SUSSEX PARTNERSHIP NHS FOUNDATION TRUST

MEETING OF THE BOARD OF DIRECTORS HELD IN PUBLIC

29 July 2015

10.30 – 12.40

Training Centre, Trust Headquarters, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP

Contact: Rebecca Huth, Corporate Governance Administrator, [email protected], 01903 843033

BOARD OF DIRECTORS MEETING IN PUBLIC

To be held on 29 July 2015 at 10.30 In the Training Centre, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP AGENDA

TBP34 /15 INTRODUCTION

1030 TBP34 .1/15 Chair’s Welcome and Introduction Verbal

1030 TBP34 .2/15 Apologies for Absence & Declaration of Interests Verbal A Minutes of the Board of Directors meeting held 24 June 2015 & 1031 TBP34 .3/15 (to Action Points (not covered on the agenda) follow) 1032 TBP34 .4/15 Questions from Members of the Public Verbal

TBP35 /15 STRATEGY

To receive the Revalidation Report 1035 TBP35 .1/15 B (Tim Ojo, Executive Medical Director)

To receive the Equality Performance Hub Annual Report 1040 TBP35 .2/15 C (Vincent Badu, Strategic Director of Social Care and Partnerships)

To receive and agree the Medical Workforce Strategy 1045 TBP35 .3/15 D (Tim Ojo, Executive Medical Director)

TBP36 /15 PERFORMANCE AND QUALITY

E 1050 TBP36 .1/15 Chief Executive Report (to follow)

To receive a report on the Performance of the Trust to the end of June 2015 1105 TBP36 .2/15 F (Sally Flint, Executive Director of Finance & Performance, Managing Directors)

G 1135 TBP36 .3/15 To agree the Q1 in-year Governance Statement to Monitor (to (Peter Lee, Head of Corporate Governance) follow)

To receive the Q1 Performance against Business Objectives 1140 TBP36 .4/15 H (Sally Flint, Executive Director of Finance and Performance)

To receive a report on Learning from Serious Incidents 1145 TBP36 .5/15 I (Helen Greatorex, Executive Director of Nursing and Quality)

To receive the Complaints Annual Report 1150 TBP36 .6/15 J (Helen Greatorex, Executive Director of Nursing and Quality)

To receive the Sign Up to Safety Quarterly Report 1155 TBP36 .7/15 K (Helen Greatorex, Executive Director of Nursing and Quality)

To receive an update on Safe Staffing 1200 TBP36 .8/15 L (Helen Greatorex, Executive Director of Nursing and Quality)

TBP37 /15 GOVERNANCE

Feedback from the Council meeting held on 27 July 2015 1205 TBP37 .1/15 Verbal (Caroline Armitage, Chair)

To receive and agree the Board Assurance Framework 1210 TBP37 .2/15 M (Helen Greatorex, Executive Director of Nursing and Quality)

To receive the Quarterly Notification of Sealed Documents 1215 TBP37 .3/15 N (Peter Lee, Head of Corporate Governance)

TBP37 .4/15 To receive a report on the last meeting of the Finance and O Investment Committee (Richard Bayley, Non-Executive Director) TBP37 .5/15 To receive a report on the last meeting of the People Committee P (Diana Marsland, Non-Executive Director) 1220 TBP37 .6/15 To receive a report on the last meeting of the Audit Committee Q (Tim Masters, Non-Executive Director) To receive a report on the last meeting of the Charity Committee TBP37 .7/15 (Diana Marsland, Non-Executive Director) R

1235 TBP38 /15 ANY OTHER BUSINESS

Date and Venue for Next Meeting: 30 September 2015 10.00– 12.30 Training Centre, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP

To adopt the motion:

“That representatives of the press and other members of the public be excluded from the remainder of this meeting, having regard to the confidential nature of the business to be transacted, publicity on which

would be prejudicial to the public interest ” (Section 1(2) Public Bodies (Admission to Meetings) Act 1960)

NB Those present at the meeting should be aware that their name will be issued in the notes of this meeting which may be released to members of the public on request

Sussex Partnership NHS Foundation Trust Board of Directors 29th July 2015, Public Agenda Item: TBP35.1/15 Attachment: B For Discussion/Information By: Dr Tim Ojo Executive Medical Director

IN CONFIDENCE

2014/2015 Medical Appraisal for Revalidation Annual Report

SUMMARY & PURPOSE

The Board of Directors is asked to note, discuss and seek any required clarification assurance about the implementation of ‘Medical Appraisal for Revalidation’ process within the Trust.

This paper is a mandated requirement to provide an annual update to the Board within the context of the Framework of Quality Assurance for Responsible Officers and Revalidation published by NHS England in April 2014.

LINK TO 20/20 vision

The Strategic goals this paper relates to are:

1. Safe, effective, quality patient care. 4. Be the provider, employer and partner of choice

ACTION REQUIRED BY BOARD

The Board of Directors is also asked to approve the ‘Statement of Compliance’ confirming that Sussex Partnership NHS Foundation as a designated body is in compliance with the statutory regulations to be signed by the CE.

1.0 Executive Summary

1.1 Revalidation is the process by which the General Medical Council will confirm the continuation of a doctor’s license to practise in the UK.

1.2 Its purpose is to assure patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practise.

2.0 Introduction

2.1 The Medical Profession (Responsible Officers] Regulations 2010 (and as amended 2013 ) and GMC (License to Practice and Revalidation) Regulations 2012, set out the statutory responsibilities of Responsible Officers for each Designated body

2.2 Sussex Partnership NHS Foundation Trust is a ‘Designated body’ under these regulations and the Executive Medical Director is the Trust’s Responsible Officer. The Responsible Officer makes the recommendations to the GMC on behalf of the ‘Designated body.’

2.3 Revalidation started on 3 December 2012 and it is anticipated that the majority of licensed doctors will by revalidated for the first time by 2016.

3.0 Report

Requirements.

3.1 Revalidation recommendations are based on successful completion of:

a) Annual medical appraisal (as set out in the Medical Appraisal Guide model form); b) At least one 360 degree (patient & colleague) feedback in a 5 year cycle. c) Royal College of Psychiatrists requirements such as evidence of participation in audit and case based discussion on an annual basis (the requirements are set out in College report 172).

Revalidation is on a 5 year basis on the assumption that those revalidated will continue to fulfil their annual medical appraisal obligations over the said period.

3.2 The Responsible officer has three options available in making the revalidation recommendation:

a) To recommend revalidation; b) To ask for a deferral; c) To inform the GMC of non-engagement in appraisal*

* Non-engagement can potentially result in the GMC withdrawing a doctor’s license to practise through the administrative removal route.

3.3 The revalidation of trainee doctors is the statutory responsibility of the relevant Deaneries and their successor bodies such as HE-KSS. The Trust as a Local Education Provider plays a significant role in the process nevertheless.

Performance Monitoring

3.4 In 2014/15 the Trust had a prescribed connection to 233 medical practitioners.

3.5 In 2014/15 the Trust made 90 positive revalidation recommendations and 11 deferrals to the GMC. (Please see appendix for breakdown of deferral reasons.)

The number of recommendations was in keeping with GMC mandated scheduling which is as follows.

2013/14: 23% of doctors with a prescribed connection 2014/15: 40% of doctors with a prescribed connection 2015/16: 37% of doctors with a prescribed connection

3.6 In 2014/15 overall 80.6% of all doctors with a prescribed connection completed their annual appraisal with the prescribed timeframe.

3.7 Of the 46 doctors who had not completed their appraisals at the end of March 2015 all but 6 doctors have now completed their appraisals as at early July 2015.

3.8 Of these 6 doctors, 4 have now had the appraisal meeting and are awaiting sign-off, 1 is on long-term sick and 1 is about to have the appraisal meeting.

Governance

3.10 The Trust as a Designated body is statutorily obliged to provide the Responsible Officer with the resources required to provide the appraisal and governance infrastructure to support Revalidation and oversee the following:

a) Monitoring the frequency and quality of medical appraisals; b) Checking there are effective systems in place for monitoring the conduct and performance of doctors; c) Confirming that feedback from patients is sought to inform appraisal and revalidation; d) Ensuring appropriate pre-employment background checks are carried out.

3.11 The Responsible Officer has completed and submitted an Annual Organisational Audit (AQA) to NHS South (May 2015) in accordance with National guidance.

3.12 The Statement of Compliance is attached to this paper for Board information and agreement. (Appendix 1)

3.13 The Executive Medical Director is supported in the Responsible Officer role by the Deputy Medical Director (Workforce Governance), the Revalidation Support Administrator, and his Executive Assistant.

3.14 In line with the regulation the Trust has trained 40 enhanced appraisers who have been assigned a number of appraisees they are responsible for appraising over the next 2/3 years.

We have also provided for alternate appraisers in the circumstances that the originally assigned appraiser is suddenly unable to undertake the function.

Additionally 5 colleagues have undergone Case Investigator training who can now assist in the clinical performance assessment in the cases where remediation might be required.

3.15 The Trust has a Medical Appraisal for Revalidation Policy which has had Equality and Human Rights Impact Analysis with no areas of concerns identified.

3.16 There is a Revalidation Delivery Group that meets monthly to address any operational challenges in the delivery of Revalidation compliant annual appraisal for all doctors.

3.17 Quality Assurance of the Appraisal portfolio content is undertaken by the Deputy Medical Director who also organises Appraiser Training and oversees the provision of any additional support.

3.18 The Trust has electronic portals for the purpose of collecting appraisal information using Allocate software and all doctors have a personal license with which to access the e-Appraisal, e-Job Planning, e-360 and e-Leave portals.

3.19 Access to the software platforms is on a licensed named user only basis for appraisers and appraises. The Responsible Officer, Revalidation Lead, Revalidation Support Administrator and the Responsible Officer’s Executive Assistant all have ‘managerial’ licenses for managing/administrating the system. The relevant Trust Information Governance policies apply to the retrieval of information from the system.

Partnership working

3.20 The successful implementation of Revalidation in the Trust requires close working with the HR/People Directorate, Clinical Governance and Customer Experience Teams.

The required access to HR expert advice and data/information exchanges are already established.

3.21The Executive Medical Director is an active member of the local Responsible Officer Network part of the NHS South Cluster. He has undertaken the relevant Responsible Officer training and uses the Responsible Officer network peer support opportunities.

3.22 As early adopters of the Allocate system we have a very strong relationship with the software owners and have been instrumental in getting required software updates and improvements in user interface functionality.

4.0 Recommendation/Action Required

4.1Board members are asked to note the information and approve the statement of compliance for submission to NHS England.

5.0 Next Steps

5.1 The Medical appraisal for Revalidation process will continue to be operated within the Trust in accordance with the relevant NHS England, GMC and RST guidance.

5.2 Sussex Partnership NHS Foundation Trust will continue to participate in the relevant training and auditing cycles in accordance with the relevant guidance.

A Framework of Quality Assurance for Responsible Officers and Revalidation Annex E - Statement of Compliance

Version 4, April 2014

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NHS England INFORMATION READER BOX

Directorate Medical Operations Patients and Information Nursing Policy Commissioning Development Finance Human Resources

Publications Gateway Reference: 01142 Document Purpose Guidance Document Name A Framework of Quality Assurance for Responsible Officers and Revalidation, Annex E - Statement of Compliance Author NHS England, Medical Revalidation Programme Publication Date 4 April 2014 Target Audience All Responsible Officers in England Additional Circulation Foundation Trust CEs , NHS England Regional Directors, List Medical Appraisal Leads, CEs of Designated Bodies in England, NHS England Area Directors, NHS Trust Board Chairs, Directors of HR, NHS Trust CEs, All NHS England Employees Description The Framework of Quality Assurance (FQA) provides an overview of the elements defined in the Responsible Officer Regulations, along with a series of processes to support Responsible Officers and their Designated Bodies in providing the required assurance that they are discharging their respective statutory responsibilities. Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010 (as amended 2013) and the GMC (Licence to Practise and Revalidation) Regulations 2012 Superseded Docs Replaces the Revalidation Support Team (RST) Organisational (if applicable) Readiness Self-Assessment (ORSA) process Action Required Designated Bodies to receive annual board reports on the implementation of revalidation and submit an annual statement of compliance to their higher level responsible officers (ROCR approval applied for). Timings / Deadline From April 2014 Contact Details for [email protected] further information http:// www.england.nhs.net/revalidation/ Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet

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Annex E – Statement of Compliance

Designated Body Statement of Compliance

The board of Sussex Partnership NHS Foundation Trust has carried out and submitted an annual organisational audit (AOA) of its compliance with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013) and can confirm that: 1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer; Yes Dr Tim Ojo

2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained; Yes Allocate e-Portal

3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners; Yes 40- Appraisers. 4 Training days in 2014/15

4. Medical appraisers participate in ongoing performance review and training/ development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers or equivalent); Yes Quality Assurance audit undertaken by DMD Medical Workforce

5. All licensed medical practitioners1 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken; Yes Database+ process for monitoring of and facilitating the rescheduling of overdue appraisal is done by the Revalidation Support Administrator under the auspices of the DMD workforce/Trust appraisal Lead

1 Doctors with a prescribed connection to the designated body on the date of reporting.

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6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners1, which includes [but is not limited to] monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues, ensuring that information about these is provided for doctors to include at their appraisal; Yes The required information is collated and forms part of the Appraisal meeting inputs.

7. There is a process established for responding to concerns about any licensed medical practitioners1 fitness to practise; Yes In accordance with MHPS & GMC guidance.

8. There is a process for obtaining and sharing information of note about any licensed medical practitioners’ fitness to practise between this organisation’s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where licensed medical practitioners work; Yes We use the MPIT form in line with national guidance.

9. The appropriate pre-employment background checks (including pre- engagement for Locums) are carried out to ensure that all licenced medical practitioners2 have qualifications and experience appropriate to the work performed; and Yes We routinely undertake all the required checks for both locum and substantive doctors.

10. A development plan is in place that addresses any identified weaknesses or gaps in compliance to the regulations. Yes In line with Trust response to AOA Signed on behalf of the designated body

Name: ______Signed: ______Colm Donaghy

[Chief Executive] Dated: ______

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Board of Directors: 29 July 2015 – Public Agenda Item: TBP35.2/15 Attachment: C For Decision By: Vincent Badu – Director of Social Care & Partnerships

Equality Performance Report

SUMMARY & PURPOSE

Sussex Partnership has obligations under the specific duties of the Equality Act 2010 (179(1)) to annually produce key data information on its employment and service delivery outcomes across the protected characteristics.

The Equality Performance report is an opportunity to produce a clear and comprehensive tool that assists the Trust Board and our stakeholders to fully understand how our policies and decisions impact on the people who access our services (Goal 1 - Safe, effective, quality patient care) and enabled the Trust to better communicate how we are identifying and tackling entrenched inequalities (Goal 3 – Put research, innovation and learning into practice).

ACTION REQUIRED BY BOARD MEMBERS

The board of directors is asked to consider the Equality Performance Report (Appendix A) and supporting data hub (available via board pad) and approve the reports for publication

Equality Performance Report

1.0 PURPOSE AND RECOMMENDATION

The board of directors is asked to consider the Equality Performance Report (Appendix A) and supporting data hub (available via board pad) and approve the reports for publication.

The report provides a summary of the activity and progress delivered by the organisation to support our compliance with the general duties of the Equality Act 2010 (EA2010) and to specifically meet the requirement of section 179(1) of the Act.

2.0 OVERVIEW

Sussex Partnership has an obligation under the specific duties of the Equality Act 2010 to annually produce key data information on its employment and service delivery outcomes. This will be the seventh year the Trust have produced one of the most comprehensive annual reports in the NHS, which has been recognised and adopted by NHS England as best practice

The report is an opportunity to produce a clear and comprehensive tool that assists and supports commissioners, the Trust board, service managers, operational colleagues, staff, and patients by analysing outcome, experience and access across the protected characteristics, whilst supporting the Trust board to fully understand how their policies and decisions impact on the people who access our services.

3.0 PERFORMANCE MONITORING

The Board of Directors has specific responsibilities for ensuring that issues of equality and human rights are appropriately reflected in all aspects of the Boards strategic planning, activity and performance scrutiny. The Chief Executive, who is the accountable officer, has a legal responsibility for ensuring all policies; functions and services delivered by the organisation do not discriminate against those who hold, are associated or perceived to have a protected characteristic under the Equality Act 2010.

The Chief Executive is the Chair of the Trust wide Equality and Diversity Steering Group which acts a sub group of the Executive Management Board and maintains strategic oversight of our compliance. The Executive Team have specific responsibilities for overseeing the delivery of actions which are produced to mitigate the findings of our Equality Performance Hub, leading on a specific equality dimension within our Equality Performance Scheme 2014-2018.

4.0 GOVERNANCE

By publishing information on the extent to which people with different protected characteristics use our services, we will be better able to monitor how effective our services are, whether the services are operating as intended, and whether there are any problems that need to be addressed. Publishing this information is an important part of being more transparent and it will enable the Trust to better communicate how we are identifying and tackling entrenched inequalities over time.

For the third year the Equality Performance Report will be supported by an extensive data hub, which supports our compliance and a positive culture of service improvement and

design based on data, which goes beyond legal compliance.

The Equality Performance Hub, managed by the Equality and Diversity team and accessed via the public website provides an opportunity to drill the data down by division, care group and protected characteristic, supporting the EHRC’s recommendation to disaggregate information on staff and service users where relevant and achievable. For the first time the hub provides an analysis of 6 board performance standards and any inequality in breaches

1. New cases of psychosis 2. Serious Incidents 3. CPA 7 day follow up breaches 4. Delayed transfer of care 5. Long term patients reassessed in 7 days 6. CPA approach review (every 12 months)

For example black and minority ethnic (BME) patients represent 14% of new cases of psychosis against the population average of 6%. Leading us to use the equality data to design and plan services that address health inequalities.

As the Trust develops Care Delivery Services it is critical that they understand and reflect the access to their services in the development and planning of services that meet the needs of their local population.

5.0 PARTNERSHIP WORKING

The Equality Performance Hub and supporting summary document have been produced in partnership with colleagues from across our core services.

6.0 STRATEGIC DEVELOPMENT AND CONTROL

The detailed spread sheets contained within the Equality Performance Hub have been reviewed and approved by the members of the Equality and Human Rights Steering Group prior to being submitted to Trust Board. The Trust has a legal obligation to produce data within 12 months of the previous publication.

7.0 SUMMARY AND CONCLUSION

The Equality Performance Report is a valuable tool which will support the Trust to use data intelligently to support our business activities. The data available through the hub can be used in work to consider services redesign, improvements strategies and tendering processes for new services.

The Trust board is asked to approve the Equality performance report and its findings.

Equality Performance Hub 2014 “The people delivering and supported by your local Mental Health Service”

Document not for circulation

This document is available in alternative formats upon request, such as large print, electronically or community languages. Please contact the Equality, Diversity and Human Rights Team: Email: [email protected] or telephone: 01273 716565

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What is it? Our Equality Performance Hub is a clear and comprehensive online tool which captures and publishes information on the diversity of our organisation. It enables us to identify the experience and outcomes of the people who work with us or use our services. We have to be open to what our data says and evidences about the characteristics of the people who are accessing our services; and those that are not. We have to be open about how health outcomes may differ for people with different characteristics. This can mean challenging ingrained and institutional processes and attitudes to lead to more open and transparent services; this is at the core of our 2020 vision.

How does it support patients and their care? In practice, we use the data to monitor how effective our services are, whether the services are operating as intended, and whether there are any problems that need to be addressed. Where inequalities are evident our Equality Reference Groups will set SMART mitigating actions aligned to our Equality Performance Scheme 2014-2018.

The data might also be used by the people who access our services, local charities or commissioners that are examining barriers in access or performance outcomes. Publishing this information online is an important part of being more transparent, it enables us to better communicate how we are tackling inequalities over time and assists us to improve the high standard we aim to deliver

What about those who deliver your services? Having a diverse workforce enables us to ensure that our services are more inclusive and responsive to the diverse needs of the population. National research suggests that the degree to which organisational demography is representative of community demography yields positive effects in terms of patient experience (Why organisational and community diversity matter: representativeness and the emergence of incivility and organizational performance, King et al., 2011) and the Trust has been recognised for its continued work on advancing equality of opportunity in both employment and services delivery at the national diversity awards (Diverse company of the year 2014)

Our Workforce Captured below is the Trust workforce profile across the protected characteristics for 2014. For a more detailed breakdown by pay scale and profession please visit the equality performance hub http://www.sussexpartnership.nhs.uk/equality-performance-hub-equality

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Workforce  12% of the organisation define as Black and Minority Ethnic (BME), compared to the local population of Sussex, Hampshire and Kent of 6.2%  BME staff are predominately in band 5 (19%), and are underrepresented between bands 6-8d when analysed against the Trust BME average of 12%.  Women account for 72% of the workforce and are well represented in senior posts (8a – 9 including executive board members)  7% of employees declared that they have a disability, below the national average of disabled people employed in the UK workforce (10.5%).  5% of employees define themselves as Lesbian, Gay & Bisexual.  17% of staff declared their religion as “Other” a significant over representation against the 2011 ONS data (0.5%).

Recruitment  Statistically BME applicants are less likely to be appointed into roles within the Trust, with a significant decrease in the percentage of BME staff progressing from application (23%) through shortlist to appointment (13%).  While only 4% of the 15,715 applicants in 2014 declared themselves as gay, lesbian or bisexual, they accounted for 6% of the appointed applicants, a positive indicator that there are no immediate barriers in the recruitment of the LGB candidates.

Leavers, Redundancy & Maternity  The majority of leavers are aged 41-60 (48%) with the likelihood of leaving the organisation increasing with age.  BME staff represent 6% of women taking maternity leave against the workforce profile of 12%  16% of redundant staff were aged 61-70 against the workforce mean of 7.5%

Employee Relations  BME staff are over represented in all forms of employee relations cases (15%) when compared to the workforce mean (12.1%). There is a significant over representation of BME staff involved in Bullying and Harassment (27%) and Disciplinary cases (24%).  Staff aged 61-70 are almost 5 times more likely to be involved in a formal capability case when compared to the workforce profile.  Men represent 35% of all employee relations case and are significantly overrepresented in bullying and harassment (35.1%) and disciplinary (42.2%) cases.  Staff declaring a disability are significantly over represented in formal capability (21%)

Volunteers  There has been a significant BME recruitment drive in 2014 and as a result 27% of our volunteer bank define as BME  In 2014, there has been a significant take up of volunteers aged 16-20 (4%) and 21-30 (19%)  4% of our volunteers define as lesbian, gay or bisexual

Staff Survey  BME staff gave a more positive response to questions related to satisfaction with their job than White employees.  Men are more positive in their responses related to their satisfaction at work than women.  Employees identifying themselves as Lesbian and Gay have higher job satisfaction than their heterosexual counterparts.  Staff who have identified a disability have lower job satisfaction than their non-disabled counterparts.

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Patient Services Captured below is the headline data for service access across the protected characteristics in 2014. The imbalances and disparities below are to be mitigated by operational actions set by the Equality Reference Groups under the Equality Performance Scheme 2014-2018.

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Data to be considered for info graphics

Adult Services West Sussex  6% of patients admitted to our acute services defined as BME.  While those aged 71 and above account for 41% of patients in our community services, they represent only 18% of patients in our acute services.  The LGB patients represented less than 1% of all caseloads open.  87% of our patients who disclosed their religion and belief defined as Christian, followed by any other religion (5%), agnostic (2%) atheist (2%) and Muslim (2%).  69% of our patients declared a mental health condition and 17% of patients disclosed no disability.  West Sussex Core services represent 22% (309 sessions) of language interpreting activity in 2014.  The most interpreted languages were Polish (55 sessions), Cantonese (41 sessions) and Spanish (31 sessions)  40% of the interpreting activity in West Sussex was delivered in our Adult Mental Health Acute Care teams.  2% (6) of BSL sessions in 2014 were delivered in West Sussex, a significant decrease on the activity for 2013 and the service will need to ensure there are no barriers in accessing services for the deaf and hard of hearing community.

Brighton & Hove

 The largest age group accessing the services are aged 41-50 and account for 19% of caseloads open, a significant over representation against the 2011 ONS data (15%).  The LGB community represented 9% of patients accessing services in Brighton and Hove, with 11% accessing primary care services.  9% of acute patients defined as BME compared to the local population of 11%  38% revealed that they had no disability. 4% disclosed that they had a disability that was not listed and 44% had a mental health condition.  Patients who are single account for 57% of patients while 22% are married or in a civil partnership  Brighton and Hove Core services represent 44% (615 sessions) of language interpreting activity in 2014.  39% of the interpreting activity was delivered in Primary Care and 18% in our Assessment and Treatment and Inpatient services.  The most interpreted languages were Arabic (126 sessions), Bengali (117 sessions), Amharic (63 sessions) and Farsi (63 sessions), which is consistent with 2013.  79% (214) of BSL sessions in 2014 were delivered in Brighton and Hove with the highest demand for BSL interpreters in June and July.

East Sussex  The largest age group of patients accessing services in East Sussex are 71 or over (26%). This shifts in our primary care services, where the majority are 31-40 (24%).  2% of patients accessing services in East Sussex define as BME against a local population of 4%  14% of patients accessing our community services declared mobility impairment and 3% were deaf/hard of hearing.  41% of patients in East Sussex were single whilst 35% were married or in a civil partnership  East Sussex Core services represent 13% (187 sessions) of language interpreting activity in 2014.

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 50% of the interpreting activity in East Sussex was delivered in our Primary Care, Health in Mind service.  The most interpreted languages were Portuguese (43 sessions), Turkish (23 sessions) and Arabic (17 sessions)  4% (10) of BSL sessions in 2014 were delivered in East Sussex

Children and Young People’s Services Sussex

 4% of acute patients defined as BME and 3% in our community services  8 patients defined as gypsy and traveller, a dip on previous years but an indication that this community is still confident in disclosing their data to the Trust.  32% of patients in the community are aged 16-20. This shifts significantly in our acute services to 53%  53% of patients in the community are boys; however this shifts significantly in our acute services where girls represent 78% of caseloads open.  There are a lower proportion of patients who are undecided about their sexual orientation in our acute services (13%) than in our community services (56%).  Whilst the sample size for acute service is very small it does identify that young people are happy to disclose that they are lesbian, gay or bisexual  14% of patients in the community disclosed as atheist, this rises to 25% in our acute services.  Sussex CAMHS community and CAMHS inpatient services represent 50% (110 sessions) of interpreting activity across all children and young people’s services in 2014  15% of the interpreting activity in CAMHS was delivered in Brighton and Hove Early Intervention services  The most interpreted language in Sussex CAMHS was Arabic (22 sessions), Hungarian (13 sessions) and Portuguese (12 sessions)  5% (12) of BSL sessions in 2014 were delivered in CAMHS

Hampshire

 The percentage of undefined data for ethnicity in Hampshire has significantly reduced since 2011 but is still high at 34%.  3% of patients defined as BME, a slight under representation against the demographics (5%).  69% of patients are aged 0-15, which is consistent with other CHYPS community services in the Trust.  While 66% of patients declared no disability, 10% declared a disability other than the categories provided on the list, 8% Asperger’s or Autism and 7% a learning disability  Hampshire CAMHS community represent 2% of interpreting activity across all children and young people’s services  The most interpreted language in Hampshire CAMHS was Bengali (2 sessions)

Kent  2% of patients defined as BME and 51% did not disclose their ethnicity.  65% of patients are aged 0-15, which is consistent with other CHYPS community services in the Trust.  54% of patients accessing the services have defined as male, which is consistent with other CHYPS community services in the Trust.  56 patients were asked and disclosed their sexual orientation, a significant increase on 2012 when we had 0 responses. 1 patient defined as lesbian.  8% of patients declared they had Asperger's syndrome or autism.

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 Kent community CAMHS represent 44% (96 sessions) of interpreting activity across all children and young people’s services in 2014  The most interpreted language in Kent CAMHS was Arabic (23 sessions) and Polish (10 sessions).

Secure and Forensic Services

 The majority of patients in our acute secure and forensic services are aged 21-30 (30%).  There is an over representation of BME patients in our acute services (20%) against the 2011 census (6.2%) and against BME patients accessing all services Trust-wide (3%).  Men represent 74% of our acute secure and forensic services and 72% in the community  41% of acute patients accessing our secure & forensic services defined themselves as having a religion other than the ones listed and 5% identified themselves as Muslim.  87% of patients accessing our acute secure and forensic services are single. 6% are married or in civil partnership shifting significantly in our community services to 16%  33% of detentions in our secure and forensic services under the Mental Health Act were patients who defined as BME. Even though this may relate to multiple detentions or section renewals of one or two patients, it could be related to a trend in over representation of BME groups in detentions, which was also identified nationally by the CQC.  The most interpreted language in Secure and Forensic was Farsi (22 sessions) and German (3 sessions)  2% (6) of BSL sessions in 2014 were delivered in Secure and Forensic community services

Learning Disability Services

 11% of the 18 residential patients defined as BME, this is an over representation against the 2011 ONS demographics of 6.2%.  The majority of patients accessing our residential or community learning disability services are male (55%), increasing to 61% at the Selden Centre, a figure consistent with all caseloads open Trust-wide (52.6%).  Patients across community and inpatient LD services are predominantly aged 21-30 years old (29%)  Whilst the sample size is very small 1 patient in our community LD services defined as lesbian and the Trust should ensure that its LD services are taking account of a patients sexual orientation  8% (22) of BSL sessions in 2014 were delivered in our Learning disability community services  The most interpreted language in learning disability was Bengali (3 sessions)

Substance Misuse Services

 The majority (68%) of patients defined as male, an over representation against the 2011 census for the South East Coast population (49%).  BME patients represent 5% of our community and 6% of our acute substance misuse service  4% of patients accessing our Substance misuse services defined as LGB.  The most interpreted language in substance misuse services was Polish (6 sessions) and Farsi (5 sessions)

8

Findings across the protected characteristics This year’s Equality Performance Hub has identified areas where the Trust is excelling as well as areas where considerable change is required. The findings of our report will be utilised by the Equality Reference Groups to support the delivery of accessible and individualised service.

Ethnicity The Equality Performance Hub has clearly identified some major concerns associated to the treatment of our black and minority ethnic patients and staff. Many of these concerns are recognised and being tackled nationally, in particular the higher rates of admissions into the acute hospital inpatient units and higher rates of detentions under the Mental Health Act. There is evidence to suggest that national concerns about BME staff development (Kline 2014) are evident within our workforce demographics and the through the implementation of the Workforce Race Equality Standards the Trust will aim to close the gap between the experience of our BME staff and their white counterparts.

Gender & Gender Identity The evidence from the Equality Performance Hub suggests that the concerns relating to gender predominantly affect staff. Work needs to be undertaken to ensure equal opportunities for all applicants at recruitment and in career progression and pay. The data identifies that the Trust needs to undertake further engagement and consultation with the Trans community, as a low percentage of service users identifying as Trans could highlight a barrier in accessing our services. Findings from the recent Care Quality Commission inspection identified several breaches of privacy and dignity associated to gender separation within our inpatient services. A detailed programme of work is addressing the concerns and this will be further explored in the 2015 performance hub.

Age The Equality Performance Hub has identified that there are no major concerns regarding age in the delivery of services or employment practices. It has identified that the younger cohorts of both patients and staff have higher satisfaction with both our services and with the Trust as an employer. Concerns arise for the older cohort of staff (41-70) especially in the areas of redundancy, training and formal capability cases.

Disability Data from the Equality Performance Hub identifies that there is evidence that both patients and staff declaring a disability are less satisfied with the Trusts service delivery and employment practices. Evidence would suggest that there is an overrepresentation of staff declaring a disability in employee relations cases, incidents and amongst leavers. Patients identified that the Trust needs to concentrate on support provided to their family or carer(s) and the Trust will be addressing these concerns through the Disability reference group

Sexual Orientation Evidence from the Equality Performance Hub suggests that the Trust has encouraging employment practices and service provisions for individuals that identify as lesbian, gay or bisexual. The Trust is seen as an LGB-friendly employer by its employees as well as the community, reflected in the high percentage of LGB job applicants, employees and Stonewall accolades. Feedback from our patient experience questionnaires has identified that patients who identify as LGB have been less satisfied with the overall care they have received in the last 12 months and the Trust needs to continue to develop strong links with community organisations such as Allsorts and MindOUT.

Religion & Belief The Equality Performance Hub has identified that the Trust needs to continue to develop a culture that supports our patients and staff to feel open and confident about declaring their religion and

9

belief. Whilst the collection of data is low it evidences that our patients come from a broad range of beliefs. Whilst there are no major concerns surveys indicate that patients belonging to a religious group other than Christian are less satisfied with our services.

Marriage and Civil Partnership The Trust’s data on marriage and civil partnership in both service delivery and employment is consistent with national findings. As per national research, there seems to be a correlation between marital status and mental wellbeing. The Trust needs to ensure that mechanisms are in place to capture marital status of patients and employees accurately given the recent changes in the legislation.

Pregnancy and Maternity Evidence from the Equality Performance Hub suggests that there are no immediate barriers for staff taking maternity leave. However, very few BME staff took maternity leave and the Trust needs to ensure that staff requesting paternity and adoption leave are captured within the Electronic staff records to allow an analysis across the protected characteristics.

Conclusion We understand that promoting equality is closely related to the pursuit of quality. A quality service is one that recognises the needs and circumstances of each patient, carer, community and staff member, and ensures that services are accessible, appropriate, safe and effective. A service cannot be described as a quality service if only some of the patients are receiving positive outcomes.

As a Trust we already have a culture that recognises the equality challenges we face. We capture this in our strategic action plan across the protected characteristics that has been developed in early 2014; our Equality Performance Scheme 2014-2018. The findings of the previous report have supported the development of this strategy and this year’s report will give the basis for the operational actions.

We recognise the need to work in partnership with staff and the people that use and access our services. For staff this means using the Better by Experience commitments to ensure that every member of staff feels valued, respected and is able to progress through the organisation. For patients and their carers this means being able to access our services, receive care or support and be treated as individuals with dignity.

Our reports show how far we have come in terms of delivering real change to the diverse people that access and deliver our services. Many staff, patients, carers, members and voluntary sector partners have worked with us to accomplish the success we have enjoyed over the past 6 years. Many of the achievements listed in this report wouldn’t have happened without their hard work. Though progress has been made during 2014 to collect the protected characteristics of our workforce, there is still work to be done on collecting the data and improving workplace equality, whilst maintaining maximum confidentiality.

Knowing the diversity of our patients is vital to the delivery of effective, compassionate and appropriate care. We aim to ensure that the data is used intelligently to deliver services that are high quality, accessible and relevant to the needs of the local community. During 2015 the equality, diversity and human rights team will be working with our clinical delivery services (CDS) to improve the quality of data held in care notes. Whilst our new clinical information system will make it easier to collect the protected characteristics it is apparent from the data contained within the Hub that colleagues require training, knowledge and confidence in “asking the questions”.

10

Board of Directors: 29th July 2015 - Public Agenda Item: TBP35. 3/15 Attachment: D For Information By: Tim Ojo, Executive Medical Director

Medical Workforce Strategy 2015-2020

Engaging for Outstanding Care

SUMMARY & PURPOSE

This paper outlines to the Board of Directors the approach and content of our medical workforce strategy for the next five years and explains how we will engage our medical workforce in ‘delivering outstanding care’ in line with ‘Our 2020 Vision’.

ACTION REQUIRED BY BOARD MEMBERS

The Board of Directors is asked to review the content of this paper for information and provide comments / feedback as appropriate.

Medical Workforce Strategy 2015-2020 Engaging for Outstanding Care

1. Executive Summary

The medical workforce constitutes an essential element in the delivery of the NHS five year forward plan. Nationally, parity of esteem and the integration agenda frame how we will respond to demographic changes, constraints on public sector finances and increased demand pressures. As such, extra effort is required to sustain adequate levels of commitment and medical engagement.

Locally, post CQC inspection, the 2020 Vision, Listening into Action and development of Care Delivery Services, frame how we devolve clinical autonomy to the most appropriate level. As such, a refresh of our approach to supporting the medical workforce is required.

This paper gives an overview of our five year programme in line with ‘Our 2020 Vision’. Over this period, we can expect a significant change in the profile of the workforce, necessitating different expectations of senior clinicians. Additionally, patient choice, commissioned service requirements and PbR pathway care models will reshape service delivery obligations of the medical workforce.

This paper sets out the approach to engaging our medical clinicians in ‘delivering outstanding care’ with an understanding of relevant total workforce interdependencies.

2. Introduction

This paper translates ‘Our 2020 Vision’ objectives to the medical workforce context by describing five propositions for which we have identified enablers, requirements and timelines for delivery.

3. Medical Workforce Strategy

3.1 Safe, effective, quality patient care

We will deliver safe effective, high quality patient care through optimising the benefits of the medical appraisal and provide increased support for clinicians and teams through effective use of capability and disciplinary processes.

Intention Key requirements & Enablers Implementation Timeline

Strengthen the current medical Appoint an appraisal lead to improve Q2 appraisal infrastructure. quality assurance and governance.

Consolidate a performance Medical Workforce Project Manager Q2 dashboard for individual doctors. to support design and

implementation with relevant departments. Produce a toolkit to facilitate early Provide expertise and accompanying Q2 commencement of capability and toolkit. Appoint a Medical Workforce disciplinary processes. Support Lead.

3.2 Local, joined up patient care

We will contribute to the implementation of the Care Delivery Service model through effective job planning to enable effective deployment of medical clinicians working in partnership with other clinicians, managers, corporate and administrative staff.

Intention Key requirements & Enablers Implementation Timeline

Codify and operationalise a Job planning master classes and Q2 consistent approach to job planning internet based toolkit. across the trust. Updated mediation policy for job planning appeals

Optimise transparency and clinician Clinical Activity Management (CAM) Q4 accountability for delivery on job plan software. expectations.

Support the development of both Deputy Medical Director (Workforce) On-going and as medical and non-medical roles and Project Manager to contribute to required including Non-Medical Prescribers, on-going trust-wide workforce Non-Medical Responsible Clinicians planning and development across and Physicians Associates in disciplines. response to changing workforce requirements.

3.3 Put research, innovation and learning into practice

We will contribute to and participate effectively in emerging clinical academic groups and clinical senate. We will support celebrate and reward innovative clinical practice, research and service redesign.

Intention Key requirements & Enablers Implementation Timeline

Optimise the use of supporting Effective job planning. Q3 programmed activities within job plans for the benefit of Clinical Academic Groups, service development and quality improvement.

Improve individual clinician and team Monitor clinical audit activity as part Q3 level participation in clinical audit in of revalidation. line with the trust clinical audit plan.

Incentivise clinical excellence Deputy Medical Director (Workforce) Q3 through revised Clinical Excellence and Deputy People Director to Awards (CEA) policy in line with review CEA policy. national guidance.

Support active research participation Appoint a medical lead for research Q3 on trust key themes. and identify medical research champions.

Improve communication of good Establish an editorial board. Q3 practice in relation to research through rejuvenation of the Partnership Psychiatrist.

3.4 Provider and employer of choice

We will improve the productivity, flexibility, resilience and wellbeing of the medical workforce by enhancing support for all grades of doctors. We will focus on developing both formal and informal medical leadership and strengthen our existing mentoring arrangements.

Intention Key requirements & Enablers Implementation Timeline

Optimise professional development Create a more flexible non- Q3 and contribution to trust business. Consultant grade doctor.

Increase quality of care through Medical quality improvement Q3 development of leadership on quality leadership development programme. improvement.

Consolidate the existing mentoring Launch and revitalise the mentorship Q3 programme. scheme with support from Organisational Development consultants.

Improve trainee engagement to Leadership development for trainee Q3 positively impact on Local Education representatives. Provider reputation and with Health Education Kent, Surrey & Sussex (HEKSS).

Collaborate with HEKSS and Deputy Medical Director (Medical Q3 Brighton & Sussex Medical School Education) to review current profile (BSMS) to set expectations for and recommend required additional senior clinicians to supervise and training and job planning guidance train junior doctors and around supervisory activities. multidisciplinary colleagues.

Promote equality and value diversity Embed an equality and diversity Annual within the workforce. value based appraisal and analyse the medical workforce across the protected characteristics.

3.5 Live within our means

We will monitor and ensure the most effective use of the medical workforce by the Care Delivery Services to reduce agency spend and maximise value for money from rotas. We will explore additional income generation for the trust from clinician activity.

Intention Key requirements & Enablers Implementation Timeline

Reduce agency spend by working Revise and agree control Q2 with Care Delivery Services to mechanisms for agency spend on a embed flexible working patterns. trust-wide and CDS level with relevant colleagues.

Proactive and responsive shift rota Deputy Medical Director (Workforce) Q3 management. and Deputy Medical Director (Medical Education) to work with operational services to review and evolve rota structures as required.

Explore feasibility of providing Collaborate with the Director of Q3 services to direct fee paying Strategy & Improvement to customers. crystallise opportunities.

4. Recommendation/action required

The Board is asked to reflect on the paper and to suggest ways in which any improvements can be taken forward either immediately or in the annualised review of the strategy.

5. Next steps

Strategy launch followed by monitoring of implementation of intentions against quarterly targets and proactively respond to changes in commissioning expectations, changes in national terms and conditions as well as organisational reconfiguration.

We will continue to use surveys to inform, consult and engage with our medical colleagues as well as other relevant stakeholders in the delivery of the strategy set out above.

Medical Workforce Strategy 2015-2020 This document is available in alternative formats such as electronic format or large print upon request Please contact the Equality, Diversity and Human Rights Team on 01903 845724 or email [email protected]

1. Equality and Human Rights Impact Analysis (EHRIA) Help

1.1 Board Lead: Tim Ojo, Executive Medical Director 1.2 Analysis Start Date: 18th March 2015 1.3 Analysis Submission Date: 15th July 2015 1.4 Analysis Team Members: 1) Author / Editor: Tim Ojo, Executive Medical Director, Duncan Angus, Deputy Medical Director (Workforce), Panos Argiriu, Deputy Medical Director (Medical Education), Medical Leadership Group. 1.5 If this is a cross agency policy/service or strategy please 2) Staff Groups: Clinical Commissioning Groups, Health Education Kent, Surrey, Sussex. indicate partner agencies and their formal title: 3) We, being the author(s), acknowledge in good faith that this analysis uses accurate evidence to support accountable decision-makers with due regard to the National Equality Duties, and that the analysis has 1.6 Completion Statement been carried out throughout the design or implementation stage of the service or policy.

The medical workforce strategy outlines the approach to engaging medical clinicians in ‘delivering outstanding 1.7 Policy Aim care’ for the next five years in line with ‘Our 2020 Vision’.

Send draft analysis along with the policy, strategy or service to [email protected] for internal quality control prior to ratification.

1.8 Quality Assessor sign off A.Churcher

1.9 Reference Number AC229

Equality and Human Rights Impact Analysis (EHRIA)

2. Evidence Pre-Analysis – The type and quality of evidence informing the assessment Help X 2.1 Types of evidence identified as relevant have X marked against them X Patient / Employee Monitoring Data Risk Assessments Please provide detailed evidence for the areas X Recent Local Consultations Research Findings  Staff consultation by e-mail April 2015 Complaints / PALS / Incidents X DH / NICE / National Reports  Survey Monkey by e-mail May 2015  Focus Groups / Interviews Good Practice / Model Policies Royal College of Psychiatry 2013 Census Data  Equality Performance Hub 2014 X Service User / Staff Surveys Previous Impact Analysis X Contract / Supplier Monitoring Data Clinical Audits X Sussex Demographics / Census Serious Untoward Incidents X Data from other agencies, e.g. Services, Equality Diversity and Human Rights Police, third sector Annual Report

3. Impact and outcome Evaluation – Any impacts or potential outcomes are described below. Help

People’s Characteristics (Mark with ‘X’):

Mark Describe how this policy, strategy or service will lead to positive outcomes for the protected characteristics.

one X Describe how this policy, strategy or service will lead to negative outcomes for the protected characteristics.

+ – (Please describe in full for each)

Disability & & Disability Carers Gender Reassignment & Pregnancy Maternity Race & Religion Belief Sex Sexual Orientation Human Rights Ref Age 3.1 X Men are significantly overrepresented amongst the senior medical workforce, most prominent X at 57% of our consultant profile and although men represent 57% of doctors on the medical register in 2012 (The state of medical education and practice in the UK 2013, General Medical Council) the Trust 5 year strategy will need to strongly consider the current and future workforce profile and remove any barriers to employment. 3.2 X 5 year strategy will be available in alternative formats upon request. X X 3.3 X Strategy includes info graphics to support communication. X X 3.4 X BME Consultants, Registrars and SAS Doctors continue to be over-represented at our senior X clinical positions and we recognise that this career path is consistent with other NHS trusts as well as national statistics by the General Medical Council (The state of medical education and practice in the UK 2013).

© East Sussex Hospitals NHS Trust (v.0.1) 2

People’s Characteristics (Mark with ‘X’):

Mark Describe how this policy, strategy or service will lead to positive outcomes for the protected characteristics.

one X Describe how this policy, strategy or service will lead to negative outcomes for the protected characteristics.

+ – (Please describe in full for each)

Disability & & Disability Carers Gender Reassignment & Pregnancy Maternity Race & Religion Belief Sex Sexual Orientation Human Rights Ref Age 3.5 X Strategy sets out the objective to ensure that an individual’s values and understanding for X X X X X X X X equality, diversity and human rights are challenged in appraisal. It may be necessary for the medical workforce to complete further training in cultural competencies and unconscious bias and this will be explored further. Add more rows if necessary with new reference numbers in the left column

4. Monitoring Arrangements Help 4.1 The arrangements to monitor the effectiveness of the policy, Analyses of the medical workforce across the protected characteristics will be strategy or service considering relevant characteristics? E.g. included in the annual Equality Performance Hub presented to the board ↘ survey results split by age-band reviewed annually by EMB http://www.sussexpartnership.nhs.uk/equality-performance-hub-equality and Trust Board ↘ Service user Disability reviewed quarterly by Equality and Diversity Steering Group or annually in the EDHR Annual Report

© Sussex Partnership NHS Foundation Trust March 2011 3

5. Human Rights Pre-Assessment Help The Impacts identified in sections ( ) have their reference numbers (e.g. 4.1) inserted in the appropriate column for each relevant right or freedom + – A2. Right to life (e.g. Pain relief, DNAR, competency, suicide prevention) A3. Prohibition of torture, inhuman or degrading treatment (e.g. Service Users unable to consent) A4. Prohibition of slavery and forced labour (e.g. Safeguarding vulnerable patients policies) A5. Right to liberty and security (e.g. Deprivation of liberty protocols, security policy) A6&7. Rights to a fair trial; and no punishment without law (e.g. MHA Tribunals) A8. Right to respect for private and family life, home and correspondence (e.g. Confidentiality, access to family etc) 3.2, 3.3, 3.4, 3.1 3.5 A9. Freedom of thought, conscience and religion (e.g. Animal-derived medicines/sacred space) A10. Freedom of expression (e.g. Patient information or whistle-blowing policies) A11. Freedom of assembly and association (e.g. Trade union recognition) A12. Right to marry and found a family (e.g. fertility, pregnancy) P1.A1. Protection of property (e.g. Service User property and belongings) P1.A2. Right to education (e.g. accessible information) P1.A3. Right to free elections (e.g. Foundation Trust governors)

6. Risk Grading Help 6.1 Consequence of negative 6.2 Likelihood of negative 6.3 Equality & Human Rights Risk Score impacts scored (1-5) 1 impacts scored (1-5): 4 = Consequence x Likelihood scores: 4

© East Sussex Hospitals NHS Trust (v.0.1) 4

7. Analysis Outcome– The outcome (A-D) of the analysis is marked below (‘X’) with a summary of the decision Help X 7.1 The outcome selected (A-D): 7.2 Summary for the outcome decision (mandatory) A. Policy, strategy or service addresses quality of outcome and is positive in its language and terminology. It promote equality and fosters good community relations Strategy updated to reflect comments provided by Equality and Diversity team before board approval X B. Improvements made or planned for in section 9 (potential or actual adverse impacts removed and missed opportunities addressed at point of design) C. Policy, service or strategy continues with adverse impacts fully and lawfully justified (justification of adverse impacts should be set out in section 3 above D. Policy, service or strategy recommended to be stopped. Unlawful discrimination or abuse identified.

8. Equality & Human Rights Improvement Plan

Actions should when relevant and proportionate meet the different needs of people. Help Impact What directorate Reference(s) (team) action plan will Action Lead Person Timescale Resource Implications (from assessment) this be built into 3.1 Medical Staffing Analyse gender profile of medical Medical Director Annual – April Equality Performance Hub workforce and take mitigating action 2016 profile produced by Equality and Diversity team

© Sussex Partnership NHS Foundation Trust March 2011 5

Board of Directors: 29th July 2015 - Public Agenda Item: TBP36.2/15 Attachment: F For Information By: Sally Flint, Executive Director of Finance & Performance Specialist Services section, Simone Button, Managing Director Specialist Services Adult Service Section, Lorraine Reid, Managing Director Adult Services

Trust Quality and Performance Report - June

SUMMARY & PURPOSE

The Trust Performance report provides a summary of Trust performance against an agreed set of performance indicators related to Quality, People, Finance, and those set by Monitor and CCG Commissioners. The Executive Summary also highlights key risks, which are detailed further in the main report.

The Trust Board is asked to:  Review the performance of the organisation as reported.

LINK TO ANNUAL PLAN

The Annual Plan areas this paper relates to –

1. Quality and Experience of patients 2. Finance Information and Performance 3. People

ACTION REQUIRED BY BOARD MEMBERS

The Trust Board is asked to:  Review the performance of the organisation as reported and consider / test the actions in place to address the concerns raised.

Trust Quality and Performance Report -June

1.0 Executive Summary

The Trust Performance report provides a summary of Trust performance against an agreed set of performance indicators related to Quality, People, Finance, and those set by Monitor and CCG Commissioners. Key Trust issues identified in the month are highlighted below and described in more detail in the report.

1.1 KEY AREAS OF ACHIEVEMENT IN THE MONTH

1.1.1 The Trust has achieved the following indicators at the end of Q1: 7 day follow-ups, Early Intervention new cases of psychosis, Gate-keeping of Inpatient Admissions, Access to Healthcare for people with a Learning Disability, Mental Health Minimum Dataset (completeness) and Mental Health Minimum Dataset (Outcomes).

1.1.2 The Trust has achieved the indicator which measures whether patients have had a review under the Care Programme Approach (CPA) in the last 12 months. 97.7% of patients on CPA have had a review in the last 12 month. Reported performance has improved through teams focusing on ensuring reviews are complete, and by ensuring the data quality is improved. Information reports that show when review dates are coming up are now being used to plan effectively.

1.2 AREAS OF CONCERN

1.2.1 Bed Pressures. The Trust has experienced continued bed pressures which require the use of external placements. A review of the underlying reasons behind the situation has been undertaken and length of stay is a significant factor. Delayed transfers of care contribute to the overall length of stay and are therefore crucial in terms of bed availability and patient flow. The Trust has not achieved the Delayed Transfers of Care indicator in Q1 and is reporting 9.95% against the target of 7.5%. With the implementation of the clinical leadership structure, adult services are now taking a clinically led approach to improving patient flow and bed management. There is a detailed action plan which looks at length of stay, CRHT gatekeeping and manualizing care pathways. This is being led by the Senior Clinical Director and the Divisional Clinical Directors are involved. The most recent surge in demand stems from fewer beds being available in Coastal following the breakdown of a number of community placements.

1.2.2 Finance, Cost Improvement Plan (CIP): In the month £315k savings were delivered against a target of £977k, a shortfall of 622k, taking the year to date shortfall to £2,052k. From 2015/16 only recurrent CIP is being reported as achieved, with non-recurrent savings remaining in the divisional position, and not being used to off-set the CIP target. This ensures full visibility about savings and ensures the Trust remains focused on delivering recurrent CIP. However, it should be noted that year to date the Trust has made non-recurrent savings of £1,233k

1.2.3 Temporary staff costs as a proportion of pay: Temporary staff costs accounted for 11.1% of the pay bill in June. Of this, agency costs accounted for 4.3% of the pay bill. A more detailed analysis of these costs and mitigating actions is described in the Adult and Specialist sections below.

1.3 EMERGING AREAS OF CONCERN

1.3.1 Sickness Absence rates: The Trust sickness absence rates are 3.9% compared to 3.97% for the same period last year. Adult services are reporting 4.8% sickness rates and Specialist services 3.13%.

1.3.2 Serious Incidents.

In June, the Trust has seen a further increase in the number of Serious Incidents reported in the month. It should be noted that 14 of the 36 incidents reports related to late reporting of incidents. (A further analysis is shown at 3.2.5)

2.0 Introduction

The Trust Performance dashboards are attached to this paper. They are presented as follows:-

1. A Trust wide performance dashboard covering Quality, Finance, and People indicators that are appropriate to report for the Trust as a whole. This report includes some indicators, such as sickness absence and the management of complaints that have a unique Trust level performance that is not covered by the separate Adult and Specialist sections due to the inclusion of corporate services.

2. An Adult Services performance dashboard covering the performance of the Adult Services directorate.

3. A Specialist Services performance dashboard covering the performance of the Specialist Services Directorate. This includes Child and Adolescent Mental Health Services, Secure & Forensic Services, Learning Disabilities, Substance Misuse Services, Prison Services and complex care pathways.

A table summarising responsibility for areas of concern is included as Appendix A.

3.0 Report

3.1 MONITOR INDICATORS

3.1.1 The Trust has achieved the following indicators in quarter 1. 2015/16: 7 day follow- ups, Care Programme Approach reviews in the last 12 months, Early Intervention new cases of psychosis, Gate-keeping of Inpatient Admissions, Access to Healthcare for people with a Learning Disability, Mental Health Minimum Dataset (completeness) and Mental Health Minimum Dataset (Outcomes).

3.1.2 The Trust is reporting 9.9% delayed transfers of care in June and 9.9% for quarter 1 2015/16, against the Monitor target of 7.5%. 54 patients were delayed at the end of June. A further narrative is provided at 3.4.4 later in this report.

3.2 TRUST WIDE PERFORMANCE DASHBOARD

TRUST WIDE - KEY ACHIEVEMENTS IN THE MONTH

3.2.1 Patient Experience, Friends & Family test: Patient experience is now being reported through the Friends and Family Test. It asks patients and their carers to rate whether they would recommend the service received to friends and family in similar circumstances. The survey asks for a rating on the scale from extremely likely to extremely unlikely and asks for a reason for the rating. Team leads and service managers will receive a summary of their feedback on a weekly basis. In June a positive response was received by 92.9% of respondents. 55.4% of respondents would be extremely likely to recommend the service to friends and family.

TRUST WIDE - AREAS OF CONCERN

3.2.2 Patient Experience, Complaints: Performance improved in June with 86.9% complaints responded to within the Trust’s target of 25 working days or other mutually agreed timeframe.

79 new complaints were received in June compared to an average of 60 per month over the last year. (There has been a 32% increase in complaints over the last 12 months). A further breakdown of the reasons for complaints and examples of how the Trust is learning from these complaints is detailed in the Adult and Specialist services sections.

100 90 Complaints received

80

70 Adult Total 60 50 Specialist Total 40 Trust Total 30

20 Linear (Trust Total)

10 0

Jul-14

Jan-15

Jun-14 Jun-15

Oct-14

Apr-14 Apr-15

Feb-15 Sep-14

Dec-14

Aug-14

Nov-14

Mar-15 May-15 May-14

The Deputy Director of Patient Experience has been asked to set out the scope for a review of the Trust’s approach to responding to and learning from complaints.

Sponsored by the Executive Director of Nursing and Quality and Strategic Director of Social Care and Partnerships, it is anticipated that the work will be undertaken over the summer and report in the early autumn. Key issues for consideration include the form and function of the Complaints Team, effective working with Care Delivery Services and how best to capture, share and test the changes made as a result of complaints received.

The review will also consider the benefits of a new approach to reparation, and the form and function of the Trust’s Patient Advice and Liaison Service (PALS)

3.2.3 People, Sickness Absence: The Trust sickness absence rates are 3.9% compared to 3.97% for the same period last year. Adult services are reporting 4.8% sickness rates and Specialist services 3.13%

In response to an increase in sickness absence, and in line with our strategy to encourage more accountable local services, HR advisors are working pro-actively with local teams to embed systems for responding to both short and longer term sickness. This work is incorporated as part of the turnaround process for reducing use of temporary staff in those areas where it is highest. The aim is to consistently apply the Trust Policy and the Bradford Factor is being used as a tool to improve attendance and support staff to return from sick leave. People with serious conditions which prevent them from working all have individual care planning. However in relation to short term absence, greater attention is being given to involving staff in managing their own wellbeing, and improving attendance forms part all managers’ annual objectives.

3.2.4 Temporary staff costs as a proportion of pay: Temporary staff costs accounted for 11.1% of the pay bill in June. Agency accounted for 4.3% of the pay bill in May. NHS Employers have suggested that staffing time should be less than 11% and agency spend less than 2 to 3% of the total pay bill.

3.2.5 In the month £315k savings were delivered against a target of £977k, a shortfall of 622k, taking the year to date shortfall to £2,052k. From 2015/16 only recurrent CIP is being reported as achieved, with non-recurrent savings remaining in the divisional position, and not being used to off-set the CIP target. This ensures full visibility about savings and ensures the Trust remains focused on delivering recurrent CIP. However, it should be noted that year to date the Trust has made non-recurrent savings of £1,233k

A summary of the planned and actual year to date savings are shown in the table below.

Year to Date at Month 3 Total Target £k Actual £k Variance £k Corporate 47 22 - 24 Estates and Site Rationalisation 226 223 - 3 Strategic Pay 585 29 - 556 Operational Services 1,962 603 - 1,360

Procurement and Non Pay 110 - - 110 Total 2,930 878 - 2,052

Financial Recovery Plan

Given the concerns around the delivery of cost improvement plans and the impact on financial performance the Executive Team are working on addressing the key financial issues. An Executive lead is being identified for each area, together with the group / committee that has an oversight of the issues. The main issues being addressed are set out below:-

o External placements o Inpatient Spend o Community Services re-design o Re-design of rehabilitation services o Adult Services in-patient staffing o Brighton & Hove s75 agreement o Brighton & Hove Wellbeing contract o Non-pay expenditure o Medical staffing

TRUSTWIDE - EMERGING ISSUES

3.2.5 Serious Incidents: All SIs are reviewed by the Trust in accordance with the severity of the incident. Level 1 reviews relate to moderate harm, Level 2 incidents relate to serious harm which involves a death. Level 3 incidents involve a homicide event. Final SI reports should be shared with Commissioners within 60 working days of the SI being reported.

Analysis of trends, themes and hotspots as well as benchmarking of the number SIs is carried out by the Director of Nursing Standards and Safety. Information regarding SIs is also presented to each locality divisional leadership team to ensure that data is triangulated with other performance information to identify and act on any emerging areas of concern. The outliers identified are given further review by each operational area in partnership with the Director of Nursing Standards and Safety.

A common theme has been identified in the analysis of trips and falls in that the reported falls that have resulted in serious incidents have occurred in inpatient setting who have yet to implement the revised falls clinical protocol. Trust wide implementation is in progress with the target implementation date for all inpatient settings being mid-July.

A further skewing of the in-month figures was caused by late reporting. This can happen for a number of reasons and is often beyond the Trust’s control. It should be noted that 14 of the 36 reported in the month relate to prior months.

The Trust has experienced an increase in unexpected deaths in the last month (15 level 2). There was a cluster of 7 unexplained deaths across East Sussex which is being investigated as part of the Trusts standard review processes. A joint Serious Incident review of this cluster is being chaired by the adult Managing Director.

In addition, the Trust is focusing on ensuring that all Incident reports are completed

and shared with partners within 60 days of the incident occurring. This will be reported in Board performance reports in future months.

Absence without leave, Working in the same focused way as the slips, trips and falls work, a programme designed to reduce the risks of patients going absent without leave (AWOL) is underway and currently being piloted on Caburn Ward at Mill View Hospital.

3.2.6 Finance, Financial performance: At the end of quarter one (Month 3) the Trust is reporting a deficit of £819k, after committing £750k of reserves. However, given the Trust’s strong liquidity position, the Trust continues to report a Continuity of Services Risk Rating of 3, against a planned rating of 3.

3.3 SPECIALIST SERVICES PERFORMANCE DASHBOARD – Managing Director for Specialist Services

SPECIALIST SERVICES - KEY ACHIEVEMENTS IN THE MONTH

3.3.1 Waiting times to assessment, Sussex: 95% of patients in CAMHS and Learning Disability services were assessed within 4 weeks in Sussex.

3.3.2 The Early Intervention service has achieved the quarterly Monitor target for new cases. (59 against a target of 48)

3.3.3 The Early Intervention service has achieved the quarterly Monitor target for Care Programme Approach reviews to be completed every 12 months.

SPECIALIST SERVICES - AREAS OF CONCERN.

3.3.3 Waiting times to assessment and treatment in Hampshire: Performance against waiting times in Hampshire Children and Young people’s services is not achieving the contractual targets.

The service has modelled the actual and budgeted clinical staffing capacity for each team against demand (assessment rates and caseload). This was carried out to ascertain where capacity sits across the service.

This review shows that to clear the waiting list by March 2016, you need 5000 clinical contacts per month. With a full staffing capacity the service could deliver 4456. At the current vacancy rate the service is forecast to deliver 3599. The service is currently delivering 3629 per month.

In the longer term we need to work with commissioners to positively affect the number of referrals we receive by expanding and up skilling the services at tier 1(universal) and tier 2 (targeted) levels. The Hampshire Service is going through the process of re-tendering. The services tender response includes the use of a single point of referral with an enhanced triage function which will impact the level of demand seen by the service.

In the short to medium term the service is reviewing treatment packages for young people who don’t fit the prescribed pathway, i.e those with no formal diagnosis but

with symptoms that require a specialist service. This will be delivered though short term focused packages of care.

At the same time, the service is focused on ensuring that patients are discharges in a timely manner.

SPECIALIST SERVICES - EMERGING CONCERNS

3.3.5 Waiting times to assessment, CAMHS Kent & Medway: 47.1% of assessments were seen in 4 weeks, 60.5% were seen in 6 weeks (the contractual target).

The service has recovery trajectories agreed with quality leads and commissioners. Due to the continued high demands, the team are investing some time at their next away day to build team sustainability and resilience.

985 referrals were received in June which is significantly higher than was originally planned, at 740 referrals per month. In particular the number of urgent referrals has been consistently higher than planned which impacts on team capacity.

The numbers of patients waiting for assessment has increased in the month, from 848 to 907. Those waiting for treatment have reduced from 242 to 185.. However the Trust is seeking additional funding from commissioners to meet this extra demand. In addition the waiting time to assessment has risen from 6 weeks to 7 weeks.

The service has made significant progress cleaning up the manual waiting lists prior to going live with Carenotes on 13th July. From the start of Q3 the service will rely on only the system based waiting time’s reports.

3.3.6 Sussex CAMHS Demand & Capacity: Whilst this service continues to meet the contractual targets for waiting times, the removal of the social workers which represents 20% of the tier 3 workforce from the teams in West Sussex is likely to have a significant detrimental impact on community team capacity. Information on the potential loss of activity including type and volume was completed by the end of June and has been shared with Commissioners. It has been agreed that further discussion about how this gap in capacity will be managed will take place in the near future.

The service is learning from the experience of Kent CAMHS, where clinicians allocate discharge days to ensure that patients are discharged in a timely manner, where clinically appropriate. This helps maintain throughput in the services to best utilise capacity.

3.3.7 Complaints. 33 new complaints were received in June in specialist services. 91% of complaints responded to in the month were responded to in the agreed timeframe.

The service has systems in place to ensure the information regarding the types of complaints is triangulated with other quality indicators including Serious incident, friends and family and staff sickness. All specialist services are putting tracking systems in place to highlight to the management team the status of complaints and

SIs to ensure that responses are dealt with in a timely manner. In June all Sis are meeting their targets for completion within 60 working days.

The reason for complaints is summarised in the table below.

Specialist Complaints Breakdown - June Complex Care Learning Prison Secure & Category Type CAMHS Pathways Disabilities Services Forensic Total Admission/Discharge/Transfer Arrangements 6 0 0 0 1 7 All Aspects Of Clinical Treatment 9 0 1 0 0 10 Appointment Delay/Cancellation (OP) 3 0 0 0 0 3 Attitude of Staff 3 0 1 0 0 4 CCG Commissioning (inc waiting lists) 2 0 0 0 0 2 Communication to Patient 6 0 0 0 0 6 Other 1 0 0 0 0 1 Grand Total 30 0 2 0 1 33

3.3.8 Temporary Costs as a proportion of Pay: The Temporary costs as a proportion of pay is 9.19% in Specialist Services. Agency spend is 4.7% of the total pay bill.

Learning Disability Services: Temporary staff 14% as a proportion of pay, agency 6%. This is in the Selden Centre and Mayfield court. Some intensive work is taking place led by the organisational development consultants with the Mayfield Court staff team to address concerns raised by staff. This connected to high levels of sickness in the service

Secure & Forensic services: Temporary staff 12% as a proportion of pay, agency 2% (Commentary on secure and forensic to be received)

CAMHS: Temporary staff 8% as a proportion of pay, agency 6%. Agency staffing is reducing in Kent and is ahead of recovery trajectory. Interviews for all but three vacant posts within Kent and Medway are due to take place

3.3.9 Sickness Absence: Sickness absence is 3.13% in Specialist Services.

3.3.10 Serious Incidents: A number of serious incidents have been experienced in CAMHS services in relation to information governance issues in recent months, particularly in Hampshire CAMHS. The service has developed a comprehensive action plan to respond to the issues highlighted from a review of each incident.

The first extended CAMHS Divisional leadership team was held this month that reviewed complaints and serious incidents. This is being written up into a newsletter for teams to complement local versions. Key themes identified are as follows:-

o Communications remains a key issue in complaint letters and requires a focus in the coming quarter both at team level and with corporate partners. The next leadership meeting day in September will focus on writing SI reports and complaints with interactive sessions from corporate partners.

o Waiting times for ASC – Further discussion needs to be held with teams and commissioners about how we manage these complaints in partnership where there is a gap in provision.

3.4 ADULT SERVICES PERFORMANCE DASHBOARD – Managing Director for Adult Services

ADULT SERVICES – AREA OF ACHIEVEMENT

3.4.1 Performance against the 7 day follow up has improved in the month. 97.5% of patients were seen in 7 days. 272 patients received a follow up in June.

3.4.2 Learning from Serious Incidents.

The serious incidents process is being moved closer to operational services. A new post will help with the learning and facilitation of reporting.

SI learning for a have been developed drawing on clinical leaders to formulate plans and consider how learning from previous SIs and triangulates with other data sources. These are currently focusing on local feedback on recent learning and incidents

In Brighton & Hove, action plans resulting from the review of an incident in January are focusing on improved Care Programme Approach processes, team meeting structures, communication in duty services and risk assessments.

3.4.3 The Trust has achieved the indicator which measures whether patients have had a review under the Care Programme Approach (CPA) in the last 12 months. 97.9% of patients on CPA have had a review in the last 12 month. Reported performance has improved through teams focusing on ensuring reviews are complete, and by ensuring the data quality is improved. Information reports that show when review dates are coming up are now being used to plan effectively and maintain performance levels.

ADULT SERVICES - AREAS OF CONCERN

3.4.3 Bed Pressures / Delayed transfers of care: Pressures on adult acute care continue, in spite of seemingly good progress in April 250 beds days were placed externally in May as the number of referrals for acute care and consequently the number of admissions was considerably higher than the usual monthly average. A combination of factors are involved and the service has undertaken a root and branch review of whole system pressures, including approaches previously taken to improve bed availability.

The current system is fragile, closure of Hanover Crescent, in effect; removed 9 intermediary beds from the system, 3 acute beds are unavailable in Eastbourne due to much needed refurbishment 6 Dementia beds are also no longer operational in East Sussex, giving a reduction of 18 beds in total. The 3 acute beds in East Sussex will be out of use for another 5 months. Hanover will not reopen and it is unlikely that the Dementia beds will re-open.

Inconsistencies in length of stay along with increased delayed transfers of care mean that we are not utilising our total bed capacity effectively. Therefore, fluctuations in demand (e.g. through exam pressures, community placement breakdown), staff capacity (e.g. school holidays) and minor changes (building and refurbishment work) result in increased out of area placement.

The plan is to focus on:

1. Reducing length of stay to 28 days. This would free up 9,660 bed days. 2. Reduce the number of re-admission over a 90 day period to ensure that reducing LoS does not impact on the quality of care or patient experience. 3. Reducing delayed transfer of care. Accepting that zero DTCs is and unrealistic target, a 25% reduction on current performance would provide an additional 3,500 bed days.

Managing resource in line with season fluctuations in demand, which involves managing annual leave effectively and increasing staffing in CRHTs and liaison services pro-actively at those points in the year when demand is traditionally higher. The approach will be different because it will involve greater clinical engagement with clinical leadership provided by the local Clinical Directors.

It is worth noting that West Sussex Dementia services improved whole systems working across the whole care pathway, with a focus on timely discharge, is currently reducing demand on these beds and reliance on inter-trust transfers, enabling East Sussex to progress their improvement plans.

3.4.4 Delayed Transfers of Care Indicator

The Trust has not achieved the Delayed Transfers of Care indicator in June and Adult service is reporting 11.7% against the target of 7.5%. 54 patients were delayed at the end of June.

The Adult leadership team has sight of the details of each individual patient who is delayed, and the reason for these delays. The Trust is focused, through a working group led by the Deputy Managing Director of Adult services, to ensure any delayed in operational processes are identified and minimised. This group is also working to develop of forecast of when the Trust expects the delays to be reduced.

The Trust is also engaging which Commissioners to ensure that system wide issues are addressed.

3.4.6 Temporary Costs as a proportion of Pay: The Temporary costs as a proportion of pay is 13% in Adult Services, 4.8% for agency staff. The performance in each area is as follows:-

North West Sussex: 22% of pay is temporary pay (bank and agency), agency is 11%.

Brighton & Hove: 14% of pay is temporary pay, 5% agency. There is agency expenditure in acute adults’ wards, both medical and nursing. Medical agency will increase for the next six-eight weeks to cover maternity leave. Medical agency in Dementia services is due to a delay in recruitment, with an August start date. There is an agency turnaround programme in place at Mill View and Lindridge centre which includes a rolling programme of recruitment days.

East Sussex: 11% of pay is on temporary pay, 3% on agency. Agency costs significantly decreased in July. Spend has now been eliminated in a number of areas. Spend has been reduced in Beechwood, Bodium, Amberley and St Gabriel.

Coastal West Sussex: 11% of pay is on temporary pay, 3% on agency.

3.4.7 Payment by Results: The Trust is preparing for the introduction of Payment by results for Mental Health. The timeliness of Payment By result reviews is indicative of the Trusts progress towards achieving preparedness. Adult services have been asked to provide action plans for improvement as the performance level has remained static at 81% for the past few months against the Trust target of 95% A start and finish group is planned to review the process changes that are needed to bring about a sustainable improvement in performance.

3.4.8 Sickness Absence. Sickness absence in Adult Services is 4.8% in May (reported 1 month in arrears). East Sussex (5.6%) and Brighton & Hove (3.96%) are reporting reducing levels of sickness absence compared to prior months as a result of the actions taken as described in 3.2.3 5.6%. North West Sussex is reporting over 6% sickness absence and Coastal West Sussex 5%

ADULT SERVICES – EMERGING CONCERNS

3.4.7 Complaints. 43 new complaints were received in June in Adult services. 85% of complaints responded to in the month were responded to in the agreed timeframe. The reason for complaints is summarised in the table below. Adult services are reviewing the reasons for complaints at their monthly Divisional Leadership teams, and learning will be shared with the Board in future months.

Adult Complaints Breakdown -June North Brighton & Coastal East West Category Type Hove West Sussex Sussex Sussex Total Admission/Discharge/Transfer Arrangements 0 2 1 0 3 Aids Appliances, Equip, Premises (And Access) 1 0 0 0 1 All Aspects Of Clinical Treatment 5 1 6 4 16 Appointment Delay/Cancellation (OP & IP) 0 1 1 0 2 Attitude of Staff 2 2 1 3 8 Communication to patients 1 2 1 2 6 Failure To Follow Agreed Procedures 0 2 0 0 2 Hotel services (inc food) 1 0 0 0 1 Patient Status / discrimination 0 0 1 0 1 Waiting times 0 0 2 0 2 Other 1 0 0 0 1 Grand Total 11 10 13 9 43

3.4.8 Waiting times for assessment in 4 weeks: 93% of patients were assessed within 4 weeks in Sussex. 79.8% of patients in Brighton & Hove were assessed in this timeframe. The division has an action plan in place to improve this performance which is regularly reviewed with the Brighton & Hove clinical commissioning group.

3.5.8 Discharge Summaries: The Trust has recently undertaken an audit of the timeliness of communication of discharge summaries to GPs and patients. The initial audit shows that performance levels are not achieving the current contractual targets. (Same day for inpatient services, 48 hours for community) The following actions are planned:-

 A repeat audit is being carried out, as part of the clinical audit programme. The scope of the audit is being extended to gain an understanding of how long the discharge summaries take to be communicated.  Agree and implement standard templates for discharge summaries.  Consider automation of discharge summaries through the Carenotes programme.

4.0 Recommendation/Action Required

The Trust Board is asked to:

Review the performance of the organisation as reported and consider / test the actions in place to address the concerns raised.

5.0 Next Steps

The performance of the organisation is reviewed each month in Adult and Specialist Services performance contact meetings, which review key areas of Finance, Performance, quality and people issues.

APPENDIX A

Issues Identified Executive Responsible Professional Lead Assurance Adult Bed Pressures Adult Services Managing Executive Medical Director Executive Assurance Board Director Finance & Investment Committee CPA Reviews Adult Services Managing Clinical Academic Director Executive Assurance Board Director, Specialist Service Finance & Investment Committee Managing Director (for early intervention services) Temporary Staffing costs as Adult Services Managing Executive Director of Executive Assurance Board a proportion of pay Director, Specialist Services Corporate Services People Committee Managing Director Sickness Absence Rates Adult Services Managing Executive Director of Executive Assurance Board Director, Specialist Services Corporate Services People Committee Managing Director Serious Incidents All Executive Directors Executive Director of Executive Assurance Board Nursing Quality Committee Delayed Transfers of Care Adult Services Managing Executive Medical Director Executive Assurance Board Director Finance & Investment Committee Cost Improvement Plans Adult Services Managing Executive Director of Executive Management Board Director, Specialist Services Finance & Performance Finance & Investment Committee Managing Director Complaints Adult Services Managing Executive Director of Executive Assurance Board Director, Specialist Services Nursing Quality Committee Managing Director Waiting times to Assessment Specialist Services Managing Specialist Services Clinical Executive Assurance Board in Hampshire & Kent Director Director Finance & Investment Committee Rehabilitation development Director of Strategy and Executive Medical Director Transformation Board Improvement Trust Board Payment By Results Adult Services Managing Clinical Academic Director Executive Assurance Board Director, Finance & Investment Committee

Adult Services Dashboard

June 2015

Sussex Partnership June 2015 Adult Services Dashboard NHS Foundation Trust Page RESPONSIVE

Extra Contractual Referrals (ECRs) No Target 1

Delayed Transfers of Care - Timely discharge of patients - less than 7.5% MONITOR TARGET 1

Crisis Team Gate-keeping - Avoiding unnecessary admissions - target 95% MONITOR TARGET 2

Routine Assessments within 4 weeks of referral - target 95% CONTRACTUAL TARGET 2 WELL LED

Sickness absence - 3.5% or less TRUST-ONLY TARGET 3

Temporary and Agency costs - 11% or less TRUST-ONLY TARGET 3

Income/Expenditure performance against budget TRUST-ONLY TARGET 3

Cost Improvement Plan (CIP) performance against target TRUST-ONLY TARGET 3 SAFETY

7 Day Follow-up - Acute inpatient discharges followed up <7 Days - 95% threshold MONITOR TARGET 4

Serious Incidents - Reporting on and demonstrating learning No Target 4 CARING

Complaints resolved within 25 working days - target 85% CONTRACTUAL TARGET 5

CPA Patients having a Formal Review at least every 12 months - target 95% MONITOR TARGET 5

Reporting Patient Experience Feedback - Friends and Family Test No Target 6

PbR - Reassessment frequency in accordance with patient needs - target 95% TRUST-ONLY TARGET 6

performance meets or exceeds target

performance is within 10% of target

performance is 10% or more below target

June 2015 2 Index June 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

Extra Contractual Referrals (ECRs) 0.13 450 TRUST-WIDE (Local indicator) 400

350

Month: June 2015 300

Month YTD 250 Responsive Number of Bed Nights 414 903 200 150

100 Extra Contractual Referrals (ECRs) relate to Trust patients who 50 are receiving care in inpatient units outside of the Trust. These 0 referrals are made in situations where the Trust has no available Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 beds to accommodate new patients. ECRs

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 ADULT 239 250 414 000000000

Delayed Transfers of Care (DTC) 15% Adult Services (MONITOR Indicator)

Month: June 2015 Target: <7.5% 10% Month Quarter YTD

% Delayed (Adult) 11.7% 11.9% 11.9% 5% % Delayed (TRUST) 9.9% 9.9% 9.9%

0% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Non-acute adult patients aged 18 and over from AMHS % delays Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 (inc Dementia). Reported to MONITOR quarterly. TRUST Responsive figure (for MONITOR) includes numbers from S&F. ADULT 7.5% 6.6% 5.6% 6.0% 4.0% 4.0% 6.0% 5.0% 10.0% 11.5% 12.6% 11.3% 11.7% TARGET 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5%

25% Performance by CCG - June 2015 Month end patient delays % delayed 20% Coastal W Sussex18 13.2% Crawley9 32.3% 15% Horsham & Mid Sx11 27.8% 10% Brighton & Hove13 15.5%

Eastbourne0 0.0% 5% High Weald0 0.0%

0% Hastings & Rother1 1.9% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & South-East TRUST Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG Hants CCG CCG Seaford CCG Havens CCG S-E Hampshire1 0.0% % delays Target Other CCGs1 5.1%

June 2015 1 Adult Services June 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

Gate-keeping of Admissions 100% Adult Services (MONITOR Indicator)

95% Month: June 2015 Target: 95%

Month Quarter YTD 90% No. of Admissions 194 537 537 85% No. Gate-kept 192 534 534

% Gate-kept 99.0% 99.4% 99.4% 80% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

% gatekept Target

AMHS patients under 65 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Responsive TRUST 99.5% 100.0% 100.0% 100.0% 100.0% 98.9% 100.0% 100.0% 100.0% 99.5% 99.4% 100.0% 99.0% TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Performance by CCG - June 2015 100% Admissions Gate-kept % gate-kept

Coastal W Sussex 56 56 100.0% 95% Crawley 7 7 100.0%

Horsham & Mid Sx 7 7 100.0% 90% Brighton & Hove 45 44 97.8% Eastbourne 36 35 97.2% 85% High Weald 18 18 100.0%

80% Hastings & Rother 20 20 100.0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & South-East TRUST Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG Hants CCG CCG Seaford CCG Havens CCG S-E Hampshire 0 % gatekept Target Other CCGs 5 5 100.0%

4 week waiting time to assessment 100% Adult Services (Local indicator) 95% Month: June 2015 Target: 95% 90% Month YTD 85% Number of Assessments 934 2,666 % assessments <4 Weeks 93.0% 93.8% 80%

Average Wait Days 18.2 17.1 75% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Indicator covers AMHS (inc Dementia) % assessments <4 weeks Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15

Average Wait Days = average wait time from receipt of Responsive ADULT 95.3% 96.3% 96.8% 97.3% 96.6% 96.8% 97.7% 97.1% 96.9% 98.4% 94.5% 93.8% 93.0% referral to assessment. TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Performance by CCG - June 2015 100% Assessments <4 weeks Wait Days 90% Coastal W Sussex 305 95.1% 17.4

Crawley 66 92.4% 17.8 80% Horsham & Mid Sx 139 97.8% 16.5 70% Brighton & Hove 114 79.8% 24.4

Eastbourne 103 93.2% 18.9 60% High Weald 92 94.6% 15.4

50% Hastings & Rother 112 93.8% 18.1 Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & South-East TRUST Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG Hants CCG CCG Seaford CCG Havens CCG S-E Hampshire 1 100.0% 0.0 % assessments <4 weeks Target Other CCGs 2 100.0% 21.0

June 2015 2 Adult Services June 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

Sickness Absence 6.5% Adult Services (Local indicator) 6.0% 5.5%

Month: May 2015 Target: <=3.5% 5.0%

4.5%

Month Year Well Led Trust absence rate 3.90% 4.00% 4.0% 3.5% Adult Services absence rate 4.80% 4.70% 3.0%

2.5% Reported one month in arrears May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Trust Absence rate Adult Services Absence rate Absence rate (previous 12 months) Target

May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 TRUST 3.74% 3.39% 3.54% 3.32% 3.85% 4.10% 4.39% 4.99% 5.30% 5.10% 4.98% 4.10% 3.90% ADULT 3.99% 3.39% 3.26% 3.24% 3.95% 4.23% 4.26% 5.09% 6.24% 5.63% 5.91% 4.84% 4.80%

Temporary Costs (Bank & Agency) 20% Adult Services (Local indicator) 15% Month: June 2015 Target: 11%

Month YTD 10% Well Led Temporary Spend 13.20% 13.35% Agency Spend 4.81% 4.43% 5%

0% Agency and temporary staff spend as a proportion of the total Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 pay bill. Target is to maintain this below 11%. Temporary Costs - Adult Agency Spend - Adult Target

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 ADULT 13.55% 13.15% 13.20% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% AGENCY 4.92% 3.56% 4.81%

Income/Expenditure Budget £1,500 TRUST-WIDE (Local indicator) £1,000

Month: June 2015 £K

£500

YTD Well Led (000s) £0

Income/Expenditure Variance 718 -£500 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

YTD Variance against I&E Budget - Adult YTD Variance against I&E Budget - Trust

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 ADULT 498 1,008 718 000000000 Any positive variance against budget is an overspend

Cost Improvement Plan (CIP) 100% TRUST-WIDE (Local indicator)

80% Month: June 2015 YTD 60% Well Led

(000s) 40%

CIP Target 1,265 20% CIP Achieved 121 0% CIP % Achieved 9.6% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 CIP Recurring/Non-recurring - Adult Target

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 Recurring and non-recurring actual costs YTD against plan ADULT 0.00% 8.78% 9.57% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% TARGET 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

June 2015 3 Adult Services June 2015 Sussex Partnership

Key Indicators - Safety NHS Foundation Trust

7 Day Follow-up 100% Adult Services (MONITOR Indicator)

95% Month: June 2015 Target: 95%

Month Quarter YTD 90% Discharged 279 747 747 85% Followed-up 272 726 726

% Followed-up 97.5% 97.2% 97.2% 80% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

% followed-up Target

All adults aged over 18 discharged from Adult Mental Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 TRUST 95.7% 97.7% 97.4% 97.6% 98.2% 99.2% 98.1% 96.3% 96.2% 94.7% 95.5% 98.7% 97.5%

Health inpatient units TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Safety

Performance by CCG - June 2015 100% Discharged Followed-up % follow-up 90% Coastal W Sussex 78 77 98.7%

Crawley 11 11 100.0% 80% Horsham & Mid Sx 19 19 100.0% 70% Brighton & Hove 64 62 96.9%

Eastbourne 40 38 95.0% 60% High Weald 20 20 100.0%

50% Hastings & Rother 37 37 100.0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & South-East TRUST Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG Hants CCG CCG Seaford CCG Havens CCG S-E Hampshire 0 % followed-up Target Other CCGs 10 8 80.0%

Serious Incidents - reported in month 24 Adult Services (Local indicator) 20

Month: June 2015 16

12

All Serious Incidents Level 1 Level 2 Level 3 8

Adult Services 4

Sussex 15 13 0 0 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Sussex SIs (Adult) - Level 1 Sussex SIs (Adult) - Level 2

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Level 1964482212103815

Level 2258954543810613 Safety

Performance by CCG - June 2015 SUSSEX Level 1 Level 2 Level 3 Coastal W Sussex 1 2 0 Crawley 2 1 0 Horsham & Mid Sx 8 1 0 Brighton & Hove 1 2 0 Eastbourne 1 2 0 High Weald 2 4 0 Hastings & Rother 0 1 0 S-E Hampshire 0 0 0 Other CCGs 0 0 0

June 2015 4 Adult Services June 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

Complaints resolved in month 100% Adult Services (Local indicator) 80%

Month: June 2015 Target: 85% 60% Resolved within 25 working days or agreed timeframe 40% Complaints resolved this month 39 Resolved within the agreed timeframe 33 20%

% resolved within agreed timeframe 84.6% 0% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Average number of days to resolution 24.1 TRUST - resolved within timeframe Adult Services - resolved within timeframe Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 TRUST 75.0% 71.6% 88.2% 85.4% 90.0% 96.1% 86.2% 87.9% 85.1% 82.5% 69.8% 70.0% 86.9%

Complaints received (as at month end) 43 ADULT 63.0% 65.9% 90.9% 90.0% 92.0% 93.8% 91.2% 87.2% 83.9% 77.8% 71.8% 61.8% 84.6% Caring

100 Performance by CCG - June 2015

Complaints Resolved Ave Days 80

Coastal W Sussex 9 88.9% 22.7 60 Crawley 1 100.0% 25.0 40 Horsham & Mid Sx 4 75.0% 32.3

Brighton & Hove 10 80.0% 24.3 20

Eastbourne 5 100.0% 18.8 0 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

High Weald 3 66.7% 28.3 Adult new complaints

Hastings & Rother 3 100.0% 25.0 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 S-E Hampshire ADULT30382735323753394254293443 Other CCGs 4 75.0% 21.0

CPA 12 month Formal Review 100% Adult Services (MONITOR indicator) 80% Current Month: June 2015 Target: 95% 60% Month 40% Adults on CPA at end of month 2,505 Last Review within 12 months 2,453 20%

% adults with review <12 months 97.9% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

% <12 month Review Target This indicator shows a snapshot position as at the end of Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 the month and is submitted to MONITOR quarterly ADULT 88.2% 90.8% 97.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Caring

Performance by CCG - June 2015 Patients Vaild Review % Valid Coastal W Sussex 812 802 98.8% Crawley 110 106 96.4% Horsham & Mid Sx 304 291 95.7% Brighton & Hove 639 624 97.7% Eastbourne 281 280 99.6% High Weald 118 116 98.3% Hastings & Rother 212 206 97.2% S-E Hampshire 8 7 87.5% Other CCGs 21 21 100.0%

June 2015 5 Adult Services June 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

Patient Experience Feedback 100% Adult Services (Local indicator) 80%

Month: June 2015 60% Month Quarter YTD

40% Caring Friends & Family Test 114 318 318

% Positive 93.0% 89.4% 89.4% 20%

% Extremely Likely 58.8% 56.0% 56.0% 0% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 % Negative 1.8% 3.1% 3.1% % Positive Feedback

% Extremely Unlikely 0.9% 0.9% 0.9% Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 ADULT 0.0% 0.0% 0.0% 78.9% 88.1% 83.8% 85.8% 92.9% 85.4% 87.7% 87.7% 87.0% 93.0% Figures reported from September 2014 onwards TARGET 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Payment by Results (PbR) Adult Services (Local indicator)

Month: June 2015 Target: 95% Under 65 65 & over TOTAL With a Cluster 11,318 11,764 23,082 With a valid Cluster 8,149 10,640 18,789 % valid Cluster 72.0% 90.4% 81.4%

Each cluster has a review period and the cluster is valid if the patient's needs are reassessed before the end of the

respective review period and the patient is re-clustered. Caring

Performance by CCG - June 2015 100% Patients + valid Cluster % valid Cluster 80% Coastal W Sussex 8,270 6,849 82.8%

Crawley 1,837 1,404 76.4% 60% Horsham & Mid Sx 3,385 2,746 81.1% 40% Brighton & Hove 3,093 2,512 81.2%

Eastbourne 2,465 2,017 81.8% 20% High Weald 1,778 1,448 81.4%

0% Hastings & Rother 2,182 1,755 80.4% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & South-East TRUST Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG Hants CCG CCG Seaford CCG Havens CCG

S-E Hampshire 72 58 80.6% % valid cluster Target

June 2015 6 Adult Services Sussex Partnership Sussex CCG Map NHS Foundation Trust

© Graham Ainsworth - Sussex HIS - December 2012

Population Number of CCG (2013-14) GP Practices Coastal West Sussex CCG 492,515 55

Crawley CCG 127,372 13

Horsham & Mid Sussex CCG 228,231 23

Brighton & Hove CCG 300,900 46

Eastbourne, Hailsham & Seaford CCG 186,798 22

High Weald, Lewes, Havens CCG 166,464 27

Hastings & Rother CCG 183,178 33

South Eastern Hampshire CCG 209,845 26

June 2015 7 Adult Services

Specialist Services Dashboard

June 2015

Sussex Partnership June 2015 Specialist Services Dashboard NHS Foundation Trust Page RESPONSIVE

Routine assessments within 4 weeks of referral (Sussex) - target 95% CONTRACTUAL TARGET 1

Routine assessments within 4 weeks of referral (CAMHS Hants) - target 95% CONTRACTUAL TARGET 1

Routine assessments within 6 weeks of referral (ChYPS Kent) - target 95% CONTRACTUAL TARGET 2

Early Intervention in Psychosis - New Cases - performance against target MONITOR TARGET 2 WELL LED

Sickness absence - 3.5% or less TRUST-ONLY TARGET 3

Temporary and Agency costs - 11% or less TRUST-ONLY TARGET 3

Income/Expenditure performance against budget TRUST-ONLY TARGET 3

Cost Improvement Plan (CIP) performance against target TRUST-ONLY TARGET 3 SAFETY

Serious Incidents - Reporting on and demonstrating learning No Target 4 CARING

Complaints resolved within 25 working days (Sussex) - target 85% CONTRACTUAL TARGET 5

Complaints resolved within 25 working days (CAMHS Hants) - target 85% CONTRACTUAL TARGET 5

Complaints resolved within 25 working days (ChYPS Kent) - target 85% CONTRACTUAL TARGET 5

Reporting Patient Experience Feedback - Friends and Family Test No Target 6

CPA Patients having a Formal Review at least every 12 months - target 95% MONITOR TARGET 6

performance meets or exceeds target

performance is within 10% of target

performance is 10% or more below target

June 2015 2 Index June 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

4 week waiting time to assessment 100% Specialist Services - CAMHS Sussex (Local Ind) 95% Month: June 2015 Target: 95% 90% Month YTD 85% Number of Assessments 423 1,274

% assessments <4 Weeks 95.0% 97.3% 80%

Average Wait Days 13.6 12.8 75% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Indicator covers CAMHS Sussex and LDS. % assessments <4 weeks Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15

Average Wait Days = average wait time from receipt of Responsive SUSSEX 99.8% 99.8% 97.9% 99.2% 98.5% 99.4% 99.6% 98.5% 98.9% 96.6% 99.5% 97.3% 95.0% referral to assessment. TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Performance by CCG - June 2015 100% SUSSEX Assessments <4 weeks Wait Days 90% Coastal W Sussex 98 96.9% 11.9

Crawley 16 87.5% 15.7 80% Horsham & Mid Sx 45 73.3% 25.3 70% Brighton & Hove 61 100.0% 11.2

Eastbourne 53 92.5% 17.0 60% High Weald 49 100.0% 15.9

50% Hastings & Rother 100 100.0% 8.5 Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & South-East TRUST Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG Hants CCG CCG Seaford CCG Havens CCG S-E Hampshire 0 100.0% % assessments <4 weeks Target Other CCGs 1 100.0% 0.0

4 week waiting time to assessment 100% Specialist Services - CAMHS Hants (Local Ind) 80%

Month: June 2015 Target: 95% 60% Month YTD 40% Number of Assessments 285 762 % assessments <4 Weeks 42.8% 40.3% 20%

Average Wait Days 56.6 51.6 0% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Indicator covers CAMHS Hampshire % assessments <4 weeks Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Average Wait Days = average wait time from receipt of Responsive HANTS 34.3% 45.6% 42.2% 55.7% 46.0% 45.2% 40.5% 40.0% 45.7% 39.2% 43.5% 35.0% 42.8% referral to assessment. TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Performance by CCG - June 2015 100% HAMPSHIRE Assessments <4 weeks Wait Days 80% Fareham 50 30.0% 52.5 North Hampshire 28 35.7% 68.9 60% N E Hampshire 36 33.3% 90.1 40% S E Hampshire 50 40.0% 48.3 West Hampshire 108 49.1% 53.8 20%

Other CCGs 13 92.3% 8.2 0% Fareham & North NE Hampshire South East West Hampshire Other CCGs HAMPSHIRE Gosport CCG Hampshire & Farnham Hampshire CCG CCG CCG CCG

% assessments <4 weeks Target

June 2015 1 Specialist Services June 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

4 week waiting time to assessment 100% Specialist Services - ChY PS Kent (Local Indicator) 80% Month: June 2015 Target: 95% 60% Month YTD 40% Number of Assessments 433 1,158 % assessments <4 Weeks 47.1% 47.4% 20%

Average Wait Days 46.2 43.7 0% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Indicator covers ChYPS Kent % assessments <4 weeks % assessments <6 weeks Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15

Average Wait Days = average wait time from receipt of Responsive <4 WK 46.9% 45.0% 38.4% 42.5% 47.7% 52.5% 55.6% 51.0% 58.5% 54.5% 49.4% 46.2% 47.1% referral to assessment. <6 WK 57.0% 53.7% 48.3% 51.9% 57.1% 70.5% 68.5% 66.9% 69.0% 75.3% 65.8% 59.4% 60.5%

Performance by CCG - June 2015 100% Assessments <4 weeks Wait Days 80% Ashford 30 50.0% 28.5

Canterbury 47 46.8% 66.0 60% Dartford 63 39.7% 32.1 40% Medway 75 34.7% 58.8

South Kent Coast 38 71.1% 24.4 20% Swale 38 28.9% 39.6 0% Ashford Canterbury Dartford, Medway South Kent Swale Thanet West Other KENT Thanet 50 54.0% 68.0 CCG & Coastal Gravesham CCG Coast CCG CCG CCG Kent CCGs CCG & Swanley CCG West Kent 89 53.9% 42.3 CCG % assessments <4 weeks Target Other CCGs 3100.0%0.7

EIS - New Psychosis Cases 200 Specialist Services (MONIT OR indicat or)

Month: June 2015 150 Responsive

National Target: 48 cases/quarter 100 Month Quarter YTD

50 West Sussex 16 25 25

East Sussex 7 23 23 0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Brighton & Hove 2 10 10 EIS New Cases - TRUST - YTD Target

TRUST265959 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 NEW CASES 19 33 59 Reported to MONITOR quarterly. TARGET 16 32 48 64 80 96 112 128 144 160 176 192

June 2015 2 Specialist Services June 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

Sickness Absence 6.5% Specialist Services (Local indicat or) 6.0% 5.5%

Month: May 2015 Target: <=3.5% 5.0%

4.5% Month Year Well Led Trust absence rate 3.90% 4.00% 4.0% 3.5% Specialist Services absence rate 3.13% 3.56% 3.0%

2.5% Reported one month in arrears May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Trust Absence rate Specialist Services Absence rate Absence rate (previous 12 months) Target

May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 TRUST 3.74% 3.39% 3.54% 3.32% 3.85% 4.10% 4.39% 4.99% 5.30% 5.10% 4.98% 4.10% 3.90% SPECIAL 3.77% 3.08% 2.91% 3.52% 3.75% 4.08% 4.90% 5.13% 5.57% 5.29% 4.49% 3.99% 3.13%

Temporary Costs (Bank & Agency) 20% Specialist Services (Local indicat or) 15% Month: June 2015 Target: 11%

10% Month YTD Well Led Temporary Spend 9.19% 9.98% 5% Agency Spend 4.37% 4.51%

0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Agency and temporary staff spend as a proportion of the to Temporary Costs - Specialist Agency Spend - Specialist Target pay bill. Target is to maintain this below 11%. Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 SPECIALIST 9.89% 10.08% 9.19% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% AGENCY 4.65% 4.52% 4.37%

Income/Expenditure Budget £1,500 TRUST-WIDE (Local indicator) £1,000

Month: June 2015 £K

£500

YTD Well Led (000s) £0

Income/Expenditure Variance -156 -£500 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

YTD Variance against I&E Budget -Specialist YTD Variance against I&E Budget - Trust

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 SPECIALIST ‐80 ‐257 ‐156 000000000 Any positive variance against budget is an overspend

Cost Improvement Plan (CIP) 100% TRUST-WIDE (Local indicator)

80% Month: June 2015 YTD 60% Well Led

(000s) 40%

CIP Target 956 20% CIP Achieved 499 0% CIP % Achieved 52.2% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 CIP Recurring/Non-recurring - Specialist Target

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 Recurring and non-recurring actual costs YTD against plan SPECIALIST 0.00% 51.43% 52.20% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% TARGET 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

June 2015 3 Specialist Services June 2015 Sussex Partnership

Key Indicators - Safety/Caring NHS Foundation Trust

Serious Incidents - reported in month 24

Specialist Services (Local indicat or) 20

Month: June 2015 16 All Serious Incidents Level 1 Level 2 Level 3 12

Specialist Services 8

Sussex 2 1 0 4

Hampshire 1 0 0 0 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Kent 2 10 Sussex SIs (Specialist) - Level 1 Sussex SIs (Specialist) - Level 2

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Level 12522141361511105 Level 22235221045322

Performance by CCG - June 2015 Performance by CCG - June 2015 SUSSEX Level 1 Level 2 Level 3 HAMPSHIRE Level 1 Level 2 Level 3

Coastal W Sussex 0 0 0 Fareham 0 0 0 Crawley 0 0 0 North Hampshire 0 0 0

Horsham & Mid Sx 0 0 0 N E Hampshire 0 0 0 Safety Brighton & Hove 0 1 0 S E Hampshire 1 0 0 Eastbourne 1 0 0 West Hampshire 0 0 0 High Weald 0 0 0 Other CCGs 0 0 0 Hastings & Rother 1 0 0 S-E Hampshire 0 0 0 Other CCGs 0 0 0

Performance by CCG - June 2015 KENT Level 1 Level 2 Level 3 Ashford 000 Canterbury 000 Dartford 100 Medway 0 1 0 South Kent Coast 0 0 0 Swale 0 0 0 Thanet 1 0 0 West Kent 0 0 0 Other CCGs 0 0 0

June 2015 4 Specialist Services June 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

Complaints resolved in month 100% Specialist Services (Local indicat or) 80%

Month: June 2015 Target: 85% 60% Resolved within 25 working days or agreed timeframe 40% Complaints resolved this month 21 Resolved within the agreed timeframe 19 20%

% resolved within agreed timeframe 90.5% 0% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Average number of days to resolution 26.9 TRUST - resolved within timeframe Specialist Services resolved within timeframe Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 TRUST 75.0% 71.6% 88.2% 85.4% 90.0% 96.1% 86.2% 87.9% 85.1% 82.5% 69.8% 70.0% 86.9% Complaints received (as at month end) 33 SPECIAL 65.0% 84.6% 82.4% 78.3% 86.7% 100.0% 80.0% 86.2% 86.7% 91.7% 61.9% 79.2% 90.5%

100 Performance by CCG - June 2015

SUSSEX Complaints Resolved Ave Days 80

Coastal W Sussex 3 100.0% 26.0 60 Crawley 40 Horsham & Mid Sx 1 100.0% 19.0 Caring

Brighton & Hove 2 100.0% 28.0 20

Eastbourne 3 100.0% 25.3 0 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

High Weald Specialist new complaints

Hastings & Rother 3 100.0% 26.0 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 S-E Hampshire SPECIAL19191915192023231931272333 Other CCGs 1 100.0% 21.0

Performance by CCG - June 2015 Performance by CCG - June 2015 HAMPSHIRE Complaints Resolved Ave Days KENT Complaints Resolved Ave Days Fareham Ashford North Hampshire 1 100.0% 14.0 Canterbury N E Hampshire Dartford S E Hampshire Medway West Hampshire 5 60.0% 31.6 South Kent Coast Other CCGs Swale

Thanet West Kent 2 100.0% 32.5 Other CCGs

June 2015 5 Specialist Services June 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

Patient Experience Feedback 100% Specialist Services (Local indicat or) 80%

Month: June 2015 60% Month Quarter YTD

40% Caring Friends & Family Test 41 169 169

% Positive 92.7% 88.1% 88.1% 20%

% Extremely Likely 65.9% 55.0% 55.0% 0% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 % Negative 0.0% 4.1% 4.1% % Positive Feedback

% Extremely Unlikely 0.0% 1.2% 1.2% Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 SPECIAL 0.0% 0.0% 0.0% 0.0% 73.7% 82.4% 80.6% 88.8% 93.3% 82.8% 76.8% 98.0% 92.7% Figures reported from September 2014 onwards TARGET 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

CPA 12 month Formal Review 100% Specialist Services (MONIT OR indicat or) 80%

Current Month: June 2015 Target: 95% 60% Month 40% Adults on CPA at end of month 232 Last Review within 12 months 225 20%

% adults with review <12 months 97.0% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

% <12 month Review Target This indicator shows a snapshot position as at the end of Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 the month and is submitted to MONITOR quarterly EIS 94.8% 89.0% 97.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Caring

Performance by CCG - June 2015 Patients Vaild Review % Valid Coastal W Sussex 65 62 95.4% Crawley 19 19 100.0% Horsham & Mid Sx 21 21 100.0% Brighton & Hove 55 52 94.5% Eastbourne 17 17 100.0% High Weald 25 24 96.0% Hastings & Rother 28 28 100.0% S-E Hampshire 0 Other CCGs 2 2 100.0%

June 2015 6 Specialist Services Sussex Partnership Sussex CCG Map NHS Foundation Trust

© Graham Ainsworth - Sussex HIS - December 2012

Population Number of CCG (2013-14) GP Practices Coastal West Sussex CCG 492,515 55

Crawley CCG 127,372 13

Horsham & Mid Sussex CCG 228,231 23

Brighton & Hove CCG 300,900 46

Eastbourne, Hailsham & Seaford CCG 186,798 22

High Weald, Lewes, Havens CCG 166,464 27

Hastings & Rother CCG 183,178 33

South Eastern Hampshire CCG 209,845 26

June 2015 7 Specialist Services

Performance Dashboard

June 2015

Sussex Partnership June 2015 Trust Dashboard NHS Foundation Trust

Page RESPONSIVE

Delayed Transfers of Care - Timely discharge of patients - less than 7.5% MONITOR TARGET 1 MONITOR

MHMDS Data Completeness Identifiers - target 97% MONITOR TARGET 1

MHMDS Data Completeness Outcomes - target 50% MONITOR TARGET 1

WELL LED

Sickness absence - 3.5% or less TRUST-ONLY TARGET 2

Temporary and Agency costs - 11% or less TRUST-ONLY TARGET 2

Income/Expenditure performance against budget TRUST-ONLY TARGET 2

Cost Improvement Plan (CIP) performance against target TRUST-ONLY TARGET 2 SAFETY

Serious Incidents - Reporting on and demonstrating learning No Target 3

CARING

Complaints resolved within 25 working days - target 85% CONTRACTUAL TARGET 3

CPA Patients having a Formal Review at least every 12 months - target 95% MONITOR TARGET 4

Reporting Patient Experience Feedback - Friends and Family Test No Target 4

June 2015 2 Index June 2015 Sussex Partnership

Key Indicators - Responsive/MONITOR NHS Foundation Trust

Delayed Transfers of Care (DTC) 15% (MONITOR Indicator)

Month: June 2015 Target: <=7.5% 10%

Month Quarter YTD Responsive % Delayed 9.9% 9.9% 9.9% 5%

Non-acute adult patients aged 18 and over from AMHS (inc 0% Dementia), LDS and S&F. Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 % delays Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 TRUST 6.7% 6.1% 4.6% 5.2% 4.4% 3.9% 4.6% 4.7% 8.8% 9.8% 10.5% 9.3% 9.9% TARGET 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5%

Data Completeness Identifiers 100% 100.0% 100.0% 99.8% 99.8% 99.7% 99.5% TRUST-WIDE (MONITOR indicator) 99.2% 98% Month: June 2015 Target: 97% MHMDS Identifier Month Quarter YTD 96% MONITOR Commissioner Code 99.5% 99.5% 99.5% 94% Date of Birth 100.0% 100.0% 100.0%

92% Gender 100.0% 100.0% 100.0% Commissioner Date of Birth Gender GP Code NHS Number Postcode TOTAL Code GP Code 99.8% 99.8% 99.8% % valid Target NHS Number 99.8% 99.8% 99.8% Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Postcode 99.2% 99.2% 99.2% TRUST 99.3% 99.5% 99.7% 99.7% 99.7% 99.4% 99.7% 99.8% 99.7% 99.7% 99.7% 99.7% 99.7% TARGET 97.0% 97.0% 97.0% 97.0% 97.0% 97.0% 97.0% 97.0% 97.0% 97.0% 97.0% 97.0% 97.0% TOTAL 99.7% 99.7% 99.7%

Data Completeness Outcomes 100% 96.8% 95.3% 94.7% TRUST-WIDE (MONITOR indicator) 92.5% 80%

Month: June 2015 Target: 50% 60%

MHMDS Outcome Month Quarter YTD MONITOR 40% Accommodation 96.8% 96.8% 96.8% Employment 95.3% 95.6% 95.6% 20%

HoNOS 92.5% 92.3% 92.3% 0% Accommodation Employment HoNOS TOTAL

TOTAL 94.7% 94.8% 94.8% % valid Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15

TRUST 90.7% 91.7% 90.5% 90.3% 89.4% 88.5% 88.3% 88.1% 87.4% 86.5% 87.9% 91.4% 94.7% TARGET 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0%

June 2015 1 Trust-wide Performance June 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

Sickness Absence 6.5% TRUST-WIDE (Local indicator) 6.0%

5.5% Month: May 2015 Target: <=3.5% 5.0%

Month Year 4.5% Well Led Current year absence rate 3.90% 4.00% 4.0% Last year absence rate 3.97% 4.22% 3.5%

3.0% Reported one month in arrears. The 2014-15 year figure is 2.5% for the whole 12 month period. May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15

Trust Absence rate Absence rate (previous 12 months) Target

May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 TRUST 3.74% 3.39% 3.54% 3.32% 3.85% 4.10% 4.39% 4.99% 5.30% 5.10% 4.98% 4.10% 3.90% TARGET 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

Temporary Costs (Bank & Agency) 20% TRUST-WIDE (Local indicator) 15% Month: June 2015 Target: 11%

Month YTD 10% Well Led Temporary Spend 11.10% 11.01% Agency Spend 4.28% 4.07% 5%

0% Agency and temporary staff spend as a proportion of the total Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 pay bill. Target is to maintain this below 11%. Temporary Costs - Trust Agency Spend - Trust Target

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 TRUST 10.88% 11.14% 11.10% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% AGENCY 4.26% 3.68% 4.28%

Income/Expenditure Budget £1,500 TRUST-WIDE (Local indicator)

£1,000 Month: June 2015 £K

YTD £500 Well Led (000s)

£0

Income/Expenditure Variance 819 -£500 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

YTD Variance against I&E Budget - Trust

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 Target is breakeven for the month and YTD TRUST 300 435 819 000000000

Cost Improvement Plan (CIP) 100% TRUST-WIDE (Local indicator)

80% Month: June 2015 YTD 60% Well Led

(000s) 40%

CIP Target 2,931 20% CIP Achieved 877 0% CIP % Achieved 29.9% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 CIP Recurring/Non-recurring - Trust Target

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 Recurring and non-recurring actual costs YTD against plan TRUST 0.00% 28.83% 29.92% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% TARGET 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

June 2015 2 Trust-wide Performance June 2015 Sussex Partnership

Key Indicators - Safety/Caring NHS Foundation Trust

Serious Incidents - reported in month 40 TRUST-WIDE (Local indicator) 35

30

Month: June 2015 25

All Serious Incidents Level 1 Level 2 Level 3 20

Sussex (Adult) 15 13 0 15 Sussex (Specialist) 2 1 0 10 5 Hampshire (Specialist) 1 0 0 0 Kent (Specialist) 2 10 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 TRUST Level 1 SIs TRUST Level 2 SIs Corporate 10 0 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 TRUST 21 15 0 Level 1 11 11 6 6 9 7 3 4 9 26 14 18 21 Level 2471114766471313815 Safety

April May June Level 1 Level 2 Level 3 Total Level 1 Level 2 Level 3 Total Level 1 Level 2 Level 3 Total Serious Incident Category Accidental Event 000000000000 AWOL 300310011001 Drug Error 000000000000 Fall, Slip, Trip 100160064004 Ill Health 100110010000 Fire 100100000000 MH Act Break 000010010000 Privacy and Dignity (inc CAMHS beds)600640043003 Security & Information Governance200221035005 Self Harm 020220026006 Unexpected death 09090707015015 Violent Incident 021310012002 TOTAL 14 13 1 28 18 8 0 26 21 15 0 36

Complaints resolved in month 100% (Local indicator) 80% Month: June 2015 Target: 85% 60% Resolved within 25 working days or agreed timeframe Complaints resolved this month 61 40%

Resolved within the agreed timeframe 53 20% % resolved within agreed timeframe 86.9% 0% Average number of days to resolution 24.8 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 TRUST - resolved within timeframe Target

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Complaints received (as at month end) 79 TRUST 75.0% 71.6% 88.2% 85.4% 90.0% 96.1% 86.2% 87.9% 85.1% 82.5% 69.8% 70.0% 86.9% TARGET 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% Caring

100

80

60

40

20

0 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Trust new complaints

Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 TRUST49574751534978636289585979

June 2015 3 Trust-wide Performance June 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

CPA 12 month Formal Review 100% (MONITOR indicator) 80% Current Month: June 2015 Target: 95% 60% Month

Adults on CPA at end of month 2,737 40% Caring

Last Review within 12 months 2,678 20% % adults with review <12 months 97.8% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 This indicator shows a snapshot position as at the end of the % <12 month Review Target month and is submitted to MONITOR quarterly Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 TRUST 88.7% 90.6% 97.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Patient Experience Feedback 100% Trust-wide (Local indicator) 80%

Month: June 2015 60% Month Quarter YTD

Friends & Family Test 155 487 487 40% Caring % Positive 92.9% 88.9% 88.9% 20% % Extremely Likely 60.6% 55.6% 55.6% 0% % Negative 3.9% 5.1% 5.1% Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 % Positive Feedback % Extremely Unlikely 0.6% 1.0% 1.0% Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Figures reported from September 2014 onwards TRUST 0.0% 0.0% 0.0% 78.9% 86.4% 83.4% 84.0% 90.7% 89.3% 85.7% 83.4% 91.1% 92.9% TARGET 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

June 2015 4 Trust-wide Performance ` Sussex Partnership NHS Foundation Trust Board of Directors: 29th July 2015 - Public Agenda Item: TBP36.4/15 Attachment: H For Information By: Sally Flint Executive Director of Finance and Performance

IN CONFIDENCE

PERFORMANCE REPORT – Quarter 1, 2015-16

Trust Corporate Business Objectives Report – Q1 2015/16

SUMMARY & PURPOSE

This report reviews the Trusts performance against the Trusts Corporate Business Objectives. At the end of June 2015, of the 31 corporate business objectives for 2015/16, 18 are fully met, 11 are partially met and 2 are not achieved

LINK TO ANNUAL PLAN

This paper reviews performance against all of the Trusts Corporate Business Objectives which are also aligned to the 2020 vision.

ACTION REQUIRED BY BOARD MEMBERS

The Trust Board is asked to:  Review the performance of the organisation as reported and ask any questions of the responsible Executives (EMB lead), as described in the quarterly report

Page 1 of 1 Corporate business objectives 2015 - 2016

Quarter 1 update

@withoutstigma www.sussexpartnership.nhs.uk Strategic Goal 1: Safe, Effective, Quality Care

Ref Lead Deliverable Target

1.1 To deliver our 5 Sign up to safety pledges: Put safety first; Continually learn; Honesty; Collaborate; Support

Publish improvement plan, to incorporate 1.1.1 EDNQ Plan completed end May 2015 (Revised to end Q2) G CQC feedback and concerns from other stakeholders.

Following the Quality summit that was hosted by the Care Quality Commission in May, the Quality Improvement Plan is now in development. The Plan is to be presented to the

Q1 board in September, target for completion has been revised to the end of Q2 due to the timing fo the CQC report. Position

Develop a Sussex Partnership Suicide Prevention Strategy by Strategy presented to Trust Board by end Q1 1.1.2 EDNQ A end Q1. To include an agreed methodology for reporting suicide rates Monitoring by end Q2 (University of Manchester guidance)

The draft Suicide Strategy has been written and will be presented to the Trust Board in September. Baseline data has been established which will inform the identification of

Q1 the reduction target. Position

G 1.1.3 EDNQ Safety Thermometer in active use in all wards Fully complete over next 12 months. Wards / Teams submitting data The Trust is on target to have all wards and community areas completing the 100 Safety Thermometer by the end of the year. The data is reported in the quality and safety reports. Briefings have been shared with all staff and the Director 50 of Nursing Standards and Safety has visited ward areas to discuss how the Safety Thermometer is used. The active use of the Safety Thermometer is an Q1 Position Q1 area for more targeted work in quarter 2. 0 Apr‐15 May‐15 Jun‐15

Page 1 of 12 Strategic Goal 1: Safe, Effective, Quality Care

Ref Lead Deliverable Target

Develop a Sussex Partnership Strategy to reduce slips, trips and Strategy presented to Trust Board by end Q1, including the agreement of improvement 1.1.4 EDNQ A falls targets. Monitoring by Q3

After a 3 month pilot of new falls paperwork and guidance which are NICE compliant, the Trust is now in the process of rolling out the new falls bundle across 42 sites, covering all care groups. The target date for full implementation is 31st August, and as of June 35% of the sites have been implemented. The approach taken is that all sites are visited by one or both of the falls leads, and receive a benchmarking report on the number of falls in their area for the last quarter. This will be repeated at Q2 in order to monitor the number of falls and evaluate the revised protocol. The falls steering group is in the process of agreeing falls guidance for

Q1 Position Q1 community staff, as well as agreeing Trust guidance for aids such as falls sensor mats, patient wristbands, and cushioned flooring.

The proportion of actions from serious incident reviews signed Develop baseline in Q1 and agree an improvement target. 1.1.5 EDNQ G off as completed within the agreed timeframe. Monitoring from Q2

Of the 15 Action Plans submitted for SIs that occurred in Quarter 1 15-16, there were 36 actions identified. Of those actions there are 16 that are not yet due, 16 were

Q1 completed in the agreed timeframe and 4 on-going actions that have no end date. Position

Set up a process to monitor that we are being open and honest with patients and families in 1.1.6 EDNQ Evidence of genuine candour and learning G Q1

A monitoring and reporting system against the Duty of Candour requirements has now been established and is in use. Timely compliance with the written aspect of Duty of Candour (DoC) regulations continues to be a concern. This is for a variety of issues including lack of next of kin details, delays in allocation of reviews and most frequently the delay in which services report serious incidents. Staff have been provided with letter templates and briefings. Manager and senior clinicians have received DoC specific training. An e-learning package is currently being developed and further training has been arranged for matrons. Q1 Position Q1

Page 2 of 12 Strategic Goal 1: Safe, Effective, Quality Care

Ref Lead Deliverable Target

Share learning from serious incident reports with key partners A 1.1.7 EDNQ 90% of SI reports achieving internal sign-off within 45 working days 90% of SI reports completed and shared with commissioners in 60 working days

The SI process has been streamlined and the quality improved by the introduction of panel reviews for all unexpected deaths; feedback from staff regarding these has been very positive. All SI reports have offered the SI reports signed‐off internally within SI reports submitted to commissioners opportunity to both families and GP for their contribution. Timeliness of the agreed timeframe in 60 days completion of SIs has improved but there continues to be delay particularly at 100% 100% allocation stage by services, this is currently under review. 50% 50%

Q1 Position Q1 6 out of 23 serious incidents reports due for internal sign-off in Q1 were signed off within the agreed timeframe. 8 out of 18 serious incident reports 0% 0% due to be shared with commissioners in Q1 were shared within the 60 day Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 target, (for serious incidents that occurred after 1st April 2015).

1.2 Improving experience for people who use services

Patient Experience: Monitor and show improvement in the Areas showing below average performance to demonstrate improvement over the year. 1.2.1 SDSC G following question, measured using the Friends and Family test. • “Would you recommend this service to friends and family?”

Care Delivery Service (CDS) leads now receive a monthly report that has two graphs dedicated to highlighting feedback in relation to the patient friends and family test. In Q2 the Trust will be analysing the results from Q1 and liaising with CDS's where performance is below average. This work will continue throughout the year. Work in on-going, with the support of the communications team, to promote completion of the National Patient Survey. This survey will highlight where adult community services are in relation to involving service users in care planning. Q1 Position Q1

Page 3 of 12 Strategic Goal 1: Safe, Effective, Quality Care

Ref Lead Deliverable Target

Carers: 1.2.2 SDSC G Carry out a survey to establish baseline engagement and Survey planning with partners in Q1 involvement in care for Carers. Survey complete in Q2

Develop an action plan based on Q2 survey. Action plan complete in Q2 Carry out a survey to demonstrate improvement. Repeat survey in Q4

With regards to Adult Services the Trust has worked closely with Health Watch and Carers organisations across Sussex in designing and planning a questionnaire which will be undertaken in Q2 using both paper and online formats. Work has been undertaken with Children and Young People's services (ChYPS) to revise the friends and family test Q1

Position (FFT) questions and will be having a carers focus for FFT in ChYPS during a planned period in Q2.

1.3 Achieve a measurable improvement in physical health for those using our services

Medical Early Warning Signs (MEWS) in place in all wards by 31 Improved physical healthcare of our patients 1.3 EMD G December 2015.

Mews is in place in all inpatients units with variances in adherence to protocol. Work continues to promote this tool to aid the early detection of clinical deterioration and initiation of timely responses. Facilitated Master class workshops have been introduced to support this, the first of which was held on 13th May and was attended by 40 staff members; a further class is booked in August due to demand. Future Plans are to evaluate and revise the current MEWS tool adopting a task and finish group methodology to include representation from all Care Delivery Services across all bands and the designated Audit team lead. A bespoke tool is to be developed for Children and Young Peoples services following best practice guidance and PEWS-(Paediatric Early Warning Scoring System). This work is in the early stages and will be reported in detail in future reports Q1 Position Q1 once piloted

1.4 Continue to improve the crisis care pathway

Reduction of 5% in unplanned readmissions to hospital within 28 Work closely with service users, carers, the Police, Ambulance Trust, GPs and other G 1.4 EMD days of discharge partners to improve the crisis care pathway, 24/7, 7 days a week.

An internal workshop across Specialist and Adult Services to review crisis care pathways was held in Q1. All Care Delivery Services, as part of their Business Planning, are working with a wide range of stakeholders and partners to deliver improved pathways and respond to the requirements of the local Crisis Concordats. Crisis pathways and the role and function of local crisis team are being reviewed as part of the Acute Action Plan. A review of the internal Mental Health Helpline is to be launched in Q2. Q1 Position Q1

Page 4 of 12 Strategic Goal 1: Safe, Effective, Quality Care

Ref Lead Deliverable Target

1.5 Making changes to the delivery of care as a result of learning from Clinical Audit

To implement a tracing system to check that SMART actions Quarterly reporting: 90% of actions are implemented by the agreed date. A 1.5 CAD following clinical audit agreed, owned and implemented by a specified date. In this way we can be sure that services learn and improve.

65% of actions have been implemented by the specified date. The tracking system is in place and monthly dashboard reports detailing unmet actions are reported to division leadership and governance groups. These are forwarded to service Boards in Adults, CHYPs and Specialist Services quarterly. It is expected that the systyem and processes in place will address the shortfall and that 90% of actions will be implemented by end of year resulting in improvement to the quality of service user experience as a result of clinical audit. Q1 Position Q1

1.6 Successful implementation of Care Notes

CHYPS Services go live August 2015 G 1.6 CAD Carenotes rolled out to all services by March 2016 Adults and other services by December 2015 All Services by March 2016

Carenotes went live across Sussex, Kent and Hampshire CAMHS on the 13th July. Other services are expected to go live in November. Q1 Position

1.7 Care Quality Commission Hospital Inspection

Address compliance notices and areas highlighted for Q1 – Quality Summit 1.7 ALL G improvement by Care Quality Commission Q2 – Action plan agreed and being implemented Q4 – Address all compliance notices

The Quality Summit hosted by the Care Quality Commision (CQC) took place on May 22nd. As required by CQC, the Trusts action plans for each required area were returned

Q1 to CQC on June 30th and are now published on our website. Quality Improvement Plan is now in development, to be presented to the board in September. Position

Page 5 of 12 Strategic Goal 2: Local, joined up care

Ref Lead Deliverable Target

2.1 Joint working with Commissioners and partners to ensure we meet the needs of each local population Quarterly update Business plan aligned to Commissioner plans by Quarter 4. 2.1 ALL G Feedback from partners Evidence of our shaping services directly as a result of partnership Local community plans developed with partners by Quarter 4 working

The Care Delivery Service (CDS) development programme has been launched in Adult Services in Q1. Each divisional leadership team will deliver a series of workshops in

Q1 localities to develop the CDS Business Plans. These plans will need to align with local Commissioner plans and those of other partners agencies and stakeholders. Position

2.2 Increase ownership and engagement of clinical services by devolving decision making to clinical teams.

A 2.2 EDFP Quarterly update Care Delivery Service Programme established by April 2015 Each Care Delivery Service will have a development plan by June 2015 and for this to include a target milestone for completion of CDU implementation by December 2015. Each Care Delivery Unit operating (with or without conditions) by December 2015

The Care Delivery Service (CDS) programme has been established. Secure and forensic services was accredited as a CDS in Q1. Readiness meetings for CDS accreditation are

Q1 taking place with other services during July. Development plans for each CDS are being agreed at the readiness meetings. Position

2.3 Deliver evidence based clinical pathways MDAS 2.3 Quarterly update Clinical care pathways available for each local population and patient group. A MDSS

Within Adult Services, the development of the four core clinical care pathways is a key work stream of both the Adult Services Transformation Group and the Acute Services Action Plan. Operational and Executive leads have been identified and work stream activity is on-going within Q1. The development work runs in parallel to the creation of the Clinical Academic Groups; which will support the formation of the core care pathways. Planning is in place to deliver masterclasses in psychosis treatment and management to support the development of the pathways.

Q1 Position Each of the Specialist Services Care Groups and Secure and Forensic Care Delivery Service has work underway to develop clinical care pathways. For some, this work is at an advanced state and in others work is ongoing to finalise their key pathways. It is anticipated that all care groups will have finalised their respective pathways by the end of Q2. These will be ratified in Q3 with implementation throughout Q4

Page 6 of 12 Strategic Goal 2: Local, joined up care

Ref Lead Deliverable Target

2.4 Establish lively local community fora so that we can listen to and act on feedback Work with local Health-watch groups, Clinical Commissioning Groups, and the Care Delivery 2.4 SDSC Quarterly update G Units to establish community engagement and listening fora for each local population.

20- 20 Vision engagement events are taking place at venues across Sussex, Kent and Hampshire. In addition the Trust is working closely with local Healthwatch groups in responding to concerns, requests for information or formal reports. The Trust also supports a number of enagement forums, for example, the Service User Reference Group in Adult mental health services; and community organisations are well represented in the Reference groups supporting the Equality Performance Strategy. A major engagement event is being planned for World Mental Health Day in October. Q1 Position

2.5 Each Care Delivery Unit to have their own service plan MDAS Each Care Delivery Service’s business plan will describe their key service offer, outcomes 2.5 Quarterly update A MDSS and delivery plan agreed in accordance with the milestones in their development plan (see 2.2)

Preparation workshops have taken place for all five Adult Service Clinical Delivery Services (CDS) during Q1. The workshops launched the CDS toolkit to support the development of the Business Plan for each CDS. During Q2 all shadow CDS's will deliver development workshops to facilitate the production of the Business Plan for the CDS.

Each of the Specialist Services Care Group and Secure and Forensic CDS has developed a service plan. Each plan describes the service offering or product along with an

Q1 Position analysis of the stakehlder groups. These plans include service priorities and mechanisms for enagagement. Secure and Forensic CDS, Children and Young People Services, Learning Dissability Services and the Nursing Home Service are complete. Work is continuing to finalise Complex Care Pathways service plan by the end of Q2.

Page 7 of 12 Strategic Goal 3: Put research, innovation and learning into practice

Ref Lead Deliverable Target

3.1 Increase compliance with mandatory training requirements through Trust wide adoption of a new Learning and Management System

A 3.1 CAD Mandatory training compliance dashboard. Q4 Achieve 75% compliance

The new Learning Management System 'My Learning' went live on 30th April 2015. Staff are logging on in increasing numbers and teams are being supported to build the correct hierarchies (management reporting lines) into the system. The new system moves the Trust from a position where infrastructure was the main limiting factor on core mandatory training compliance to one where human factors (time release, motivation and instruction to complete) are the main limiting factors. We set ourselves the trajectory of 40% compliance at the end of Q1 for all core mandatory areas. 7 out of 23 core mandatory areas are currently achieving at least 40% compliance, with Health and Safety Awareness training achieving 71% compliance at the end of Q1. During Q2 core mandatory training reporting will be included in Q1 Position local performance contract reports, which will drive local management action to increase compliance.

3.2 Establish the Clinical Academic Groups (CAGS) CAGS in place by end of Quarter 1. Terms of reference and membership approved by 3.2 CAD Report outcomes achieved to Transformation Board G Transformation Board.

The leadership of the CAGS and terms of reference have been agreed by the Executive Management Board. The implementation of the groups is well underway with

Q1 Q1 an expectation that all groups will be established by the end of the year. Formal agreement of the chairs of the CAGs is yet to be finalised due to a delay in funding. Position

3.3 Develop and implement Trust approach and capabilities for continuous improvement drawing on best evidence and methodologies.

A 3.3 DSI Continuous improvement plan Improvement approach and capabilities plan by end of Quarter 1 Strategic partner to support continuous improvement secured by end of Quarter 2

A paper will be presented in relation to the Lean Programme to the Executive Transformation Board on the 28th July. Q1 Q1 Position

Page 8 of 12 Strategic Goal 4: Be the provider, employer and partner of choice

Ref Lead Deliverable Target

4.1 Improving staff engagement Improve the response rate to the Staff Friends and Family Test to G 4.1 EDCS Create a listening and responsive culture supported by the staff engagement strategy and 50% of employees surveyed by quarter 4. workforce strategy Improve friends and family test scores on staff recommending the Introduce Listening into Action model trust as a place to work by 5% across all 4 quarters. Reinforce work in teams

Staff Survey Response Rate Staff Engagement and Workforce Strategies have been approved by the Trust Board in Q1. Implementation of these strategies is being monitored through the 100% For the Q1 staff friends and family People Committee. test, corporate staff were invited 50% A Listening into Action (LiA) Coordinator has been appointed and the to complete the survey. 107 staff completed the survey, out of 338 Q1 Position implementation plan for Listening into Action is on target. Wide staff 0% engagement has been achieved through LiA conversations in Q1. Q1 Q2 Q3 Q4 invited

4.2 Development of skills and behaviours in line with our Trust values Completion of appraisals set at 85% by end Qtr 1 based on current 4.2 EDCS Organisational development programme supporting accreditation of care delivery units R reporting methods. Dissemination of values and behaviours in teams through the review of appraisal Improve % of staff having well-structured appraisals from 39% to documentation, the implementation of the behaviours framework, and putting a further 80 50% by end of Q4 (Staff Survey results 2015) managers through the leadership development programme by the end of Q4.

The Organisational Development Strategy and Programme for 2015/16 is in place. Organisational Development leads are establishing development programmes with each Care Delivery Service (CDS) according to assessed need. These programmes are being co-designed with each CDS.

Data on the completion of appraisals by the end of Q1 will be reported in August using a survey of 100 staff. Future quarterly reports will include data based on appraisal dates

Q1 Position uploaded by all staff onto My Learning (the new Learning Management System).

Page 9 of 12 Strategic Goal 4: Be the provider, employer and partner of choice

Ref Lead Deliverable Target

4.3 Recruiting and retaining of high calibre staff Reduce level of turnover of joiners within the first two years of 4.3 EDCS G service from 27% to 20% by Q4 Developing and implementing CDU-based retention strategies and increasing opportunities in hard to recruit areas. Improving retention of staff in areas with very high turnover Reduce time to hire to 14 weeks by end of Q3.

Figures on the turnover of joiners within the first two years of service are not yet Trust Time to Hire (weeks) 15.0 available. Target 14 weeks by end Q3 12.5 The time to hire for the Trust has decreased from between 14 and 15 weeks in the first two months of the quarter to 13 weeks in June 2015; it is not yet clear if Q1 Position 10.0 this represents a sustained improvement. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

4.4 Improving working environments and the wellbeing of staff Reduce sickness absence days lost by reviewing the occupational health and employee 4.4 EDCS Reduce sickness absence days lost to 3.5% by end of Q4 A assistance programme contracts to focus on prevention and health promotion rather than just Improve results of staff survey on work pressures from 3.28 to 3.07 reactive sickness interventions. (National average) Develop and implement CDS-based health and wellbeing strategies to address local issues such as stress and anxiety and MSK.

Trust Sickness Absence Rate Full Q1 figures for sickness absence rate will not be available until August. The current trend for April/May shows a reduction in sickness absence to around 5.0% 4%, with 3.9% in May. The Care Delivery Services (CDS) are in different Target 3.5% 2.5% stages of development in terms of their health and well-being strategies. Each Q1 Position CDS will have a local strategy by the end of Q2. 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

4.5 Delivering intelligent workforce information triangulated with quality and financial data to determine trends/risks Produce KPI information for the Care Delivery Services dashboard to ensure triangulation of 4.5 EDFP Delivery of required information by Qtr 2 G information.

The performance team have produced CDS reports that describe performance against a range of quality, financial and workforce indicators. These reports include a review of performance against a rolling three months, to encourage a more tactical focus on key issues. These are being used at the monthly performance meetings to provide robust Q1

Position debate.

Page 10 of 12 Strategic Goal 5: Living within our means

Ref Lead Deliverable Target

5.1 Maintain sound financial performance to deliver financial governance and stability

A 5.1 EDFP Continuity of Services Rating of 3. Rating of 3.

A rating of 3 has been achieved overall, although the capital service rating is 1, compared to the planned rating of 2. This is due to the deficit position. Q1 Position

5.2 Fully deliver the agreed cost improvement programme.

R 5.2 EDFP Cost savings Q4: £11.75m by 31.03.16

We have delivered £878k recurrent savings compared to the planned level of £2,930k, therefore a shortfall of £2,052k. The main variances relate to the following three areas:

Q1 overspend in inpatient units, external placements and the slow progress on service re-design in Adult Services. Position

5.3 To meet contracted levels of performance

G 5.3 EDFP Contractual targets and standards No penalties or remedial action plans approved with Commissioners

No contractual penalties have been received. Q1 Position

5.4 To improve effectiveness and efficiency of our office services

G 5.4 EDCS Cost savings Conclude admin services review and implement recommendations

An 18 month programme of review and implementation is taking place over 2015/16 and 2016/17. A model has been proposed including job roles, bandings and the centralisation of key prcoesses including referrals. Wide admin staff engagement has been undertaken. The Q2 programme will include clincial engagement, detailed referral mapping processes and defining estates support solutions. The business case is to be completed by December 2015. Q1 Position

Page 11 of 12 Key: Executive management team abbreviations

CAD Clinical Academic Director CE Chief Executive CS Company Secretary DSI Director of Strategy and Improvement EDCS Executive Director - Corporate Services EDFP Executive Director of Finance and Performance EDNQ Executive Director of Nursing and Quality EMD Executive Medical Director MDAS Managing Director - Adult Services MDSS Managing Director - Specialist Services SDSC Strategic Director - Social Care and Partnerships

Page 12 of 12

Board of Directors: 29 July 2015 – Public Agenda Item: TBP36.5/15 Attachment: I For Information By: Helen Greatorex, Executive Director of Nursing & Quality

LEARNING FROM SERIOUS INCIDENTS

INTRODUCTION & SUMMARY

The June Board of Directors meeting formally received the Annual Serious Incident report.

A request was made that an additional paper be presented to the next Board meeting, setting out how learning from Serious Incidents is not only captured, but shared across the Trust as a whole, and changes made to practice as a result of learning.

The attached paper includes examples of learning and changes made as a result of Serious Incidents drawn from a range of services.

LINK TO ANNUAL PLAN

Safe, Effective Quality Care

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to consider the paper presented, endorse the direction of travel and ask questions of the executive.

Board of Directors: 29 July 2015 – Public Agenda Item: TBP36.5/15 Attachment: I For Information By: Helen Greatorex, Executive Director of Nursing & Quality

LEARNING FROM SERIOUS INCIDENTS

Learning from Serious Incidents

Immediately an SI is reported, a senior manager (Service Director or equivalent) takes the lead in ensuring that any urgent local action required is taken. Depending on the nature of the incident, this could include providing immediate support to relatives and staff, securing notes, allocating additional staff. They will also identify the most appropriate person to take on the role of Lead Investigator.

The time permitted to investigate, write the final report for and close a Serious Incident depends on the initial grading it has been allocated. For the most serious, (Level 2), SIs, 45 working days (eight calendar weeks) is permitted. For Level 1 SIs, 30 days (six weeks) is allowed.

This does not however mean that the Trust waits until 45 days before sharing learning or changing practice where that is found to be needed in the immediate aftermath of an incident. Table 1 sets out examples of learning identified and action taken following SIs over the last two years.

The majority of Lead Investigators are trained in Root Cause Analysis methodology, (RCA). This prescriptive and systematic approach to setting out the chronology of events is nationally recognised as good practice.

The lead investigators’ final report, signed off by the Clinical Director for the service, generates an action plant with local and Trustwide actions.

Trust policies are revised in response to recommendations from reviews. Examples of policies revised following SIs include Incident Reporting, Inquests & Claims, Clinical Risk Assessment, Trips, Slips & Falls, Adult Safeguarding, AWOL, Observation, Patient & Property Searching, Improving Physical Health and the Being Open Policy.

Building On, and Building In, Assurance Once an action plan is complete and a team monitoring its delivery, the Governance Support Team agree how to test the embeddedness of the required change. The annual audit program is designed to achieve this and examples of audit testing changes made after SI recommendations include audits of supervision, record keeping and documentation, observation and the use of the Medical Early Warning Signs tool. Findings from audits are shared with teams and reported to the Quality Committee.

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TABLE 1: Serious Incidents, Learning and Changed Made

Incident Incident Summary Learning & Changes Made Type/Service Information Screenshot of map captured  Service stopped using screen Governance patient details in the image which shots and provided links to Google was emailed out to patients inviting maps them to an appointment.  Admin trained on use of screen shots and cropping functions  Service now working more closely with IG. All staff have completed their IG training Information Common room incident – staff  Common room closed Governance across the Trust saving patient  All staff contacted to advise of the identifiable data in the common seriousness of the breach and room folder, accessible by all staff advise on good practice when saving patient information  Common room now continually monitored by IG team to ensure no further reoccurrence  All staff IG trained  Promoted good working relationships with IT and Comms  IG training updated to reiterate good practice guidance on saving patient information Information Use of social media – member of  New social media policy Governance staff tweeted a picture of a cheque introduced (personal information) without  IG training updated to reflect new express consent of cheque donor policy

Mental Health Invalid detention caused by a  Office processes streamlined and Act (MHA) failure to detect an error on a process document in place to paperwork on admission, and on support staff first and second scrutiny  MHA Audits undertaken by MHA staff and reported to MHA Committee  Bite size training delivered to staff by MHA team to raise awareness of MHA processes. Substance Client being treated for alcohol The S.I found that this client had an Misuse dependence self discharged from historical addiction to heroin IV and Community residential rehab and died after a was prone to occasional use. The key heroin overdose. recommendation was that any historical use of heroin would trigger a Naloxone mini-jet being given to the client using the Patient Group Direction. This was adopted across the treatment system and care pathway with immediate effect.

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Substance The small child of a couple recently  The S.I highlighted a range of Misuse engaged in treatment sustained a learning points for the whole Community very serious head injury as the treatment system (SPFT and 3rd result of a fall. sector partner agencies). It also came a year or so after an earlier near miss (chip pan fire).  Despite initial learning this second S.I highlighted that the whole child protection/safeguarding pathway was not robust enough and needed system wide change in the service.

The learning from the S.I review led to:

i) formation of a regular Safeguarding Children's Hub- responsible for overseeing all issues related to the treatment population, training and audit activity in addition to regular case discussion and advice for practitioners. ii) periodic audits of the relevant paperwork and its quality linked to recommendations for training and re- audit. The audits showed an incremental improvement in standards across all agencies. iii) improved quality of Multi-Agency Safeguarding Hub liaison and referral content.

Child & A cluster of S.I reports was  A key theme was that the quality Adolescent reviewed to analyse whether there and consistency of documentation Mental Health were themes or commonalities for especially risk assessments was in Services / learning and service need of improvement. Early improvement/development.  A comprehensive review has been Intervention set in motion that is designed in Psychosis around training and audit i.e staff commitment as opposed to compliance to ensure that this fundamental element of care is embedded and sustainable.  Further audit is programmed.

Inpatient A patient died of physical health A key learning point was that Medical Substance issues (cardiac) shortly after Early Warning Signs (MEWS), Mis-use admission monitoring and assessment should always be done at the outset of admission regardless of whether the full medical admission has been completed and as happened in this case the patient requested to rest before observations were taken. The

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Ward re-instated admissions being undertaken jointly by nurses and doctors so a joined up admission plan is agreed and specific observations agreed for each patient.

Prison An inmate unexpectedly went Following S.I review it was agreed that Healthcare AWOL and was subsequently the service adopt GAD7 and PHQ9 as found deceased after hanging tools for monitoring mood. In this case himself where he had originally the person had reported "low mood" lived but there was no way of measuring this either for severity or for a baseline to review against.

The routine use of evidence based assessment tools has improved the safety of the service.

In addition to the overview in Table 1, a series of examples of learning in action are appendixed to this report:

Appendix 1: B&H Acute Service Briefing on Administration of Insulin & Monitoring Appendix 2: Caburn Ward: Improving Safety in mental Health Collaborative Appendix 3: Procedure if patient is suspected/known to be AWOL Appendix 4: Patient Safety Alert – the Stay Live App Appendix 5: Unexpected Patient Deaths in Crisis Teams in SPFT – An exploratory Audit Appendix 6 – Engagement & Observation Policy Update Appendix 7: Urgent Message from Helen Greatorex and Dr Tim Ojo – three key points Appendix 8: Fire Safety in inpatient units Appendix 9: Patient Safety Alert – Observation & Engagement

Summary & Conclusion

Consistent work over the last six months is showing improvements in both the Trust’s ability to demonstrate and test learning from SIs. With the development of Care Delivery Services and Sign up to Safety, this will be further strengthened.

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SERIOUS INCIDENTS QUESTIONS AND ANSWER OVERVIEW

Q Is there a standard definition of an SI?

A Yes there is. NHS England use the following definition:

A Serious Incident is defined as ‘an incident that occurred in relation to NHS funded services and care resulting in an unexpected or avoidable death or serious harm to one or more patients, staff or members of the public; a provider organisation’s ability to continue to deliver healthcare services; allegations or incidents of physical or sexual assault or abuse; adverse media coverage and/or one of the core set of Never Events’

Q What is a ‘Never Event’?

A Never Events are serious incidents that are viewed as being wholly preventable because the existing guidance or safety recommendations provide strong systemic protective barriers. Never Events in general acute settings include wrong site surgery, retained instruments in the patient’s body after a surgical operation and wrong route administration of chemotherapy.

Q What are the Never Events in Mental Health Settings?

A Currently there are two specific Mental Health Never Events; 1. Failure to install functional collapsible shower or curtain rails 2. Escape from within the secure perimeter of medium or high secure mental health facility

Q Who decides what is and is not an SI?

A The Director of Nursing Standards and Safety and her team use a nationally agreed matrix to grade all incidents.

Q Are there different types of SI?

A Yes there a range of incidents meet the criteria to be reported as an SI. They include serious breaches of Information Governance (for example, a confidential letter being found by a member of the public) as well as unexpected deaths whilst in our care, assaults or violent incidents and homicide.

Q How and to whom are they reported?

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A SIs are reported via the National Report and Learn System (NRLS) using a national form. This is sent to our Clinical Commissioning Groups, CQC and NHS England and internally to all senior clinicians and managers

Q How many SIs do we have a year?

A SPFT reported190 in 2014.

Q How does that number compare to other similar sized trusts?

A NHS England do not currently share this information so the only means of finding out currently how we compare is by agreeing with other trusts that it would be helpful to share information. We are part of a network that is currently working towards that aim.

Q What happens immediately an SI is reported?

A When an SI is reported immediate actions are taken to reduce any further harm occurring. This is always at a number of levels, the first being on the ground and in the team who reported the incident. Checking and or changing equipment, local processes or how a team works are all potential immediate changes. These are communicated quickly and if a similar incident could happen in another part of the Trust, the learning immediately shared.

Q What is the Trust doing about the CQC’s feedback on its SI learning processes?

A We listened carefully to what CQC told us. There were two main themes in relation to SIs. The first was that our practice in relation to sharing learning following an incident was variable. They found some teams who had well organised learning and feedback mechanisms following an incident but this approach was not consistent everywhere.

They told us too, that our systems for signing off final investigation reports was not consistently efficient.

We are working on both themes and our Sign up to Safety campaign (part of a national, CQC, Monitor and NHS England campaign) sets out our plan to learn from the best practice nationally and build our processes to match them.

This work is already underway and our first, annual Report and Learn Live event, focusing on learning from SIs is in September. The Board of Directors is receiving regular updates on progress, as is the Quality Committee.

Brighton and Hove Acute Service Briefing on Administration of Insulin and Monitoring

Following these incidents we have had support Dear Colleagues and advice from the hospital pharmacists who

Near Miss Serious Patient Safety Incidents will be providing ward based training and awareness. We have recently had 2 serious near miss incidents on the acute wards involving the In addition we will be working with the administration of short acting insulin. These Governance and Nursing Directorate to incidents resulted in patients developing a consider appropriate training for nursing staff to hypoglycaemic state which could have resulted enhance the skills and knowledge of nursing in significant harm and potentially death. staff. We will update you with information on this training and in the meantime ensure that Medical staff intervened in both these incidents you are aware of the following: which averted a tragic outcome. Although physically both patients did receive emergency Qualified nursing staff will be responsible for the treatment and have recovered physically the administration of all medications experience was distressing for the patients and and will be responsible to their nearest relatives. ensure that they are knowledgeable about the Procedure for the Administration of Insulin medication, side effects and and Monitoring of Patients monitoring following administration. We advise all It is vital that all qualified nursing staff are qualified nursing staff to be

aware of the guidance for the administration of aware of the NMC Standards for insulin and monitoring of diabetic patients. This Medicines Management. link to the guidance is provided below and copies of this information will be provided to all  Query any dose higher than 30 units acute wards and it is expected that Ward  Novorapid must only be used and Managers will ensure that this information is Actrapid has been withdrawn provided to all qualified nursing staff.  All insulin dependent diabetics will be

prescribed insulin with a ‘pen’ delivery http://www.sussexpartnership.nhs.uk/gps/med- system info/med-docs/finish/2030/6643  Insulin pens will be prescribed for 1 Investigation Process patient and are not to be shared between patients Both these incidents will be investigated in  All diabetic patients will be encouraged accordance with the Incident Policy and the to self-administer insulin using pens learning and recommendations will be shared under supervision with all acute staff in due course. Safeguarding  Insulin must never be drawn up in a non- Adults at Risk alerts were also reported and insulin syringe these will be independently investigated and we  A doctor, pharmacist or senior nurse are expecting that the outcome from these must be present to supervise SAAR investigations will find that both patients administration of any insulin drawn did suffer harm as a result of the failure to by syringe rather than pen device provide the appropriate care and treatment that would be expected on the acute wards. March 2015

Caburn Ward Improving Safety in Mental Health Collaborative Reducing AWOL Incidents

The South of England Improving Safety in Mental be robustly identified. The Action Period is based Health Collaborative has been adapted and upon the principles of the PDSA change model. extended from the South West Quality and Patient Trina is identified as the Team Leader and the Front Safety Improvement Programme for Mental Health. Line Team for Caburn will include members of the There are a number of aims for the collaborative MDT and the implementation of this will be which will drive learning and enhancing practice dependent upon the active involvement of the identified through the local work completed by entire staff team on the ward. invited teams. The Chief Executive actively signs up to the programme and Emma Wadey, Director of To ensure that as a team Patient Safety and Standards, is the Programme you will have resources to Manger. National Learning Sessions are attended work together as a skilled by Emma and Trina who is leading the quality and knowledgeable group Caburn have been improvement work for Caburn ward. identified as a Pioneer Clinical Team for the Listening into Action programme. Caburn ward has been identified along with other wards within the Trust to develop a deeper Listening into Action is a national programme for understanding of the incidents of AWOL, how we health providers and over 50 NHS Trusts have could work as a team to reduce incidents and signed up. Listening into Action helps to unblock contribute to local and national learning. obstacles to change, identify additional resources and share learning so that improvements to clinical At the Learning Sessions all the participating teams outcomes and patient safety can be shared through will share information and develop strategies to ‘pass it on’ events. improve patient safety. Action plans will be developed based upon this sharing of knowledge Nationally other mental health NHS Trusts have and between the Learning Sessions teams will enter been working on quality improvement projects to an Action Period. identify factors that have been identified as contributing to the root cause for AWOL incidents. The Action Period will provide an opportunity to test out new ways of working and evaluate the The information that has been gathered and shared impact in order that the most effective actions can has identified key issues for wards which should be considered and inform the Driver Diagram:

 Rule Clarity and Location Awareness

 Post admission risk assessment to identify those at high risk of going absent

 Risk mitigation: dealing with home worries, promoting controlled access to home, family, friends  Skilled communication of dynamic risk  Post incident debrief with patient/carer  Post incident multi-disciplinary team review What action have we taken to date for Caburn populate our local action plan. The PDSA cycle will Ward? help to evaluate the items that have been identified A driver diagram will be used to further explore as the secondary drivers to achieve the overall aim primary drivers which are highlighted on the to reduce AWOL incidents. Completing the driver previous page. The secondary drivers are the diagram will assist in expanding the knowledge and actions and interventions that will impact on the understanding the contributory factors. primary drivers. The secondary drivers will help to

What do we know about AWOL incidents on 9 of these incidents were classified as AWOL Caburn Ward? although the patient did not manage to leave the A total of 28 AWOL incidents have been reported hospital site due to staff intervention. on the Safeguarding system between April 2014 The graphs below present some more analysis of and April 2015. these incidents. Of these AWOL incidents it should be noted that

Fig 1. AWOL incidents by day of the week - most incidents 7 occur during the week 6 5 4 3 2 10 1 9 0 8 7 6 5 4 3 Fig 2 AWOL incidents are more likely to happen later 2 during they day with the majority happening between 1 8pm and midnight 0 00:00-08:00 08:00-12:00 12:00-16:00 16:00-20:00 20:00-00:00

Fig 3 The circumstances where the patient has been reported as AWOL are most likely to be a failed to return from u/e leave patient becoming AWOL from the ward. These incidents all involved patients attempting to abscond on e/leave abscond or going AWOL from the garden. Only one incident was an AWOL via a ward secured abscond from ward door which was disabled during a fire alarm.

given leave in error Procedure if patient is suspected/known to be AWOL

1. The nurse-in-charge must be informed immediately

Unless the patient is known to have left the grounds, an immediate search of the ward, building and grounds should be made (Appendix A, Part 2).

The nurse in charge must review the evidence of current clinical risk to self and others which will inform discussions with the clinical team, the RC, and the police if it is necessary to contact them .

2 . Attempts to contact the patient

Attempts will be made to contact the patient by telephone either at home or on their personal mobile or by any other appropriate means of communication, and attempts made to ascertain their whereabouts and wellbeing. If possible staff should encourage the patient to either return or to maintain telephone or other appropriate contact on a regular basis whilst advice is sought from the RC, if possible. Please refer to Trust policy on communication when the patient has limited knowledge of English or is deaf/hard of hearing.

3. Conducting a search

Staff searching for the patient should not take any risks and ensure that they are sufficient in number, should they find, and are to return the patient. The Police cannot be expected to assist with searches on Trust property due to low staffing levels. If this situation arises then the on call Director should be informed. The AWOL / missing patient form (Appendix A, Part 3) should be completed when a patient is

found to be AWOL or missing. An electronic incident form needs to be completed for all such patients. This enables accurate monitoring across the Trust and allows the MHA Services team to notify the CQC where a patient is AWOL from a secure setting (see 3.3 above).

4. Discussion with the RC and clinical team

The RC or acting RC must be advised that the patient is AWOL / missing at the earliest opportunity. The nurse in charge, clinical team and where possible the RC must discuss and agree the current level of risk, the potential risks, mental state and physical presentation, legal status and circumstances in which the patient left the premises, and agree a plan of action.

5. Categorisation or risk and/or vulnerability

Before categorisation of low/medium or high risk, the nurse in charge, clinical team and RC should refer to Appendix B for guidance on categorising the current level of risk. If the risk assessment indicates that it is necessary to contact the Police. It is the responsibility of the nurse in charge to give the Police a comprehensive handover on the patient’s presentation and it is the duty of the Police to determine the level of response.

6. If the patient is assessed as safe in the Community

If a detained patient is assessed in the community as safe then the RC should consider application of Section 17 Mental Health Act 1983 enabling the patient to be placed on leave. If the patient is assessed in the community and no longer meets the criteria for detention under the Mental Health Act they can be discharged from their Section by the RC.

7. Informing necessary parties

Nursing staff must ensure that all necessary parties are informed, as specified on the AWOL / missing patient form and enquire if the patient has made contact with them. This should include the nearest relative/next of kin and staff must take account of the sensitivities offering support and reassurance as necessary.

8. Visiting the patient’s home

Careful consideration should be given and a plan made and documented for a visit to the patient’s home address to establish whether they are present and plan return to hospital if appropriate. It is not automatically a police responsibility to return a patient.

The nurse in charge must establish whether it is possible for the in-patient staff to safely return the patient. If the in-patient staff are unable to return the patient then an appropriate team in the patient’s locality should be contacted for assistance.

Where a patient is admitted to hospital outside of their locality and is AWOL, the hospital will liaise with services in the patient’s home area to locate the patient.

9. Contact with Sussex Police

At all times the nurse in charge and clinical team will decide whether the Police should be contacted.

If the circumstances suggest immediate and life threatening risk to the patient or another, consideration should be given to contacting the Police via 999 (i.e. High Risk on Appendix B model).

Where the assessment is that there is a Medium Risk, the nurse in charge should contact Sussex Police on 101, recording the incident number and the time the report is made within the patient’s records.

If the patient is assessed to be Low Risk a notification to the Police will not be necessary. Low risk patients may be discharged in their absence if a) they are informal and entitled to 10. A low risk/vulnerability assessment absent themselves from hospital and b) their absence does not lead to heightened risk (see box 6 above).

Using the agreed model, the Police will make a decision on the level of risk presenting and their response.

Decisions to discharge patients should be made by the multi-disciplinary team or by an assessing doctor in the community and documented in the patients clinical records.

10. Police response

If a person is reported as ‘absent; the Police will record details and ensure that a Neighbourhood Response Supervisor is aware. Agreement will be reached about a suitable review period and the reporting party may be asked to call back at an agreed time. If the person has not returned at the end of the review period(s) or additional information is received that raises the risk, the person may be reclassified as ‘missing’ (see definitions table)

Where a person is reported as ‘missing’ police will attend the report address and take full details of the person and the circumstances. They will make proportionate enquiries in an effort to locate and return the missing person, however on occasion it may be decided to file as long term missing and take no further action.

11. Actions by staff following contact with the Police

Having reported the incident to the Police, hospital staff will continue to make further enquiries, although these should be discussed and agreed with the Police to avoid duplication of effort. Any information received by staff that affects the risk level or the reporting category should immediately be communicated to the Police. If the missing patient is seen by staff this must be immediately communicated to Police. The Police should also be informed immediately if the patient returns or is located by staff.

12. Returning a detained patient to hospital The Trust staff, on behalf of the Trust, are responsible for the return of patients absent without leave. Assistance may be sought from other professionals and services.

Patients liable to detention who are AWOL may be taken into custody and returned by an AMHP, any member of the hospital staff, any police officer, or anyone else authorised in writing by the managers of the hospital. The Police do not have powers beyond this to return a patient to hospital.

Following a risk assessment of the patient including the views of the RC or Acting RC it may be necessary to contact the Police for support in returning the patient (please refer to paragraph 4.7 on execution of s135(2) warrant . Consideration should be given to:

 risk to the patient and others  risk to the staff returning the patient

13. Conveying a patient to hospital

The issue of arranging transport for the patient’s safe return, and bearing the cost and their individual needs (possibly related to disability, for instance) is the responsibility of the detaining hospital. (Please refer to the Multi Agency Conveyance Policy).

14. Returning informal patients

If the missing patient was admitted to hospital on an informal basis and is found by the Police, there is no power to forcibly return the patient to hospital. Consideration should be given to raising a SAR alert when appropriate

15. Patients returned

When the patient is found and has been returned to the unit, Part 4 of AWOL / missing patient form (Appendix A) and a management plan should be completed to reduce the likelihood of the patient going AWOL / missing again. The decision should be reflected in the care plan.

16. Informing the MHA Office

At the earliest opportunity the nurse in charge must inform the MHA office of the date and time a patient is returned to the ward.

17. Review

A review of the clinical risks of the patient must be undertaken at the earliest opportunity. Risk assessment must be updated and level of observations reviewed. This will include an examination of the reasons behind their absence and the means by which the patient went missing and location where they were found and fully documented in the records. Family and nearest relative must be informed.

PATIENT SAFETY ALERT The Stay Alive App

Action Required by; - All Clinical Staff

The Stay Alive app is the first of its kind to offer UK-wide information on where to get help. It has been developed by Brighton-based charity Grassroots Suicide Prevention and digital company Switchplane and is supported by Network Rail and Sussex Partnership NHS Foundation Trust. Stay Alive is a pocket suicide prevention resource whose user is only a few presses away from crisis support, up-to-date resources, guidance and interactive tools to support suicide prevention.

The app is highly customisable: as well as links to services, the app includes a ‘LifeBox’ section where you can upload pictures which remind you why you want to stay alive, a mini-safety plan for use in a crisis, and a draft message asking for help that can be edited and texted to contacts on the user’s phone. Other features include a myth- busting section about suicide, research-based reasons for living and useful information and strategies about what to do if you have thoughts of suicide.

Director of Grassroots, said: 'Many of us have been affected by suicide in some way, and have some understanding of how important it is for help to be available and accessible when needed. This app literally puts a suicide prevention resource in people’s pockets, making help easier to find in times of need.' Programme Manager (Suicide Prevention), Network Rail: 'The rail industry operates through the very heart of communities devastated by suicide and these events impact deeply on our own people too. It is important that we support such communities by doing what we can to address this issue and offering our support to those seeking to affect change within their own neighbourhoods and beyond'. Director of Nursing Standards and Safety at Sussex Partnership NHS Foundation Trust, said: 'Suicide is everyone's business; it devastates so many lives no matter who you are, where you work or where you live. We want to use every method available to us to make Sussex, and beyond, a place where people thinking about suicide are supported and helped in their workplace and their community.'

Action: Please promote and distribute information on the App to service users and patients.

Paul White, Head of Risk & Safety. Governance Support Team Emma Wadey, Director of Nursing Standards & Safety

Unexpected Patient Deaths in Crisis Teams in Sussex Partnership Trust: An Exploratory Audit

All unexpected patient deaths in crisis teams Other key findings include: occurring between April 2009 and March 2013 have recently been audited. The audit found a  65% of the sample were male, and 85% were total of 20 deaths across all 6 teams in the trust. between the ages of 35 and 64. Using serious incident reports and patient notes to gather data on a range of topics, the audit aimed  65% had a diagnosis of a depressive disorder, to learn more about this group of people, how their which was the most common type of diagnosis lives were lost, and see any important themes found. emerged relevant to improving crisis care.  80% were already known to mental health Research Background services. At a national level, the number of recorded patient suicides in crisis teams has increased in recent  90% had made documented previous attempts to years, but the rate of suicides per treatment take their own life. episode has actually been gradually decreasing. This suggests the increase in absolute numbers  50% were early discharges and 50% were may be due to larger CRHT caseloads. However community referrals. the rate of recorded patient suicides under CRHT remains persistently higher than the rate of  70% had suffered recent life events. inpatient suicides, suggesting CRHT is an inherently higher risk form of care.  35% of the sample were living alone at the time.

Results  55% had serious co-existing healthcare problems Both numbers and rates of unexpected patient death per treatment episode have increased in the  30% had a current history of drug or alcohol time period. However, the rates of death appear to misuse, and 45% a documented prior history. have remained close to the national average for that period. In addition, more than 50% of serious incident reports audited had 1 or less ‘lesson  Only 10% demonstrated recent self-harming learned’ recommendation by the reviewer. behaviour, though 30% had a documented history.

 70% of the deaths involved violent means.

 Engagement with CRHT appeared complex or problematic in 60% of cases.

The audit team are currently disseminating the findings to CRHTs in the trust. Feedback from staff will be used to develop any plans to improve crisis care in the trust.

For further information, contact Bree Macdonald ([email protected])

www.sussexpartnership.nhs.uk

ENGAGEMENT AND OBSERVATION POLICY UPDATE 30/01/2014

POLICY TO BE IMPLEMENTED IN ALL INPATIENT SERVICES ON FEBRUARY 1ST 2015.

Dear General Managers, Matrons and Ward Managers.

The Engagement and Observation Policy has been updated as a result of learning from Serious Incidents (SI), Coroner's rulings, best practice and CQC practice recommendations.

Version 3 includes changes made as a result of feedback from services which were shared in the alert sent on the 10/12/2014 in addition to the following;

 The introduction of appendix B – Location codes which services need to use to populate appendix A (part ii) which should then be photocopied as the template for use in that area.

 Addition of Appendix K to reflect the use of Enhanced Engagement and Observations within the Selden Centre.

 Section 4.3 – Reducing enhanced engagement and observations.

- This had stated ‘ Generally a minimum of the nurse in charge of the ward in conjunction with the MDT on duty can reduce the intensity of engagement and observation when risk assessment indicates the person is able to maintain their own safety with less direct care from staff’.

- Now states - ‘Generally a minimum of the nurse in charge of the ward in conjunction with another clinician on duty can reduce the intensity of engagement and observation when risk assessment indicates the person is able to maintain their own safety with less direct care from staff’

- All other sections in the policy that used the term ‘in conjunction with the MDT’ have been changed to ‘in conjunction with another clinician on duty’.

 Section 4.14 – Ensuring a Safe Environment

- This had stated ‘All staff must be aware of environmental dangers but the ward manager or in their absence, nurse in charge, must review the ward environment on an hourly basis’

- Now states – ‘All staff must be aware of environmental dangers but the ward manager or in their absence, nurse in charge, must review the ward environment as a minimum at each shift handover. This should be incorporated and then documented on local allocation sheets’.

 14.7.2 - Planned – Intermittent Engagement & Observation

- Had stated ‘The maximum interval will be documented in the care plan (see Appendix C) and will be between 5 and 30 minutes. Maximum intervals planned cannot be less than 15 minutes or more than 30 minutes’.

- Now states ‘The maximum interval will be documented in the care plan (see Appendix C) and will be between be 5 and 30 minutes. Maximum intervals planned cannot be less than 5 minutes or more than 30 minutes’.

- The paragraph that states when not to use intermittent engagement and observation had stated ‘ With very short maximum time intervals (i.e. below 15 minutes) that are likely to encourage a mechanistic process of care and place ‘unrealistic’ expectations on the clinician undertaking the engagement and observation. In these cases, within eyesight or within arms’ length engagement & observation may be warranted.’

- Now states ‘With very short maximum time intervals that are likely to encourage a mechanistic process of care and place ‘unrealistic’ expectations on the clinician undertaking the engagement and observation. Best practice would be at intervals of not less than 15 minutes however, where individual care plans indicate a more frequent level of observation this should be clearly documented and evidence why within eyesight or within arms’ length engagement & observation are not warranted’.

 The revised Policy will be available on Susi as from 1st February 2015.

 Word versions of all appendices will be available on Susi under the forms section.

 A trust wide audit will be completed at the end of April 2015 to monitor compliance with this Policy.

 Please can you ensure that the information is shared with all of your teams and that all previous versions and their appendices are removed from services and destroyed.

If you have any further questions or issues following the implementation of this policy please contact [email protected].

URGENT MESSAGE FROM HELEN GREATOREX & Dr TIM OJO

Dear Colleagues

SERIOUS INCIDENT LEARNING _ ACTION REQUIRED – Three Key Points

1. Clinical Record Keeping If it is not recorded, it did not happen.

2. Clinical Review and Risk Assessment A patient who has returned from a being Absent Without Leave must always trigger re-assessment, adjustment of care plan and specifically, consideration of the appropriate level of observation.

3. Managing Entry and Exit Points on Wards Where doors have manual (key) locks, ensuring that the door is locked as you leave it is essential. There have been instances where locks have appeared to have worked, but not been tested and then doors found to be open.

Helen Greatorex Tim Ojo Executive Director of Nursing & Quality Executive Medical Director

FIRE SAFETY ALERT FIRE SAFETY IN INPATIENT UNITS

Action Required by: - Matrons & Managers

Message sent on behalf of Peter Wright – Fire Safety and Property Assurance Manager

Following a number of fire related incidents can you remind all staff to follow the agreed fire safety instructions for your wards or unit.

For any fire alarm activation staff must report the incident on the trust wide web incident reporting system Safeguard. This allows us to monitor ALL false alarms.

If the fire alarms have been activated and there is a confirmed fire, staff MUST always notify the fire brigade by dialling the emergency services. This is a back up to the monitoring station calling out the fire brigade.

Staff must only “SILENCE” the fire alarm when it is safe to do so. A call must then be made to Estates for the on call engineer to “RESET” the fire alarm.

Under no circumstances must staff reset the fire alarm.

Action Required: 1. Please acknowledge receipt of this alert by 24th October 2014 2. Review staff training records to ensure all staff are trained and understand correct fire procedures.

Fire Team: Peter Wright: Fire safety and Property Assurance Manager tel: 01903 843060 Karon Hunter Fire Safety & Property Assurance Trainer tel: 07920 295 265 Paul Loosemore Fire Safety & Property Assurance Trainer tel: 07881517021

PATIENT SAFETY ALERT Observation and Engagement

Action Required by; - Matrons, Home Managers and Ward Managers Following a serious incident all matrons and home managers are reminded to ensure that all staff who undertake enhanced engagement and observation of patients are competent to do so and are fully aware of the correct policy and procedure to follow.

It is the responsibility of matrons, ward managers and team leaders to ensure the action of this alert.

Please acknowledge receipt of this alert by 27th March 2015

Emma Wadey Director of Nursing Standards and Safety

Board of Directors 29 July 2015 – Public Agenda Item: TBP36 .6/15 Attachment: J For Information By: Helen Greatorex, Executive Director of Nursing & Quality

Complaints & PALS Annual Report 2014/15

SUMMARY & PURPOSE

The Trust’s Complaints & PALS Service provides an annual report to the Board of Directors on its activity as required by the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009

LINK TO OUR 2020 VISION

The 2020 Vision goal(s) this paper relates to

1. Safe, effective, quality patient care 2. Local, joined up patient care

ACTION REQUIRED BY BOARD MEMBERS

The Board of Directors is asked to receive the report and ask any questions of the Executive Director of Nursing & Quality.

Title of paper

1.0 Executive Summary

Succinct summary outlining the most important factors

2.0 Introduction

Following on from the summary in the cover sheet, the detail about what the paper is about and its aim.

3.0 Report

The actual report (referring to any appendices etc.)

4.0 Recommendation/Action Required

Setting out any recommendations or conclusions and then what the members are being asked specifically to do.

5.0 Next Steps

What will happen next…?

Complaints and Patient Advice and Liaison Service Annual Report 2014/15

1

Introduction

This report provides a detailed summary of complaints and concerns received during the period 1 April 2014 to 31 March 2015.

The overarching focus for our 2020 vision is to deliver “Outstanding care and treatment you can be confident in”

In the person-centred environment of Sussex Partnership NHS Foundation Trust, patients, relatives, carers and service users are encouraged to express concerns and complaints about the treatment and services that they receive.

The trust ethos and commitment to effectively manage complaints is to ensure that all complaints are taken seriously, responded to in a timely manner and opportunities for informing continous service improvements are acted upon.

Being Open

The Trust continues to adhere to the Being Open policy in accordance with the National Patient Safety Agency (NPSA) guidance, which has been approved by the Board of Directors and in accordance with the principles of Being Open includes the need to:

 Establish an environment where service users and/or carers receive the information they need to enable them to understand what happened and be reassured that everything possible will be done to ensure that a similar type of incident does not reoccur.  Create an environment where service users and/or their carer’s, frontline staff and managers feel supported when things go wrong, and  Integrate the Being Open policy with other key risk management processes and policies, including the Complaints Policy and Procedure.

National Context

National reports highlight the increase in the number of complaints received about NHS care in England. The Health and Social Care Information Centre (HSCIC) report that a total of 174,872 written complaints were made to the NHS in 2013/14 www.hscic.gov.uk, in comparison with 162,019 written complaints that were made in 2012/13.

There has been a rising trend of increasing numbers of complaints raised against Doctors at the national level which has been widely reported. This echoes the findings of the empirical research report funded by the General Medical Council “Understanding the rise in fitness to practice complaints from members of the public”,

2 which provides an in-depth and independent evaluation of the social, political and cultural factors which have driven the increase in complaints from the public for the period 2007-2012.

GMC funded report “Understanding the rise in fitness to practice complaints from members of the public” Dr Julian Archer et al July 2014

On 18 November 2014 the Parliamentary & Health Service Ombudsman (PHSO), Local Government Ombudsman (LGO) and Healthwatch England (HE) published ‘My Expectations’, a vision of a user-led complaints system. This vision describes people’s expectations for good complaint handling through a series of “I” statements under five headings;

 Considering a complaint  Making a complaint  Staying informed  Receiving outcomes  Reflecting on the experience

My Expectations report http://www.ombudsman.org.uk/__data/assets/pdf_file/0010/28774/Vision_report.pdf

Local Context

The Trust received 774 formal complaints for the period 1 April 2014 to 31 March 2015 compared to 762 for the same period during 2013/14. This is an increase of 12 complaints from last year.

Complaints Management Overview

People can raise a concern either directly to the service involved, providing an opportunity for front-line staff to reach a resolution. Alternatively people can contact the complaints service directly.

Formal complaints are managed by the Complaints Team who work collaboratively with the designated service lead to investigate the complaint and provide a formal response letter to the complainant.

All complainants are offered the opportunity to attend a resolution meeting, either at the outset of the process, or following receipt of a written response. The Complaints & PALS Manager reviews and triages all complaints received. The Complaints Team provides information for the monthly Performance Report, the quarterly Quality Report and most recently for the Report and Learn Bulletin.

3

Complaints Response Times

The Trust aims to acknowledge all complaints on the day received, or next working day and to close them providing a detailed response within 25 working days or if a complaint is particularly complex, an extended agreed timescale.

In 2014/15- 82.8% of all complaints received were responded to within the timeframe agreed with the complainant. This shows considerable improvement from 2013/14 where performance was 71%.

Complaints Q1 Q2 Q3 Q4 YTD Trust – Complaints 121 166 149 185 621 resolved

Trust – Complaints 88 134 135 157 514 resolved in time

Trust - % resolved 72.7% 80.7% 90.6% 84.9% 82.8% within timescale

Target 85% 85% 85% 85% 85%

Complaints received

There was a significant increase in the number of complaints received during the last two quarters of the year. This coincided with the Care Quality Commission (CQC) Inspection visit held in January 2015 and the CQC has advised that this is a pattern with which they are familiar.

Fig. 1

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The five year trend (see Fig 2 below) shows an increase in the number of complaints since 2011/12. It is important to note that during this time, the Trust’s services have increased to include Hampshire CAMHS in April 2011 and Kent CAMHS in September 2012.

Fig. 2

Fig. 3 below shows the number of complaints for the period 1 April 2014 to March 2015 by month.

5

Complaints received by Directorate

Of the 774 complaints received by the Trust

 479 (62%) of all complaints were about Adult Mental Health Services (including Dementia, Later Life and Primary Care)

Brighton & Hove 112 East Sussex 119 Coastal West Sussex 136 North West Sussex 112

 202 (26%) of all complaints were about Child & Adolescent Mental Health Service (CAMHS)/Children & Young People’s Services (ChYPS)

Hampshire 56 Sussex 76 Kent 70

 51 (7%) of all complaints were about Secure & Forensic & Prison Healthcare Services

Secure & Forensic 38 Prison Healthcare 13

 42 (5%) of all complaints remaining were as follows

Corporate Services 21 Substance Misuse Services 9 Learning Disability Services 7 Complex Care Services 5

Fig. 4 below shows the Directorate breakdown. A comparison to last year is also shown.

6

Source of complaints

303 (39%) complaints were made by patients and 355 (46%) were from carers (including partners, children and relatives).

Complaints Investigations

Of the 774 complaints received, 743 investigations have been completed, 1 remains under investigation, 1 has a resolution meeting planned and 10 are suspended due to ongoing investigations by partner agencies.

Complaint Themes

The Health and Social Care Information Centre provides a reporting template that ensures national consistency in describing complaints by type.

Of the 774 complaints received the top three complaint themes for Sussex Partnership were:-

 All aspects of clinical treatment – 293 (38% of all complaints made)  Attitude of staff – 156 (20% of all complaints made)  Communication – 132 (17%) of all complaints made)

Fig. 5 shows the top three complaint themes

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Outcome of complaint handling

In line with Parliamentary & Health Service Ombudsman guidelines, Tthe investigation of a formal complaint can result in one of three outcomes; upheld, partially upheld and not upheld.

The table below sets out last year’s outcomes.

Outcome Number of complaints Upheld – where all issues raised in the complaint were fully 153 upheld Partially upheld – only some of the issues raised in the 175 complaint are upheld

Not upheld – none of the issues raised were upheld 336

Withdrawn – complaints withdrawn by complainants 46

Parliamentary and Health Service Ombudsman

8

During the year 35 complainants contacted the Parliamentary and Health Service Ombudsman for an independent review of their complaint after it had been closed by the Trust. 1 was upheld, 9 were partially upheld and 10 were not upheld. 7 cases were withdrawn and 8 cases are ongoing

Member of Parliament Complaints and Enquiries

The MPs in Sussex, Hampshire & Kent maintain a keen interest in the Trust’s work, both in raising concerns on their constituents’ behalf, and making more general queries about the future direction of services across the region.

Working closely with the office of the Chief Executive, the Complaints team ensures all enquiries from MPs are investigated and a full response provided.

In 2014/15 MPs formally wrote on 114 occasions on behalf of constituents making general enquiries and/or seeking assurances.

Patient Advice and Liaison Service (PALS)

The Patient Advice and Liaison Service (PALS) is a free, confidential and impartial service available to everyone who uses Trust services, their families, carers or advocates who need advice or information about a particular issue. Since January 2015 the PALS service and function has been integrated and is currently managed by the Complaints team.

From 1 April 2014 to 31 March 2015 PALS received a total of 201 contacts from patients, service users, carers and families as well as members of the public seeking general information.

Fig. 6 shows enquiry by type

9

Compliments

The Complaints Team keep a record of all compliments received directly or via individual team members, teams or units. In 2014/15 484 compliments were recorded by the team in addition to plaudits received and recorded by services locally.

Learning Lessons from Complaints

Over the past year, the team has worked with services to ensure that the quality of letters sent in response to complaints has improved. They have also worked to ensure that where lessons have been learned or practice changed as the result of a complaint, that change is shared with the complainant and across the Trust.

Below are some examples of lessons learnt and changes made to practice as a result in 2014/15.

Complaint Lessons Learnt and what changed as a result of the Complaint

A young person who was undergoing As a result of this complaint patients are assessment. Following the assessment asked at assessment how they would like the outcome was provided by letter. This the results to be shared with them. The caused understandable distress and services have made changes and now resulted in a complaint. provide an opportunity for a supported appointment to share this information.

10

A patient told us that night staff did not Details of the ward activity programme interact with patients and that also there and cover arrangements during staff was a lack of opportunity to exercise absence has been shared with everyone outdoors on the ward so the programme now runs during periods of staff absence in the team.

A rotation programme for night staff has been implemented and staff from the day rota regularly join the night team. Regular activities are now run in the evenings.

A family member required an admission A protocol, emphasising the importance to hospital and a number of clinical and of advance communication and planning social care staff were involved. The with families where admission is or may process felt disorganised and uncaring, be required, has been developed. resulting in additional distress to the patient and their family. Sussex-wide multi-agency training has been developed for clinical and social care staff focusing on roles and responsibilities or professionals in relation to the Mental Health Act process.

A patient told us she had used our Clear guidance has been issued to all services for a considerable time and had staff who correspond with external had never received copies of the letters agencies reminding them that letters sent from her Consultant Psychiatrist to about patients should be shared with her GP despite repeated requests. them unless the patient requests not to receive them or where to share letters is assessed as causing a potential risk. A rolling audit programme is in place to check compliance regularly

Complaint Lessons Learnt and what changed as a result of the Complaint

A complaint was received regarding an The appointment cancellation process appointment cancelled at short notice but has been reviewed and the service now the letter did not arrive until the day after ensures that short notice cancellations or the appointment and they had a wasted those cancelled over a holiday period are journey. On another occasion they done so by telephone and then followed arrived for an appointment and were left up in writing. waiting in Reception for 45 minutes as The Reception area has been the clinician hadn’t been told they were redesigned so CAMHS and Adult there. Services now have a separate Reception area to reduce the possibility of anyone being overlooked.

11

A patient felt unsupported whilst being A leaflet has been developed in referred between the Assessment & conjunction with Health in Mind Treatment Service and Health in Mind explaining what each service does and what support is available.

Family member became unwell and was Care Coordinators now record messages taken to A&E. Family tried to contact on mobile phones detailing days worked team and left messages that were not and alternative contact numbers so responded to until the following day. people can access advice at all times Acute and Mental Health staff were during service opening hours. involved but communication between A pathway for young people presenting teams was unclear and no one was with a mental health need in an acute taking the lead. hospital setting has been designed and is being piloted. Care Programme Approach (CPA) documents are now updated with contact numbers and support options available and details of the nominated lead

A young person had been on the waiting The waiting times for ASD assessments list for a specialist Autistic Spectrum were raised with commissioners and as a Disorder (ASD) assessment for a number result Sussex Partnership was asked to of years and left wondering when or if provide these assessments. Families on they would be seen. the waiting list have been advised and a significant project is underway to see all the families who are waiting for assessment.

Complaints service objectives achieved 1st April 2014- 31st March 2015

Complaints Service Objectives What we did

Responding to all complainants on time Improved average response time across the year from 71% to 82.8%. Clearly more work to do, and sustained delivery of target is this year’s objective.

Introduced a revised escalation protocol

Ensure that an updated easy to read Revised the complaints policy to include Complaints Policy and Guidance is the Ombudsman principles and clearly available for all staff defined roles and responsibilities - draft currently being reviewed

12

Providing greater opportunities for Ensure complainants have the Resolution meetings opportunity to access this and are supported by the Complaints service

Work collaboratively with services to Developed a schedule for ongoing local improve the timeliness and quality of site visits and attending team meetings responses Attended Schwartz Rounds

Raise the profile of the benefits of Develop and embed systems for lessons effective complaints management linked learnt and share through reporting to service improvement mechanisms

Summary and Conclusion

The focus for 2014/15 was the development of a more efficient complaints handling service with the emphasis on both improving response times and increasing quality. This work continues and the priority for 2015/16 is to further enhance the quality of complaint responses and improve collaborative working throughout the Trust. The complaints service are committed to ensuring that they deliver an efficient and effective service and below are a list of initiatives currently planned and under development.

 A series of ongoing meetings planned to support the implementation of Care Delivery Services  A web version to support effective and timely complaints management and learning is planned for implementation in September  A programme of meeting teams at local bases and providing training at a local level is being developed  Design of a web page for complaints on the Trust’s website is underway  Offering mini master classes for complex complaints or where there is an identified need to work in very close partnership with services  Pilot a questionnaire for complainants to capture the overall experience of the service provided by the complaints team. This data will be analysed and used to inform ongoing service improvements

13

Jayne Bruce, Deputy Director of Nursing Standards & Safety

In conjunction with Simon Street, Complaints & PALS Manager

14

Board of Directors: 29 July 2015 – Public Agenda Item: TBP36.7/15 Attachment: K For Information By: Helen Greatorex, Executive Director of Nursing & Quality

SIGN UP TO SAFETY

SUMMARY & PURPOSE

The Trust joined the national Sign up to Safety campaign in April this year, and in doing so joined the majority of NHS trusts in publically committing to make care safer.

The five pledges made by the Trust have been developed and a significant amount of work undertaken in the first quarter of the Sign up to Safety two year plan.

The attached report sets out our commitments as a Trust and provides an update against each at the end of Quarter 1.

LINK TO ANNUAL PLAN

The provision of high quality, safe care

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to note progress against each of the pledges, and agree a timescale for future updates to be presented.

Sign up to safety Improvement plan 2015-2017 Quarter 1 Status Update

The areas we believe Our Goal The Measures Action we need to Timescales Status at end of Q1 could make the take 2015/16 most difference

Put safety first Put safety first Put safety first Put safety first Put safety first Put safety first Building on national  A clinically lead  A reduction in the  Establish a task and  Strategy to be  Executive Medical best practice, reduce Sussex Partnership incidence of suicide. finish group to completed by Director leading. the rate of suicide suicide prevention develop the strategy November 2015  Task & Finish across the Trust strategy understood  Establish links with and launched. Group established and owned by national and  Baseline data and first meeting everyone, and international leaders established and held in June. developed in in the field shared by end Q1.  Key partners partnership with  Establish our identified people who use our baseline and set the  Contact made with services target for reduction national trail blazers in Merseycare and Devon Partnership.  First outline of strategy drafted  Baseline data established and informing the identification of the reduction target Reduce the number of  A reduction by 25%  A month on month  Draw upon the  Roll out of pilots to  Executive Director of slips, trips and falls in in 2015/16 overall reduction benchmarking from wards by end of Q1 Nursing and Quality our wards compared to Q3 2014 and 2015/16 leading 2014/15 success of the Q4  Monthly reporting  Roll out to all wards pilot sites across the and monitoring complete. Trust. working towards  Monthly reporting  Work with the pilot year end reduction template in pilot sites as Expert by at least 25%. stage Partners to  Reduction by 42% of implement the slips trips, falls seen successful practice on pilot wards. everywhere.

The areas we believe Our Goal The Measures Action we need to Timescales Status at end of Q1 could make the take 2015/16 most difference

Ensure all staff are up  A clear rolling  Monthly reports  Monitor our  Clinical Academic to date with core programme leading showing performance against Director leading mandatory training. to all staff being up improvements to an the clear programme Trajectory agreed and to agreed trajectory with metrics and shared milestones Monthly progress  Provide reports to all reported to Executive staff Assurance Committee  Share improvements and support continued focus

Continually Learn Continually Learn Continually Learn Continually Learn Continually Learn Continually Learn Improve our approach  Review and revise  A streamlined  Identify national  Review SI policy  Executive Director to learning from our approach, process informed by best practice, liaise and revise by end of Nursing and Serious Incidents learning from the practitioner and learn from their September 2015. Quality leading across the Trust. national best feedback with easy experience   Policy review practice to audit Trust-wide  Adjust our approach  Establish links with underway learning and and test it field leaders by end  National links improving following Q1 established incidents  Trust-wide Report  Learning event and Learn, annual booked and SI learning event by advertised. end September

Honesty Honesty Honesty Honesty Honesty Honesty Ensure that everyone  Efficient and  Performance  Establish a rolling  Training programme  Executive Director understands and effective systems to reports to Care programme of established. of Nursing and meets the Duty of ensure duty is Delivery Services, training for all staff. Quality leading Candour always met. Divisions, Executive  Agree a clear  Training rolling out. Assurance mechanism for  Monitoring and Committee and the capturing and reporting system Board. reporting established and in compliance with the use Duty

Sign up to Safety Improvement Plan 2015 – 17 Page 2

The areas we believe Our Goal The Measures Action we need to Timescales Status at end of Q1 could make the take 2015/16 most difference

Foster a culture of  Ensure all staff are  Feedback from  Confirm the Trust’s  Agree Trust’s  Executive Medical safety and learning in able to easily raise Listening into Freedom to Speak Freedom to Speak Director leading which all staff feel safe concerns at any Action, appraisals, Up Guardian Up Guardian by end to raise a concern. time. supervision and  Ensure that every Q1  Programme of staff survey. member of staff discussions and  Evidence of staff knows how to speak  Agree development reflections using speaking up and up and feels able to programme, existing meetings in action being taken do so informed by development to resolve issues as  Ensure that Listening in to a result induction, appraisal, Action feedback by  Board paper in supervision and end Q2 development Listening in to Action all reflect the  Board of Directors  Induction training importance of to formally receive content review establishing a and consider Sir initiated listening, Robert Francis responsive and QC’s report, open culture Freedom to Speak up. Collaborate Collaborate Collaborate Collaborate Collaborate Collaborate

Working with the NHS South Patient Safety Mental Health Collaborative

Reduce the incidence  To improve the  A reduction by 50%  Identify baseline  Baseline identified of patients going safety of our of incidents of activity and highlight by September 2015. Absent without Leave patients. AWOL by April hotspots.  Revised Process. (AWOL) 2016  Review our policy against national best practice.

Sign up to Safety Improvement Plan 2015 – 17 Page 3

The areas we believe Our Goal The Measures Action we need to Timescales Status at end of Q1 could make the take 2015/16 most difference

Reduce the use of  We aspire to  Reduction in the  Establish  Ongoing updates Physical restraint on become a trust use of physical throughout the our Psychiatric where the use of restraint. PDSA cycle Intensive Care Wards physical restraint is minimal.

Strengthen our Peer Safety Review process

Support Support Support Support Support Support Use Listening into  Every member of  Services shaped by  Champions and Action staff feeling valued staff sponsors for their contribution throughout the  Positive feedback Trust.

Celebrate and share  Create a new  Award created,  Clear criteria and  First award to be excellent practice in annual safety award multiple support from Chief made at Staff relation to safety nominations Exec awards ceremony received. 2016

Sign up to Safety Improvement Plan 2015 – 17 Page 4

Board of Directors: 29 July 2015 – Public Agenda Item: TBP36.8/15 Attachment: L For Information By: Helen Greatorex, Executive Director of Nursing & Quality

Safe Staffing

SUMMARY & PURPOSE

The Board of Directors is presented at every meeting, with a report setting out the previous month’s performance in relation to safe staffing on the Trust’s wards.

The report is populated by the Trust’s Lead Nurse for Safe Staffing, and its contents informed by Matrons.

A key pressure continues to be created by the national shortage of Registered Mental Health Nurses (RMNs) as a consequence of which, the Trust is working to reintroduce a programme of rolling secondment of Healthcare Assistants to undertake training. In the meantime, assertive, creative and dynamic recruitment campaigns, area by area do show some positive results.

LINK TO ANNUAL PLAN

The provision of high quality, safe care

ACTION REQUIRED BY BOARD MEMBERS

The board is asked to consider the report, asking any questions of the executive.

Safer Staffing Summary Report ‐ September 2014

Day Duty Night Duty Day Duty Night Duty TOTAL

Qualified Nurses Healthcare Assistants Qualified Nurses Healthcare Assistants Qualified Nurses Healthcare Assistants Qualified Nurses Healthcare Assistants Total monthly Total monthly Total monthly Total monthly planned staff Total monthly planned staff Total monthly planned staff Total monthly planned staff Total monthly Average Fill Rate Average Fill Rate Average Fill Rate Average Fill Rate Average Fill Rate Ward name Type of ward hours actual staff hours hours actual staff hours hours actual staff hours hours actual staff hours % WTE Variance % WTE Variance % WTE Variance % WTE Variance % WTE Variance Comments 1 Bodiam Acute 900 900 900 972 630 630 630 672 100% ‐ 108% 0.44 100% ‐ 107% 0.26 104% 0.70 2 Maple Ward Acute 900 885 1,350 1,350 300 300 900 900 98%‐ 0.09 100% ‐ 100% ‐ 100% ‐ 100%‐ 0.09 3 Oaklands Ward Acute 900 900 900 900 645 645 645 671 100% ‐ 100% ‐ 100% ‐ 104% 0.16 101% 0.16 4 Rowan Ward Acute 900 900 900 900 300 300 600 700 100% ‐ 100% ‐ 100% ‐ 117% 0.62 104% 0.62 5 Woodlands Centre Acute 1,035 690 690 1,998 690 690 690 1,961 67%‐ 2.14 290% 8.11 100% ‐ 284% 7.88 172% 13.85 X 6 Amberley Ward Acute 900 900 900 1,809 630 630 630 1,449 100% ‐ 201% 5.64 100% ‐ 230% 5.08 156% 10.72 X 7 Coral Ward Acute 690 832 690 920 345 667 690 414 121% 0.88 133% 1.42 193% 2.00 60%‐ 1.71 117% 2.59 X 8 Jade Ward Acute 900 858 900 1,387 410 342 630 889 95%‐ 0.26 154% 3.02 84% ‐ 0.42 141% 1.61 122% 3.95 X 9 Caburn Ward Acute 900 1,185 900 1,134 600 544 300 321 132% 1.77 126% 1.45 91% ‐ 0.35 107% 0.13 118% 3.00 10 Regency Ward Acute 900 900 900 1,075 600 540 300 339 100% ‐ 119% 1.09 90% ‐ 0.37 113% 0.24 106% 0.95 X 11 Chalkhill CAMHS 900 959 900 1,117 600 438 300 527 107% 0.36 124% 1.35 73% ‐ 1.01 176% 1.41 113% 2.11 X 12 Beechwood Dementia 900 447 900 1,469 300 300 900 1,030 50%‐ 2.81 163% 3.53 100% ‐ 114% 0.81 108% 1.53 13 St Gabriel Ward Dementia 345 488 1,035 1,082 345 345 690 690 141% 0.89 105% 0.29 100% ‐ 100% ‐ 108% 1.18 14 Burrowes Ward Dementia 480 696 1,440 1,210 300 300 600 600 145% 1.34 84%‐ 1.42 100% ‐ 100% ‐ 100%‐ 0.09 15 Grove Ward Dementia 450 771 1,350 1,186 314 384 627 679 171% 1.99 88%‐ 1.02 123% 0.44 108% 0.32 110% 1.73 X 16 Brunswick Ward Dementia 900 976 1,125 1,547 300 304 600 1,143 171% 0.47 137% 2.62 101% 0.02 191% 3.37 136% 6.48 X 17 Iris Ward Dementia 900 989 1,350 1,352 300 360 760 1,070 110% 0.55 100% 0.01 120% 0.37 141% 1.92 114% 2.85 X 18 Heathfield Ward Integrated 900 889 900 856 315 326 630 620 99%‐ 0.07 95%‐ 0.27 103% 0.07 98%‐ 0.07 98%‐ 0.34 19 Larch Ward Integrated 900 878 900 900 600 600 300 300 98%‐ 0.14 100% ‐ 100% ‐ 100% ‐ 99%‐ 0.14 20 Meridian Ward Integrated 900 894 1,125 1,656 300 300 610 890 99%‐ 0.04 147% 3.29 100% ‐ 146% 1.74 127% 4.99 X 21 Opal Ward Integrated 840 840 840 1,003 300 300 600 600 100% ‐ 119% 1.01 100% ‐ 100% ‐ 106% 1.01 22 Orchard Ward Integrated 450 458 900 1,308 323 323 323 677 102% 0.05 145% 2.53 100% ‐ 210% 2.20 139% 4.77 X 23 St Raphael Ward Integrated 690 701 690 910 690 345 690 1,173 102% 0.07 132% 1.36 50% ‐ 2.14 170% 3.00 113% 2.29 X 24 Selden Centre LD 360 360 1,800 2,665 360 360 720 912 100% 0.01 148% 5.36 100% ‐ 127% 1.19 133% 6.56 X 25 Fir Ward Low Secure 690 704 690 871 690 552 690 828 102% 0.08 126% 1.12 80% ‐ 0.86 120% 0.86 107% 1.21 26 Hazel Ward Low Secure 690 657 1,035 1,220 690 345 690 1,104 95%‐ 0.21 118% 1.14 50% ‐ 2.14 160% 2.57 107% 1.36 27 Pine Ward Low Secure 690 672 690 848 345 345 690 690 97%‐ 0.11 123% 0.98 100% ‐ 100% ‐ 106% 0.87 28 Southview Low Secure 690 667 1,380 1,469 690 428 690 916 97%‐ 0.15 106% 0.55 62% ‐ 1.62 133% 1.40 101% 0.18 29 Ash Medium Secure 690 771 1,380 1,070 345 437 1,035 955 112% 0.50 78%‐ 1.93 127% 0.57 92%‐ 0.50 94%‐ 1.36 X 30 Oak Ward Medium Secure 1,042 914 1,380 1,989 690 630 1,035 1,232 88%‐ 0.80 144% 3.78 91% ‐ 0.37 119% 1.22 115% 3.83 X 31 Willow Ward Medium Secure 690 690 1,725 1,691 345 345 1,380 1,380 100% ‐ 98%‐ 0.21 100% ‐ 100% ‐ 99%‐ 0.21 32 Amber Ward PICU 1,277 1,116 1,702 1,892 621 611 1,242 1,305 87%‐ 1.00 111% 1.18 98%‐ 0.06 105% 0.39 102% 0.51 33 Pavillion Ward PICU 900 966 1,350 1,402 600 560 600 670 107% 0.41 104% 0.32 93% ‐ 0.25 112% 0.43 104% 0.91 X 34 Amberstone Rehab 900 931 900 896 300 300 554 554 103% 0.20 100%‐ 0.02 100% ‐ 100% ‐ 101% 0.17 35 Bramble Lodge Rehab 345 368 690 785 345 345 345 357 107% 0.14 114% 0.59 100% ‐ 103% 0.07 107% 0.80 36 Connolly House Rehab 780 738 570 577 323 323 323 323 95%‐ 0.26 101% 0.05 100% ‐ 100% ‐ 98%‐ 0.22 37 Rutland Gardens Rehab 615 588 450 435 300 320 300 280 96%‐ 0.17 97%‐ 0.09 107% 0.12 93%‐ 0.12 97%‐ 0.26 38 Shepherd House Rehab 450 478 900 870 300 300 300 300 106% 0.17 97%‐ 0.19 100% ‐ 100% ‐ 100%‐ 0.02 39 Dove Ward Substance Misuse 690 637 345 357 345 345 345 345 92%‐ 0.33 103% 0.07 100% ‐ 100% ‐ 98%‐ 0.26 40 Promenade Ward Substance Misuse 1,006 946 590 597 300 300 300 300 94%‐ 0.37 101% 0.05 100% ‐ 100% ‐ 98%‐ 0.33

TRUST TOTAL 30,985 31,132 40,062 47,669 17,724 16,757 24,883 30,760 100% 119% 95% 124% 111% Bodiam Acute Maple Ward Acute Oaklands Ward Acute Rowan Ward Acute Woodlands Centre Acute Amberley Ward Acute Coral Ward Acute Jade Ward Acute Opal Ward Acute Meridian Ward Acute Caburn Ward Acute Regency Ward Acute Chalkhill CAMHS Beechwood Dementia St Gabriel Ward Dementia St Raphael Ward Dementia Burrowes Ward Dementia Grove Ward Dementia Brunswick Ward Dementia Iris Ward Dementia Heathfield Ward Integrated Larch Ward Integrated Orchard Ward Integrated Fir Ward Low Secure Hazel Ward Low Secure Pine Ward Low Secure Southview Low Secure Ash Medium Secure Oak Ward Medium Secure Willow Ward Medium Secure Amber Ward PICU Pavillion Ward PICU Amberstone Rehab Bramble Lodge Rehab Connolly House Rehab Dove Ward Substance Misuse Promenade Ward Substance Misuse

Board Assurance Framework 2015 - 16

Version 2 : July 2015 Changes made to Version 1 in order to create V2 are shown in bold italics

Strategic Goals

1. Safe, effective, quality care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means

Contents Page

Assurance Framework

3.0 Key to Abbreviations 3

4.0 Board Assurance Framework 4

Appendices

A Likelihood Risk Rating

B Likelihood x Consequence/Impact Rating Table C Risk Radar

Page 2

3.0 Assurance Framework Key to Abbreviations

Organisations and Functions

MEWS Medical Early Warning Signs BbD Better by Design NHS LA NHS Litigation Authority BbE Better by Experience NICE National Institute for Health & Clinical Excellence CCG Clinical Commissioning Groups NIHR National Institute for Health Research CDS Care Delivery Service PBR Payment by Results CIP Cost Improvement Programme PEAT Patient Environment Action Team CMO Change Management Office R&D Research & Development CQC Care Quality Commission SGC Strategic Governance Group CQUIN Commissioning fo Quality & Innovation SMART Specific, Measurable, Achievable, Realistic and Time DLT Divisional Leadership Team specific EAC Executive Assurance Committee STAR Staff Time Attendance Rostering EHRC Equality Human Rights Commission SI Serious Incident EMB Executive Management Board TiA Transition in Action EOS Equality Objectives Scheme U1R Under One Roof FFT Friends and Family Test

HR Human Resources IM&T Information Management & Technology KPIs Key Performance Indicators LiA Listening into Action

Key Personnel

CAD – Clinical Academic Director CE – Chief Executive DS&I – Director of Strategy& Improvement EDCS – Executive Director Corporate Services EDFP – Executive Director of Finance & Performance EDNQ – Executive Director of Nursing & Quality EDSD – Executive Director of Strategic Development EMD – Executive Medical Director MDCS – Managing Director Core Services MDSS – Managing Director Specialist Services SDSC – Strategic Director of Social Care & Partnerships

Page 3

All Assurances shown are Positive

Risk

Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objective Key Controls Gaps in Control post

achievement of Assurance

Lead Impact

Ref Impact Treat- Director

objective) Independent Management Likelihood Likelihood ment

1. Safe Effective Quality Care 1.1 Deliver 5 Sign up to ED  Inadequate  SMART objectives  CCG  Progress  Inconsistent  Initial gaps Safety pledges: NQ capacity and  EAC reports feedback on reports compliance due to 1. Put safety first engagement  Clear plan with CQIN  Milestones programme 2. Continually learn to deliver milestones achievement met setting up 3. Honesty 5 4  Quarterly Board  Perform- 3 4 12 4.Collaborate reports ance Mtgs 5. Support  Care Delivery Service Development 1.2 Improving SD  Lack of  Agreed care  FFT  Audits of  In areas of high  Feedback experience for PS consistency pathways feedback care use of mechanism people who use C of approach  Clear standards pathway temporary not yet as services permits poor agreed adherence staffing, more sophisticate standards  Performance and difficult to d or fast as  Failure to ensure we would 5 5 quality assurance 3 3 9 engage  Care Delivery consistent like. service Service approach users and Development carers in co- production of care models 1.3 Achieve a  Lack of clear  Physical health   MEWS  In areas of high  CareNotes measurable baseline data strategy reports use of not yet improvement in and delivery  Matrons’ training  Physical temporary rolled out – physical health for plans to  Physical health Health staffing, more mix of 5 4 3 4 12 those using our address champions Strategy difficult to manual and services needs  Care Delivery  CQUIN ensure electronic Service consistent records Development approach

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All Assurances shown are Positive

Risk

Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objectives Key Controls Gaps in Control post

achievement of Assurance

Lead Impact

Ref Impact treat-

Director ikelihood

objective) Independent Management Likelihood L ment 1.4 Continue to SDS  Failure to  Improvement Plan  Reduction of  Bed Data  Level of long  None improve the Crisis CP deliver Crisis  Crisis Care 5% in  Re-admission term investment identified Care Pathway Care Concordat Group unplanned and length of from external Concordat  Concordat readmissions stay data partners pledges Declaration to hospital  Care within 28 5 5  Targets re Section Pathway 3 5 15 136 days of Audits  Street Triage discharge  136 Reports  Care Delivery  Feedback Service from partners Development (including Police) 1.5 Improving the CAD  Failure to  Quarterly reporting:  Audit reports  Performance  None  None delivery of care as capture, 90% of actions are Meetings a result of learning share and implemented by the  Report & from Clinical Audit test required agreed date Learn changes 3 3  Quality Committee information 2 3 6 reporting  Care delivery Service development 1.6 Successful CAD  Pace of  Service Plan  Internal  Timescales  System is new  As yet implementation of change not  Steering Group audit set are met to Trust untested Carenotes fast enough  Agreed Milestones  Staff fully in Trust 4 5  Reports to EAC feedback 3 5 15  Care delivery Service Development

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All Assurances shown are Positive

Risk

Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objectives Key Controls Gaps in Control post

achievement of Assurance

Lead Impact

Ref Impact treat- Director

objective) Independent Management Likelihood Likelihood ment

2. Local Joined up Care 2.1 Joint working with DS&I Lack of  Identified exec team  CCG feedback  Performance  CCGs intentions  Realtime Commissioners to meaningful & leads for each CCG.  FFT feedback data re tendering patient honest services feedback not ensure we meet the 4 4  Clear agreement  CDS feedback 2 4 8 needs of each local engagement about priorities.  Reduction in yet available.

population complaints

2.2 Increase ownership EDFP CDS model fails  Validation process  Staff survey  LiA feedback  CDs are newly  Model is new and engagement of to deliver  Pairing with exec feedback  Milestone appointed, will to SPFT and clinical services by expected and non-exec  FFT feedback reports take time to untested. benefits  Clear pathway  EAC scrutiny orientate devolving decision 4 4 3 4 12 making to clinical  Corporate Services  CDs are not yet in place everywhere teams. support  Project support

2.3 Deliver evidence – MDA Pathways not  Clinical Academic  Internal audits  Audit reports  CDs are newly  CareNotes based clinical S agreed or Groups of adherence  Mini audits appointed, will not yet pathways MDS audited.  MDs’ objectives take time to implemented 4 4  Performance 3 4 12 S  CD appointments reports orientate  CDs are not yet in place everywhere 2.4 Establish local SDS Lack of a robust  2020 events  Audit of  Feedback  None identified  None community fora for C participation and  Meetings with CCGs meetings and reports identified receiving / listening involvement outputs to feedback and strategy 4 4 3 4 12 reporting progress and improvement

2.5 Each Care Delivery MDS Capacity to  Exec and Non-Exec  Business plan  Timescale  Pressures on  None Service to have S deliver in the pairing scrutiny  Clear plan services vary identified their own business MDA midst of 4 4  Validation process  Authorisation 3 4 12 plan S competing  Project support Process demands

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All Assurances shown are Positive

Risk

Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objectives Key Controls Gaps in Control post

achievement of Assurance

Lead Impact

Ref Impact treatm Director

objective) Independent Management Likelihood Likelihood ent

3 Put research innovation and learning into practice 3.1 Meet statutory CAD  Lack of take  Individual  MyLearning  Weekly  Sickness  CQC training up of objuectives reports update Absence, Inspection requirements MyLearning  Clear trajectory reports turnover rates feedback 5 5 3 5 15  EAC oversight  Supervision unpredictable  Board Reporting  Appraisals

3.2 Establish the CAD  Pressure on  Clear Plan - CAGs   Update  None identified  None Clinical Academic services and in place by end of reports by identified Groups (CAGs) lack of clarify Quarter 1. Terms of CAG results in reference and  Clear ToR inertia 3 4 membership and outputs 2 4 8 approved by Transformation Board.

3.3 Develop and DSI  Insufficient  Improvement  Strategic  Update  None identified  None implement Trust capacity ot approach and partner reports Identified approach and ensure capabilities plan by feedback  Approlach capabilities for universal end of Quarter 1  agreed and continuous buy-in 3 3  Strategic partner to implemented 2 3 6 improvement support continuous drawing on best improvement evidence and secured by end of methodologies. Quarter 2

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All Assurances shown are Positive

Risk

Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objectives Key Controls Gaps in Control post

achievement of Assurance

Lead Impact

Ref Impact treat- Director

objective) Independent Management Likelihood Likelihood ment

4. Be the provider, employer and partner of choice 4.1 Improved staff EDC  Lack of  LiA implementation  Staff Survey  EAC reports  Variation in  Difficult to engagement S mgmt.  FFT feedback  Improved levels of assess capacity to  Survey informal commitment changes as 5 5  20-20 3 5 15 focus on Monkey feedback they change reports  Appraisal happen required  LiA reports 4.2 Development of EDC  Length of  Clear Chief Exec &  FFT  Leadership  Reliant on each  Not all skills and S time taken to team commitment  Staff Survey fora individual to activity is behaviours in line embed  Leadership  Survey understand and seen all the with our Trust’s behaviours development Monkey concur with time. values course values 5 5 3 5 15  Supervision  Appraisal feedback  Behaviours framework through OD Development

Page 8

All Assurances shown are Positive

Risk

Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objectives Key Controls Gaps in Control post

achievement of Assurance

Lead Impact

Ref Impact treat- Director

objective) Independent Management Likelihood Likelihood ment

4.3 Recruiting and EDC  Shortage of  Workforce strategy  Reduction  Developing /  National  None retaining high S candidates  People Committee from 27% to implement- shortages identified calibre staff  Circle of oversight 20% of ting CDU-  Hard to work  Individual joiners based compete with pressures on objectives leaving in retention locations near wards  OD programme first 2 years strategies & Gatwick impacting on  Demand & by Q4 increasing retention Capacity  Reduction of opportuni- 5 5 Programme time to hire ties in hard 3 5 15 to 14 weeks to recruit by end of areas. Q4  Improving retention of staff in areas with very high turnover 4.4 Improving working EDC  Pressure on  Partnership Forum  Reduction in  Monthly  Current high  Indepen- environments and S services and work programme sickness reports (20%) turnover dent the wellbeing of financial  LiA absence days  Performance of joiners sources of staff challenge  Estates work lost to 3.5% meetings feedback makes this programme by end of Q4  Supervision (eg staff un-  Clear local  Appraisal survey) are deliverable  Improvement often 4 4 management feedback 3 3 9 plans in results of  LiA events published a  CDS business staff survey on consider- plans work able time  Leadership pressures after discussions from 3.28 to completion  2020 priorities 3.07 (National – time lag average) therefore.

Page 9

All Assurances shown are Positive

Risk

Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objectives Key Controls Gaps in Control post

achievement of Assurance

Lead Impact

Ref Impact treat- Director

objective) Independent Management Likelihood Likelihood ment 4.5 Delivering EDF  Capacity of  KPIs agreed  Governance  Regular  Newly  System as intelligent P performance information for the review report reports introduced yet workforce team to CDS’s dashboard  CQC  Managers system will take untested. information deliver to ensure inspection feedback time to embed triangulated with  Lack of triangulation of feedback  Accurate quality and support from information. identification 3 3 9 financial data to CDS to use  Review dashboard of trends determine data to  EAC scrutiny and risks trends/risks improve  Clinical senate patient and staff experiences

Page 10

All Assurances shown are Positive

Risk

Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objectives Key Controls Gaps in Control post

achievement of Assurance

Lead Impact

Ref Impact treat- Director

objective) Independent Management Likelihood Likelihood ment

5. Living within our Means 5.1 Maintain sound EDF  Failure to  Budget management  Q1 Monitor  Specialist  Agency and  Reporting financial P deliver meetings and scrutiny rating Services private bed from performance to investment at all levels  Internal Audit savings spend is agencies deliver financial stragegy  Daily bed meeting reports delivery unpredictable not sent governance and resulting in  Agency review group  External Audit  Private bed due to clinical immediately stability organisation’l  Clear communication use need and out of . vulnerability plan and consistent reduction hours pressure.  Failure to messaging  Lack of real deliver  Adult Services time reporting 5 5 4 5 20 service redesign on agency redesign and  CDS implementation usage. achieve CIP  F&I Committee  Incomplete  Lack of  EAC scrutiny compliance & operational  Budget manager grip. grip on detail training,  Salary  Over payment controls and triggers

Page 11

5.2 Fully deliver the EDF  Failure to  Chief Exec team  Q1 Monitor  Budget  Pace of change  Not all agreed Cost P deliver plans objective rating reports is affected by agreed Improvement or find  Individual objectives  Internal Audit showing multiple, plans Programme. alternative  EAC scrutiny reports some simultaneous delivering schemes to  Next in line meeting  External Audit savings pressures yet. meet shortfall  Budget reports delivered  Incomplete  Budget forecasts  compliance 4 5 4 5 20  Budget manager and grip. training,   Salary  Over payment controls and triggers  5.3 To meet EDF  Increasing  Performance  CCG  Internal  Unpredictable  None contracted levels P demands on meetings Reports reports peaks in identified of performance services  CCG performance  Internal audit  Board demand  Failure to meetings reports reports  Availability of identify early 5 5  Performance reports workers to 5 3 15 shortfall in  SD & CDs resolve performance objectives shortfalls  Supervision

5.4 To improve EDC  Admin  Clear programme  Other areas  Key  Some staff  None effectiveness and S Services  Exec Leadership where this milestone may leave identified efficiency of our review fails  Comms plan model has met during the admin services to deliver worked. process  Timing coinciding with other 4 4 2 4 8 key programmes such as CareNotes implement- tation

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Appendix A LIKELIHOOD RISK RATING

Likelihood Rating is a matter of personal judgement; the table below provides some structure to aid thinking.

Likelihood Descriptor Score This type of event will happen or certain to occur in the future, (and Certain frequently) 5

This type of event may happen or there is a 50/50 chance of it happening High again 4 probability This type of event may happen again, or it is possible for this event to Possible happen (occasionally) 3

This type of event is unlikely occur or it is unlikely to happen again (remote Unlikely chance) 2

Rare Cannot believe this type of event will occur or happen again (in the 1 foreseeable future)

Appendix B

Table LIKELIHOOD X CONSEQUENCE/IMPACT = RISK RATING

Assess the likelihood of the occurrence and multiply by the likely impact to arrive at a rating CONSEQUENCES / IMPACT Insignificant Minor Moderate Major Catastrophic (1) (2) (3) (4) (5)

Certain (5) 5 10 15 20 25 High probability (4) 4 8 12 16 20 Possible (3) 3 6 9 12 15

Unlikely (2) 2 4 6 8 10 LIKELIHOOD

Rare (1) 1 2 3 4 5

Low Moderate High Extreme 1 – 3 4 – 6 8 – 12 15 – 25

IN CONFIDENCE

ASSURANCE FRAMEWORK 2015-16 TRACKER

(Recording changes made to Version 4 creating Version 1)

Tracker June 2015

Page No / Trust risk No. Change Rationale

internal audit shown in independent Important source of assurance. 1.6 assurance column

1,1 Gap in control added – inconsistent Theme of Audit Committee compliance discussion

Care Delivery Service development Audit Committee discussion 1.1,1.2,.1.3,1.4,1.5, added as key control 1.6

Risk rating increased from 8 to Audit Committee discussion – 12 2.5 is similar in content to 2.2 2.2 and already rated as high risk (12) – therefore ratings should match

Gap in assurance added – CQC Audit Committee discussion – 3.1 inspection feedback CQC highlighted this as a key added risk

5.1, 5.2 New Gap in Control added – CIP not consistently delivering, inconsistent compliance and Audit Committee concerns re grip grip and pace

New controls added, EAC scrutiny, audit committee discussion 5.1, 5.2 budget manager training, salary over highlighted more controls added Payment controls and than reflected in BAF Version 1 triggers

Page 1 of 1 Board Assurance Framework V1 2015/16 – Risk Radar – July 2015 (showing risk grading)

1. Safe, Effective Quality KEY: Care  Shows movement from last 2 version. 5. Living within our 3  Indicates risks with an impact of means ‘4-severe’ and ‘5-catastrophic’ 4 1. Quality  Objective 5

6 2.1  Sub-objective 1.5 8 5.4 2 - 25  2 – 25 indicate risk rating 9 1.2 10

12 1.1 1.3 5.3 15 1.4 16 1.6 5.2 2.1 20 5.1 2. Local, joined up care 25 2.2 4.5 4.3 2.3 4.2 4.4 4.1 2.4

4. Be the Provider, 3.1 2.5 Employer & Partner of Choice

3.2

3.3

3. Put research, innovation & learning into practice

5.4

Risk Radar Key to Abbreviations

1. Safe Effective Quality Care 1.1 - Deliver five Sign up to Safety Pledges 1.2 - Improving experience for people who use services 1.3 - Achieve a measurable improvement in physical health for those using our services 1.4 – Continue to improve the Crisis Care Pathway 1.5 – Improving the delivery of care as a result of learning from Clinical Audit 1.6 – Successful implementation of CareNotes 2. Local Joined up Care 2.1 – Joint working with Commissioners to ensure we meet the needs of each local population 2.2 - Increase ownership and engagement of clinical services by devolving decision making to clinical teams 2.3 – Deliver evidence-based clinical pathways 2.4 – Establish local community for a for receiving and listening to feedback and reporting progress and improvement 2.5 – Each Care Delivery Service to have their own business plan 3. Put Research, Innovation and Learning into Practice 3.1 – Meet statutory training requirements 3.2 – Establish the Clinical Academic Groups (CAGs) 3.3 – Develop and implement Trust approach and capabilities for continuous improvement, drawing on best evidence and methodologies 4. Be the Provider, Employer and Partner of Choice 4.1 – Improved staff engagement 4.2 – Development of skills and behaviours in line with our Trust’s values 4.3 – Recruiting and retaining high calibre staff 4.4 – Improving working environments and the wellbeing of staff 4.5 – Delivering intelligent workforce information triangulated with quality and financial data to determine trends/risks 5. Living Within our Means 5.1 – Maintain sound financial performance to deliver financial governance and stability 5.2 – Fully deliver the Cost Improvement Programme 5.3 – To meet contracted levels of performance 5.4 – To improve effectiveness and efficiency of our office services.

Sussex Partnership NHS Foundation Trust Board of Directors: 29 July 2015 – Public Agenda Item: TBP37 .3/15 Attachment: N For: Information By: Peter Lee, Head of Corporate Governance

NOTIFICATION OF SEALED DOCUMENTS

Q1 REPORT

1.0 PURPOSE AND RECOMMENDATION

Standing Order 8.3 requires the Board of Directors to receive a report each quarter, on all sealed documents. This is the Q1 summary report of sealed documents (25 March 2015 to 30 June 2015).

2.0 SEALED DOCUMENTS

No. Date Document 288 26.03.2015 Land Registry Transfer of part of registered title 22 Lyndhurst Road, Worthing, BN11 2LN. Western Sussex Hospitals NHS Foundation Trust and Sussex Partnership NHS Foundation Trust 289 Transfer relating to Summerfold House, 152 Leyland Road, Burgess Hill between (1) Sussex Partnership NHS Foundation Trust and (2) MJH Executive Homes Ltd.

Board of Directors: 29th July 2015 - Public Agenda Item: TBP37.4/15 Attachment: O For Information By: Richard Bayley, Non-Executive Director & Chair, Finance and Investment

FINANCE AND INVESTMENT COMMITTEE SUMMARY REPORT

SUMMARY & PURPOSE

This report provides a summary of the papers and discussions held at the Finance and Investment Committee meeting held on the 19th June 2015 in order to provide the Board with assurance on the Trust’s financial and operational performance and investment decisions.

The purpose of this Committee is to drive excellent financial performance and ensure that the Trust has an investment strategy that supports the business and is financially deliverable. The Committee is responsible for ensuring that robust scrutiny is in place, taking action to commission further work as required in the achievement of this objective.

It should be noted that a summary of the Finance and Investment Committee is reported to the Board on a monthly basis and the paper is public part of the Board and therefore the paper is available on the Trust’s website. It should also be noted that the full minutes of the meeting are circulated to all members of the Board for information.

LINK TO ANNUAL PLAN

This paper relates to the Trust’s strategic goals:-

1. Safe, effective, quality care 2. Local joined up care 4. Be the provider, employer and partner of choice 5. Live within our means

ACTION REQUIRED BY BOARD MEMBERS

The Trust Board is asked to note the contents of this report and ask any questions of the Chair of the Finance and Investment Committee.

FINANCE AND INVESTMENT COMMITTEE SUMMARY REPORT

1.0 Executive Summary

This report provides a summary of the papers and discussions held at the Finance and Investment Committee meeting held on the 19th June 2015.

The Committee Received papers on a number of current topics including:-  Month 2 Financial position  Update from Brighton & Hove Adult Services  Delivery of the Cost Improvement Programme for 2015/16  Addressing the Pressures within Acute Care  Agency Reduction Programme  Effectiveness of Selection Assessment Days  Operational Performance  Contract Update  Commercial Report  East Sussex Dementia Plan

2.0 Introduction

The purpose of this Committee is to drive excellent financial performance and ensure that the Trust has an investment strategy that supports the business and is financially deliverable. The Committee is responsible for ensuring that robust scrutiny is in place, taking action to commission further work as required in the achievement of this objective.

The Finance and Investment Committee meet in the week before the Board meeting. The next Committee meeting is due to be held on the 24th July 2015. This report provides a summary of the meeting held on the 19th June 2015, the main areas of discussion are set out in the body of the report below.

3.0 Report

Month 2 Financial Report and Delivery of Cost Improvement Plan for 2015/16 The Committee received a report on the Trust’s financial performance for month 2 noting that the Trust had seen a small improvement in its financial position in Month 2 reporting a deficit of £136k (Month 1: £300k deficit) for the month after the release of £250k reserves, taking the year to date deficit to £435k. However, given the Trust’s strong liquidity position, the Trust continues to report a Continuity of Services Risk Rating of 3, against a planned rating of 3.

Good progress was made in the month to reduce agency costs. However, there remains concern over the use of external placements due to the pressure on adult in-patient beds and the delivery of cost improvement plans. The Committee were advised that the majority of the financial issues were in Brighton & Hove and North West Sussex and if the issues in these two areas can be addressed this would begin to turn around the financial position.

The Committee discussed the key areas of concern and held a lengthy discussion on the areas impacting on financial performance. The Committee posed a number of questions to the Executive Directors to gain assurance that the issues are being addressed and tackled early on in the year. A summary of these discussions is set out below:-

 Operating Position and Financial Risk Rating of the Care Delivery Units - The Committee discussed the Financial Risk Ratings for the Care Delivery Services and based

on the Month 2 position requested that Care Delivery Services are invited to the Committee to discuss their financial performance. The Service Director from Brighton and Hove attended the meeting to discuss the issues and the actions being undertaken to improve their financial performance. It was noted the some of the financial problems were due to the lack of accommodation in Brighton and the pressures on the s75 risk share agreement with the City Council. It was agreed to meet with the CCG and Council to take forward these issues. It was agreed to invite senior members of the North West Sussex Adult Services Team to the next Committee meeting to discuss their issues and to set out the assistance they required from Corporate Services and the Committee in order to improve their financial position.  Use of Temporary Staffing - The Committee were update on the use of temporary staff, which continues to be an issue for the Trust. However, it was noted that there had been an overall reduction in agency usage in the month as new staff were recruited to vacant posts. However, there are still key risks around retention of staff with staff turnover increasing to almost 14% in May. To address this work is taking place around exit interviews to really understand the reasons why staff are leaving and discussions are also being held with staff through Listening into Action events. The Committee were also updated on the progress that was being made on the transition to the new agencies on the national framework. The Committee also received a paper setting out the effectiveness of having pre-booked selection days organised for areas with high turnover/ vacancies, noting that over the last year the Trust had held 28 recruitment days, resulting in 157 staffing taking up employment, with a further 51 staff at the pre-employment stage.  Pressure on Adult In-patient Beds – the Committee noted that there continues to be pressures on the use of beds in Adult Services, with a high number of external placements in May. The cost of external placements in the month was £98k, which was £51k lower than the spend in April. However, the number of external placements began to increase again at the end of May and this has continued into June. There was a separate paper on the Committee agenda setting out the details of the bed pressures and the action being undertaken to reduce the level of external placements, including the detailed work being undertaken to look at delayed transfers of care and length of stay, together with the performance of community and crisis teams which impact on the bed pressures.  Non-pay - Overall in the month non-pay was overspent by £210k, which was an improvement on the £437k for Month 1. The main pressures on non-pay were the cost of external placements, pressures on the s75 agree in Brighton and Hove, and slippage on the delivery of cost improvement plans. The Committee noted that given the continuing overspend on non-pay, a workstream to project manage a number of areas of non-pay expenditure is being established in order to get a better grip on these issues and to demonstrate that the Trust is using its resources efficiently.  Cost Improvement Plan – In the month £370k savings were delivered against a target of £977k, a shortfall of 607k, taking the year to date shortfall to £1,309k. Further to the request from the Committee, the paper set out the top ten areas being addressed by the Executive Team. It was agreed to discuss this in more detail at the next meeting in order for the Committee to obtain assurance that the Trust had plans in place to deliver the financial plan for 2015/16.

Operational Performance Report The Committee received the Performance Reports for Adult and Specialist Services for Month 2, noting the further changes to the style of the report, with the Managing Directors for Adult and Specialist Services providing the narrative for their areas.

The key issues in month were around bed pressures and CPA reviews. Work during the month had focussed on a change in the way temporary staff costs are reported as a proportion of pay and giving focus to the learning from Serious Incidents and how quickly reports can be shared with Commissioners. The learning from Serious Incidents is also being reviewed in the context of

learning from complaints. The number of complaints reduced in the month having previously increased in April. It was noted that waiting times in Hampshire Children and Young People’s Services continue to be an area of concern. Overall, waiting times have reduced slightly but there had also been a significant increase in urgent referrals which has had an impact on the time taken for assessment and treatment. The Committee noted the performance report now sets out the ownership of the issues identified, and what Committee or Group has an oversight of the issues.

Contract Update The contract report provided the Committee with details of the good progress made to secure additional income from the Clinical Commissioning Groups in Sussex and noted that the contract had now been signed by the Trust. The Committee were also updated on the outcome of the external mediation with NHS England for its contract for Specialist Services, predominantly around the funding for Secure & Forensic services, which had resulted in a favourable outcome for the Trust. The Contract Update also set out the details of the Trust’s CQUIN schemes for 2015/16.

Commercial Report The Committee received and discussed the Commercial Report noting the current bids, an update on current tenders and new developments being considered by the Trust. The Committee also received a paper on the plans for dementia services in East Sussex.

4.0 Recommendation/Action Required

The Trust Board is asked to note the contents of this report and ask any questions of the Chair of the Finance and Investment Committee.

5.0 Next Steps

The next Finance & Investment Committee is on 24th July 2015 and the Chair of the Committee will be able to provide a verbal update on the discussions held at the July Committee meeting, highlighting any matters for action or ratification by the Trust Board.

Board of Directors: 29 July 2015 – Public Agenda Item: TBP37 .5/15 Attachment: P For: Information By: Diana Marsland, Non Executive Director

PEOPLE COMMITTEE SUMMARY REPORT

SUMMARY & PURPOSE

The People Committee met on 20 July 2015. This report provides a summary of the meeting; the main areas of discussion are set out below.

ACTION REQUIRED BY BOARD MEMBERS

This report is for discussion.

PEOPLE COMMITTEE SUMMARY REPORT

1. Executive Summary

Clare Fuller, Non-Executive Director was welcomed to her first meeting. A member of the Ernst & Young governance review team was also in attendance from the Leadership Development item onwards.

The Committee received and considered papers/presentations on the following:

 Listening into Action  Organisational Development Programme  Draft Medical Workforce Strategy 2015-2020  Exceptions report on Workforce Indicators  Progress reports on statutory and mandatory training  Employee Relations Report Quarter 1  Finance and Agency Programme Updates  Progress report on electronic solutions

The agenda was focussed on staff experience and strategy and performance identifying key risks and mitigation

2. REPORT

2.1 Listening into Action

The Committee were updated on progress in implementation of Listening into Action and considered the very detailed feedback gained from the 600 staff who attended the LiA conversations during June and July. The feedback had been organised into the themes of environment and procurement; communications and IT; clinically meaningful targets and demand and capacity issues creating work pressures. Clinical pioneer teams have been established as well as 6 enabler projects.

Following discussion the importance of embedding LiA in the culture of the trust and it would be productive to ensure the LiA language and tools were used in the Leadership Development Programme, in particular used as the model for their projects.

In response to a question, further thought will be given to reporting on progress and outcomes to the Board.

2.2 Organisational Development Programme

The Organisational lead presented on progress on the delivery of this significant programme.

 OD support to the Care Delivery Services, with support programmes co-designed with the Directorate leadership teams. The Committee heard from the Managing Director of Specialist Services on the bespoke support being delivered with the learning disability, secure and forensic and CAMHS teams.  Cultural development through embedding our values and aligned behavioural expectations through the trust. The Committee received a draft of behaviours required to deliver on the values set out in our 2020 vision. The behaviours are based on the NHS Constitution and are defined for different roles across the trust.

 Bespoke people development for teams involved in complex change or experiencing difficulty and embedding a “working in teams approach”.

2.3 Leadership Development Programme The Committee received a summary of the very positive feedback received from the Leadership Development Programme Cohort 3 (July 2015)..

3 MEDICAL WORKFORCE STRATEGY

Tim Ojo presented the draft Strategy linking the plans to the strategic goals in the 2020 vision. Committee members were pleased to see the clarity and succinct actions required.

Feedback from Committee members included the need for clear outcomes from each of the requirements so that the impact on the trust could be measured; the need to include the ambition of working towards 7 day working and the need for more clarity on future medical staff numbers and roles in the trust. Completion of the work on care pathways and community re-design will help shape the future workforce numbers required.

4. PERFORMANCE – EXCEPTIONS

Sue Esser presented the new style People report and invited comments. The Committee supported the focus on exceptions and trends. In particular the dashboard was very helpful and it was agreed that targets would be added. The exceptions chart helped identify key risks.

Following more detailed discussion on the issue of qualified nurse recruitment and retention it was agreed there would be specific workforce projections defined for the next few years linked to the interventions outlined in the Workforce strategy. The Committee requested a plan to deal with recruitment issues and evidence of progress in achieving the targets.

4.1 Sickness absence – Continuing improvements supported by intensive interventions with managers and HR business partners.

4.2 Exit Interviews – The high percentage of exit interviews without reasons for leaving remained a concern and discussions centred on actions to resolve this gap. It was noted that the introduction of e –forms for leavers and starts should improve this position.

5. EMPLOYEE RELATIONS REPORT – QUARTER 1

This was the first report produced for the Committee providing detailed analysis of data on employee relations cases and trends. The initial report suggests a high number (211 live cases) in Quarter 1. A comparison with other trusts and comparative data taking into account size of staff group will be produced in the next report, together with equalities data.

Risks were noted as both the number and length of time taken to resolve cases. A summary of the main risks and actions was requested for the Board.

6. EDUCATION AND TRAINING PERFORMANCE REPORT

The Committee were pleased to receive a detailed report on the status of statutory and mandatory training following My Learning implementation. For the first time the figures on recording of activity were considered accurate and it was noted that the programme to update the hierarchy of staff information was still continuing as information on the electronic staff record had contained inaccuracies.

Compliancy remains very low and is failing to meet the trust’s own target despite the focus on this by the CQC. The Executive team will consider how to significantly increase priority across the trust.

7. FINANCE AND AGENCY SPEND

The Committee considered the workforce CIP and impact of temporary staff costs on the overspend position for some wards. There was scrutiny of the actions in place to address the high spend areas. The Committee were updated on the pilot to centralise bank and agency bookings through the Bank Team for Langley Green; the slips, trips and falls reduction pilot and the transition to the new agencies.

8. RECRUITMENT PLANS – SUMMARY AND ASSURANCE

The Committee scrutinised a detailed report summarising the wide number of actions already in place and planned for attracting staff and improving retention. The Committee were pleased to note the range of initiatives to be progressed although retention and recruitment remain a significant risk to the trust.

9. RECOMMENDATION/ACTION REQUIRED

To note the report, including the risks identified, for information.

Board of Directors: 29th July 2015 – Public Agenda Item: TBP37.6/15 Attachment: Q For Information By: Tim Masters, Non-Executive Director and Committee Chair

AUDIT COMMITTEE SUMMARY REPORT

SUMMARY & PURPOSE

This report provides a summary of the papers and discussions held at the Audit Committee meeting held on 29th July 2015.

The Audit Committee is responsible for monitoring and reviewing matters such as the integrity of financial statements, internal controls and overseeing the internal audit function. It is also focused on providing assurance to the Board that the systems and processes are functioning effectively (so that the Board is discharging its duty) and that those committees that are reviewing quality information in more detail are doing so effectively. The Audit Committee’s annual work plan is designed to cover these responsibilities and sets the agenda for each meeting, which is built around the following areas:-

• Risk Management • Governance • Financial Controls • Accountability • Self-Assessment • Minutes of the meeting are circulated to all Board members.

LINK TO ANNUAL PLAN The Audit Committee acts on behalf of the Board to review audits designed to assess whether or not management’s systems and processes are working effectively and support the delivery of the Trust’s annual plan. Additionally the Committee reviews management’s preparation of the Board Assurance Framework, to assess whether or not risks and mitigating controls are properly reported and reflect the Trust’s planned activities.

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to note the contents of the summary report and address any questions to the Chair of the Audit Committee.

AUDIT COMMITTEE SUMMARY REPORT

1.0 Executive Summary

This report provides a summary of the papers and discussions held at the Audit Committee meeting held on 20th July 2015. It should be noted that there was no governor representative at the meeting.

The Committee received papers including:-

• Risk Management - progress reports from the Internal Auditors and Local Counter Fraud Service • Governance - Compliance Update - Update on the Development of Care Delivery Services - Terms of Reference for the Executive Assurance Committee - Board Assurance Framework - Summary of Mock CQC Inspections • Financial Controls - Review of Losses & Special Payments - Schedule of Debtor & Creditor Balances over £5k & over 6 months old • Quality - Quality Committee Summary - Assurance Framework Review • Accountability - Lindridge Audit Update

2.0 Introduction

This report summarises the detailed discussions of the Committee. Information which is confidential to the Trust or its employees is not included in the report.

3.0 Report

The agenda for the Audit Committee in July focused on the areas of work over the first quarter of the new financial year since the closure of the accounts for 2014/15 and included discussion of the following reports:-

Internal Audit Update Report on progress being made to deliver the 2015/16 internal audit plan – the Trust’s Internal Auditor presented an update on the progress being made to deliver the Internal Audit Plan for 2015/16. The report highlighted that one audit had been finalised this year. This was the follow up report on the Lindridge Centre cash handling, which set out the good progress made in this area since the initial report. The Committee noted that the field work had started on five audits areas, as follows:-

- Follow up on Location Visits - Clinical Audit - The Cost Improvement Plan - The Agency Pilot at Langley Green Hospital - Security of Mobile Devices

The terms of reference were also currently being agreed for a further three audits on the roll out of the Clinical Information System, Supervision for Staff and the Board Assurance Framework. The remaining audits in the plan also have provisional start dates. The Committee also noted the new style report, which aims to highlight any areas of concern during the year that may impact on the Head of Internal Audit Opinion.

The Committee discussed the audits that were in progress, noting that the brief for the Cost Improvement Plan (CIP) audit had been expanded to ensure that the assumptions underpinning the CIP plans were valid and that the audit would also include a survey of budget managers understanding of the Trust’s financial issues. The scope of the payroll audit was also discussed to ensure that it reviewed the main areas of risk and it was noted that the audit of the Knowledge and Skills Framework (KSF) was being replaced by a review of the work the Trust was undertaking to ensure compliance with Annex W of the Agenda for Change terms and conditions. Further work was also being undertaken on contract management and whistle-blowing. The Committee also noted the general update on theft of data and requested that the local counter fraud service brief the Committee on this area at a future meeting. It was noted that the Trust had recently employed an IT Security manager, who was also planning to attend the Committee later in the year.

Local Counter Fraud Service (LCFS) – the Committee received an update on the proactive work being undertaken by the LCFS service, including details of the newsletter shared with staff to promote awareness of fraud covering recent cases, whistle blowing and cybercrime. The Committee was also update on the annual National Fraud Initiative and Quality Assurance programme, as well as an update on the reactive cases being investigated. The Committee requested that in future there were further details included in the report on how reactive cases were being concluded if referred to Human Resources and they also raised their concerns regarding the length of time taken to bring cases to conclusion. It was also requested that any LCFS cases or internal audit reports are taken into account when assessing the governance rating of Care Delivery Units and individual units. The Committee also received the LCFS Annual Report for 2014/15.

Compliance Update – the Committee received details on the compliance of the Corporate and Operational Services against a number of measures including budgetary control and salary over payments. The Committee was not assured that sufficient and effective measures had been taken to prevent future salary overpayments or to bring agency spend down to target levels. The Committee requested that the Executive Assurance Committee consider the corrective actions recommended by the Committee and the urgent implementation of these or equivalent measures. The Committee also held a lengthy discussion on how to improve compliance across the Trust, with the aim to developing the report to include other areas of compliance to help inform the governance rating for Care Delivery Services.

Board Assurance Framework – the Committee received a paper setting out the Board Assurance Framework for 2015/16, which also set out the top five key risks for the Trust. The Committee was not assured that the framework fully described shortcomings in control or assurance and requested that the Board Assurance Framework includes the details of any gaps in assurance raised by the CQC Inspection and internal audit and LCFS reports.

Mock CQC Inspections - the Committee received a report on the programme of mock CQC inspections undertaken across the wards over the last year. The Committee requested that a timetable of future mock inspections is established in preparation for the follow up visit from the CQC in due course. The Committee confirmed their desire to establish the system of risk rating every operating unit within the Trust under a traffic light RAG rating. It was agreed that these ratings would take into account both the results of the CQC and Trust inspections and other evidence of compliance with Trust procedures arising from other sources including the work of the Audit Committee.

Other Reports The Committee also received and discussed a number of other papers including the progress being made on the development of Care Delivery Units, an update from the Quality Committee, terms of reference for the Executive Assurance Committee and review of Losses and Special Payments and debtor and creditor balances over £5k and 180 days old. Specific matters of concern were the theft of patient monies and overdue debt from a former consultant. For both, further investigation from management was requested to be reported at the September Committee meeting.

4.0 Recommendation/Action Required

The Trust Board is asked to note the contents of the summary report and address any questions to the Chair of the Audit Committee.

5.0 Next Steps

This report is for information. The next Audit Committee is due to be held on 14th September 2015.

Sussex Partnership NHS Foundation Trust Board of Directors: 29 July 2015 – Public Agenda Item: TBP37.7/15 Attachment: Q For Information By: Diana Marsland, Non-Executive Director & Chair, Charity Committee

CHARITY COMMITTEE SUMMARY REPORT

1.0 EXECUTIVE SUMMARY

1.1 The last meeting of the Charity Committee was held on the 15th June 2015, this report provides a summary of the meeting.

1.2 Charity Strategy Review: Kay Macdonald presented a written update on the delivery of the charity’s strategy in its first six months since re-launch.

The Committee were pleased with progress to date and noted that the charity is now in the implementation phase of a new fundraising and grant making strategy. The Committee acknowledged that real growth on investment is expected in 2015/16.

1.3 Grant Making- General Fund Applications: the Committee reviewed and approved the second round of applications made to the General Fund in the 2015/16 financial year. Funding was approved for the following projects:

 Contribution towards course fees for a West Sussex patient to undertake a Phd in International Relations £3,000  Art Project at East Sussex CAMHS, Highmore £6,950  Photography project for patients of Assertive Outreach Team in Adur, Arun & Worthing £590  Chichester Centre Summer Activity Week £1,610  Blue Plaque to be placed at Aldrington House in memory of Dr Helen Boyle £1,200 (subject to investigating of whether funding is available with the Trust to support this)

Total Funding Awarded from the General Fund: £10,350

The Committee declined to fund an application to continue music sessions on Grove & Burrowes wards delivered by the music charity Rhythmix due to concerns over the sustainability and cost of the intervention.

1.4 Income Generation: the Committee noted an application for £5,000 has been submitted in partnership with Plumpton College to the University of Brighton’s CUPP Seed Fund to support the development phase of the Mill View Garden’s project.

The Committee noted that 98 people have registered for Walk for Wards 2015 and the event was taking place on Saturday 20 June 2015. This is double the number of walkers that participated in 2014.

1.5 Financial Reports: The Financial Report, Income Analysis and Investment Update were noted by the Committee.

1.6 Investment Policy: the Committee approved a revised Investment Policy.

1.7 Draft Accounts 31st March 2015: the Committee approved the draft accounts.

1.8 Funded Projects Update: the Committee received a verbal update from Penny Dodds on the progress of the roll out of the PARO seal project following concerns raised over infection control in other Trusts. The committee noted that no infection- control situations have arisen within SPFT, but the national use of PARO within the UK is now uncertain due to potential issues raised in other trusts.

Therefore PD requested that the charity fund just one ‘clean’ PARO to enable an additional infection control strand to be added to the research around the use of PARO in SPFT.

The committee approved 3:1 the purchase of one additional PARO, subject to the backing of Helen Greatorex as infection control lead for the Trust. Helen Greatorex has subsequently confirmed approval for the revised project.

2.0 MATTERS FOR ACTION OR RATIFICATION BY THE BOARD

There were no matters for action or ratification by the board.

3.0 MATTERS FOR ACTION OR RATIFICATION BY OTHER COMMITEES OF THE TRUST BOARD

There were no matters arising.

4.0 RECOMMENDATION

The Trust Board is asked to note the contents of this report and ask any questions of the Clinical Academic Director.

Board of Directors: 29 July 2015 – Private Agenda Item: TBP38 /15 AOB For Decision By: Karl Goatley, Director of IT

IN CONFIDENCE

Contract Renewal for Data Centre Services

SUMMARY & PURPOSE

The Board is asked to approve the arrangements for the re-procurement of data centre services ahead of the expiration of the current G-Cloud contract on the 24 July 2015.

The new contract runs for a period of six years with the option for a one year extension and has a full term value of £5,206,443 which represents a reduction/saving of £781,679 when compared with the 6 year value of the current contract.

LINK TO ANNUAL PLAN

 IT Transformation Programme (Technology in Action)  Carenotes Programme  Underpinning dependency for other strategic programmes of business change underway e.g. aAdult and Specialised Services reviews.

ACTION REQUIRED BY BOARD MEMBERS

To approve the award of a new contract for Data Centre Managed Services.

IN CONFIDENCE IN CONFIDENCE

Contract Renewal for Data Centre Services

1.0 Executive Summary

In 2013 the Board agreed a 6 year contract for data centre services on the basis of renewal every 2 years (constraint of the G-Cloud framework) but we now have an opportunity to move to a more suitable terms and conditions and also realise cost savings by effectively resetting the contract.

The Data Centre Managed Service, provided by Daisy, has proven highly successful. Our clinical systems, since being migrated from the ageing Eastbourne servers 20 months ago, have benefitted from 100% availability (a stark contrast from previous years).

The new contract, based on the more robust Office of Government Commerce (OGC) Terms and Conditions, runs for a period of six years with the option for a one year extension. The contract has a full term value of £5,206,443 and represents a reduction/saving of £781,679 when compared with the 6 year value of the previous contract. Additionally, the new contract provides for a range of improvements based upon our first two years

2.0 Introduction

After taking legal advice following the collapse of 2e2 the original G-Cloud agreement for data centre services was approved on the 24 July 2013. At the time this framework represented the quickest and safest route to provide the Trust with continuity in respect of its plans to move off ageing and failing servers to a more reliable platform. One key restriction of the G-Cloud agreement was an enforced maximum contract period of 2 years, however, pricing had been agreed for a period of six years to remain aligned with the business case and our original 7 year investment profile. We could have renewed under the G-Cloud framework in line with our original strategy (2+2+2), however, after completing the first iteration of this service it was considered more beneficial to align our IT contracts utilising the more robust Office of Government Commerce (OGC) Terms and Conditions (both the Daisy tTelephony and Capita IT Services contracts are OGC).

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3.0 Report

3.1 OPTIONS APPRAISAL A number of options were considered to ensure the renewal process conformed to procurement law and represented the best possible deal for the Trust. Four options were shortlisted:

Option 1 Do Nothing The data centre services are vital to the day to day running of the Trust and are required for a number of business critical applications. Failure to continue providing a stable, secure data centre service would pose an immediate and significant clinical and business risk.

Option 2 Continue with Daisy for 2 years through the G-Cloud option The G-Cloud framework does not allow for the extension of contracts beyond two years. A new contract via a direct award mechanism to Daisy is an option, but the two year contracting period remains a barrier to achieving best value for money and a long term sustainable, secure and stable partnership. Furthermore the G-Cloud terms, conditions, and schedules are not as robust as the Trust would wish for. The standard OGC terms and conditions, adopted for both the Capita Managed IT Services and the Daisy Telephony Managed Services are considered far more suitable and would make managing multiple contracts significantly easier and more cost effective.

Option 3 Run a Restricted Competition A restricted competition would give the Trust the ability to alter the Terms and Conditions of the agreement and potentially drive down costs, but changing supplier would cause a significant disruption to our services and plans, after only just reaching a steady state. It is possible to change supplier, but the planning and implementation process is both costly and timely. Additionally, we have recently added to the data centre infrastructure in support of Carenotes and the new Telephony Managed Service, and a change of supplier at this stage would also severely hamper our ability to continue the IT transformation programme.

IN CONFIDENCE IN CONFIDENCE

Option 4 VEAT Notice with Daisy The VEAT1 process represented the most efficient way of altering the Terms and Conditions and ensuring Daisy continue to be the Trust’s preferred data centre provider. The Trust has good reason to procure Daisy’s services through the VEAT process, as a procurement for a new data centre provider would represent a significant and disproportionate technical challenge for a new data supplier to replicate the bespoke configuration at this point in the Trust’s IT transformation programme.

3.2 EVALUATION In conjunction with the Trust’s pProcurement team and having taken advice from our contracts and procurement specialist (Realm IT Partners) option four (VEAT process) was chosen as the best choice for the re-procurement of the data centre solution, when considering these essential criteria:

a. Value for money. The VEAT process is significantly cheaper than alternative procurement options and allowed the Trust to continue the Daisy services without incurring any significant additional costs. Conversely, the process has allowed us to negotiate a far more favourable position with Daisy and with assured pricing for the next six years. In turn that provides stability and assurance for the ongoing delivery of Carenotes.

b. Commercial alterations. The VEAT process allowed the Trust to ensure the inclusion of all prevalent points from the original G-Cloud agreement whilst bringing the contract in line with the Trust’s other commercial arrangements, and making amendments that would otherwise have required additional effort through formal change control process.

c. Stability through the IT Transformation and Carenotes delivery. Changing our data centre supplier, without a lengthy and costly planning process (approximately one year), would critically hinder the Trust’s ability to complete the IT transformation programme and the Carenotes roll out.

1 A Voluntary Ex-Ante Transparency (VEAT) Notice is a form of contract award notice which was introduced in December 2009 and allows the Trust to award directly to Daisy, after a period of notice without challenge. In this circumstance it is on the basis of the data centre and telephony services being technically intertwined and dependent on each other.

IN CONFIDENCE IN CONFIDENCE

3.3 PROCUREMENT PROCESS The VEAT notice (2015/S 054-095171) was published on Tenders Electronic Daily on the 18 March 2015 and ran until midnight on the 27 March 2015 and was not challenged by the marketplace, and thus allowing the Trust to progress to contract signature. The VEAT notice is appended to this paper. Justification for using the VEAT Process:

a. Data migration. The Trust stores over 70TB of patient and critical business data, which is paramount to our operation. Migrating this data would carry an inherent risk of corruption/disruption if attempted without adequate planning time. b. Network redesign. The design of the Trust’s new network (2e2 era – to support an outsourcing model) was an extremely complex technical task. A new supplier would require a redesign, giving rise to further risk of disruption and additional cost. c. Underlying complexity. The Trust currently runs approximately 220 virtual servers across two data centres configured in a bespoke manner. Altering the configuration requires comprehensive planning to minimise disruption to services, and could be very costly. d. Impact on the Trust’s strategic objectives. The IT Transformation (includes new telephony service being introduced) and Carenotes, which underpin the delivery of our strategic objectives, are heavily reliant on the data centre service. A change of supplier at this point would critically hamper our ability to bring these programmes to a successful conclusion. e. Value for money and financial risk. The Trust has negotiated significant discounts with Daisy on the basis of committing to a longer term, and they have provided additional and/or improved services compared to the original contract. When considering the cost of running a procurement it is highly unlikely that any further savings could realised. Conversely, we should consider the underlying cost to the Trust in terms of the IT team’s time and the disruption to our services.

3.4 LEGAL AND PROFESSIONAL ADVICE The Trust engaged with Clarion Solicitors for legal advice, who have steered us through the complexity of the VEAT notice, particularly ‘Section IV: Procedure’ which details the basis on which the Trust is justifying such an approach. Realm IT Partners - our commercial/contracts specialists who were highly instrumental in achieving the best possible position with our other post-2e2 contracts - have worked closely with us to secure another excellent outcome. NHS

IN CONFIDENCE IN CONFIDENCE

Commercial Solutions were also engaged by the Trust to publish and manage the VEAT notice.

3.5 CONTRACT HIGHLIGHTS All benefits negotiated in the original G-Cloud contract, as reported to the Board in June 2013 and which have since provided the Trust with an exceptionally stable platform for its clinical systems, have been carried forward into the new agreement. Additionally:  We have aligned the Data Centre Contract Terms and Conditions with the Managed Telephony and IT Services Agreements, improving the efficiency with which the Trust can manage its commercial affairs and simplify its agreements with suppliers

 Key performance indicators have been strengthened, e.g. building new servers for the Trust will be completed over a much shorter time frame.

3.6 FINANCIAL IMPLICATIONS The table below demonstrates the notable savings achieved through this new procurement, in direct comparison with the existing contract, if we were to simply renew under that agreement from year 3:

G-Cloud Contract Model VEAT Contract Annual (including any additions Model Savings e.g. Carenotes provision)

Year 3 £1,096,132.01 £969,263.95 £126,868.06

Year 4 £1,007,236.35 £880,368.29 £126,868.06

Year 5 £988,663.85 £841,324.29 £147,339.56

Year 6 £1,025,944.01 £899,075.95 £126,868.06

Year 7 £937,048.35 £810,180.29 £126,868.06

Year 8 £933,098.35 £806,230.29 £126,868.06

TOTAL £5,988,122.92 £5,206,443.06 £781,679.86

Table 3.1 – Comparison of Costs with Existing Contract

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The following table demonstrates the same overall saving, but noting the total Cost of Ownership for the previous 2 year G-Cloud contract with the new 6 year contract (i.e. comparing over a full 8 year term).

G-Cloud Contract Model VEAT Contract Total (including any additions Model Savings e.g. Carenotes provision)

Year 1* £1,042,169.86 £1,042,169.86

Year 2* £1,238,056.46 £1,238,056.46

Years 3 - 8 £5,988,122.92 £5,206,443.06

TOTAL £8,268,349.24 £7,486,669.39 £781,679.86

*Actual Billing incurred in the G-Cloud contract

Table 3.2 – Comparison of Costs over total 8 year term (past and future contracts)

3.7 RISK MITIGATION The risk of not renewing with Daisy, as explained through the options appraisal in paragraph 2.2 above, has severe implications for the completion of the IT and Carenotes transformation programmes, and with potential disruption to the continuity of clinical services. By proceeding down the VEAT process the Trust has sufficiently mitigated this risk.

3.8 SUMMARY AND CONCLUSION The Trust has enjoyed a much needed and high degree of stability since migrating its applications to the data centres in December 2013 (20 months without failure or notable disruption to our clinical systems). The original contract, on legal advice, was procured through the G-Cloud framework and was considered the quickest and safest route to achieve stability post 2e2. One major constraint with that framework is the 2 year restriction on contract length. Following a comprehensive options appraisal a recommendation is made for renewal with Daisy, but not through the G-Cloud framework and through the VEAT notice in lieu, in order to mitigate the risk of disruption to our critical services. The new contract, based on the more robust OGC Terms and Conditions, runs for a period of six years with the option for a one year extension. The contract has a full term value of £5,206,443 and represents a reduction/saving of £781,679 when compared with the 6 year value of the previous contract.

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4.0 Recommendation/Action Required

It is recommended that we take the opportunity to move to the new terms and conditions which are better suited to the Trust’s requirements and which will realise much needed savings. The Board is asked to approve the award of the new data centre services contract to Daisy ahead of the 24 July 2015.

5.0 Next Steps

With Board Approval the Executive Director of Corporate Services, in the absence of the Chief Executive (annual leave), will sign the contract with Daisy ahead of the 24 July.

Subsequently, the Technology Board will continue to monitor the performance of the contract/data centre managed services.

IN CONFIDENCE APPENDIX A Copy of VEAT Notice

A-1 APPENDIX A Copy of VEAT Notice

A-2 APPENDIX A Copy of VEAT Notice

A-3