set and approved at least 6 weeks in advance. This has a
positive impact on staff experience and demonstrates effective management of rosters. Through
proactive reporting and escalation of non-compliance, the current overall Trust roster lead time
has met the 6-week approval lead time. From the 247 areas reported during the June 2025 roster
period, 245 (99.2%) were compliant which is a continued improvement to previous roster periods
in April and May 2025 and mirrors the improvement in overall average lead time shown in figure
3. Further improvement in compliance will be monitored at the monthly NMAHP Workforce and
Education Forum.
Figure 3
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Apr 23
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Nursing Rostering Lead Time
page 6
Safecare is a system that facilitates the measurement of acuity and dependency needs of
patients within inpatient areas to determine the hours of care required by the patient occupying
the bed. In November 2024, SafeCare was upgraded by the supplier (Allocate) and refresher
training was delivered to over 400 Ward/Team Managers, Matrons, Lead Nurses and Heads of
Nursing across the Clinical Groups.
Strengthening the understanding and use of Safe Care helps teams to proactively highlight and
address risks before they lead to patient safety incidents. In the longer term, this is expected to
reduce the number of staffing-related incident, whilst also improving the early identification and
management of staffing pressures and facilitate effective workforce deployment.
Compliance with use of SafeCare has increased from 56% in December 2024 to 73.1% in June
2025 (figure 4), with compliance levels ranging from 65% to 95% across all Clinical Groups.
Improvement in compliance is now being monitored through the NMAHP Workforce and
Education Forum.
Figure 4
In 2022 a team from Institute for Fiscal Studies, Imperial College Healthcare NHS Trust and the
Health Foundation published a research study which investigated nurse staffing and inpatient
mortality (a). It concluded that Registered Nurse (RN) staffing and seniority levels were associated
with patient mortality, and the lack of association for Care Support Workers indicated they are
not effective substitutes for RNs who regularly work on the ward. MFT are part of a multi-site
study, led by The Institute for Fiscal Studies and Shelford Group, which aims to build on the
evidence by using data for a more recent period.
(a) “Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study”
in BMJ Quality and Safety (September 2022).
4. Establishing Safe Nurse Staffing Establishment
The Safer Nursing Care Tool (SNCT) is an evidence-based tool and methodology developed by
the Shelford Group and endorsed by the National Institute for Health and Care Excellence (NICE)
to support nursing establishment and skill mix assessments. The tool provides a framework for
incorporating professional judgement and assessment of nursing sensitive outcomes as part of
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Apr 24
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Jun 25
Safecare Usage Compliance %
page 7
a triangulated approach to ensure nursing establishments reflect patient needs in terms of acuity
and dependency.
Adult and Children and Young Persons Inpatient Ward Safer Nursing Care Tool (A&CYP IPW
SNCT)
The latest census was conducted from 16th June 2025 to 15th July 2025 across all Clinical Groups
within Adult inpatient areas. The CYP inpatient census was conducted from the 16th June 2025
to 11th July. The findings from this census will support the re-assessment of the nursing
establishment and skill mix. The recommendations and actions from this census will be presented
in the next bi-annual safe staffing report presented to the Workforce Education Management
Committee in December 2025. The review and refresh of the CYP SNCT is currently underway.
Collective feedback on the launch version of the tool has been collated from the Clinical Groups
and shared with the national team.
Community Nursing Safer Staffing Tool (CNSST)
The tool sets out safety standards for district nursing workforce and will provide a recommended
nursing workforce model for each district nursing team based on patient acuity and caseload.
The CNSST has been revised and relaunched by NHSE during January 2025 following its testing
stage, which involved a pilot at MFT in 2023. The license for the revised tool has been renewed
for use at MFT and a census period is planned for September 2025.
Emergency Department Safer Nursing Care Tool (ED SNCT)
Additional work has recently been undertaken to incorporate a new algorithm for patients
spending longer than 12 hours in the department. Collective feedback from the 4 ED’s on the
launch version of the tool has been collated from the Clinical Groups and shared with the national
team.
Registered Nursing
The current registered nursing establishment for roles band 5 and above in May 2025 was
9,062wte.
Figure 5
Since March 2025, the establishment has seen an overall decrease of 15.8wte due to small
changes across all Clinical Groups.
Unregistered Nursing
7,500
8,000
8,500
9,000
9,500
10,000
10,500
Apr 22
May 22
Jun 22
Jul 22
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Trust Registered Nursing Establishment (WTE)
page 8
The current unregistered nursing establishment in May 2025 was 3,658wte, with no significant
change in the previous two months.
Figure 6
5. Achieving the set establishment
Registered Nursing
The number of staff in post has remained within standard variation in the last two months at
8,799wte in line with reduced recruitment activity in the past two months (Figure 7). Recruitment
planning and maximising domestic candidate attraction is fundamental to maintain or further
increase staff in post position.
Figure 7
Continued improvement has been noted in registered nursing turnover rates, which have
decreased month on month since April 2023 (Figure 8), current MFT rate is down to 8.0%. This
has followed a national trend with a turnover rate currently reported at 7.2%.
2,500
3,000
3,500
4,000
4,500
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Unregistered Nursing Establishment (WTE)
7,000
7,500
8,000
8,500
9,000
9,500
10,000
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Registered Nursing Staff in Post (WTE)
page 9
Figure 8
The trend of registered nursing vacancies has followed an annual cycle with the regular influx of
graduate starters in Autumn each year (Figure 9). There are currently 278.0wte (2.8%) registered
nursing vacancies where some vacancies are reserved intentionally for planned graduate
recruitment in quarter 3. The current vacancy position continues to be significantly less than the
current national vacancy rate at 6.0%. Detailed breakdown of current registered nursing
vacancies by clinical group and speciality can be found in Appendix A.
Figure 9
MFT continues to be an employer of choice for newly qualified and experienced nurses. 1300
student nurses will graduate each year having had a clinical placement at MFT during their last
year of study. MFT’s projected Band 5 registered nurse and midwifery vacancy position in
September 2025 will be c220wte, and the pool of available graduates will be c1100. This position
is mirrored across Greater Manchester (GM) and the North West of England. A task and finish
group has been established by the NW office of NHS England and GM NMAHP Workforce Office
is also coordinating a response across GM.
The NMAHP Workforce team have established a scheme to guarantee interviews for all nursing
and operating department practitioner graduates on placement at MFT as a fair and equitable
approach to recruitment. Expressions of interest were received from 417 candidates. Interviews
0%
2%
4%
6%
8%
10%
12%
14%
16%
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Registered Nursing Turnover (%)
0
100
200
300
400
500
600
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Registered Nursing Vacancies (WTE)
page 10
across all Clinical Groups are scheduled in July 2025. To support the planned graduate
recruitment, all non-specialist Band 5 roles were paused for advert across all Clinical Groups.
The Theatre workforce forum collectively supported a guaranteed job offer initiative offering
opportunity for all operating department practitioners (ODP’s) due to graduate in September 2025
following clinical placement at MFT. Expressions of interest were received from 13 candidates
who have been allocated across Clinical Groups and are likely to commence post before October
2025.
Additional factors impacting the availability of registered nurses are sickness and maternity leave.
Sickness rate for registered nurses has seen no significant variation in recent months and for the
past 3 months has dipped below the mean average of 6.3% at a current rate of 5.8% (Figure
10). There is currently an unbudgeted pressure on nursing workforce due to maternity leave of
389.9wte (4.4%). Further details and breakdown of registered nursing workforce metrics by
clinical group can be found in Appendix A.
Figure 10
Unregistered Nursing Support
In the last two months, the number of unregistered nursing support colleagues in post has been
maintained at 3,354 in May 2025. The current recruitment pipeline for unregistered nursing
represents a narrowly improved picture. Clinical Groups are actively using a range of approaches
to attract and recruit applicants, including regular recruitment events, working with the widening
participation team to support the pre-employment initiative and the T-level programme with
Manchester, Trafford and Stockport colleges.
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Registered Nursing Sickness (%)
page 11
Figure 11
Continued improvement has also been noted in unregistered nursing support turnover rates,
which have decreased month on month since February 2023 (Figure 12), current Trust rate is
down to 13.4%. The national unregistered nursing support turnover rate has seen a similar trend
in decreases since April 2023, currently this is reported at 11.1%.
Figure 12
Increases to staff in post have driven a recent decrease in unregistered nursing support
vacancies down to 449.7wte in May 2025 (Figure 13). An increased pipeline is required to reduce
vacancies in the short and long term and this will be supported through the implementation of the
support worker apprenticeship programme and the widening participation programme. Detailed
breakdown of current unregistered nursing vacancies by clinical group and speciality can be
found in Appendix A.
2,600
2,700
2,800
2,900
3,000
3,100
3,200
3,300
3,400
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Unregistered Nursing Staff in Post (WTE)
0%
5%
10%
15%
20%
25%
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Unregistered Nursing Turnover (%)
page 12
Figure 13
The unregistered nursing support sickness rate in May 2025 is 9.1% (Figure 14). A
comprehensive programme approach to absence prevention and attendance management is
underway through the MFT Absence Management Improvement Plan including, 1:1
conversations with ward/team managers, work trial pre-recruitment and the development of a
career pathway.
There is currently an unbudgeted pressure on unregistered nursing support workforce due to
maternity leave of 80.7wte (2.4%). Further details and breakdown of unregistered nursing
workforce metrics by clinical group can be found in appendix A.
Figure 14
6. Managing Staff Shortfalls
Temporary Staffing
MFT has a contract with NHS Professionals (NHSP) for the provision of temporary staff to cover
shortfalls in the nursing workforce. Systems are in place to monitor usage and key lines of enquiry
0
100
200
300
400
500
600
700
800
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Unregistered Nursing Vacancies (WTE)
0%
2%
4%
6%
8%
10%
12%
14%
16%
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Unregistered Nursing Sickness (%)
page 13
are established through NMAHP ‘check and challenge’ financial workstreams to control bank and
agency usage.
The nursing bank at MFT is well established, primarily by a large proportion of substantive staff
who are registered with NHSP to undertake bank additional hours. During April and May 2025, a
total of 414,638 hours were requested through NHSP, and 351,471 hours were filled (84.8%). A
further detailed overview of nursing NHSP bank fill can be found in Appendix B.
The volume of registered nursing filled shifts reduced from April down to a new average of 422wte
per month in April and May 2025. Effective rostering and workforce planning continue to be
monitored through the monthly Temporary Staffing Check and Challenge meetings held by the
NMAHP Workforce team and Clinical Group Directors’ of Nursing/Midwifery, Finance and
Workforce. (Figure 15)
Figure 15
In the first two months of the financial year, unregistered nursing usage has followed previous
financial year trend, currently averaging 608wte per month (Figure 16). This has been largely
due to continued scrutiny of staffing rosters and NHSP bookings through use of the WERM tool
and oversight by Heads of Nursing and Midwifery and Directors / Deputy Directors of Nursing
and Midwifery. 28.8% of unregistered bank usage during this period was to support enhanced
therapeutic observations of care across our clinical groups. The remaining filled shifts are to
support gaps associated with vacancies, sickness and maternity leave.
Fill rates for each individual Clinical Group are provided in appendix C.
0
100
200
300
400
500
600
700
800
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Registered Nursing NHSP Fill (WTE)
page 14
Figure 16
Reduction of enhanced pay rates
Phase 2 of the enhanced rate reduction plan has now concluded, with additional reduction in
rates being implemented in May 2025 across Theatres, Emergency Departments, Critical Care
and Neonatal units. Fill rates across all affected areas collectively reduced from a mean average
of 88.3% to 74.4% in the first week of phase 2 reductions. The fill rates have then remained at
c74% since this date (Figure 17).
Figure 17
Staffing levels across all EDs have not been directly affected, and no concerns have been
escalated in relation to safe staffing since the rate reduction on 12th May 2025.
The Clinical Groups reported a total of 13 theatre lists were cancelled affecting 24 patients as a
direct result of being unable to fill NHSP bank shifts since rate reduction on 12th May 2025. In
addition, 12 procedures were cancelled due to colleagues being unwilling to stay beyond the end
of the shift time when theatre lists overran. 36 patients were affected in total across
Ophthalmology and Gynaecology, CYP, Cardiac and General Surgery.
During the period since the rate reduced on 12th May 2025 no beds have closed, or safety
incidents have been reported across adult critical care areas related to the reduction in pay rates.
0
200
400
600
800
1,000
1,200
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Unregistered Nursing NHSP Fill (WTE)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
17/06/24
01/07/24
15/07/24
29/07/24
12/08/24
26/08/24
09/09/24
23/09/24
07/10/24
21/10/24
04/11/24
18/11/24
02/12/24
16/12/24
30/12/24
13/01/25
27/01/25
10/02/25
24/02/25
10/03/25
24/03/25
07/04/25
21/04/25
05/05/25
19/05/25
02/06/25
16/06/25
30/06/25
NHSP Fill Rate % - All enhanced rate areas
page 15
One elective surgery procedure was cancelled due to an unfilled shift, resulting in no bed for the
patient in Paediatric Critical Care. This was escalated to Specialist Hospitals SLT. Since the rate
reduction on 12th May 2025 there have not been any refusals of regional admissions.
There was one occasion when a baby who was a regional transfer into the neonatal unit at St
Mary’s Hospital from Bolton, was deferred until the next day to allow a more urgent transfer from
NMGH when staffing levels reduced below BAPM standards. NHSP fill rate has not decreased
since 12th May 2025 and there were other influencing factors such as sickness and increased
acuity of neonates.
A total of 12 study sessions have been postponed to support safe staffing levels since the rate
reduced on 12th May 2025. This involved individual colleagues being recalled from study
sessions or sessions cancelled due to Practice Educators supporting clinical duties. The
postponed sessions were distributed across all Clinical Groups and have been re-scheduled.
Proposals for a further rate reduction for Neonatal units with associated Quality Impact
Assessment will be presented to TLTC in October 2025.
All Clinical Groups have mitigation plans in place, including regular monitoring of demand and fill
rates with support from the NMAHP Corporate Workforce team.
Enhanced Therapeutic Observations and Care
MFT is part of the national improvement collaborative sponsored by NHSE with a focus on
Enhanced Therapeutic Observations of Care. A Steering Group has been established, and an
improvement plan has been developed to focus on clinical assessment and decision making,
data, workforce deployment models, temporary staffing escalations and staff training. The overall
aim of the programme is to ensure ETOC is least restrictive, thereby reducing the reliance on
1to1 observation and the use of temporary staffing.
NHSE have invited MFT to lead the development of a national ETOC risk assessment tool that
would be validated for application across the NHS. This is being progressed through collaboration
with Manchester Catalys and Manchester Metropolitan University (MMU). NHSE NW has
established a community of practice with all provider organisations across the North West.
Pilot wads across all Clinical Groups have completed a Quality Improvement project and the
learning from these areas is being implemented across areas with the highest demand for ETOC
during June and July 2025.
Staffing Escalation and Daily Review.
Recommendations set out in DWS focus on accountability and monitoring of nursing
establishments and responding to unplanned changes in daily staffing. The guidance states
organisations must demonstrate compliance with the key principles of safe staffing, supporting a
triangulated approach to decide staffing requirements.
Nursing staffing levels within the Clinical Groups are reviewed daily in real time and monitored
through the safer ‘staffing huddles’ to ensure they are adequate to meet patient acuity and
nursing needs on each ward and department. The daily staffing levels are viewed along with
reported outcome measures to provide safe and effective patient care. Professional judgment in
managing unplanned absences or increased demand, alongside the skill mix and competences
is paramount to provide the safest care possible across the organization.
page 16
Temporary staffing requirements are approved by the Matron and are reviewed on a weekly basis
by the Heads of Nursing / Midwifery. The Corporate Director of Nursing for Workforce chairs
monthly ‘Temporary Staffing Check and Challenge’ sessions with each Clinical Group
represented by the respective Director of Nursing/Midwifery, Director of Finance and Director of
Workforce.
The daily staffing review process informs identification of the staffing escalation position and the
identification of any red flag staffing events. A risk rating is calculated for each area. Staffing
escalation above level 3 initiates a Director of Nursing workforce escalation meeting chaired by
the Chief/Deputy Chief Nurse to review staffing and identify mitigating actions such as mutual aid
between Clinical Groups. Director of Nursing daily staffing escalation meetings are undertaken
during periods of escalation and in response to the trusts EPRR process.
The Nursing Dashboards shared with the Hospital Directors of Nursing provide a comparison of
Nursing workforce and safe staffing data against quality outcomes.
7. Fill rate
MFT is required to submit a monthly Safe Staffing Unify Report to NHSI detailing actual
registered nurse staffing levels as a percentage against those that were planned. On average
the MFT level fill rate has been maintained between 94 and 96% for the last 6 months. It is
important to note that these fill rates are based on the budgeted bed base of each area and do
not take account of any additional beds that are open, therefore caution should be applied with
this data. Additionally, it should be noted, actual fill rates are inclusive of additional staff sourced
through NHSP bank or additional substantive hours. 58 areas from a reported 120 met the trust
fill rate standard of 95.0% or above in May 2025. This metric features in the workforce IPR.
Figure 18 Planned vs Actual Nurse Staffing fill rate (%)
8. Care Hours Per Patient Bed Days (CHPPD)
Care hours per patient day (CHPPD) is the principal measure of workforce deployment in ward-
based settings since April 2016. CHPPD is a metric to reflect care hours per patient bed day and
is calculated by taking all the shift hours worked over the 24 hours period by registered nurses
and nursing assistants and dividing this by the number of patients occupying a bed at midnight.
88%
90%
92%
94%
96%
98%
100%
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Trust Planned vs Actual Staffing Fill %Trust Planned vs Actual Staffing Fill %
page 17
CHPPD is not indicative of the total amount of care provided on a ward nor does it directly show
whether care is safe, effective or responsive, therefore must be considered in conjunction with
measures of safety and quality and using professional judgement.
CHPPD relates to hospital inpatient wards only where patients stay overnight.
CHPPD can be viewed for each professional group that deliver care in a ward-based setting or
as a combined total for benchmarking productivity against regional providers or national peers.
This ensures skill-mix is well-described and the nurse-to-patient ratio is considered when
deploying the clinical professionals to provide the planned care, reflected alongside an
aggregated overall actual CHPPD.
There is no national target for CHPPD, however NHSE publish the data on the NHSE Model
Hospital portal for Trusts to benchmark the data against other organisations. Figure 19 illustrates
CHPPD data trend which has remained stable over the last 20 months demonstrating the
workforce is being deployed to meet patient activity and patient needs.
The MFT wide average CHPPD in April and May 2025 was 9.7 against a Shelford Group rolling
average of 9.7 hours.
Figure 19 Care Hours Per Patient Bed Days (CHPPD)
On further review of the latest available NHSE model hospital published data (March 2025),
CHPPD at MFT is in the middle of the range when compared to the Shelford Group of NHS Trusts
as shown in the table below.
Table 1 – NHSE Model Hospital CHPPD Overview for Shelford Group Trusts
Trust name
Total Nursing and Midwifery
CHPPD
University College London Hospitals NHS Foundation Trust
12.2
Guy's and St Thomas' NHS Foundation Trust
10.7
Imperial College Healthcare NHS Trust
10.4
King's College Hospital NHS Foundation Trust
10.0
Oxford University Hospitals NHS Foundation Trust
9.8
Manchester University NHS Foundation Trust
9.7
Cambridge University Hospitals NHS Foundation Trust
9.3
Newcastle Hospitals NHS Foundation Trust
9.0
University Hospitals Birmingham NHS Foundation Trust
8.5
Sheffield Teaching Hospitals NHS Foundation Trust
8.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Care Hours Per Patient Bed Days (CHPPD)
page 18
9. Safe Staffing Incidents
MFT has an established staffing escalation system through the incident reporting process,
managed through the patient safety management system (Ulysses).
During the period March 2025 to June 2025, a total of 924 incidents related directly to staffing
levels were reported. The majority of the incidents were recorded as no harm and the appropriate
actions were taken at the time (when investigations were successfully closed). (Table 2)
Of the 4 incidents recorded as moderate, 3 related to corporate services and had no direct impact
on patient care, and one related to low staffing levels on a respiratory ward with high acuity.
Table 2 Incidents
Incident Actual Impact
Incident Period March 2025 – June 2025
Level 1 – No harm
808
Level 2 –Slight
112
Level 3 – Moderate
4
Level 4 -Severe
0
Overall
924
Pressure Ulcers
There were 9 category 3 or 4 attributable pressure ulcers in May 2025. 6 associated to community
and 3 in acute settings (1 WTWA, 1 CSS and 1 MRI).
Figure 20 Attributable pressure ulcers (grade 3-4)
Falls
No Special Cause Variation Noted for Falls per 1,000 in May 2025. MRI (3 falls) and WTWA (3
fall) have reported the largest number of level 4 and 5 reported falls. A Falls Academy (MRI) and
Dementia and Falls Operational Group (WTWA) have been established to capture and
Implement learning, which included completion of falls risk assessments, recognition of lying and
standing blood pressure and mental capacity assessments.
0
2
4
6
8
10
12
14
16
18
20
Apr 22
Jun 22
Aug 22
Oct 22
Dec 22
Feb 23
Apr 23
Jun 23
Aug 23
Oct 23
Dec 23
Feb 24
Apr 24
Jun 24
Aug 24
Oct 24
Dec 24
Feb 25
Apr 25
Number of pressure ulcers
page 19
Figure 21 Falls per 1,000 bed days (level 4 and 5 harm)
10. Theatre Staffing
The Theatre Workforce forum was reinstated in April 2025 with senior nursing representation
from theatre departments across all Clinical Groups. The purpose of the forum is to oversee the
NMAHP workforce plan for Theatres to support the Clinical Groups to deliver the elective surgery
programme and maintain non-elective surgery capacity. The forum reports into the NMAHP
Workforce and Education Forum. The work plan for the forum includes training the future
workforce, recruitment and retention initiatives and professional development.
There are 9 Theatre units across MFT which provide elective and non-elective surgery across a
range of clinical specialities. Emergency surgery is provided at NMGH / Wythenshawe / MRI and
RMCH Hospital sites for adults and children respectively. Maternity theatres provide elective and
non-elective caesarean sections at the NMGH, Wythenshawe and St Mary’s hospital sites with
specialist Gynaecology theatres based at the latter. Trafford Hospital is the home of Trafford
Elective Surgical Hub where a range of surgical specialities provide day case and short stay
surgery, and The North West Heart Centre and The North West Centre for Lung Surgery are
based at Wythenshawe Hospital.
Achieving the Set Establishment in Theatres
The current registered nursing/ODP establishment for roles band 5 and above in May 2025 was
932.2wte (Figure 22). Breakdown per Clinical Group given in Appendix E. Since March 2025, the
establishment has seen an overall increase of 18.6wte, with the largest changes noted in WTWA
TGH with an increase of 10.2wte and RMCH with an increase in 7.9wte.
Figure 22
-0.4
-0.2
0
0.2
0.4
0.6
0.8
1
1.2
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Number of falls
820.00
840.00
860.00
880.00
900.00
920.00
940.00
Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25
Theatre Registered Nursing/ODP Establishment
Mean
page 20
The number of staff in post has remained static overall with an average of 908wte for the last
four months (Figure 23). Breakdown per Clinical Group given in Appendix E.
The recruitment activity for graduates qualifying in September will impact the staff in post position
in quarter 2 of 2025/26.
Figure 23
The current turnover rate for registered nursing/ODP is at 7.8% which is a slight increase of 0.4%
since March 2025 (Figure 25). The highest turnover rate is noted with SMH (12.5%) followed by
MRI (10.9%) and WTWA Trafford (10.2%). MREH continues to maintain the lowest turnover rate
(2.8%). Breakdown by Clinical Group is provided in Appendix E.
Figure 24
Newly formed establishments have increased the vacancies with the current overall vacancies
at 16.64wte (Figure 25). RMCH has the highest vacancies (8.5wte) resulting from launch of
Vanguard followed by WTWA Trafford (5.7wte). Two unfunded theatres in Wythenshawe are
now established since April 2025 increasing the vacancies by 3.8wte. Breakdown per Clinical
Group given in Appendix E.
To maximise opportunities for graduate ODP’s and support the theatre vacancy position, a
guaranteed job offer scheme was offered for ODP learners on placement at MFT. Expressions
of interest were obtained from 14 learners qualifying in September 2025 with this initiative
830.00
840.00
850.00
860.00
870.00
880.00
890.00
900.00
910.00
920.00
930.00
940.00
Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25
Theatre Registering Nursing/ODP Staff in Post
Mean
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25
Theatre Nursing/ODP Turnover %
Mean
page 21
resulting in the recruitment of 13 ODP graduates who are anticipated to start at MFT by October
2025.
Figure 25
Temporary staffing usage continues to see marked reduction with the volume of registered filled
shifts reduced from 99.66wte to 52.93wte in May 2025 (Figure 26). This improvement is attributed
to the enhanced rate reduction implemented in November 2024 and May 2025. The highest
usage was noted in WTWA (15.0wte), followed by SMH (10.4wte) and MRI (9.3wte). The lowest
usage was noted in MREH (2.7wte). Breakdown by Clinical Group is provided in Appendix E.
Figure 26
Equally, the supernumerary period in theatres for registered nursing has been standardised to
(upto) 12 weeks across all Clinical Groups as part of the Value for Patients programme of work
in quarter 3 of 2024/25. Monitoring of supernumerary periods is undertaken using the
standardised supernumerary tracker in use to ensure consistency and provide assurance of
compliance with the 12-week standard.
Recommendations
The Board of Directors is asked to:
0.00
5.00
10.00
15.00
20.00
25.00
30.00
Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25
Theatre Nursing/ODP Vacancies WTE
Mean
0.00
20.00
40.00
60.00
80.00
100.00
120.00
140.00
160.00
Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25
Theatre Registered Nursing/ODP Temporary Staffing Usage WTE
Mean
page 22
• Receive this report and note that MFT remains compliant with the national guidance (NQB
2026; DWS 2018) in relation to safer nurse staffing.
• Note the report was received and discussed at the People Board Committee on 3rd
September 2025.
• Receive assurance of safe nurse staffing as described in sections 4, 6, 7 and 9.
page 23
Appendix A
Registered Nursing - Workforce Metrics by Clinical Group (May 2025)
Clinical Group
Establishment
(WTE)
Staff in Post
(WTE)
Vacancies
(WTE)
Vacancy
Rate %
Turnover %
Maternity
Leave %
Sickness %
CSS
940.1
1000.1
0.0
0%
8.7%
4.6%
4.9%
LCOD
1079.0
1032.2
46.8
4.3%
8.8%
3.6%
7.1%
MRI
1766.1
1680.5
85.6
4.8%
8.2%
4.2%
5.3%
NMGH
893.1
885.8
7.3
0.8%
6.6%
3.9%
4.8%
SPEC – REH
171.5
166.6
4.9
2.8%
3.1%
4.4%
6.3%
SPEC – RMCH
1129.1
1123.5
5.6
0.5%
8.1%
5.7%
7.3%
SPEC – SMH
654.5
612.6
41.9
6.4%
9.0%
5.4%
5.2%
WTWA
2044.5
1970.4
74.1
3.6%
7.9%
4.3%
6.1%
Unregistered Nursing - Workforce Metrics by Clinical Group (May 2025)
Clinical Group
Establishment
(WTE)
Staff in Post
(WTE)
Vacancies
(WTE)
Vacancy
Rate %
Turnover %
Maternity
Leave %
Sickness %
CSS
85.5
125.9
0.0
0%
4.1%
0.0%
7.7%
LCOD
462.0
359.5
102.5
22.2%
13.9%
1.9%
7.4%
MRI
883.8
824.3
59.5
6.7%
12.8%
3.0%
11.5%
NMGH
575.6
504.0
77.8
13.5%
13.6%
3.4%
9.0%
SPEC – REH
69.0
59.6
9.4
13.6%
11.2%
1.7%
9.7%
SPEC – RMCH
347.1
300.4
46.7
13.4%
14.6%
1.9%
4.4%
SPEC – SMH
113.8
93.1
20.8
18.3%
7.3%
1.0%
8.2%
WTWA
1054.8
925.2
129.6
12.3%
14.4%
2.4%
10.3%
page 24
Appendix B
NHSP Fill Overview – Nursing
page 25
Appendix C
NHSP registered nursing fill rate by clinical group
page 26
page 27
Appendix D
NHSP unregistered nursing fill rate by clinical group
page 28
page 29
Appendix E
Theatre Registered Nursing/ODP Workforce Metrics by Clinical Group
Establishment WTE – Theatre Nursing/ODP Staff in post WTE – Theatre Nursing/ODP Vacancies WTE – Theatre Nursing/ODP
Turnover % - Theatre Nursing/ODP Temporary Staffing WTE – Theatre Nursing/ODP
page 30
Appendix F
Reduce access to and use of premium overtime and agency.
Nursing overtime across all Clinical Groups
Pay to shift rather than pay to band.
Shifts booked inappropriately at a higher band since the audits commenced in October 2024
page 31
Page 1
Public Board of Directors
Wednesday 1st October 2025
Paper title:
Saint Mary’s Managed Clinical Services (SM MCS) Midwifery and
Newborn Services bi-monthly Safe Staffing Reporting period May
and June 2025
Agenda
Item
12.3
Presented by:
Kimberley Salmon- Jamieson, Interim Deputy Chief
Executive & Chief Nursing Officer
Prepared by:
Kathy Murphy, Director of Nursing and Midwifery, Specialist
Hospitals Clinical Group (SHCG)
Meetings where content has
been discussed previously
Specialist Hospital Clinical Group (SHCG) Management
Board and SHCG Workforce and Education Committee.
Trust Workforce and Education Management Committee
People Board Committee
Purpose of the paper
Please check one box only:
☐ For approval
☒ For discussion
☐ For support
Executive summary / key messages for the meeting to consider
The Maternity and Newborn Services Divisions bi-monthly safe staffing report provides
assurance that the Trust remains compliant with the national guidance in relation to safer staffing.
Safer Staffing report covers the reporting period May - June 2025 regarding:
• National professional staffing standards
• National nursing and midwifery challenges
• Maternity Incentive Scheme (MIS) Safety Action requirements1
Maternity Services are compliant with the nationally recommended establishments in accordance
with Birthrate Plus (BR+) calculations2 and in line with MIS Year 71 requirement to repeat this
establishment review 3 yearly, have commenced a further BR+ exercise due to be completed in
the Autumn of 2025. BR+ safe staffing toolkit has been endorsed by the Royal College of
Midwives (RCM) as the recommended midwifery workforce planning tool to support review of
midwifery staffing levels against NICE Guideline Safe Staffing for maternity setting (NG4,
27/02/2015)3
Up to 30th June 2025, there has been a sustained reduction in overall Red Flag midwifery staffing
incidents.
Turnover is being maintained within Maternity Services with a slight rise on 0.44 WTE in Newborn
Services. Newborn Services had hoped to be at full establishment by March 2025, however, there
has been a 19% withdrawal rate from candidates in pipeline. Newborn Services have fully
1 MIS-Year-7-guidance.pdf
2 https://birthrateplus.co.uk/workforce/
3 https://www.nice.org.uk/guidance/ng4/resources/safe-midwifery-staffing-for-maternity-settings-pdf-51040125637
Page 2
Recommendation(s)
The Board of Directors is asked to:
• Receive SM MCS Maternity and Neonatal report and the continued compliance with
the national guidance in relation to safer staffing
• Receive the report and recognise the progress undertaken to support midwifery
staffing in the Division of Maternity Services and nurse staffing in the Division of
Newborn Services
• Note the sustained reduction in midwifery red flag incidents reported
• Recognise the risk related to Qualified in Specialty (QIS) and support the
recommendation to continue to support 40 nurses per year access QIS training
• Support presentation of this report at the Board of Directors in October 2025.
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐ Yes (please set out in your report what action
has been taken to address this)
☒ No
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☐
LHL objective 2
☐
HQSC objective 1
☐
HQSC objective 2
☐
HQSC objective 3
☐
PEW objective 1
☒
PEW objective 2
☒
VfP objective 1
☒
VfP objective 2
☐
R&I objective 1
☒
R&I objective 2
☐
Good Governance
☒
recruited into Band 5 posts with 20 WTE due to commence between July 2025 and October
2025.
As informed previously, Qualified in Specialty (QIS) compliance within the Newborn Services
division remains non-compliant and remains risk score 12. To improve compliance Newborn
Services division, support up to 40 nurses to attend QIS course annually.
It is acknowledged that nationally there is an expected proportion of student midwives who may
not be offered a substantive post on qualification. Due to clear monitoring of vacancies, all 42
SM MCS midwifery students qualifying in autumn 2025 have, following a successful round of
interviews, been offered substantive posts equating to 33.6 WTE (at an average of 0.8 WTE
per head). Within this group, 10.4 WTE are allocated to the community hybrid model across all
three sites, directly targeting our current community staffing gaps.
Page 3
Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks:
The work contained with this report links to the following
strategic, corporate or operational risks:
• MFT/005896: Midwifery staffing. Risk score 8
• MFT/007891: Community Midwifery Staffing. Risk score 12
• MFT/008478: Implementation of homebirth staffing model.
Score 12
• MFT/004452: Insufficient neonatal nursing workforce
qualified in specialty (QiS) to meet national service
specification. Risk score 12
Care Quality Commission
domains
Please check all that apply
☒ Safe
☒ Effective
☒ Responsive
☒ Caring
☒ Well-Led
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
• Maternity Incentive Scheme Year 71
• NHS England 3 Year Delivery Plan for Maternity and
Neonatal services4
• CQC
Main report
Background
This report will detail the reporting period May to June 2025, for Saint Mary’s Managed Clinical
Services (SM MCS) Divisions of Maternity and Newborn Services, in relation to:
• National professional staffing standards
• National nursing and midwifery challenges.
• Maternity Incentive Scheme (MIS) Safety Action requirements
The paper sets out the midwifery and nursing staffing position of the SM MCS Divisions of
Maternity and Newborn Services and provides:
• Nationally Recommended Establishments
• Current Midwifery Establishment.
• Current Nursing Establishment in line with British Association of Perinatal Medicine
(BAPM) nurse staffing standards.
• Evidence of supernumerary midwifery workforce compliance with oversight of birth
activity within the service and the escalation process
• Evidence of compliance the service requirement to support 1:1 care in labour.
• Evidence of compliance to the Foundation in Neonates (FiN) programme, which forms
part of the QiS pathway.
• Evidence of compliance to QiS in line with the national BAPM standard of 70%.
• Health Roster benchmarking against KPI standards
4 NHS England » Three year delivery plan for maternity and neonatal services
Page 4
• Further to the March 2023 Care Quality Commission (CQC) inspection of Maternity
Services safe staffing remains a focused workstream and changes have been
embedded into ‘business as usual’. Progress on the workstream continues to be
managed through the Division and reported through the approved Governance
framework.
• SM MCS continues to attract and recruit staff across all three sites, recruiting nurses
and midwives both newly qualified and experienced. June to October historically
demonstrate the highest number of vacancies in the calendar year as newly qualified
midwives and nurses graduate in September and take up their first posts throughout
September to January.
Nursing and Midwifery workforce productivity
As reported in the Nursing Safer Staffing Paper finance accelerator schemes have been
maintained and monitored by the NMAHP Corporate Workforce team in collaboration with the
NMAHP Workforce leads for each Clinical Group and have been supported by a designated
Clinical Group Director of Finance to ensure the financial impact is accurately reported. The
schemes are as follows:
• Confirm roster and establishment alignment which is a bi-annual process.
• Monitor and reduce access to and use of premium overtime and agency.
• Establish the optimal supernumerary period considering professional and regulatory
standards / guidelines. Standardise across MFT where appropriate.
• Establish bank payment mechanisms, e.g. pay to shift rather than pay to grade.
• Establish plan for the removal of overtime.
Both Maternity and Newborn Services are engaged in tracking all these schemes supporting
control over financial efficiency related to workforce.
In January 2025, the NMAHP Corporate Workforce focused on the workforce planning
improvement programme and the priorities have become business as usual across Maternity
and Newborn Services:
• Increase roster approval lead time – Both Maternity and Newborn Services are compliant.
• Bi-annual roster template alignment to ledger establishments review completed Jan/Feb
2025 with Heads of Midwifery and Nursing and NMAHP Workforce Programme Lead –
being completed again in July 2025 across SM MCS.
The roster KPI’s are monitored by the Interim Deputy CEO and Chief Nursing Officer (CNO)
and reported per roster period, see Table 1 for the last two months reported KPI’s specific to
Maternity and Newborn Services.
Table 1 Roster KPI’s for Maternity and Newborn Services (Please note safecare is a staffing tool
utilised in adult nursing and not utilised or measured in Maternity and Newborn Services – the
red non-compliant areas pertain to the Saint Mary’s Gynaecology area and are covered in the
nursing paper)
Page 5
Additional duties are reviewed weekly at staffing meetings across the MCS and are measured
and scrutinised by Heads of Midwifery alongside NHSP requests. Hours owed by staff and
time owing are reviewed weekly by the Matrons overseeing rosters in maternity and newborn
services alongside roster template reviews which are due to be completed in July 2025.
There is now a recognised standard that all Clinical Groups ensure all nursing rosters are set
and approved at least 6 weeks in advance. This is known to have a positive impact on staff
experience and demonstrates effective management of rosters. Through proactive reporting
and escalation of non-compliance both Maternity and Newborn Services in all areas have met
the required 6-week target throughout this reporting period.
• Safer Staffing Standards and calculation of Establishments using recognised
staffing models
• NICE Guideline Safe Staffing for maternity setting (NG4, 27/02/2015)3 covers safe
midwifery staffing in all maternity settings, including at home, the community, day
assessment units, obstetric units, and midwifery led units. It aims to improve
maternity care by advising on staffing levels and actions to take if there are
insufficient midwives to meet the needs of women and babies in the service.
• Maternity provider Trusts undertake a systematic process to calculate the midwifery
staffing establishment using a NICE endorsed toolkit; Birthrate Plus (BR+) safe
staffing toolkit also endorsed by the Royal College of Midwives (RCM) as the
recommended midwifery workforce planning tool to support review of midwifery
staffing levels against NICE guideline NG4.
• The use of BR+ every 3 years is also incorporated within NHS Resolution Maternity
Incentive Scheme year 71 standards.
• The NHS England Three-Year Delivery Plan for Maternity and Neonatal Services,
March 20234, outlines that Trusts will meet establishment set by staffing tools and
achieve fill rates by March 2027. The most recent BR+ review was completed in
May 2023, the recommendations from this review were implemented with support
from SM SLT by April 2024.
• The next BR+ review has commenced with final reports expected in the autumn of
2025.
Table 2 Current Funded Midwifery Establishment (WTE)
ORC
Wythenshawe
North
Manchester
Grand Total
Page 6
Current
Midwifery
Establishment
378.68
228.56
188.5
795.74
(Please note changes to establishments in March-April report due to skill mixing)
• BAPM recommend minimum standards for neonatal nurse staffing levels for each
category of neonatal care. Neonatal Intensive Care: 1:1 nursing for all babies,
Neonatal High Dependency Care: 2:1 nursing for all babies, Neonatal Special Care:
4:1 nursing for all babies. All intensive care and high dependency care should be
provided by QIS staff, so where a unit has a high proportion of critical care activity,
the percentage of QIS staff required is required to be above 70%. BAPM standards
require all units to have a supernumerary shift coordinator to meet the care needs of
the babies on the unit during each shift.
Table 3 Current Funded Neonatal Nursing Establishment (WTE)
• Recruitment and Retention May - June 2025
The turnover has seen a slight reduction for Maternity Services remaining <6 WTE per month,
with a slight increase of 0.22 WTE per/month in Newborn Services. Current SMH registered
staffing turnovers reflected in Table 4 and trends demonstrated through SPC charts in Graphs
1 & 2.
Table 4 Demonstrates SMH Spec Registered Staffing Leavers
Maternity
Services
Turnover p/m
Newborn
Services
Turnover p/m
March 2025 - April 2025
5.66 WTE
2.98 WTE
May 2025 - June 2025
5.29 WTE
3.2 WTE
Variation
0.37 WTE
reduction
0.22 WTE
increase
Graph 1 Spec SMH Midwifery Registered Turnover
Page 7
Graph 2 Spec SMH Newborn Services Registered Turnover
• Midwifery recruitment between September 2024 and June 2025 equated to
153.25 WTE midwives; 65.71 WTE were MFT Learners who were supported with
guaranteed job offers (GJO). 74.98 WTE were external band 5 midwives. 12.56 WTE
were band 6 recruits.
• There are a further 7.96 WTE midwives who have commenced in post between May
and June 2025.
• The Division of Maternity is reporting a positive position in overall midwifery
establishment, midwifery vacancy at the close of Month 03 (June 2025) is
demonstrated in Table 5. The majority of the vacancy is in the community midwifery
team and the midwifery homebirth team which are both being supported with a
targeted recruitment program. Both services have a risk on the risk register with a
score of 12.
Table 5 Current Midwifery nursing vacancy
Month 03
Vacancy (WTE)
Site
SPEC - SMH Midwifery Registered Turnover (%)
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
SPEC - SMH Newborn Services Registered Turnover (%)
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Page 8
Oxford road
7.29
Wythenshawe
+4.91
North Manchester
11.17
TOTAL Vacancy
13.55
Current trend in midwifery vacancy demonstrated through SPC chart in Graph 3.
Graph 3 Spec SMH Midwifery Registered Vacancies
• The neonatal nursing vacancy at the end of June 2025 is 22.82 WTE, there are 25
WTE Band 5 nurses in the pipeline recruited against this gap leaving a residual
vacancy factor of 0 WTE across all bands of staff at the end of this reporting period.
Newborn Services are being supported to recruit to turnover into Band 5 post. 8
WTE of the Band 5 nurses in pipeline are not due to commence until August and
September 2025.The Division is aiming to be fully recruited in all bands by
September 2025 but will closely monitor band 5 pipeline dropout rate to ensure
proactive recruitment to turnover.
• Current Neonatal Nursing vacancies reflected in Table 6 and vacancy trend
demonstrated through SPC chart in Graph 4. The Division of Newborn Services has
supported several staff to rotate from the NICU at ORC to Wythenshawe to support
attrition. This has created increasing vacancies at ORC and there are 19 candidates
in pipeline to fill these vacancies.
Table 6 Current Neonatal nursing vacancies and pipeline
Site
Vacancies
April 2025
Vacancies
June 2025
Current Pipeline June
2025 (Including turnover)
Oxford road
14.1
15.1
19
Wythenshawe
6.43
1.73
1
North
Manchester
1.78
0.28
TOTAL
22.31
17.11
20
Graph 4 Spec SMH Newborn Services Registered Vacancies
SPEC - SMH Midwifery Registered Vacancies (WTE)
120
100
80
60
40
20
0
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Page 9
• The Midwifery Workforce Matron and the midwifery recruitment and retention team
have facilitated a successful round of interviews and offered 33.6 WTE to 42
candidates (at an average of 0.8 WTE per head). Within this group, 10.4 WTE are
allocated to the community hybrid model across all three sites, directly targeting our
current community staffing gaps. All our own 3rd year student midwives were
supported with guaranteed interviews this year rather than guaranteed jobs.
• The retention team have a plan in place to ‘keep in touch’ with all staff in the pipeline
to maintain engagement through coffee mornings, email updates and virtual calls.
Any candidates who withdraw, will be contacted to better understand the reasons
why.
• The Maternity Division can report a positive impact of recruiting to turnover reflected
in:
• Reduced short term sickness
• Recruitment from internal Guaranteed job interviews (GJI’s)
• Increased ability to positively impact Maternity Triage and IOL pathways.
Managing staffing shortfalls
• Maternity services review staffing and flow in real time, twice daily in an MCS
meeting which also includes Newborn Services. Staffing levels are reviewed to
ensure appropriate fill in each clinical area to support activity, and redeployment is
facilitated as required.
• There is also senior oversight of staffing levels reported through the 3 times daily
maternity status report which is circulated to the Divisional Leadership Team, Senior
Leadership Team and CNO as well as the on-call Duty Manager and on- call
Director.
• Temporary staffing is utilised to support staffing levels throughout the Trust. Weekly
NHSP temporary staffing huddles continue to ensure maximisation of engagement
between SM MCS and NHSP.
• The Heads of Midwifery and Head of Nursing attend a monthly meeting with the
NHSP Managers to review NHSP fill rates, incidents and workforce applications.
SPEC - SMH Newborn Services Registered Vacancies (WTE)
70
60
50
40
30
20
10
0
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Page 10
• NHSP fill rates are monitored on a weekly basis by the Heads of Midwifery and Head
of Nursing using the Ward Establishment Review Model (WERM Tool). Both Nursing
and Midwifery are compliant with zero spend linked to premium overtime payments.
Trends in NHSP fill rates demonstrated through SPC charts in Graphs 5 & 6, with
further data available in Appendix 1 & 2.
• The Oxford Road Maternity Team have developed a staffing to tool to review the
prospective NHSP spend measured against vacancy, supernumerary staffing and
uplift for sickness and training. The tool has been piloted in June and has supported
managers to better understand where they can utilise NHSP. Use of the tool has
proved positive, and the ORC site have seen a reduction in NHSP. This use of the
tool will be further reviewed and rolled out across all 3 Maternity sites in July.
• As neonatal units provide an emergency driven service and admissions are not
always planned, staffing requirements can vary from shift to shift and depart from
those rostered, therefore NHSP is utilised to maintain safer staffing. Newborn
Services only use NHSP to backfill shortfalls in staffing numbers, such as nursing
vacancies and unexpected staff sickness and occasionally due to high patient
acuity/workload increase to support improved skill mix. In Q4 the neonatal division
completed a Quality Impact Assessment (QIA) and Risk Assessment in relation to
the impact of removal of enhanced NHSP and in line with the organisational plan
which was agreed at Trust Leadership Team Committee (TLTC) on 20th March 2025.
In line with phase 2 of the enhanced rate reduction Newborn Services moved to a
staged reduction in rates from 12th May 2025.
• Newborn Services are continuing to monitor the impact of the reduction in rates and
since the change there has been minimal impact, the reduction in NHSP usage is
related to lower acuity and activity in the reporting period.
Graph 5 Spec SMH Midwifery Registered NHSP Fill Rates
SPEC - SMH Midwifery Registered NHSP Fill (WTE)
80
70
60
50
40
30
20
10
0
Graph 6 Spec SMH Newborn Services Registered NHSP Fill Rates
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Page 11
Sickness Absence
• Short term absence continues to be the main driver for overall sickness across both
Maternity and Newborn Services. Overall sickness has reduced in maternity from
5.07% in April to 4.72% in June and remains stable in Newborn Services at 7.12%
over the reporting period, which remains over the Trust target of 3.6% and above the
divisional trajectory of 5%. The main reasons for staff absence are anxiety/stress,
post operative recovery and musculoskeletal problems. Both divisions have
fortnightly sickness meetings to review position and have in place action plans to
address absence which is tracked at the twice weekly staffing meetings. Both
divisions are monitored via the established workforce check and challenge process.
Trends demonstrated through SPC charts in Graphs 7 & 8.
Graph 7 Spec SMH Midwifery Registered Sickness
Graph 8 Spec SMH Newborn Services Registered Sickness
SPEC - SMH Midwifery Registered Sickness (%)
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
SPEC - SMH Newborn Services Registered NHSP Fill (WTE)
45
40
35
30
25
20
15
10
5
0
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Apr 25
May 25
Page 12
• Maternity ‘Red Flags Events’, Escalation and monitoring of staffing MIS Safety
Action 5
• NICE guidance NG4 Safe Staffing for Maternity Settings (2015) recommends that the
Maternity Service has procedures in place for monitoring and responding to
unexpected changes in midwifery staffing requirements, and report ‘red flags’ if there
is a reduction in required staffing.
Red flag events are signs that there may not be enough midwives available and include:
• Activities that need to be done on time are delayed or cancelled.
• After giving birth, a woman waits for 60 minutes or more before she is washed or given
stitches, if she needs them.
• A woman does not get the medicines she needs when she's been admitted to a
hospital or a midwifery-led maternity unit.
• A woman waits 30 minutes or more to get pain relief when she's been admitted to a
hospital maternity unit or a midwifery-led maternity unit.
• A woman who is in labour or who has a problem needing midwife care waits 30
minutes or more for assessment after the midwife has been alerted.
• A woman is not given a full examination when she reports she is in labour.
• There is a delay of 2 hours or more between coming in for an induction and the induction
being started.
• Delays in spotting and acting on signs that the woman may have a serious health
problem.
On analysis of Red Flag incidents reported in June 2025 of the 22 reported across SM MCS:
• 5 related to late administration of medications/analgesia
• 8 related to delays in transfers for artificial rupture of membranes due unit acuity v’s
staffing.
• 8 related to delays in transfer to theatre due to capacity or staffing
• 1 incident related to a delay in suturing due to delays in gaining adequate supervision
for junior midwifery staff.
• Throughout the first 6 months of 2025, there has been a sustained reduction in overall
Red Flag incidents, when compared to previous months as shown in Graph 9.
SPEC - SMH Newborn Services Registered Sickness (%)
10.00%
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Apr 22
May 22
Jun 22
Jul 22
Aug 22
Sep 22
Oct 22
Nov 22
Dec 22
Jan 23
Feb 23
Mar 23
Apr 23
May 23
Jun 23
Jul 23
Aug 23
Sep 23
Oct 23
Nov 23
Dec 23
Jan 24
Feb 24
Mar 24
Apr 24
May 24
Jun 24
Jul 24
Aug 24
Sep 24
Oct 24
Nov 24
Dec 24
Jan 25
Feb 25
Mar 25
Page 13
• For comparison, the latest data for June 2025 has been provided to
demonstrate a marked reduction when compared to November 2024.
• There is clear correlation of a reduction in Red Flag incidents and a reduction in the
midwifery vacancy rate.
• Further work, supported by Trust Governance Team, has commenced to support
appropriate categorisation when delays occur that are not related to midwifery staffing.
It is expected that this will result in further reductions in Red Flag reportable incidents
going forwards.
Graph 9 Saint Mary’s MCS Midwifery Red Flag Reportable Incidents
Supernumerary status of labour ward coordinator
• The Maternity Division has continued to report and monitor compliance with
supernumerary labour ward coordinator status and the provision of one-to-one care
in active labour. The Maternity division have achieved 100% compliance with always
maintaining a supernumerary labour ward coordinator across the 3 maternity sites.
Provision of 1:1 care in labour
• During May and June 2025, the Maternity division provided one-to-one care in
labour to 99.89% and 99.36% of women. As reported previously, the Maternity
division have in place a detailed action place for occasions where with provision of
one-to-one care has not been achieved, which is monitored through the Maternity
Quality and Safety Committee and reported to the Maternity Operational Delivery
Group chaired by the Director of Nursing and Midwifery.
Qualification in Speciality
• Newborn Services is currently non-compliant with the BAPM standard for QiS (target
70%). As the service has not achieved the national standard of 70% of staff holding
the QiS qualification, a risk assessment has been undertaken, and the risk
Page 14
has been added to the Newborn Services risk register scoring 12 (MFT/004452).
Table 1 shows the percentage of compliance with national standards across all
units.
The QiS levels are affected by the large numbers of newly qualified staff who have being
recruited into vacant posts, which has diluted the QiS workforce percentage.
To mitigate the risk the service has supported additional nurses to attend the QiS course
twice yearly to increase the number of staff with the qualification. 20 staff are due to qualify in
September 2025 and a further 16 nurses have applied and are starting the course in
September 2025.
Newborn Services have considered supporting additional nurses through the QiS program
but due to other training pressures, e.g. Foundation in Neonates (FiN) program and Newborn
Life Support it is not possible due to the pressure it will cause to maintain safe staffing levels
to meet BAPM standards for cot side care. This is a recognised pressure within the service
and there has been an acceptance that NHSP backfill is utilised to support nurses to attend
these mandated courses and to support safe staffing levels within the service.
All new starters are allocated to attend or attend the FiN course within 6 months of
commencing in post and the course is facilitated on a twice-yearly basis.
Further mitigation includes having several supernumerary QiS staff who provide additional
expertise in the clinical environment including the Band 6/7 Shift Coordinator, Specialist
Nurses e.g. Surgical Nurse Specialists and site-based Matrons who provide additional clinical
leadership and oversight. On the Newborn Intensive Care Unit (NICU) there is also a Band
6/7 QiS Room Lead allocated to provide additional support and expertise to staff working in
the intensive care environment.
• Table 7 shows the current percentage compliance against national standards across
all units. The ORC position has improved since the last reporting period due to new
graduates at ORC. North Manchester’s position has decreased due to 3 newly
qualified staff commencing in post.
Table 7 Demonstrates Qualification in Speciality % Compliance (June2025)
• As informed previously, Qualified in Specialty (QIS) compliance within the
newborn service division remains non-compliant and remains risk score 12. To
improve compliance Newborn Services division, support up to 40 nurses to attend
QIS courses annually.
Page 15
Recommendations
• The Board of Directors is asked to:
• Receive SM MCS Maternity and Neonatal report and the continued compliance with
the national guidance in relation to safer staffing
• Receive the report and recognise the progress undertaken to support midwifery
staffing in the Division of Maternity Services and nurse staffing in the Division of
Newborn Services
• Note the sustained reduction in midwifery red flag incidents reported
• Recognise the risk related to Qualified in Specialty (QIS) and support the
recommendation to continue to support 40 nurses per year access QIS training
• Support presentation of this report at the Board of Directors in October 2025.
Page 16
Appendix 1 – NHSP Fill – SMH Maternity Services
Page 17
Appendix 2 – NHSP Fill – SMH Newborn Services
Agenda Item 13.1
Escalation and Assurance Report
Audit and Risk Committee
Report to: Board of Directors
Report from: Nic Gower, Non-Executive Director and Chair of Audit and Risk Committee
Date of meeting: 16/09/25
Key escalation and discussion points from the meeting
Alert
Advise
The Committee approved revised versions of the Trust’s Standards of Business Conduct Policy and
Counter Fraud policy. The importance of publicising both policies across the Trust, using a number of
different mechanisms to ensure maximum reach, was emphasised. A review of the declaration of interests
process and practice will be undertaken over the next three months.
The Committee received an update on the implementation of the revised Risk Management Framework
and Strategy since its approval in September 2024. An implementation plan was developed and 51 of the
54 actions have now been completed. The Committee emphasised the importance of developing a method
by which the Board can be assured of the effectiveness of the Framework for discussion at the next
meeting.
The Committee discussed two completed internal audits: Ward Senior Nurse Reviews and Patient Food
and Catering. The Chief Nursing Officer will be invited to the November Committee meeting to provide an
update on progress in completing the management actions agreed following the audits’ findings.
The National Audit Office have completed their review of the External Auditor’s audit of the Trust’s accounts
for 2024/25. The final audit certificate is expected in October.
The Committee discussed the September 2025 Counter Fraud Progress Report which included details of
action being taken on referrals received by the service, as well as the proactive work being undertaken,
including a new staff communications and engagement programme. The Committee noted the new ‘Failure
to prevent fraud’ legislation and the potential implications for the NHS.
The Committee received the conclusions of the ‘Mandate Fraud’ audit by the Counter Fraud Service which
reviewed the processes and controls in place to mitigate the risk of mandate fraud against MFT. Overall it
was a positive report with a small number of low priority actions required.
The Committee discussed a report from the Chief People Officer regarding key learning from disciplinary
counter fraud cases including sanctions and escalation processes. The Committee discussed the need to
ensure that reporting levels are appropriate for a Trust the size of MFT. A programme of targeting training
is planned.
The Committee received the report detailing the tenders waived for the period 1st June 2025 to 31st July
2025 above £50,000.
page 1
The Committee received the annual Losses and Special Payments report and a report covering the period
1/4/25 – 31/7/25.
Assure
The Committee received an update on the successful completion and submission of the 2024-25 Data
Security and Protection Toolkit (DSPT). The self-assessment demonstrated that MFT is practising good
data security, and that personal information is handled correctly, and met the NHSE recommended
expectation to achieve ‘standards met’. The internal audit of the self-assessment gave a rating of
“significant assurance with minor improvements’ and assessed the level of confidence in the veracity of
the DSPT self-assessment as per the NHSE guidance and provided a ‘high’ confidence level.
Report approved by: Nic Gower, Non-Executive Director and Chair of Audit and Risk Committee
Agenda
Audit and Risk Board Committee
Date: Tuesday 16th September 2025
Time: 10:00am – 12:00pm
Location: Medical Boardroom, Cobbett House, Oxford Road Campus
Agenda
Item
Purpose
Lead
Time
1.
Apologies for absence & confirmation of quoracy
(verbal).
Meeting
admin
Chair
10.00am
2.
Declaration of interest (verbal).
Meeting
admin
Chair
10.00am
3.
Minutes of the previous meetings (24th June 2025).
Meeting
admin
Chair
10.05am
4.
Action Log.
Discussion
Chair
10.10am
5.
Matters Arising.
Discussion
Chair
10.15am
6.
Risk Management Framework and Strategy Annual
Report update including effectiveness of risk
management systems and outline proposals for
Internal Audit ToR.
Discussion
Deputy
Director of
Clinical
Governance
and Risk
10.20am
7.
Internal Audit:
7.1
Internal Audit Progress Report including key risk
management factors/new IA report format.
Discussion
Internal Audit
(KPMG)
10.40am
page 2
8.
External Audit:
8.1.
External Audit Progress Report:
• Summary of 2024-25 debrief discussion with
the Finance Team.
• Forward look of the high-level timetable for the
2025-26 audit.
• Sector insights update.
Discussion
External Audit
(GT)
11.00am
9.
Local Counter Fraud:
9.1.
Counter Fraud Progress Report.
Discussion
IA on behalf of
Local Counter
Fraud
(KPMG)
11.10am
9.2.
Counter Fraud mandate fraud review.
Discussion
IA on behalf of
Local Counter
Fraud
(KPMG)
11.15am
10.
Key learning from disciplinary counter fraud cases
including sanctions and escalation processes.
Discussion
Chief People
Officer
11.20am
11.
Update on Counter Fraud, Bribery and Corruption
Policy.
Discussion
Chief Finance
Officer
11.25am
12.
Items for Noting and / or Information
12.1.
Data Security and Protection Toolkit/ Cyber Assurance
Framework submission.
Noting
Chief Digital &
Information
Officer
11.30am
12.2.
Tenders Waived for the period 1st June to 31st July
2025 above £50,000 including Easy Go Community
Transport contract update.
Noting
Procurement
Director
11.35am
12.3.
Losses and Special Payments for the period 1st June -
31st July 2025.
Noting
Operational
Finance
Director
11.40am
Good governance
13.
MFT’s Standards of Business of Business Conduct
policy.
Discussion
Director of
Corporate
Business/Trust
Board
Secretary
11.45am
14.
Escalation reports from Board committees and Trust
Risk Oversight Committee
Noting
Trust Board
Secretary
11:50am
Committee business
15.
Escalation report.
Approval
Chair
11.55am
16.
Workplan Review.
Meeting
admin
Chair
11.55am
17.
Any Other Business (verbal).
Discussion
Committee
Members
11.55am
18.
Meeting Evaluation (verbal).
Meeting
admin
Chair
11.55am
page 3
Date of next meeting: Wednesday 5th November at 10:00am – 12:00pm in the Medical Boardroom,
Cobbett House, ORC.
page 4
Agenda Item 13.2
Escalation and Assurance Report
Finance Board Committee
Report to: Board of Directors
Report from: Trevor Rees, Deputy Chairman and Chair of Finance Board Committee
Date of meeting: 26/08/25
Key escalation and discussion points from the meeting
Alert
The Trust’s financial position remains challenging during 2025/26. At M4, there is an adverse variance of
£5.5m from forecast due to industrial action costs, Value for Patients (VfP) programme under-delivery,
and cost pressures including premium pay. Measures being taken include strengthening Clinical group
recovery plans, a focus on the workforce workstream of the VfP programme, and cash preservation
activities.
Advise:
The full Value for Patients target of £165.8m has been identified with a risk adjusted value of £136m. The
Committee recognised the challenge of delivering the workforce-related schemes, the need to ensure
that a greater proportion of savings are recurrent, and emphasised the importance of developing internal
capacity and capability to support the programme in future years.
The Committee received an update on the 2025/26 capital programme including the delivery of specific
schemes. It was agreed that a regular update report would be presented to the FBC and DEBC in the
future.
The 3 year Financial Recovery Plan is being reviewed in light of new NHS England guidance and the
underlying financial position coming into 2025/26. The impact on the MFT planning process will be
discussed further at the Board seminar in October.
The Committee received an update on the North Manchester General Hospital redevelopment
programme. A fully agreed project plan with the New Hospitals Programme is expected by the end of
September 2025.
The Committee received an update on the work to identify and realise commercial opportunities for the
Trust. A Task and Finish Group involving the Chief Finance Officer and Non-Executive Directors will be
established and meet twice prior to a full Board discussion at the Board seminar in October 2025.
The Committee discussed a letter received from the Chief Executive of the GM ICB and the proposed Trust
response.
Assure:
The Committee received the Post-Submission Report for the National Cost Collection exercise and noted
the strong compliance with NHS England’s approved costing guidance.
page 1
Risks discussed at the meeting
The Committee discussed the strategic risks and corporate risks aligned to the finance element of the
strategic aim of which the committee has responsibility for oversight.
The Committee emphasised the need to ensure that the specific capital risks have clear ownership
between this Committee and the Digital and Estates Board Committee; that the risk ratings and target
dates were appropriate; and that the cash risk is correctly described and allocated as a corporate risk and
as part of the financial sustainability strategic risk.
Report approved by: Trevor Rees, Deputy Chairman and Chair of Finance Board Committee
Agenda:
Finance Board Committee
Date: Tuesday 26th August 2025
Time: 9:00am – 11:00am
Location: Teams
Agenda
Item
Purpose
Lead
Time
1.
Apologies for absence & confirmation of quoracy
(verbal)
Meeting admin
Chair
9:00am
2.
Declaration of interest (verbal)
Meeting admin
Chair
9:00am
3.
Minutes of the previous meeting (24th June 2025)
Meeting admin
Chair
9:00am
4.
Action Log
Discussion
Chair
9:00am
5.
Matters Arising
Discussion
Chair
9:00am
6.
Assurance Reporting
6.1
Strategic and Corporate risks
Discussion
Chief
Finance
Officer
9:05am
6.2
Integrated Performance Report - M4
Discussion
Chief
Finance
Officer
9:15am
page 2
7.
Strategic aim 4: Ensure value for our patients and communities by making best use of
resources
7.1
Chief Finance Officer’s report - M4
Discussion
Chief
Finance
Officer
9:25am
7.2
Value for Patients Programme update
• Including update from Carnall Farrar on current
work programmes
Discussion
Chief
Delivery
Officer /
Carnell
Farrar
9:35am
7.3
2025/26 – Capital Programme Update and Governance
Overview
Discussion
Deputy
Director
of
Estates
9:45am
7.4
Review of 3-year financial recover plan
Discussion
Chief
Finance
Officer
9:55am
7.5
North Manchester General Hospital – Redevelopment
Update
Discussion
Chief
Finance
Officer
10:05am
7.6
Update on Commercial Developments
Discussion
Chief
Delivery
Officer
10:25am
7.7
Post-National Cost Collection Submission report
Noting
Head of
Costing
10:35am
7.8
MFT – Delivering the 25/26 plan
Approval
Chief
Finance
officer
10:45am
Committee business
8.
Escalation report
Approval
Chair
10:55am
9.
Workplan Review
Meeting admin
Chair
10:55am
10.
Any Other Business (verbal)
Discussion
10:55am
11.
Meeting Evaluation (verbal)
Meeting admin
Chair
10:55am
page 3
Date of next meeting: Tuesday 21st October 2025, 2:00pm – 4:00pm, Main Boardroom, ORC
page 4
Agenda Item 13.3
Escalation and Assurance Report
Digital and Estates Board Committee (DEBC)
Report to: Board of Directors
Report from: Sam Liscio, Non-Executive Director and Chair of DEBC
Date of meeting: 09/09/25
Key escalation and discussion points from the meeting
Alert
In July, following an engagement exercise with the Information Commissioner’s Office (ICO), MFT
received a practice recommendation - a formal notice issued by the ICO under Section 48 of the
Freedom of Information Act 2000. While this is not an enforcement notice from the ICO, it signals serious
concerns with historic FOI response rates and is intended to prompt improvement. A recovery plan to
improve FOI response compliance had already been developed, and the areas for improvement which
the ICO identified are addressed within the plan. For the last reporting period, the Trust has achieved
compliance (52% against a 50% target for FOIs responded to within 20 days). MFT must write to the ICO
by 31st December 2025 to confirm that it has complied with the practice recommendations. The number
of FOI requests has increased, in part due to increasing numbers of media enquiries.
The Committee discussed the value of a full Board discussion on the medium and long term potential of
Hive and other digital innovations. Time has been allocated on the Board seminar agenda for the
December meeting, alongside the scheduled items on Cyber Security and AI.
Advise:
The digital aspects of the ‘Care on Time’ programme, established in July, will be delivered over the coming
months. The programme includes: Fast pass and rescheduling; Self-scheduling; Ambient AI Hive
integration; Digital first appointment letters; DNA predict; and Waitlist validation.
The Committee received a number of updates regarding Hive:
•Integration of MyMFT with the NHS App was discussed, along with the successful bid for Wayfinder
acceleration, and it is expected that the Epic interfacing with the NHS App will be complete in March
2026.
•The business case for LCO Digitisation continues to be developed, as is the case for Epic
Infrastructure refresh with both cases expected for review in Q3.
•Reassurance was provided, and the processes discussed, around how Hive monitoring can be used
proactively, to review productivity and effectiveness of system use.
•The net financial benefit of Hive implementation is now being forecast to be £390m compared to
the £340m forecast at business case stage. In addition, MFT have been asked by NHS England to
be part of a review of productivity increases as a result of EPR adoption.
In June, MFT contracted an external scanning provider to digitise over 1 million paper case notes that MFT
holds in its Health Record libraries over the next 7-8 years. Scanning is planned to commence in September
and the programme has committed to scanning 120K notes this financial year.
page 1
Digital Services are on track to deliver this year's VfP target, with a total of £4.1M transacted at the end of
M4. No major risks to delivery have been identified but the Committee noted that Digital Services are facing
increasing cost pressures due to changes to licensing models in the market more broadly.
The Committee discussed the Director of Estates report which included:
• Confirmation of the Board approval of the new MFT Green Plan at May’s meeting. The Committee
discussed the importance of Sustainability Impact Assessments within the business case process
and the potential for the inclusion of sustainability fines as an indicator within the IPR.
• Confirmation of the plans to achieve Net Zero at the Trafford (April 2026) and Altrincham hospital
sites (April 2027).
• Funding has been obtained to install a further 45 EV charging points across the Trust.
• Detail of the Estates metrics to be included in the IPR in the future: Estates Return Information
Collection (ERIC), Patient-Led Assessments of the Care Environment (PLACE), Premises
Assurance Model (PAM), and Inpatient survey results. The ERIC return for 2024/25 has been
submitted and is undergoing NHS England validation. The PLACE assessments for 2025 will run
from 1st September to 21st November 2025, with results to be published in early 2026.
The Committee discussed a report on the 2025/26 Capital programme update which included detail of the
backlog maintenance prioritisation. There is an unknown capital allocation for future years to address the
backlog and current estate risks have been updated to include the actions we are taking to increase
maintenance on items/systems/infrastructure that would normally be addressed by capital replacement.
There are currently no items remaining on the backlog maintenance register that are not being addressed
in either backlog replacement in 24/25 or being supported with enhanced maintenance.
The Committee received a report on MFT’s current PFI agreements at the Oxford Road Campus (ORC)
and Wythenshawe site. On the ORC, lifecycle workshops have been held between all PFI parties and MFT.
As a result, a 5-year lifecycle plan aligned to clinical strategy is being developed which shows a lifecycle
works program (including Trust variations) of over £110m up to 2030 .
A ‘Centre of Best Practice Audit’ is being carried out on the Wythenshawe site and is 40% complete. Current
findings do not show major non-conformities from the original building design but does show condition
issues that are already receiving the required investment from the PFI consortium.
The Committee discussed an update on the NMGH redevelopment programme and noted that the project
plan is to be agreed with the New Hospital Programme by the end of September 2025.
The Committee received a report giving an overview of health and safety arrangements in the Trust
including details of the governance in place and current risks. There have been no RIDDOR reportable
incidents in the last three months. There has been one request for information from the HSE which has
been completed and conformed as satisfied by the HSE.
Assure:
The Committee discussed the Digital elements of the IPR. Plans are in place to improve performance
against the following indicators: High severity incidents, MDE score, Subject Access Review
performance, and FOI performance (see ‘Alert’ section above).
MFT completed the DSPT self-assessment and published the 2024-25 CAF-DSPT on time (30th June).
The self-assessment demonstrated that MFT is practising good data security, and that personal
information is handled correctly, and met the NHSE recommended expectation to achieve ‘Standards
met’. MFT is the only Trust in Greater Manchester to achieve DSPT ‘Standards met’.
Risks discussed at the meeting
page 2
Strategic and Corporate Risks relevant to the scope of the Committee were discussed. This included a
new strategic risk related to the ‘Loss or instability of digital infrastructure’ which has been raised and
approved by the Trust Risk Oversight Committee since the last Committee meeting.
Report approved by: Sam Liscio, Non-Executive Director and Chair of the DEBC.
Agenda:
Digital and Estates Board Committee
Date: Tuesday 9th September 2025
Time: 10:00am – 12:00pm
Location: Main Boardroom, Cobbett House, ORC
Agenda
Item
Purpose
Lead
Time
1.
Apologies for absence & confirmation of quoracy
(verbal)
Meeting admin
Chair
10:00am
2.
Declaration of interest (verbal)
Meeting admin
Chair
10:00am
3.
Minutes of the Previous Meeting (19th June 2025)
Meeting admin
Chair
10:00am
4.
Action Log
Discussion
Chair
10:05am
5.
Matters Arising
Discussion
Chair
10:05am
6.
Assurance Reporting
6.1
Strategic and Corporate Risks
Discussion
Chief Digital
and
Information
Officer
10:10am
6.2
Integrated Performance Report
Discussion
Chief Digital
and
Information
Officer /
Director of
Estates and
Facilities
10:20am
page 3
Strategic aim 4: Ensure value for our patients and communities by making best use of resources
7.1
Chief Digital and Information Officer’s report (including
operational and BI performance and vertical KPIs)
Discussion
Chief
Digital and
Information
Officer
10:30am
7.2
Update on Hive programme
Discussion
Chief
Digital and
Information
Officer
10:40am
7.3
Director of Estates and Facilities’ report (including update
on Sustainability)
Discussion
Director of
Estates
and
Facilities
11:00am
7.4
Update on prioritisation of Estates and Facilities’ backlog
program against reduced capital allocation
Discussion
Director of
Estates
and
Facilities
11:10am
7.5
Update on MFT’s PFI agreements
Discussion
Director of
Estates
and
Facilities
11:20am
7.6
Update on NMGH development programme
Discussion
Director of
Strategic
Projects
11:30am
7.7
Health and Safety
Discussion
Director of
Estates
and
Facilities
11:40am
Committee business
8.
Escalation report
Approval
Chair
11:50am
9.
Workplan Review
Meeting
admin
Chair
11:55am
10.
Any Other Business (verbal)
Discussion
11:55am
11.
Meeting Evaluation (verbal)
Meeting
admin
Chair
11:55am
Date of next meeting: Tuesday 2nd December 2025 at 10:00am
page 4
page 5
Public Board of Directors
Wednesday 1st October 2025
Paper title:
M4 Financial Position
Agenda
Item
13.4
Presented by:
Claire Wilson, Chief Finance Officer
Prepared by:
Ann Bracegirdle, Deputy Chief Finance Officer
Paul Fantini, Deputy Director of Planning and Reporting
Meetings where content has
been discussed previously
Purpose of the paper
Please check one box only:
☐For approval
☒For discussion
☐For support
Executive summary / key messages for the meeting to consider
•The financial position against control total (CT) for M4, July 2025 in month is an £4.5m
deficit against a £1.0m surplus plan – adverse by £5.5m and YTD a £31.6m deficit
against a £26.2m deficit plan – adverse by £5.3m.
•After non-operating adjustments, the month 4 position is an £11.2m deficit against a
plan of a £2.8m deficit, an £8.4m adverse variance. YTD shows an adverse variance
of £10.6m.
•The M4 position includes costs/income loss of £2.7m associated with the Resident
Doctors’ industrial action in July 2025.
•Mitigations identified to reverse the adverse in month position are being worked through
in conjunction with Clinical Groups and Corporate teams
Recommendation(s)
The Board of Directors is asked to:
•Note the contents of the report
Do the recommendations in this paper
have any impact upon the requirements of
the protected groups identified by the
Equality Act?
☐Yes (please set out in your report what action
has been taken to address this)
☒
No
page 1
Relationship to the strategic objectives
The work contained with this report contributes to the delivery of the following strategic
objectives (see key below)
LHL objective 1
☐
LHL objective 2
☐
HQSC objective 1
☐
HQSC objective 2
☐
HQSC objective 3
☒
PEW objective 1
☐
PEW objective 2
☐
VfP objective 1
☒
VfP objective 2
☒
R&I objective 1
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R&I objective 2
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Good Governance
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Links to Trust Risks
The work contained with this report links to the following
strategic, corporate or operational risks:
•MFT/001760- Implications of national restrictions on
capital resource
•MFT/005092 -Delivering Financial Sustainability in the
medium term
•MFT/008655 - Risk of insufficient cash resources to fund
Trust operational and strategic requirements in 2025/26
and beyond.
Care Quality Commission
domains
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Well-Led
Compliance & regulatory
implications
The following compliance and regulatory implications have
been identified as a result of the work outlined in this report:
•
Main report
See report.
page 2
CFO Report Month 42025/26
Internal Only
Manchester University NHS
Foundation Trust
August 2025
page 3
Executive Summary
Page Area Narrative
Overview The Trust has a plan to deliver a breakeven financial position for 2025/26 which will be supported by an ambitious £165.8m Value
for Patients (VfP) savings target, equating to over 5.6% of operating expenditure. The plan contains several areas of high risk,
including full delivery of the VfP programme and the ability of commissioners to fund income for activity that achieves the Trust
and national performance requirements.
3Risks and Mitigations Notes the main financial risks included in the 2025/26 plan and any mitigations to reduce or nullify these risks
4 - 17 Income, Expenditure &
Workforce
The in month position is a £4.5m deficit against a £1.0m surplus plan. The income over-performance has been driven by ERF
income as a result of delivering activity above plan, offset by the costs of delivering activity. Discussions are ongoing with
commissioners to agree payment for performance above contract values and conversations have started in the management of
activity to deliver within the commissioner affordability envelope. Within expenditure, the costs to deliver the additional activity
are above plan plus premium pay costs covering vacancies and under-performance against budget reducing VfP. The YTD position
includes £8.4m of non-recurrent central VfP that has been delivered earlier than initially planned.
18 VfP VfP delivered in month was £9.6m, YTD £30.3m against a £25.4m target – above plan by £4.9m.
19 Capital 2025/26 capital plan of £113.4m including IFRS 16 leases. YTD expenditure (including IFRS 16 leases) of £31.1m against a plan
of £29.4m. £1.7m overspend driven by plan including an anticipated net credit from the IFRS 16 lease disposal of Gorton Parks
Nursing Home and the new replacement lease for Monet Lodge; this has been delayed to Q2 2025/26. The M4 FOT of £123.8m is
£10.4m above plan due to: £1.9m deferral from 24/25 for the grant funded Public Sector Decarbonisation scheme, £1m
additional GM envelope (UEC incentive) and additional PDC funding for NHP(£3.2m) and RAAC (£4.1m).
20 - 23 SoFP, Cash and Liquidity At the end of July 2025, the cash position is £38.4m against aplan of £57.2m, an adverse variance of £18.8m. The Trust has moved
into 2025/26 with a more challenged cash position than it has had historically and there is a risk that revenue support will be
required at the end of Q3 if the financial plan is not delivered as profiled and through cash releasing items.
page 4
Risks and Mitigations
In month 4 £5.0m of central VfP was required to mitigate under-performance across Clinical Groups and Corporate teams. The YTD value of central VfP in the
position stands at £8.4m and reduces the availability of central delivery later in the year.
Risk Mitigation/Action Being Taken Risk Value Timescale Owner
ERF Income – assumption of c.£17m above contract value currently in the
plan to deliver the performance requirements
•Working with Commissioners to agree a contract value that delivers performance requirements.
•Any additional costs required to deliver activity are approved through Trust Governance processes.
•Activity plans broken down by Clinical Group based on agreed contracts so any requirement in activity
reduction can be aligned to reduction of capacity and therefore cost.
£17.0m Ongoing Chief Delivery Officer
Vanessa Gardener
Chief Finance Officer
Claire Wilson
ERF Income – ICB contract reduced by c.£8m for delivery of activity
demand management schemes to support delivery of performance
requirements
•Monitoring of demand management schemes, working in conjunction with the ICB.
•Expectation that income will be received if demand management schemes are unsuccessful.
£8.0m Ongoing Chief Delivery Officer
Vanessa Gardener
Chief Finance Officer
Claire Wilson
Different ICB approaches and general commissioning changes resulting in
income reductions, currently extremely high risk. There are various
funding streams which are at risk.
•Discussions with the GM ICB and Specialist Commissioners and therefore NHSE continue to ensure all funding
anticipated is received, or costs can be reduced in alignment with income reduction.
£15.0m 31st March 2026 Chief Finance Officer
Claire Wilson
Expenditure run rate doesn’t reduce to deliver 25/26 financial plan •Implementation of enhanced controls to ensure consistency in application of local override of temporary
medical staffing rates.
•Only exceptional use of admin bank or agency, approved through Executive led Vacancy Control Panel.
•Carnall Farrar are providing support to develop the Value for Patients programme at pace.
£50.0m Ongoing All Executive Directors
There is no national funding for the £2.7m Industrial Action costs incurred
in July 2025.
•CGs and the Trust centrally have looked to minimise additional costs as far as possible and will continue to seek
mitigations through the remainder of the year.
£2.7m Ongoing All Executive Directors
NHSE requirement to reduce Corporate cost growth by 50% compared to
18/19
•Indicative requirements by area circulated to Executive Directors.
•Work ongoing to develop corporate services to operate within the funding available.
Ongoing All Executive Directors
Non recurrent delivery of Value for Patients and mitigations to offset
pressures will increase the Trust’s underlying deficit financial position
•Review all non recurrent schemes to determine if they can be delivered recurrently.
•Focussed work by Carnall Farrar to fast track development of recurrent schemes.
Ongoing All Executive Directors
If the financial plan is not delivered in line with cash flow assumptions the
Trust will potentially need to access revenue support funding by Q2
and/or have to slow down/reduce capital expenditure plans.
•Weekly Cash management group established to support maximisation of Trust cash balances.
•Enhanced cash flow monitoring and reporting
•Senior review and approval of all BACs payment runs
•Focus on the management of debtors.
•Working with the GM ICB to maximise the Trust’s cash position on a monthly basis
Ongoing Chief Finance Officer
Claire Wilson
page 5
Summary – M4 Position –July 2025
Summary
•In month 4, for NHSE reporting purposes, the Trust delivered a deficit of
£4.5m against a planned surplus of £1.0m – adverse to plan by £5.5m. YTD
this is a £31.6m deficit vs a planned deficit of £26.2m, adverse £5.3m.
•This position includes £5.0m in month of non-recurrent VFP schemes
transacted in month which will not continue for the remainder of the year, as
well as £2m other one-off mitigations.
•Without these adjustments, the position would have been an £11.5m deficit
which is driven by:
•£2.7m relating Industrial action (£1.2m costs and £1.5m lost elective
income)
•£6.1m relating to undelivered VfP within Clinical Groups/Corporate
teams
•c.£4.2m of premium pay costs across CGs covering vacancies,
enhanced nursing care and medical staffing gaps and activity
•Income: The favourable income variance in month of £7.8m is driven by
clinical over-performance of £1.2m, additional GLH funding of £1.1m and
CPT drugs and devices income of £3.8m. All elements are offset with
expenditure movements.
•Expenditure: Adverse expenditure variances primarily reflect under
performance against budget VfP across Clinical Groups/Corporate (offset
at a Trust level) and costs of delivering activity above the plan.
Month 4 includes estimates for the impact of Resident Doctors industrial action with income lost of
£1.5m and net costs of £1.2m included.
The estimated impact of the revised pay awards suggest an adverse gap between income and
expenditure YTD arrears of up to £2.2m – the final value is still being calculated and will only be
transacted in the position in Month 5 when pay arrears are paid.
The YTD position includes £8.4m of brought forward Value for Patients at Trust level, with £5.0m in
month 4.
2025/26 Current Month - M4 YTD
I&E Category
Original
Plan
Original
Plan Actual Variance Original
Plan Actual Variance
£'000 £'000 £'000 £'000 £'000 £'000 £'000
Income from Patient Care Activities 2,728,101 235,382 241,513 6,130 909,157 919,046 9,889
Other Operating Income 313,784 26,365 28,000 1,635 104,809 107,476 2,667
Total Income 3,041,885 261,747 269,513 7,766 1,013,966 1,026,522 12,556
Staffing Costs (1,835,239) (159,085) (168,440) (9,355) (628,360) (642,133) (13,773)
Non Pay Costs (1,133,757) (95,532) (100,846) (5,314) (387,873) (393,576) (5,703)
Total Operating Expenditure (2,968,996) (254,617) (269,286) (14,669) (1,016,233) (1,035,709) (19,476)
EBIT Margin 72,889 7,130 226 (6,904) (2,267) (9,187) (6,920)
Interest & Dividends (52,322) (2,817) (1,379) 1,438 (29,300) (27,478) 1,822
Surplus / (Deficit) before adjustments 20,567 4,313 (1,153) (5,466) (31,567) (36,665) (5,098)
Adjust PFI revenue costs to UK GAAP basis (20,567) (3,309) (3,368) (59) 5,346 5,107 (239)
Surplus / (Deficit) for CT purposes 01,004 (4,521) (5,525) (26,221) (31,558) (5,337)
I&E Excluded from CT (62,291) (3,821) (6,672) (2,851) (16,102) (21,391) (5,289)
Surplus / (Deficit) after CT excluded items (62,291) (2,817) (11,193) (8,376) (42,323) (52,949) (10,626)
page 6
M4 Financial Position –July 2025
In month 4 the Trust delivered a deficit of £4.5m, £5.5m adverse to plan. YTD shows a £31.6m deficit, £5.3m
adverse to plan.
Income
The YTD £12.6m favourable variance to plan (£7.8m favourable in month) is largely driven by:
•Under-performance against CPT Drugs and Devices of £3.5m – offset by underspends in non-pay.
•Over-performance against ERF income by £9.4m.
•Additional income for the GLH service of £3.6m.
•Education & Training income higher than plan by £2.0m –due to a non-recurrent deferred income released.
Pay Variance (£0.4m of b/f NR Central VfP supporting the position at M4)
The YTD £13.8m adverse variance to plan is driven by:
•Under-performance against the YTD budget reducing VfP target across Clinical Groups/Corporate (£6.1m)
•Premium pay use across all CGs covering vacancies, enhanced care nursing and medical staffing gaps (£4.4m)
•Costs associated with delivering the ERF over-activity (c£2.5m)
•Estimated impact of Resident Doctors industrial action on pay costs of (£1.2m).
Non-pay Variance (£8.0m of b/f NR Central VfP supporting the position at M4)
The YTD £5.7m adverse variance to plan is predominantly driven by:
•Underspends on CPT Drugs & Devices of £3.5m (offset by income).
•Central VfP support brought forward of £8.4m.
•Costs of overperforming activity levels including Supplies & Services (c£7.0m) and Insourcing costs (£2.6m),
partially offset by income.
•Under-performance against the budget reducing YTD VfP target across Clinical Groups. (£7.6m)
•Inflationary costs of goods/services, professional fees/consultancy, premises costs etc a further (£2.4m)
2025/26 Current Month - M4 YTD
I&E Category
Original
Plan
Original
Plan Actual Variance Original
Plan Actual Variance
£'000 £'000 £'000 £'000 £'000 £'000 £'000
Income from Patient Care Activities 2,728,101 235,382 241,513 6,130 909,157 919,046 9,889
Other Operating Income 313,784 26,365 28,000 1,635 104,809 107,476 2,667
Total Income 3,041,885 261,747 269,513 7,766 1,013,966 1,026,522 12,556
Staffing Costs (1,835,239) (159,085) (168,440) (9,355) (628,360) (642,133) (13,773)
Non Pay Costs (1,133,757) (95,532) (100,846) (5,314) (387,873) (393,576) (5,703)
Total Operating Expenditure (2,968,996) (254,617) (269,286) (14,669) (1,016,233) (1,035,709) (19,476)
EBIT Margin 72,889 7,130 226 (6,904) (2,267) (9,187) (6,920)
Interest & Dividends (52,322) (2,817) (1,379) 1,438 (29,300) (27,478) 1,822
Surplus / (Deficit) before adjustments 20,567 4,313 (1,153) (5,466) (31,567) (36,665) (5,098)
Adjust PFI revenue costs to UK GAAP basis (20,567) (3,309) (3,368) (59) 5,346 5,107 (239)
Surplus / (Deficit) for CT purposes 01,004 (4,521) (5,525) (26,221) (31,558) (5,337)
I&E Excluded from CT (62,291) (3,821) (6,672) (2,851) (16,102) (21,391) (5,289)
Surplus / (Deficit) after CT excluded items (62,291) (2,817) (11,193) (8,376) (42,323) (52,949) (10,626)
(73,347)
(22,179)
(229,665)
Other
(20,079)
(16,418)
3,661
(85,813)
Depreciation & Amortisation
(5,728)
(5,915)
(187)
(22,843)
(71,583)
12,466
664
(3,281)
211
(1,709)
(27,819)
Lease Expenditure
(846)
(942)
(96)
(3,492)
PFI Charges
(6,757)
(7,596)
(839)
(26,110)
(81,514)
(7,730)
(116,098)
Supplies and Services - General
(1,300)
2,635
(5,200)
Premises & Establishment Costs
(6,943)
(3,245)
(28,195)
(4,095)
1,105
904
(27,291)
(2,566)
Insourcing & Outsourcing Costs
(2,979)
(5,545)
(11,916)
Supplies and Services - Clinical
(24,474)
(35,788)
(11,314)
(98,600)
(18,200)
(6,284)
Drugs
(17,498)
(105,704)
(101,265)
4,439
712
Misc. Other Operating Income
8,424
9,151
727
33,696
34,408
101,090
37,401
1,984
(29)
35,667
Education & Training
9,017
9,939
922
35,417
Research & Development
8,924
8,911
(13)
35,696
107,091
105,603
4,399
417
(107)
3,817
14,388
(0)
(0)
922
751,828
11,988
(2,408)
143,692
ICBs
192,544
194,776
2,232
739,841
NHS England
37,019
40,776
3,757
146,100
436,957
2,221,575
Non NHS: other
1,006
1,035
28
3,982
Non-NHS: private patients, overseas patients & RTA
981
1,095
114
3,924
11,765
11,898
Local Authorities
3,597
3,597
(0)
14,388
NHS Trust and Foundation Trusts
235
235
(0)
922
2,744
43,162
3,698
3,935
(315,512)
(294,450)
(35,748)
(81,955)
(15,600)
(26,426)
(28,032)
(1,606)
page 7
I&E Run Rates vs CT –July 2025
•The charts show the monthly run rate vs the plan.
•The expenditure run rate needs to significantly
reduce over the rest of the financial year, driven
by the delivery of VfP.
•Both income and expenditure include £5.9m for
the YTD pay award uplift in month 4.
•Included as estimates for the impact of Resident
Doctors industrial action in month 4 are staffing
costs of £1.2m and an income reduction on prior
months run rate of £1.5m.
I&E performance vs CT (£000s) Income (£000s)
Staffing Costs (£000s) Non Pay Costs (£000s)
(16,000)
(12,000)
(8,000)
(4,000)
0
4,000
8,000
12,000
Ap r- 25
M a y- 25
Jun-25
Jul-25
Au g-25
Sep-25
Oct-25
Nov-2 5
D ec - 25
Jan-26
Feb-2 6
Mar-26
Actual
Orig in al Plan
(172,000)
(162,000)
(152,000)
(142,000)
Ap r- 25
M a y- 25
Jun-25
Jul-25
Au g-25
Sep-25
Oct-25
Nov-2 5
D ec - 25
Jan-26
Feb-2 6
Mar-26
Pay cost increase
for in- yea r pay
award
Actua l
Pay plan increase
for in- yea r pay
award
Ori gina l Pla n
(104,000)
(100,000)
(96,000)
(92,000)
(88,000)
(84,000)
Ap r- 25
M a y- 25
Jun-25
Jul-25
Au g-25
Sep-25
Oct-25
Nov-2 5
D ec - 25
Jan-26
Feb-2 6
Mar-26
Actual
Orig in al Plan
240,000
250,000
260,000
270,000
Ap r- 25
M a y- 25
Jun-25
Jul-25
Au g-25
Sep-25
Oct-25
Nov-2 5
D ec - 25
Jan-26
Feb-2 6
Mar-26
Income uplift for in-
year pay awa rd
Actua l
Inco me plan upli ft
for in- yea r pay
award
Ori gina l Pla n
I&E category Apr-25 May-25 Jun-25 Jul-25
£'000 £'000 £'000 £'000
Income 252,332 246,259 258,419 263,584
Income uplift for in-year pay award 5,929
Staffing Costs (157,973) (158,465) (157,255) (162,511)
Pay cost increase for in-year pay award (5,929)
Non Pay (96,975) (92,973) (102,782) (100,846)
Financing Costs (21,105) (2,747) (2,248) (1,379)
PFI revenue costs on a UK GAAP basis 15,099 (3,367) (3,257) (3,368)
I&E Performance vs CT (8,622) (11,293) (7,123) (4,520)
Note: increase due to pay award YTD in July is matched to income and plan
page 8
M4 Financial Position by Area
•Underperformance across CSS, LCO and Dental, MRI and NMGH largely is driven by under-delivery against the budget reducing VfP targets and premium costs to cover
vacancies/specialling costs.
•Significant focussed work is underway by all Clinical Groups and Corporate teams to develop and implement VfP schemes at pace. Each CG has been asked to produce a recovery
plan to address the YTD gap and to ensure delivery of their plan by the end of the year.
•The CEO and CFO is meeting with each CG CEO and CFO during August to review the recovery plans and to discuss any further actions and support needed.
•CF continue to provide additional support and capacity to the VFP programme and targeted support is being provided to specific workstreams and CGs. This is subject to a
separate item on the agenda.
•Note that internal budgets differ to the original plan against the income, pay and non-pay categories so although the overall variance is the same, at £5.3m adverse to plan, the make up is different
due to reallocation of budgets internally, as required.
YTD at Month 4 Variance Variance Variance Variance Variance Variance Variance Variance Variance Variance Variance
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
Devolved Clinical Income 1,258 (289) 4,105 741 (16) (785) 0001,385 6,400
Other Income (236) 171 342 121 260 (89) 356 (1,394) (30) 2,115 1,615
Total Income 1,022 (118) 4,447 862 244 (874) 356 (1,394) (30) 3,500 8,015
Staffing Costs (2,415) (727) (2,322) (2,298) 2,090 723 484 (676) 23 (2,057) (7,173)
Non Pay Costs (1,041) 220 (7,702) (2,724) (2,271) 1,305 (2,112) 138 46,419 (7,764)
Financing Costs 0000000(0) 01,585 1,585
Total Expenditure (3,455) (507) (10,023) (5,022) (181) 2,028 (1,628) (538) 27 5,947 (13,353)
Contribution (2,433) (625) (5,576) (4,160) 63 1,153 (1,272) (1,932) (3) 9,448 (5,337)
TOTAL
CSS
LCOD
MRI
NMGH
SPEC
WTWA
CORP
E&F
R&I
TRUST
page 9
M4 Forecast Variance by Area
•The ‘unmitigated forecast’ indicates a £66.6m deficit as a result of risks in the Clinical Groups predominantly relating to VfP delivery and operational
pressures.
•The Trust continues to externally report a break-even position through inclusion of £66.6m of mitigations. There is c. £64m of non recurrent
transactions assumed in the breakeven position, leading to an underlying deficit of c.£64m.
•Mitigations include central and technical schemes, inclusion of red rated recovery plans and a significant increase in the level of VfP delivered by Clinical
Groups as a result of the intensive focussed work on development and delivery of VfP.
•There continues to be significant risk with this position and further work is needed to ensure that all recovery actions and VFP schemes are fully
delivered by year end.
•The next slides sets out the risk adjusted forecast position which is currently estimated at £37m. Focus on progressing VFP schemes and to refine the
Trusts risk-based scenario forecasting is ongoing.
Forecast at M4 Variance Variance Variance Variance Variance Variance Variance Variance Variance Variance Variance Variance Variance
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
Income 5,356 739 14,373 3,365 5,153 1,732 284 (4,082) (89) 3,208 30,040 19,200 49,240
Total Income 5,356 739 14,373 3,365 5,153 1,732 284 (4,082) (89) 3,208 30,040 19,200 49,240
Staffing Costs (15,448) (10,608) (5,913) (7,354) (13,482) (3,379) 794 (2,028) 66 (6,982) (64,334) 20,604 (43,730)
Non Pay Costs (3,013) 9,386 (29,990) (7,069) (8,510) (9,155) (1,078) 5,583 12 9,544 (34,291) 26,804 (7,488)
Financing Costs 0000000001,978 1,978 01,978
Total Expenditure (18,461) (1,222) (35,903) (14,424) (21,992) (12,535) (284) 3,555 79 4,540 (96,647) 47,407 (49,240)
Contribution (13,105) (483) (21,530) (11,059) (16,838) (10,803) 0(528) (10) 7,748 (66,607) 66,607 (0)
YEAR END
FORECAST
Mitigations
Forecast
Pre
Mitigations
Central
R&I
E&F
CORP
WTWA
SPEC
NMGH
MRI
LCOD
CSS
page 10
9
Risk Adjusted Trust Forecast Position
Trust Position YTD FORECAST
I&E Category Plan Actual Variance Plan Actual Variance
£'000 £'000 £'000 £'000 £'000 £'000
Income 1,013,966 1,026,522 12,556 3,041,885 3,071,925 30,040
Staffing Costs (628,360) (642,133) (13,773) (1,835,239) (1,899,573) (64,334)
Non Pay (387,873) (393,576) (5,703) (1,133,757) (1,168,048) (34,291)
Finance (23,954) (22,370) 1,583 (72,889) (70,911) 1,978
Surplus/(deficit) (26,221) (31,558) (5,337) 0(66,607) (66,607)
Expected CT adjustment 0
Surplus/(deficit) (26,221) (31,558) (5,337) 0(66,607) (66,607)
Included in above: VfP (actual as per VfP tab, WD4 report) 25,421 30,331 4,910 165,800 126,214 (39,586)
YTD FORECAST
Plan Actual Variance Plan Actual Variance
£'000 £'000 £'000 £'000 £'000 £'000
VFP delivery assumed in above position
Gross forecast of £66m
includes risk adjusted
forecast for VFP.
Recovery actions being
progressed by clinical groups
and other mitigating
adjustments would reduce
this to £37m deficit
Within this gap is:
-Under delivery of VFP of
£39.5m
-Unfunded costs of IA of
£1.5m (excl. lost income)
•Continued work to mature
and implement the VFP
programme is ongoing in
order to reduce the risk of
delivery and close the
remaining forecast gap.
Mitigations and Adjustments RAG
Drugs & Devices pass though income alignment 6,800
Additional recovery plan actions 14,700
Other group consolidation adjustments 8,200
Forecast after mitigations and adjustments (36,907)
page 11
Financial Recovery Actions
Value for Patients
•Trust-wide efforts continue to focus on fully developing VfP schemes below Level 3 maturity ensuring all components are robust and
deliverable.
•External support continues to be provided via Carnell Farrar (CF) who's work is now focussed on supporting:
Focus on the delivery and implementation of high-priority schemes
Provision of intensive delivery in areas where internal capacity is constrained.
Embedded delivery support with Clinical Groups
Strengthening programme governance
high-value schemes to be effectively mobilised and tracked through to implementation.
Recovery Actions
•Workforce workstream led by the CPO focussing on premium pay costs and other staffing efficiencies.
•‘Staffing Wisely’ organisation wide continuous improvement events starting in September 2025
•MARS scheme has recently been launched for which net recurrent savings will be realised in 2026/27
•Phase 3 implementation of the ‘One MFT’ implementation new operating model is due to ‘Go Live’ at the beginning of October 2025
•Re-procurement of insourcing capacity to minimise the number of suppliers and contract at a more competitive rate.
•Review all opportunities for VAT efficiency
•Commercial opportunities (e.g private patient income) is being progressed across Clinical Groups
•Operational productivity work focussing on outpatients and theatres
•Urgent care flow improvements resulting in bed capacity reductions
page 12
Month 4 - Variable Income
Variable Income to M4
•The Trust received an Activity Query Notice from GM ICB on 8/8/25 which initiates the start of the formal activity management process as set out in the contract.
•Discussions with commissioners on the levels of overperformance are ongoing and we are working together to develop plans to bring activity back in line with planned
contract levels by the year end. However, there is a risk to our income forecasts which is being closely monitored and further updates will be provided to the
committee as the work progresses.
•Estimated industrial action for loss of income valued at £1.5m (25th July – 29th July)
Variable Income by Clinical Group - July YTD
Site / MCS
Industrial
Action Adj.
Plan Actual Var Plan Actual Var Plan Actual Var Plan Actual Var Actual Plan Actual Var
Clinical & Scientific 3,587 4,066 479 1,902 2,254 353 1,491 1,827 336 022-199 6,980 7,950 970
Manchester Royal Eye Hospital 5,052 5,811 759 1,035 1,076 41 4,698 5,022 324 000-24 10,786 11,885 1,099
Manchester Royal Infirmary 29,201 30,759 1,558 6,321 7,014 693 1,297 1,752 456 380 493 113 -569 37,200 39,451 2,251
North Manchester General Hospital 12,745 13,324 579 4,436 4,680 244 1,216 1,177 (39) 0 0 (0) -378 18,397 18,803 406
Royal Manchester Children's Hospita
16,440 18,778 2,337 3,654 4,046 392 495 632 137 437 463 26 -40 21,027 23,878 2,851
Saint Mary's Hospital 6,585 6,824 239 4,145 4,529 384 2,142 1,953 -189 000-93 12,872 13,213 341
University Dental Hospital 1,307 1,071 -236 946 963 17 1,826 1,808 -17 000-53 4,078 3,789 -289
Wythenshawe, Trafford, Withington a
33,896 34,332 437 9,497 10,112 615 5,950 6,370 420 455 473 18 -121 49,797 51,165 1,368
Trust 0004,718 5,803 1,085 0-464 -464 185 0-185 04,903 5,338 436
Total 108,814 114,965 6,151 36,653 40,477 3,823 19,114 20,076 963 1,458 1,432 -26 -1,477 166,039 175,473 9,434
Elective (£000s)
Outpatients First Attendance (£000s)
Outpatients Procedures (£000s)
Total (£000s)
Chemo (£000s)
page 13
Month 4 - Variable Activity
Variable Activity to M4
•The plan is based on data supplied by the BI/Performance team and agreed with each Clinical Group.
Variable Activity by Clinical Group - July YTD
Site / MCS
Plan Actual Var Plan Actual Var Plan Actual Var Plan Actual Var
Clinical & Scientific 1,751 1,695 (57) 21,436 24,366 2,929 6,190 7,419 1,229 29,378 33,479 4,102
Manchester Royal Eye Hospital 3,523 3,770 247 6,177 6,427 250 35,225 37,668 2,442 44,925 47,864 2,940
Manchester Royal Infirmary 26,650 27,358 709 32,880 34,647 1,767 7,421 10,074 2,653 66,951 72,080 5,129
North Manchester General Hospital 5,632 5,337 (295) 20,571 21,318 747 6,699 6,410 (289) 32,901 33,065 163
Royal Manchester Children's Hospita
9,606 9,670 64 18,325 20,110 1,785 2,709 3,507 797 30,641 33,286 2,646
Saint Mary's Hospital 2,641 2,701 60 13,633 14,678 1,044 7,352 6,195 (1,157) 23,626 23,574 (52)
University Dental Hospital 1,581 1,333 (248) 4,904 5,036 131 10,433 10,151 (283) 16,919 16,519 (400)
Wythenshawe, Trafford, Withington
13,711 13,938 227 45,200 52,847 7,647 33,317 36,438 3,121 92,228 103,224 10,996
Trust 0 0 0 0 2 2 0 19 19 021 21
Total 65,095 65,802 707 163,126 179,430 16,304 109,347 117,880 8,533 337,567 363,112 25,544
Elective
Outpatients First Attendance
Outpatients Procedures
Total
page 14
Staffing Costs – Run Rates
•July 25 includes YTD cost of the revised
pay awards at £5.9m included in both plan
and actual.
•July 25 includes an estimated £1.2m of
cost related to Resident Drs industrial
action.
Apr-25 May-25 Jun-25 Jul-25 Aug-25 Sep-25 Oct-25 Nov-25 Dec-25 Jan-26 Feb-26 Mar-26
Staffing Costs £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s
Plan inc Pay Awards (156,263) (157,106) (155,906) (159,085) (154,535) (154,534) (150,844) (150,482) (148,788) (149,207) (149,210) (149,277)
Original Plan (156,263) (157,106) (155,906) (153,156) (153,053) (153,052) (149,362) (149,000) (147,306) (147,725) (147,728) (147,795)
Actuals (157,973) (158,465) (157,255) (168,440) 00000000
Actuals exc Pay Award (157,973) (158,465) (157,255) (162,511) 00000000
Variance (1,710) (1,359) (1,349) (9,355) 154,535 154,534 150,844 150,482 148,788 149,207 149,210 149,277
page 15
WTE Trends
Select Grouping: Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25
Total Staff 29,056.82 29,326.92 28,954.96 29,053.46 28,922.82 29,300.95 29,212.14 29,334.01 29,018.73 29,381.90 29,304.85 29,634.60 29,418.94 29,598.06 29,083.58 29,232.88
Bank Staff 1,696.64 1,915.75 1,675.98 1,763.60 1,682.59 1,890.39 1,586.18 1,620.99 1,351.89 1,711.89 1,562.48 1,878.33 1,627.15 1,859.42 1,412.58 1,527.50
Substantive Staff 27,284.16 27,308.10 27,185.51 27,193.19 27,169.97 27,342.85 27,554.08 27,646.70 27,613.01 27,630.46 27,686.34 27,692.50 27,719.35 27,673.50 27,605.19 27,621.75
Agency Staff 76.02 103.07 93.47 96.67 70.26 67.71 71.88 66.32 53.83 39.55 56.03 63.77 72.44 65.14 65.81 83.63
28,400
28,600
28,800
29,000
29,200
29,400
29,600
29,800
WTE
Total Staff
0
500
1,000
1,500
2,000
2,500
WTE
Bank Staff
26,800
26,900
27,000
27,100
27,200
27,300
27,400
27,500
27,600
27,700
27,800
27,900
Apr-24 May-24 Jun-24 Jul-24 Aug-24 S ep -2 4 Oct-24 Nov-24 Dec-24 Jan-25 F eb -2 5 Mar-25 Apr-25 May-25 Jun-25 Jul-25
WTE
Substantive Staff
0
20
40
60
80
100
120
Apr-24 May-24 Jun-24 Jul-24 Aug-24 S ep -2 4 Oct-24 Nov-24 Dec-24 Jan-25 F eb -2 5 Mar-25 Apr-25 May-25 Jun-25 Jul-25
WTE
Agency Staff
page 16
Bank & Agency Expenditure vs Target
•Targets for B&A reduction are
based on the FOT expenditure at
M8 24/25.
•30% reduction in agency
expenditure.
•10% reduction in bank expenditure.
•Work is ongoing to reduce B&A
expenditure across CGs as part of
VfP initiatives.
•Projections are based on YTD run
rates with no mitigating actions.
Bank Agency Bank Agency
Clinical Group
YTD Target YTD Actual
YTD
Variance
YTD
Variance
YTD Target YTD Actual
YTD
Variance
YTD
Variance
Annual
Target
Annual
Target
£'000 £'000 £'000 %£'000 £'000 £'000 %£'000 £'000
Clinical & Scientific Services 3,489 3,658 (169) (4.8%) 807 1,321 (514) (63.8%) 10,467 2,420
Corporate 474 852 (378) (79.7%) 14 132 (118) (820.9%) 1,422 43
Facilities 557 585 (28) (5.0%) 72 131 (59) (81.1%) 1,671 217
LCO & Dental 1,135 1,338 (203) (17.9%) 97 25 72 74.1% 3,405 290
Manchester Royal Infirmary 6,694 7,246 (552) (8.2%) 665 846 (181) (27.2%) 20,082 1,996
North Manchester General hospi 7,262 7,029 233 3.2% 587 1,418 (831) (141.4%) 21,787 1,762
ORC 015 (15) 0.0% 0000.0% 0 0
Research & Innovation 16 74 (58) (362.5%) 0000.0% 48 0
Specialist Hospitals 7,804 8,378 (574) (7.4%) 329 516 (187) (56.8%) 23,413 987
WTWA 6,168 6,626 (458) (7.4%) 528 628 (100) (18.9%) 18,505 1,585
Total 33,600 35,801 (2,201) (6.6%) 3,100 5,017 (1,917) (61.8%) 100,800 9,300
page 17
WLI/ECL Expenditure
•ECL expenditure by Clinical Group is shown in the table
above.
•This expenditure is being tightly controlled by each CG.
Plans are being developed for more sustainable staffing
solutions where appropriate.
Clinical Group Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Trend
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
Clinical & Scientific Services 567 599 585 491 596 550 506 362 538 217 837 285 571 536 440 477
LCO & Dental 3 6 10 10 10 11 9 5 11 6 6 14 16 27 220
Manchester Royal Infirmary 494 355 782 263 244 374 225 283 311 337 373 627 326 343 330 984
North Manchester General hospi 62 41 49 39 100 58 102 49 89 165 82 89 25 176 82 136
Specialist Hospitals 291 288 1,091 (79) 348 460 293 397 358 618 439 496 371 572 587 779
WTWA 365 429 713 315 309 312 349 290 254 325 323 328 353 358 312 637
Total 1,781 1,719 3,231 1,040 1,608 1,765 1,484 1,387 1,561 1,669 2,060 1,838 1,663 2,012 1,755 3,033
Source - ECL/WLI element code in payroll
page 18
Insourcing & Outsourcing Expenditure
•Insourcing & Outsourcing expenditure by Clinical Group
is shown in the table above.
Clinical Group Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Trend
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
Clinical & Scientific Services 1,164 1,322 1,526 1,545 1,328 1,445 1,221 1,455 1,311 1,350 1,391 1,088 1,344 1,485 1,528 1,560
Manchester Royal Infirmary 1,237 1,087 1,177 1,473 1,373 1,346 1,500 1,072 1,000 928 1,069 1,480 1,235 1,195 1,349 1,473
North Manchester General hospi 117 75 126 107 99 110 107 48 71 55 62 62 365 417 717 482
Specialist Hospitals 246 200 263 253 288 426 524 369 211 369 1,109 726 505 761 657 353
WTWA 426 479 438 411 440 687 596 877 740 899 779 605 466 627 611 315
Total 3,190 3,163 3,530 3,789 3,528 4,014 3,948 3,821 3,333 3,601 4,410 3,961 3,915 4,485 4,862 4,183
page 19
Value for Patients
•Delivery M4 YTD £30.3m against a target of £25.4m, with £24.5m of the delivery being budget reducing savings.
•Non-recurrent delivery was above the 25% national target by 36.0% overall – which will impact on cash in future months if not recovered.
•£8.4m of central flexibility has been included YTD but has been brought forward from planned utilisation in later months. Savings across the Clinical Groups will need to delivered to
recover this position over the next 9 months.
Clinical Group / Corporate
Target
(M1-M4)
Plan L3+
(M1-M4)
Actual
(M1-M4)
Variance to
Target
(M1-M4)
Variance to
Plan L3+
(M1-M4)
Target
(25/26)
Plan L3+
(25/26)
Act/F'Cast
(25/26)
Variance to
Target
(25/26)
Variance to
Plan L3+
(25/26)
Income
Budget
Reduction
Non
Budgeted
Reduction
Total
(M1-M4)
CSS 4,222 3,475 3,351 (871) (124) 27,536 16,970 16,841 (10,695) (129) 746 2,140 466 3,351
LCO & Dental 1,686 3,262 2,273 587 (989) 10,999 9,668 9,668 (1,331) 1 8 2,266 02,273
MRI 3,787 1,765 1,772 (2,015) 624,701 11,016 10,800 (13,901) (216) 39 1,733 01,772
NMGH 1,680 1,660 1,660 (20) 010,958 10,803 10,803 (156) (0) 01,032 628 1,660
Specialist Hospitals 5,393 7,540 6,465 1,072 (1,075) 35,176 16,494 14,815 (20,362) (1,679) 613 4,488 1,365 6,465
WTWA 3,629 3,574 3,570 (58) (4) 23,667 11,033 11,030 (12,637) (3) 14 2,838 718 3,570
Total Clinical Sites 20,398 21,277 19,092 (1,306) (2,185) 133,037 75,984 73,956 (59,081) (2,027) 1,419 14,495 3,177 19,092
Corporate 1,166 1,985 1,868 702 (117) 7,604 4,708 4,503 (3,101) (205) 32 623 1,214 1,868
Digital Services 920 1,420 1,420 500 05,997 4,260 4,260 (1,737) 0 0 1,420 01,420
E&F 1,282 500 452 (831) (48) 8,363 9,031 9,002 639 (29) 0452 0452
Total Support Services 3,367 3,904 3,740 372 (165) 21,963 17,999 17,765 (4,199) (234) 32 2,494 1,214 3,740
Trust 1,656 7,500 7,500 5,844 010,800 26,083 26,083 15,283 0 0 7,500 07,500
MFT Total 25,421 32,681 30,331 4,910 (2,349) 165,800 120,065 117,804 (47,996) (2,261) 1,451 24,489 4,391 30,331
Breakdown of Actuals Delivered YTD
YTD
Annual Forecast
Non-recurrently delivered
VfP above target
Max target
of total
Actual Non-
recurrent
VfP
Variance to
target
CSS 25.0% 14.9% 10.1%
LCO & Dental 25.0% 69.7% (44.7%)
MRI 25.0% 44.8% (19.8%)
NMGH 25.0% 11.5% 13.5%
Specialist Hospitals 25.0% 74.8% (49.8%)
WTWA 25.0% 57.0% (32.0%)
Corporate 25.0% 5.0% 20.0%
Digital Services 25.0% 38.3% (13.3%)
E&F 25.0% 93.7% (68.7%)
Total 25.0% 48.2% (23.2%)
Trust 25.0% 100.0% (75.0%)
MFT Total 25.0% 61.0% (36.0%)
YTD
page 20
Capital
•MFT’s 2025/26 capital plan is a total of £113.5m including capital spend on IFRS 16 leases, PDC funded schemes, grant and charity schemes and the capital expenditure
associated with the Trust’s PFIs.
•Total Capital - YTD plan of £29.4m, actual spend of £31.1.m. Overspend of £1.7m YTD driven by;
•GM Envelope – YTD plan of £5.0m, actual spend is £6.4m. The YTD plan includes an anticipated net credit from the IFRS 16 lease disposal of Gorton Parks Nursing
Home and the new replacement lease for Monet Lodge; this has been initially delayed due to finalising construction works at the new property and is the key driver
of the £1.4m overspend for the GM envelope.
Externally Funded Schemes – YTD overspend of £0.2m, predominantly due to £2.0m additional RAAC spending as a result of increased PDC funding award and
partially offset by initial delays on the NHP (£0.4m), Public Sector Decarbonisation (£1.1m) , and charity funded (£0.3m) schemes.
•The M4 FOT is £10.4m above plan. This variance is driven by £1.9m deferral from 24/25 for the grant funded Public Sector Decarbonisation scheme, £1m additional GM envelope
allocation for UEC incentive and additional PDC funding for NHP(£3.2m) and RAAC (£4.1m). (There is also a £1.0m reallocation from GM envelope to PDC funded schemes.
YTD Forecast
Original
Plan Actual Variance Original
Plan FOT @ M4 Variance
£'000 £'000 £'000 £'000 £'000 £'000
GM Envelope (including
IFRS 16 Leases)
4,979 6,400 1,421 31,665 31,629 (36)
Other Capital (PDC, grant
and charity, PFI)
24,446 24,681 235 81,790 92,201 10,411
Total Capital
29,425 31,081 1,656 113,455 123,830 10,375
page 21
Statement of Financial Position
M4 2025/26 vs Month 12 2024/25
•Other property, plant & equipment value has decreased by £9.7m due to depreciation
and impairments YTD, partially offset by capital additions.
•Receivables reduction of £17.6m is primarily driven by receipt of income from the ICB
(£24.8m) and Education Funding (£8.9m). This is partially offset by increases in accrued
income from NHSE (£6.8m) and ERF (£3.3m) and £4m increase in CNST prepayments.
•Cash has decreased by £22m, see following slide for detail.
•Capital trade and other payables have decreased by £15.0m, reflecting the unwinding of
elevated capital activity accrued at the 2024/25 year-end. The non-capital balance has
decreased by £23.5m primarily driven by a £12m reduction in GRNI accruals, £7m
reduction in the purchase ledger control account, and a £4m reduction in Pharmacy GRNI
accrual.
•Deferred Income has increased by £25.4m - the increase is mainly driven by £16m of Q2
Education Income and £8m PFI cash receipt.
•Non-Current Borrowings have increased by £7.8m primarily driven by a £12.3m increase
in PFI liabilities, offset by £3.0m decrease in IFRS 16 ROU asset borrowings and a £1.8m
decrease in DHSC loans.
M4 vs 24/25 closing Balance Sheet
At M4
Mar-25 Actual Movement Plan Actual Variance
£'000 £'000 £'000 £'000 £'000 £'000
Non-Current Assets
Intangible Assets 10,345 9,137 (1,208) 11,528 9,137 (2,391)
On SoFP IFRIC 12 assets 385,892 381,952 (3,940) 381,712 381,952 240
Other Property, Plant and Equipment 554,145 544,414 (9,731) 544,894 544,414 (480)
Right of use assets 136,832 134,335 (2,497) 135,603 134,335 (1,268)
Investments 806 2,706 1,900 806 2,706 1,900
Trade and Other Receivables 18,691 19,096 405 18,682 19,096 414
Total Non-Current Assets 1,106,711 1,091,640 (15,071) 1,093,225 1,091,640 (1,585)
Current Assets
Inventories 31,666 29,515 (2,151) 31,666 29,515 (2,151)
Trade Receivables 188,700 171,078 (17,622) 144,814 171,078 26,264
Non-Current Assets Held for Sale 210 210 0210 210 0
Cash and Cash Equivalents 60,488 38,390 (22,098) 57,161 38,390 (18,771)
Total Current Assets 281,064 239,193 (41,871) 233,851 239,193 5,342
Current Liabilities
Trade and Other Payables: Capital (33,558) (18,609) 14,949 (18,123) (18,609) (486)
Trade and Other Payables: Non-capital (346,656) (323,059) 23,597 (340,673) (323,059) 17,614
Borrowings (38,454) (39,589) (1,135) (38,092) (39,589) (1,497)
Provisions (6,105) (5,889) 216 (5,092) (5,889) (797)
Other liabilities: Deferred Income (29,338) (54,766) (25,428) (29,338) (54,766) (25,428)
Total Current Liabilities (454,111) (441,912) 12,199 (431,318) (441,912) (10,594)
Total Assets Less Current Liabilities 933,664 888,921 (44,743) 895,758 888,921 (6,837)
Non-Current Liabilities
Borrowings (715,097) (722,882) (7,785) (724,167) (722,882) 1,285
Provisions (9,401) (9,401) 0(9,596) (9,401) 195
Other Liabilities: Deferred Income (3,912) (3,912) 0(3,826) (3,912) (86)
Total Non-Current Liabilities (728,410) (736,195) (7,785) (737,589) (736,195) 1,394
Total Assets Employed 205,254 152,726 (52,528) 158,169 152,726 (5,443)
Taxpayers' Equity
Public Dividend Capital 576,979 582,512 5,533 581,823 582,512 689
Revaluation Reserve 172,102 172,101 (1) 204,142 172,101 (32,041)
Income and Expenditure Reserve (543,827) (601,887) (58,060) (627,796) (601,887) 25,909
Total Taxpayers' Equity 205,254 152,726 (52,528) 158,169 152,726 (5,443)
Total Funds Employed 205,254 152,726 (52,528) 158,169 152,726 (5,443)
page 22
Cash and Liquidity
Key Messages
•Significant work to maximise the Trust’s cash position continues. Delivery of the financial plan in line with the
planned profile and delivery of VfP plan on a cash releasing basis is key to management of the monthly cash
position. The current forecast predicts delivery of a year-end closing balance of £65m (c. £20m below plan).
•Whilst cash profile has improved due to earlier receipt of contract income and refinement of the forecasted
impact of the pay award, sensitivity analysis on the current cash forecast indicates delivery remains challenging,
particularly around the delivery of cash releasing VfP and there remains a risk that the Trust will require access to
revenue support funding if cash outflows are not reduced.
•The Trust was holding 4.5 days of operating cash expenditure at M4 month end (3.3 days at M3). NHSE Treasury
have increased focus on any Trust reporting below 4 days of Revenue cash operating expenditure in 2025/26.
•The significant focus on cash maximisation includes fortnightly CFO led Cash Management Group, discussions
with ICB on payment for YTD contract performance, review of capital expenditure profile, as well as tight
management of working capital balances.
Month 4 Position
At month 4, the cash position was £38.4m against the plan of £57.2m, an
adverse variance of £18.8m.
Adverse variances include:
•Debtor/Creditor movements being £32.2m adverse to plan. This partly
reflects profiling issues with actual YTD supplier payments being
higher than plan profile due to seasonal timing issues. The supplier
payment profile is expected to become more closely matched to plan
from Q2 onwards. In addition, lower than planned delivery of cash
backed VfP has adversely affected reduction of supplier payments.
The above has partially been offset through mitigating actions to
actively manage supplier payments, c £12m.
•The opening cash balance was £10m lower than plan
•The operating deficit is £7.6m greater than plan
Favourable variances include:
•Deferred Income cash receipts – £26m higher than plan due to HEE
Q2 payment and PFI Cash receipt.
•Capital and lease payments being £2.8m lower than plan
•PDC and donated asset income being £1.6m above plan
Cash Plan vs Actuals - M4 £m
Plan Cash Balance 57.2
Actual Cash Balance 38.4
Variance - Higher/(Lower) than plan (18.8 )
Revenue Operating Cash Days 4.5
Monthly Low 38.0
Monthly High 228.5
page 23
Impact of Cash Preservation Activities
22
The M4 cash forecast shows a reduction in expected year end cash balances, down
from £85m to £65m.
The principal factor in this reduction is the recognition of the challenges of
delivering cash backed VfP on the scale of MFT’s target.
Despite this reduced year end forecast there remains significant risk in delivering
the forecast cash backed VfP as the savings targets increase throughout the second
half of the year.
However, In the short-term, cash preservation activities have brought forward cash
receipts in a number of areas, as noted below. The impact of these is a forecast
improvement in cash balances up to M8 from those expected in M3 forecast.
Working day liquidity has improved from 3.3 to 4.5 days since month 3 as a
result of our cash preservation activities.
This improved profile now suggests that the risk remains that the Trust may require
access to revenue support funding in Q4 if cash outflows are not reduced.
Key cash preservation impacts seen in M4 forecast
•PFI partner receipts - £8m received in July and £12m expected in September – cash outflow expected over second half of year with £3m carried into 2026/27
•Improvement in cash profile of ICB and NHS Trust income has pulled c £12m from Q4 to Q2
•Claiming of PDC capital funding receipts based on expected spend has benefitted Q2 cash position by £4m
•Revision of capital payments profile absorbing £7m CDEL increase though higher year end capital creditor balances
•Active management of supplier payments, in particular the balancing of debtor and creditor balances with key counterparties, resulted in a (short term) benefit of £12m at M4
Other significant impacts
•Refinement of the expected cash impact of the pay award and future pay run rates
•Recognition VfP savings not likely to be delivered on a 100% cash reducing basis
page 24
Aged Debt
•Key drivers for the £800k decrease in debtor balances between 31-60 days from June 2025 to July 2025 are payments of £1.6m received on Philips Electronics Ltd (WTWA)
invoices which are partially offset by NCA invoices totaling £0.7m moving from 0-30 days category.
•The £2m decrease in debtor balances between 61-90 days from June 2025 to July 2025 principally reflects the following debt moving into 90+ days: NCA £0.7m, University of
Manchester £0.5m and DHSC £0.3m .
•The £4m decrease in 90+ days from June 2025 to July 2025 principally reflects the payments of £2.1m from Manchester ICB and £2m from PSI CRO Ltd. The highest 90+ days
debtor balances as at July 2025 are: NCA £7.7m (June 2025: £7.1m), University of Manchester £2.7m (June 2025: £2.3m) and GMMH £2.9m (June 2025: £2.9m). There is an
ongoing series of meetings and action plans with these three organisations to drive forward recovery of these aged debts.
•There is a focused workstream on reducing debtors as part of the cash maximisation work.
Month - Year 0 - 30 31 - 60 61 - 90 90+ Total 90+
£'000 £'000 £'000 £'000 £'000 %
Current Month Jul-25 20,379 2,246 1,940 31,540 56,105 56.2%
Previous Month Jun-25 7,194 3,046 3,985 35,475 49,700 71.4%
Movement (13,185) 800 2,045 3,935 (6,405) 15.2%
Days
page 25
Better Payment Practice Code (BPPC)
•The Trust remains above the 95% target for invoices paid by value at 97.7%, a small increase over the previous months of 25/26.
•The percentage paid by number of invoices remains below target at 93.5% driven primarily by under-performance on payment of NHS invoices. However, the performance
against commercial invoices is also below target for the second month running.
•The run rate has been improving since 2024/25 but further work is required to get the NHS invoice payments above target. Work is ongoing with those NHS organisations
with the highest value of outstanding invoices to reduce this position by the end of Quarter 2 2025/26.
YTD to 31/05/2025 YTD to 30/06/2025 YTD to 31/07/2025
Better Payment Practice Code (BPPC) By Number By £'000 By Number By £'000 By Number By £'000
Non NHS
Total bills paid in the year 53,427 294,868 82,027 433,509 115,895 569,972
Total bills paid within target 50,866 289,837 77,138 425,930 109,158 559,992
Percentage of bills paid within target 95.2% 98.3% 94.0% 98.3% 94.2% 98.2%
NHS
Total bills paid in the year 1,535 53,566 2,227 73,293 3,201 112,594
Total bills paid within target 1,029 49,639 1,483 67,816 2,165 106,638
Percentage of bills paid within target 67.0% 92.7% 66.6% 92.5% 67.6% 94.7%
Total
Total bills paid in the year 54,962 348,434 84,254 506,802 119,096 682,566
Total bills paid within target 51,895 339,476 78,621 493,746 111,323 666,630
Percentage of bills paid within target 94.4% 97.4% 93.3% 97.4% 93.5% 97.7%
Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%
Distance from target (0.6%) 2.4% (1.7%) 2.4% (1.5%) 2.7%
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