Board of Directors 28 October 2015

www.sussexpartnership.nhs.uk

BOARD OF DIRECTORS MEETING IN PUBLIC

To be held on 28 October 2015 at 13.30 Meeting Room A, Woodside Hellingly Centre, The Drive, Hellingly Hailsham, East Sussex, BN27 4EP AGENDA

TBP44 /15 INTRODUCTION

13.30 TBP44 .1/15 Chair’s Welcome and Introduction Verbal

13.30 TBP44 .2/15 Apologies for Absence & Declaration of Interests Verbal

Minutes of the Board of Directors meeting held 30 September 13.31 TBP44 .3/15 A 2015 & Action Points (not covered on the agenda)

13.33 TBP44 .4/15 Questions from Members of the Public Verbal

TBP45 /15 STRATEGY

Eliminating Mixed Sex Accommodation/Maintaining Safety 13.35 TBP45 .1/15 Privacy and Dignity B (Dr Tim Ojo, Executive Medical Director)

TBP46 /15 PERFORMANCE AND QUALITY

Chief Executive Report 13.45 TBP46 .1/15 C (Colm Donaghy, Chief Executive)

13.50 TPB46 .2/15 Patient Story video

To receive the Annual Patient Experience Report D 14.00 TBP46 .3/15 (Vincent Badu, Strategic Director of Social Care and Partnerships)

To receive an update on CQC Action Plans E 14.10 TBP46 .4/15 (Helen Greatorex, Executive Director of Nursing & Quality)

To receive the Quality & Performance Report F (Sally Flint, Executive Director of Finance & Performance; Helen

Greatorex, Executive Director of Nursing & Quality; Managing

Directors)

To receive an update on Safe Staffing G (Helen Greatorex, Executive Director of Nursing and Quality) 14.20 TBP46 .5/15

To receive the performance against Business Objectives H (Sally Flint, Executive Director of Finance and Performance)

To receive an update on Sign up to Safety I (Helen Greatorex, Executive Director of Nursing and Quality)

To receive a report on the last meeting of the Finance and Investment Committee J (Richard Bayley, Non-Executive Director) 14.50 TBP46 .6/15 Financial Performance (Quality & Performance Report) K (Sally Flint, Executive Director of Finance & Performance) Please refer to Item TBP46.5/15, Attachment F for paper

To receive the People Report 15.00 TBP46 .7/15 L (Sue Morris, Executive Director of Corporate Services

TBP47 /15 GOVERNANCE

To agree the Q2 in-year Governance Statement to Monitor / M 15.05 TBP47 .1/15 Update on changes to Monitor’s Risk Assessment Framework (Peter Lee, Head of Corporate Governance)

To receive the quarterly notification of Sealed Documents N 15.10 TBP47 .2/15 (Peter Lee, Head of Corporate Governance)

Board Members Action Points following the Council of O 15.15 TBP47 .3/15 Governors meeting held on 19 October 2015 (Caroline Armitage, Chair)

15.20 TBP48 /15 ANY OTHER BUSINESS

Date and Venue for Next Meeting: 25 November 2015 Training Centre, Swandean 85 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: 28 October 2015 - Private Agenda Item TBP44 .3/15 Attachment: A For: Decision By: Rebecca Huth, Corporate Governance Administrator SUSSEX PARTNERSHIP NHS FOUNDATION TRUST

Minutes of the Board of Directors meeting held in private on Wednesday 30 September 2015 at 10.00 in the Training Centre at Swandean, Arundel Road, Worthing

Present: Caroline Armitage, Chair Colm Donaghy, Chief Executive Diana Marsland, Non-Executive Director Dr Tim Ojo, Executive Medical Director Helen Greatorex, Executive Director of Nursing and Quality Lorraine Reid, Managing Director of Adult Services Professor Gordon Ferns, Non-Executive Director Richard Bayley, Non-Executive Director Sally Flint, Executive Director of Finance and Performance Simone Button, Interim Managing Director of Specialist Services Sue Morris, Executive Director of Corporate Services Tim Masters, Non-Executive Director

In Attendance Dr Kay Macdonald, Clinical Academic Director Sam Allen, Director of Strategy and Improvement Vincent Badu, Strategic Director of Social Care and Partnerships Peter Lee, Head of Corporate Governance Rebecca Huth, Corporate Governance Administrator (Minutes)

Observers Dave West, Deputy Director of Performance & Information Elizabeth Hall, Governor Michael Decker, Governor Sue Esser, People Director 4 members of the public

ITEM NO ITEM

TBP31. 1/15 Chair’s Welcome and Introduction

Caroline Armitage welcomed all members of the Board and the staff, governor and public 1 observers.

TBP39 .2/15 Apologies for Absence & Declarations of Interest

2 None.

TBP39 .3/15 Minutes and Action Points from 29 July 2015

3 Caroline Armitage confirmed that the Board minutes will be circulated within two weeks of the meeting and asked directors to confirm any amendments with the corporate governance office.

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4 Helen Greatorex advised that she had an amendment to the wording of paragraph 62 and would forward her amendment to the corporate governance office. 5 Subject to this one amendment, the Board of Directors approved the minutes as an accurate record. All action points listed are either complete or on the agenda. There were no further matters arising.

TBP39 .4/15 Questions from Members of the Public

6 Caroline Armitage noted that one question has been submitted by a member of the public; 7 “Is it unreasonable for a patient to wait in excess of three years to have the agreed amendments made to their care plan?”

8 Caroline advised that it is absolutely unreasonable and the Board of Directors has committed to helping to ensure such situations do not occur in future.

9 There were no additional questions.

TBP40 .1/15 Gender Separation Strategy Update

10 Tim Ojo advised colleagues that the purpose of his verbal update is to inform the board of the progress prior to the final strategy being presented to the Board of Directors in October

2015.

11 Tim advised that this strategy eliminates mixed gender accommodation, where possible, and we are required by national guidance to sign up to this strategy. This requirement

asks us to outline our process of elimination and provide a RAG rating of each ward that includes mixed gender accommodation. There is currently some dementia wards which are RAG rated red and we’re looking at ways of mitigation. 12 Gordon Ferns queried whether this will impact on capital resources and Richard Bayley advised that this information should be included in the final strategy presented in October.

Tim Ojo confirmed that any impact on capital will be included in the final paper. 13 Colm Donaghy added that our commitment is to ensure we have gender separation, however noted that this may cause some issues around service delivery and capital resources which will be thoroughly looked at to mitigate any risk.

TBP40.2/15 To receive the Suicide Prevention Strategy

14 Caroline Armitage noted the importance of this next item, following the CQC inspection feedback.

15 Tim Ojo confirmed that the CQCs concerns related to our connection and partnership with local stakeholders in collaboratively preventing suicide and ensuring suicide safer

communities. 16 In relation to learning from incidents, the CQC addressed issues such as suicide, death within 3 days of admission and 7 days of discharge. Tim advised that these issues will be addressed in the strategy and he is working very closely with the Care Delivery Services (CDSs) to ensure this strategy is implemented and our learning happens in good time. 17 Gordon Ferns queried our integrated working with partners and how this will happen. Tim Ojo advised that he has been working closely with local CCGs throughout the development of the strategy. 18 Colm Donaghy wished to add that our focus needs to be on the prevention of suicide and a community wide response. Gordon Ferns agreed and stated that we need to ensure we hold our partner agencies to account and monitor KPIs. 19 Helen Greatorex gave an example of partnership working with Sussex Transport where each railway station has a large poster at the end of each platform with Samaritans’ contact details.

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20 Richard Bayley queried in comparison with other Trusts with a zero suicide ambition, whether we have the right suicide target rate. Colm Donaghy advised that their commitment relates to zero tolerance to suicide and this was discussed at our Clinical Senate, where our clinicians felt that zero tolerance to suicide can become confusing, and advised that it’s more effective to adopt a safer suicide strategy rather than zero suicides. 21 Tim Ojo advised that the next step following the strategy being approved by the Board in October is to develop robust action plans by CDS and these will be shared with the board in April 2016. Action: Suicide Prevention Strategy CDS Action Plans to be presented to the Board of Directors in April 2016.

TBP41 .1/15 Chief Executives Report

22 Colm Donaghy highlighted the following areas: Shoreham Airshow 23 Colm updated members on the Trust’s initial response to this tragic incident. He explained that our immediate response was difficult and we’re now in the recovery stage. We’ve

been working with West Sussex County Council who is identifying a timeline for the future when this may impact other people. Colm also wished to pay respects to Tony Brightwell, an extremely valued member of staff from our Brighton Community Service who was tragically taken in this incident. 24 Diana Marsland advised in relation to the Shoreham Airshow incident that she was extremely pleased to see our immediate action and resources, however queried what implication there will be on our resources and funding. Kay Macdonald advised that we have been asked to report any business continuity however there is a low financial impact to date. We’ve had a low level response to the helpline we’ve set up, however we’re in the process of contacting spectators and witnesses of the event to ensure there are no silent sufferers of Post-Traumatic Stress Disorder. 25 Caroline Armitage wished to note her respects to Tony Brightwell, adding that she and Colm attended his memorial. Richard Bayley wished to note his thanks to Dr. Shakil Malik and his team for their efforts.

7 Day Follow-ups 26 Colm advised that this area became a concern again as we dipped below the Monitor target of 95% last month. We’re looking into the detail of this and are highlighting general trends to ensure we can improve our quality and performance. Colm added that our 7 day follow-ups reduce the risk of suicide following discharge. 27 Lorraine Reid acknowledged our performance is not up to standard, however, felt it was important to be clear that none of the patients are forgotten; many who missed the target were seen within 8 days of discharge. Specific work is being done to ensure daily checks of follow-ups are undertaken, especially those with no fixed abode. Lorraine added that the daily clinical bed call has become a daily quality call, which now includes quality issues such as care planning. 28 Tim Masters advised that he would like further assurance from individual CDSs as they prepare for their accreditation, especially in relation to quality and finance. Colm Donaghy advised that the development and preparation for each CDS is not for a pass or fail, but for an understanding of their capability which enables us to look at areas of service improvement. Colm added that each CDS will be given planning guidelines and will be given clarity of what they need to have in place.

TBP41 .2/15 Patient Story (Care Planning)

29 Caroline Armitage advised that at future Board meetings we will try and include a patient story. At this meeting the story is by video (the video was played). 30 Following the video, Caroline Armitage queried how many clinicians and nurses have seen Page 3 of 9

it. Helen Greatorex advised that she would see about whether it can go onto Susi, the

Trust’s intranet.

31 Lorraine Reid advised that we need clinical leads on board with this incentive, and we need to have more conversations with our staff about the patient care we provide. Sam Allen advised that the video relates to the delivery of our 2020 Vision and is very much

centred around our values and behaviours, and those of our clinicians. Sam noted that

most of our formal complaints are due to the attitudes of our staff.

32 Vincent Badu stated that it’s worth remembering how these stories are articulated around different levels of the Trust. We’re working towards using these videos at staff inductions so that our staff are aware of our values and behaviours straight away. Sue Morris added that we could look into using these videos in interviews, so we can assess behaviours and values of interviewees in line with our 2020 Vision. 33 Kay Macdonald advised that Carenotes has helped us to scrutinise how we’ve been recording care plans. We’re now calling them personal support plans so they’re meaningful and make sure the support is translated. The Communications team are helping to design a good looking care plan template; to help ensure when service users receive them it is clear that they are Care Plans. 34 Tim Masters stated that our culture and encouragement is important, however we need to review our care plan procedure as it’s clear that our 12 month reviews are not up to standard. Tim added that the quality of these reviews should be re-examined. 35 Tim Ojo acknowledged that if our clinicians were better engaged with our patients, they would implement more effective care plans. Tim added that the detail of the care plan is important but it’s the engagement that’s vital. 36 Colm Donaghy stated that we should engage with our patients to see how their care plans are working for them. Caroline Armitage added that if there are members of the public that would like to contribute to the development of our care plans they could contact her directly. 37 Helen Greatorex asked the Board to agree that we will always write to our patients that record a video or come in to speak, to thank them for sharing their experience. All Board members agreed. 38 Colm Donaghy advised that it would be interesting to see the same person 6 months along the line to see what’s changed.

TBP41 .3/15 To receive an update on CQC Action Plans

39 Caroline Armitage advised that following the CQC’s inspection in January 2015, we’re in the Requires Improvement category, and we’re committed as a Board to change that. The

Executives are meeting with Louise Phillips, our new CQC lead, next Monday.

40 Helen Greatorex advised that this paper sets out a dashboard overview of the actions required following the CQC’s feedback, which includes details from their reports. A first update from individual services with progress is included. Helen added that there were some very straight forward actions which where rectified immediately, however there are

other overarching actions, such as the gender separation strategy, that requires a

dedicated lead, trust-wide action, as well as help from partners, and so these will need a

period of progress development.

41 We have committed ourselves to ensure all action plans are completed by the end of November 2015. Helen advised that Emma Wadey, Deputy Director of Nursing Standards has undertaken many ‘in-house’ inspections including of areas identified by the CQC as needing improvement, and the findings have been positive. 42 Tim Masters queried whether there are any actions that are in danger of not being completed by our committed deadline. Helen Greatorex advised that there are no actions which will be incomplete. Helen added that some overarching actions may still be in progress, although the CQC will have our plans and progress to date at the end of November, so we will be in a much stronger position.

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TBP41 .3/15 To receive the CQC Quality Improvement Plan

43 Sam Allen introduced this item. The Quality Improvement Plan extracts the CQC feedback and themes (not including the compliance actions as these are covered in separate action

plans) and creates one plan. A number of these areas we cannot address on our own, we need assistance from CCGs, the public, and financial investment as examples of the support we require.

44 Sam advised that we’ve met with all CCGs and have outlined how we’re addressing these actions. We’re liaising with the Health Overview Scrutiny Committee (HOSC) in the local areas we service, who are extremely interested in how we’re taking forward the 31 compliance actions. We’re planning to put monthly updates on our public website for all stakeholders and members of the public to view, addressing both compliance actions and quality issues.

45 Richard Bayley asked Sam to, in due course, update him on our investment needs for this plan, including how we plan for the investment and what the overall investment will include.

46 Tim Masters advised in relation to the assurance flow diagram attached, that we need to ensure the CDSs are enabling a quality lead and appropriate resources to deliver the improvement plan. Tim added that through the clinical audit findings, there were worrying

low levels of compliance. He felt that CDSs need an equivalent of a quality committee to track quality. Sam Allen thanked Tim for his helpful comment, acknowledging that we need to focus on assurance from CDS and ensure improvements are made. 47 Sally Flint advised that we also need to ensure our CCGs are fully engaged and the plan links to the commissioning intentions for 2016/17, and in preparation a quarterly meeting with CCGs is due to take place in October 2015 to discuss this. 48 Diana Marsland asked about the 75% compliance target for statutory and mandatory training and wondered what CQC make of this. Helen Greatorex advised that CQC do not approve action plans, only raise concerns if there were any and so far they have not. 49 Colm Donaghy advised that 75% is a realistic target for this year but is only a stepping stone to our target of 100%.

TBP41 .4/15 To receive a report on the last meeting of the Quality Committee

50 Gordon Ferns advised that this report includes key points discuss in the meeting including; 1) Additional KPIs 2) SIs which have increased by 12% - they were reviewed in detail but there was no

specific trend in analysis 3) Slips, trips and falls have reduced by 42% in the wards where the new strategy for reduction had been implemented. There was an imperative to roll this out to all clinical areas.

51 Helen Greatorex advised in relation to slips, trips and falls, the new strategy is rolled out in 88% of wards and it will be fully implemented by the end of November. 52 Helen added that our compliance for Duty of Candour is at 66%. This is in part due to no next of kin information being available.

TBP41 .4/15 To receive the Quality and Performance Report

53 Sally Flint introduced her report and advised that the report includes areas of concern and emerging areas of concern. Good work has been done around external placements,

thanks to the clinically lead approach lead by Dr. Shakil Malik.

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There is an on-going issue around 7 day follow-ups, which slightly missed the 95% 54 Monitor target last month. Rigorous and robust conversations are happening with individual CDSs to ensure they understand our clinically led approach to improving our quality and performance. Sally advised that in relation to Delayed Transfer of Care, the Trust missed the Monitor Q1 55 target and we’re looking at missing the Q2 target at the end of September. Throughout August, Adult Services is reporting 10.4% against the target of 7.5%. Sally was pleased to report that over the last couple of weeks an effective amount of collaboration with local partners has results in moving some of our delayed patients to much more appropriate settings for their care needs, adding that weekly conversations are taking place with local CCG’s regarding delayed patients and their care.

Richard Bayley advised that it’s good to know there is Executive focus on these issues, 56 and queried what work is taking place on the emerging concern for CPA reviews. Lorraine Reid advised that some people were not alerted to the CPA review structure implemented which has now been widely spread, giving her confidence that we’re not going to miss the next target. Lorraine added that in relation to delayed transfers, with the clinical leadership structure in place and integrated work streams, the focus is now moving patients appropriately to address their care and not their length of stay.

Diana Marsland queried the link to funding and commissioning in relation to the Ministry of 57 Justice asking us to admit a Secure & Forensic patient. Simone Button advised that in this case, someone required a bed and we didn’t have one available. Nationally, there are not

enough medium-secure beds available.

Tim Masters reminded directors that he has over the past few board meetings raised his 58 concern about the increasing numbers of complaints. Tim added that he has noticed little change and that we need to understand the reason we receive such high numbers. He suggested that in discussions with CDSs, the number of complaints and trends should be of high importance. Helen Greatorex agreed with Tim and advised that a review of our complaints processes and structure has taken place. Helen added that merging the Complaints team and the Patient Advice and Liaison Team (PALS) has resulted in a higher amount of formal complaints being logged, as there is now no procedure to raise a concern more informally. Vincent Badu advised that the Complaints review paper is being taken to the Executive 59 Assurance Committee to approve the recommendations for change; this will then be presented to the Trust Board. Those involved in the review are also going to receive feedback as to why the changes are being made.

Action: Increase in number of complaints to be monitored through the Executive Assurance Committee and analysis back to the Board in November. Simone Button wished to discuss waiting times in Hampshire and Kent, advising that we 60 have robust plans in place to address the on-going issues, which is the major focus of staff in these areas. Simone advised that there is no full report on waiting times this month due to the transfer to Care Notes. In Kent, there was a massive increase in referrals (1000). Simone added that we simple don’t have enough resource and staff to manage this demand. Simone wished to ensure Board Members are aware that some issues are not

resolvable until the whole system has been revisited. As a final note, Simone added that we’re still awaiting the outcome of the Hampshire services tender.

Colm Donaghy advised that yesterday he was in Kent at a Leadership Forum event with a 61 great turnout from staff. However, one emerging theme was how our staff feel about whether we’re more dedicated to meeting people’s needs or meeting our targets. Colm stated that we’re delivering maximum care with our capacity, yet this has added immense pressure to our staff. Simone Button advised that a lot of work has been done to ensure we’re managing risk as this is definitely an anxiety for staff. However we’re confident about protecting our young people.

TBP41 .4/15 Fundamental Standards

62 Helen Greatorex advised that the Fundamental Standards comes for information, outlining Page 6 of 9

what they are and how the standards are being monitored.

63 The Board confirmed that it had been read and no questions were asked.

TBP41 .4/15 To receive an update on Safe Staffing

64 Helen Greatorex introduced this report and advised that Appendix 1 includes the whole time impact of overstaffing and a summary of incidents on wards. Appendix 2 includes

letters from NHS England regarding safe staffing, however it is important for us to recognise that staffing on acute wards is different from mental health wards. For good practice of safe staffing on wards it has been recognised that the Quality Director and Finance Director should work mutually on these issues, which Helen advised is exactly what she and Sally Flint are doing. Sally Flint added that this is a really important piece of work and we’ve invested £1.9m into safe staffing. 65 Diana Marsland advised that she was surprised at the number of assaults on staff, and queried whether this is what we’d expect. Helen Greatorex advised that we’re aware our

reporting of incidents is not as consistent as it should be, however we’ve moved up on the National Report and Learn Service from third bottom to fifth bottom, noting that we are making improvements. Helen added that as we are making improvements, her concern

remains around whether there is a correlation to these incidents with over and understaffed wards. 66 Vincent Badu advised that we have a high level of staff who are verbally and physically assaulted by our patients, and we’re encouraging people to report it, however it’s become clear that when incidents are reported to the police, they’re not always appropriately taken forward. Vincent added that we support our staff as much as we can, and are working in every local area to ensure reporting is on-going. 67 Lorraine Reid wished to assure Board members that if we see emerging and current areas of concern we report it through the Executive Assurance Committee. Action: Incidents of Physical Assaults on staff to be monitored by the Executive Assurance Committee.

TBP41 .5/15 To receive a report on the last meeting of the Finance and Investment Committee

68 Richard Bayley introduced his report and advised that this meeting took place and the end of July, with a very helpful discussion with all of the Executives regarding the Cost Improvement Plan and their individual actions. 69 Following last Friday’s meeting, Richard advised that we’re on a reasonable trajectory for improvement, however Corporate Services still has a long way to go and we need to be extremely focussed on this. 70 Sally Flint advised that at the end of month 5, the Trust is reporting a deficit of £42k in August, after committing £250k of reserves. Year to date the Trust is reporting a deficit of £737k and is now only £7k away from improving its Capital Service Cover rating from a

rating of 1 to a 2. Monitor for now are reassured with our Cost Improvement Plan and our progress to date. Sally acknowledged the difficulties Adults Inpatient Services and Community Re-design are faced with, and noted the good work of Specialist Services under Simone Button’s leadership, leading us through by embracing their performance in finance and quality. To conclude the update, Sally advised that we need to ensure our financial pressures do not impact our front line services. 71 Tim Masters acknowledged the challenge Executive Directors have, which is to implement recommendations following the audit reports and ensure processes are managed. Tim added that it should be noted that the size of our deficit at the end of August this year is considerably lower than last year.

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TBP41 .5/15 Financial Performance (Quality and Performance Report)

72 All issues discussed in the Finance and Investment Committee update.

TBP41 .6/15 To receive a report on the last meeting of the People Committee

73 Diana Marsland advised that the People Committee had focussed on enabling staff, what was happening in response to Listening into Action and also IT where both quantitative and qualitative benefits were discussed. This includes our IT transformation, their benefits and how they’ll be measured. CDSs have been asked to think about the benefits accrued to them and whether it enables them to do their job effectively. 74 Diana advised that in relation to staff turnover, if a staff member has not completed or is not able to complete a face to face exit interview, there is now the opportunity to complete an online exit survey.

TBP41 .6/15 To receive the People Report

75 Sue Morris introduced the People Report and advised that we’re currently using around 60% of our Framework Agencies. A supplier’s day was held last week which was well attended by 6 supplier companies. Sue added that from tomorrow they’re now required to submit exception reports to Monitor and we will be submitting three, largely due to supply. 76 Negotiations with Doctors regarding 7 day working are still taking place. Jeremy Hunt and the Chair of the British Medical Association are holding another meeting in due course regarding this negotiation.

TBP41 .7/15 To receive a report on the last meeting of the Mental Health Act Committee

77 Vincent Badu advised that discussions taken place in the last Mental Health Act Committee include the increase in service activity, which has increased the requirement for sections and Mental Health Act code practice. 78 We’ve had visits from the CQC (Mental Health Act|) which were linked with their inspection in January 2015 and our action plans. Four visits from the CQC take place each quarter. 79 We have much better compliance around consent to treatment, however we’re still finding challenges with Section 17 leave requests, as service users are not returning by their agreed time.

TBP41 .8/15 To receive a report on the last meeting of the Charitable Funds Committee

80 Diana Marsland advised that our General Charity Fund has been closed to applications as we now have more applications than we can fund. This is due to the work of Rachael Duke, Head of Charity, who has raised the profile of the charity. 81 Diana made a request for all Board members to talk about Heads On when they are out and about at services and visits to help increase awareness of the charity and the need to fundraise. 82 Caroline Armitage advised that today the Annual Accounts for the Charity will be approved in the Private Board meeting. It is in private because the final Audit opinion cannot be provided until trustee approval.

TBP42 .1/15 To receive an update on Non-Executive Director Site Visits

83 Caroline Armitage advised that this is the quarterly report of Non-Executive Director visits. It’s a CQC requirement that all Board members have a full understanding of what is going Page 8 of 9

on throughout the Trust and so really important to record such visits.

84 Peter Lee advised that Executive Director visits will be added to the Board once the presentation of reporting has been agreed.

85 Diana Marsland wished to discuss a visit she undertook at Lewes Prison. Diana advised that she was very surprised by the age range of prisoners, which included a 91 year old

male. 2500 prisoners a month are seen by Lewes Prison services, and Diana wished to

note the importance of their services which also include physical health care. Diana stated that there is a need for more integrated mental and physical health care. 86 Colm Donaghy advised that he recently undertook a shift with the Eastbourne Street Triage team from 3pm-9pm. Colm advised that it was extremely interesting and really clarified the importance of our staff working with the police. It has increased the threshold of mental health sections for the police and has dramatically reduced the number of people in police custody. 87 Caroline Armitage advised that it is being recognised that the Board are much more widely engaged and it is significantly appreciated.

TBP42 .2/15 To receive a report on the last meeting of the Audit Committee

88 Tim Masters advised that this report includes very current information from the meeting on 14th September 2015. Tim advised that throughout the meeting, there was a variety and scope of issues discussed, including the in-progress External Auditor tender which is due for completion in October 2015. A recommendation for External Auditor will be made to our Council of Governors on 19th October 2015. 89 Caroline Armitage queried the Audit Committee’s oversight of rollout for care notes, and queried whether increased risk due to IT services is being overseen and managed. Colm Donaghy advised that he chairs the project board for care notes, and at any stage in the roll out where we encounter possible issues, we take the lessons. Kay Macdonald added that if there is a significant risk they’re escalated to the risk register, and the next audit report for governance of care notes will also be reported to the next Audit Committee meeting. 90 Tim Masters ensured Board members are aware that the Audit Committee does not manage risk, but ensures appropriate internal control and monitoring (via the relevant board committee, for example) is in place.

TBP42 .3/15 Board Members Action Points following the Council of Governors meeting held on 27 July 2015

91 Caroline Armitage advised that at the July 2015 Council of Governors meeting it was agreed that an action log would be presented to the Board of Directors meeting following the previous Council of Governors meeting, to highlight actions required by Board Members. 92 Kay Macdonald advised that on the action log, she is the lead for the update on Ward Activities, not Sue Morris.

TBP43 /15 Any Other Business

93 No further business. The Board of Directors adopted the motion at 12:22pm. 94 Caroline Armitage wished to remind all attendees that the next Board meeting held on 28th October 2015 will be held at Hellingly, East Sussex.

Date and Venue for Next Meeting: 28 October 2015 Meeting Room A, Hellingly Centre Woodside Annex, The Drive, Hellingly Hailsham, East Sussex BN27 4EP

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Sussex Partnership NHS Foundation Trust Board of Directors: 28 October 2015 - Private Agenda Item TBP44 .3/15 Attachment: A For: Decision By: Rebecca Huth, Corporate Governance Administrator

MATTERS ARISING: ACTION POINTS FROM THE BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON 30 SEPTEMBER 2015

Action Minute Action Points Lead Action Required Date Reference 30.09.2015 TBP40 .2/15 Suicide Prevention Strategy CDS Action Plans to be presented to Tim Complete: Added to the Board of Directors in April 2016. Ojo/Peter Board Forward Look

Lee

30.09.2015 TBP41 .3/15 Increase in number of complaints to be monitored through the Helen Complete: Added to Executive Assurance Committee and analysis back to the Board Greatorex Executive Assurance in November. /Peter Lee Committee and Board

Agendas (via Quality & Performance Report)

30.09.2015 TBP41 .4/15 Incidents of Physical Assaults on staff to be monitored by the Complete: Added to Executive Assurance Committee. Forward Look

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Board of Directors: 28 October 2015 - Public Agenda Item: TBP45 .1/15 Attachment: B For Decision/Discussion/ By: Dr Tim Ojo Executive Medical Director

ELIMINATING MIXED SEX ACCOMMODATION (ESMA )/ MAINTAINING SAFETY PRIVACY AND DIGNITY

SUMMARY & PURPOSE

The purpose of this paper is to recommend a revised policy and agree the actions proposed by the ‘Delivering Same Sex Accommodation’ (DSSA) delivery plan, which is required in response the CQC inspection visit in January 2015.

LINK TO OUR 2020 VISION

This policy and delivery plan achieves the 2020 Vision goals that this paper relates to; 1.Safe, effective, quality patient care 2. Local, joined up patient care 3. Put research, innovation and learning into practice

ACTION REQUIRED BY BOARD

The Board are requested to agree the policy and approve the recommendations and actions proposed in the DSSA delivery plan The Board is asked to demonstrate due regard for EHRIA (add number)- the EHRIA is with Adam Churcher and should be completed by the end of this week

ELIMINATING MIXED SEX ACCOMMODATION (ESMA )/MAINTAINING SAFETY PRIVACY AND DIGNITY

1.0 Executive Summary

The CQC inspection which took place in January 2015 and their subsequent report highlighted that we did not fully comply with the NHS operating framework, which requires all NHS funded care to confirm if they are compliant with the national commitment to Eliminate Mixed Sex Accommodation (EMSA). It was agreed that a task and finish working group would be convened to complete the actions below;

 To review best practice currently being taken to eliminate mix sex wards  To review update the Trust’s policy on ‘Dignity And Privacy’ to encompass the EMSA agenda  To establish a position statement on accommodation against the different types of wards stated in the ESMA guidance  To produce a Delivering Same Sex Accommodation (DSSA) delivery plan, compliant with the NHS Operating Framework. This includes actions for the estate, guidance for the workforce in reporting Single Sex Accommodation (SSA) and how wards manage compliance on a day to day basis and a description of information collection and reporting arrangements to be put in place to ensure that the Board is kept informed about EMSA

Actions

This work is now complete and there are a number of actions to be implemented

 An ESMA policy document has been drafted and the Care Delivery Services have been consulted. (Appendix A)

 A DSSA delivery plan (Appendix B) which is organised into the 4 key action areas taken from Department of Health DSSA self-assessment delivery plan; patient experience, estates, systems and processes and staff culture

 A summary of our current position with estates (Appendix C) categorised by our compliance according to national policy and guidance (colour coded by risk; Red , Amber, Green)

Wards that are fully compliant Green Wards that could be compliant with clinical ward management –Amber Wards that are not compliant because of the estate layout and cannot be managed effectively purely by clinical ward management Red

There are significant cost implications for the wards marked as Red, which are mainly the dementia and older person’s wards. These will be included in the overall estates plan and a discussion will be required as how this will be managed in the short to medium term.

3.0 Report

Context

The commitment to ‘Eliminate Mixed-Sex Accommodation’ can be found in the 2011- 12 NHS Operating Framework. This states “All providers of NHS funded care are expected to eliminate mixed-sex accommodation except where it is in the overall best interest of the patient”. The Department of Health issued guidance to NHS trusts regarding how to recognise report and eliminate breaches of this policy.

Trusts failing to publish a Declaration of Compliance or Declaration of Non-Compliance regarding single sex accommodation will be liable for retention of up to 1% of all monthly sums payable under the contract for each month or part month until published.

Since April 2011 all providers of NHS funded care have been required to routinely report breaches of sleeping accommodation requirements, as set out in the national guidance. Breaches will attract contract sanctions of £250 per day per patient affected.

Definitions

Same-sex accommodation is – an all-male only, or all female only ward

Mixed-sex wards; these are wards with single bedrooms and gender specific toilet and washing facilities (preferably en-suite) or

Mixed-sex wards – with bed bays (multi-bed rooms) occupied by either men or women with access to gender specific toilet and washing facilities. (The only exception is toilet facilities used while in day areas where service users are fully dressed).

Reporting Breaches in SSA reporting covers sleeping accommodation, bathroom/toilet accommodation (where there is a need for patients to pass through areas for the opposite sex in order to reach their own facilities) and women only day rooms/lounges.

Mental health and learning disability wards are required to provide same-sex day space, particularly for women who use services (women only lounges are mandatory for services provided in facilities built or refurbished since 2000).

All breaches must be reported as a ‘Privacy and Dignity-mixed sex accommodation’ incident via the Trust’s incident reporting system, Safeguard. ONLY breaches relating to sleeping accommodation are reportable to NHS England every month.

The CQC report found that we were not compliant with providing SSA defined by Department of Health policy. Since the inspection we have now undertaken a review of all ward environments, which shows that the wards of main concern are those ward for people with dementia and predominantly older people wards. We therefore need to have a system in place to ensure that all ward teams are managing same sex in accordance with national guidance and policy.

Governance and Monitoring Governance and monitoring of the implementation of the policy and associated action plans will be via local ATS Governance meetings, which inform the Care Delivery Service, Divisional Leadership teams. Representatives from DLT will feed back to the Trust Quality Committee.

4.0 Recommendation/Action Required

The Board are asked to endorse the policy and DSSA delivery plan

5.0 Next Steps

The policy will be disseminated to all areas to carry on working oo delivering same sex accommodation on the basis of this strategy. Awareness raising sessions for staff at induction and other relevant forums via local Governance groups to familiarise them the duties and obligations will be undertaken. Compliance with the policy and the required standards to be monitored and reported via local CDS leadership teams.

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

Appendix A

Eliminating Mixed Sex Accommodation,

Maintaining Safety, Privacy, and Dignity

(Replacing policy no 102/Clinical)

POLICY NO

POLICY VERSION

RATIFYING COMMITTEE Policy Review Group

DATE RATIFIED

DATE OF EQUALITY & HUMAN RIGHTS IMPACT ASSESSMENT (EHRIA) NEXT REVIEW DATE

EXECUTIVE SPONSOR Executive Medical Director

POLICY AUTHOR Nurse Consultant –Specialist Older adults Mental Health

KEY POLICY ISSUES:

Eliminating mixed sex accommodation (EMSA) Mainstreaming Gender and Women’s Mental Health The Dignity challenge Essence of Care

If you require this document in another format such as large print, audio or other community language please contact the Governance Support Team on 01903 845735 or email [email protected]

Did you print this document yourself? Please be advised that the Trust discourages the printing and retention of hard copies of policies and can guarantee that the policy on the Trust website is the most up-to-date version.

As a contingency a full set of up-to-date Trust policies are held by the Governance Support Team based at Trust HQ, Swandean

Status Version number Date Author Consultation Draft V3 05/10/15 B Vincent CDS, EDNQ

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

Contents

1.0 Introduction 3 1.1 Purpose of policy 3 1.2 Definitions 4 1.3 Scope of policy 4 1.4 Principles 6

2.0 Policy Statement 6

3.0 Duties 7

4.0 Procedure 8

5.0 Special Considerations 8

6.0 Development, consultation and ratification 9

7.0 Equality impact assessment 9

8.0 Monitoring compliance 9

9.0 Dissemination and implementation of policy 10

10.0 Document control including archive arrangements 10

11.0 References documents 10

12.0 Bibliography 11

13.0 Cross-reference 12

14.0 Appendices 13 Appendix 1 DSSA Overarching principles Appendix 2 What is a Breach?

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

1.1 Background and Introduction

1.1.1 Protecting the safety, privacy and dignity of our patients is paramount. Sussex Partnership NHS Foundation Trust (the Trust) has a duty to deliver services in an environment, which promotes the safety, privacy and dignity of service users. All staff are expected to treat patients, service users, relatives, carers and visitors with respect and dignity and ensure the safety and privacy of patients and service users is maintained at all times.

1.1.2 In November 2006 the Department of Health launched its ‘Dignity in Care’ campaign. The campaign aimed to put dignity and respect at the heart of care services. The principles set out in the campaign are applicable in all health and social care settings and described in the ‘10 Point Dignity Challenge’ (SCIE, 2009, Appendix 1)

1.1.3 The NHS Operating Framework for 2010/11 requires all providers of NHS funded care to confirm whether they are compliant with the national definition ‘to eliminate mixed sex accommodation except where it is in the overall best interests of the patient, or reflects their patient choice’ and requires NHS providers to have robust plans in place for continued delivery of Singe Sex Accommodation (SSA) or face possible financial penalties (DH, 2009).

1.1.4 In mental health, promoting physical and sexual safety through ‘Eliminating Mixed Sex Accommodation’ (EMSA) is one of the key things that are cited in terms of promoting sexual safety. Women in particular are vulnerable to victimisation and traumatisation, particularly when they are ill and vulnerable. The women’s mental health strategy, Into the Mainstream, Department of Health (2002) and the subsequent guidance, ‘Mainstreaming Gender and Women’s Mental Health – implementation guidance’ (2003) described the needs of women service users. At least half the women in acute inpatient units have histories of abuse; physical, emotional and/or sexual abuse, including child sexual abuse, notwithstanding any adult abuse they have experienced. Male service users may also have histories of abuse and can also be vulnerable in inpatient environments.

1.2 Purpose of Policy

1.2.1 The purpose of this policy is to describe best practice to ensure that every one of our patients and carers receives high-quality care that is safe, effective and upholds their rights to be treated with respect and dignity.

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

1.2.2 This policy sets out for all Trust staff, our roles and responsibilities in relation to EMSA in order to maintain the safety, privacy and dignity of our patients and carers.

1.2.3 It also provides two clear definitions; what constitutes privacy and dignity in a care setting and the definitions of SSA for inpatient staff

1.2.4 The Trust works in line with the Essence of care (DH 2010) benchmarks for ‘Respect and Dignity’ and the Care Quality Commission (CQC) Fundamental Standards of Care to deliver a high quality service. These will be used to inform the delivery of care.

1.3 Scope of policy

This policy applies to all Trust employees who are in direct contact with patients, service users, carers and the public. All staff need to understand and demonstrate behaviours and attitudes that promote respect for all.

1.3 Definitions

1.3.1 Same sex accommodation is:

 Same-sex wards – an all-male only, or all female only ward  Mixed-sex wards – these are wards with single bedrooms and gender specific toilet and washing facilities (preferably en-suite) or  Mixed-sex wards – with bed bays (multi-bed rooms) occupied by either men or women with access to gender specific toilet and washing facilities. (The only exception is toilet facilities used while in day areas, where service users are fully dressed).

1.3.2 Mixed sex accommodation refers to sleeping arrangements and to bathrooms or toilets and the need for patients to pass through areas for the opposite sex in order to reach their own facilities.

1.3.3 Same Sex Day Space Mental health and learning disability wards are required to have same-sex day space (a women’s sitting room), particularly for women who use services (mandatory for services provided in facilities built or refurbished since 2000) (NHS Executive,1999, Appendix 1)

1.3.4 Dignity “is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals……..Dignity applies equally to

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy those who have capacity and to those who lack it. Everyone has equal worth as human beings and must be treated as if they are able to feel, think and behave in relation to their own worth or value” (RCN 2008).

1.3.5 The Dignity in Care Campaign ‘Ten point Challenge’ High quality care services that respect people's dignity should:

1. Have a zero tolerance of all forms of abuse.

2. Support people with the same respect you would want for yourself or a member of your family.

3. Treat each person as an individual by offering a personalised service.

4. Enable people to maintain the maximum possible level of independence, choice and control.

5. Listen and support people to express their needs and wants.

6. Respect people’s right to privacy.

7. Ensure people feel able to complain without fear of retribution.

8. Engage with family members and carers as care partners.

9. Assist people to maintain confidence and a positive self-esteem.

10. Act to alleviate people’s loneliness and isolation (SCIE, 2009).

1.3.6 Essence of Care Bench Mark for Respect and Dignity

People experience care that is focussed on respect

Attitudes and behaviours People and carers feel that they matter all of the time

Personal world and personal identity People experience care in an environment that encompasses their values. Beliefs and personal relationships

Personal boundaries and space Peoples’ personal space is protected by staff

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

Communication People and carers experience effective communication with staff that respects their individuality

Privacy - confidentiality People experience care that maintains their confidentiality

Privacy, dignity and modesty People’s care ensures their privacy and dignity and protects their modesty

Privacy – private area People and carers can access an area that safely provides privacy (DH 2010)

1.4 Principles

1.4.1 The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’ (DH, 2008)

1.4.2 EMSA is an important policy that safeguards patient’s safety, privacy and dignity. However changes to the physical environment (estates) alone will not achieve safety, privacy and dignity in mental health and learning disabilities settings.

1.4.3 Privacy and dignity are an essential component of care and not additional to the service provision. Service users’ views of how safe they feel, or whether they have been treated with dignity and respect for their own privacy, are especially important considerations in mental health and learning disability settings.

2.0 Policy Statement

2.1 Protecting the privacy and dignity of our service users is integral to their feeling safe in our care. The Trust is committed to providing high quality health care, which ensures that every service user receives care that is safe, effective and upholds their privacy and dignity.

2.2 The Trust is committed to the provision of high quality care that is compliant with legislation and regulation in respect of privacy and dignity. As an organisation we are obligated to prevent discrimination by ensuring that care delivered respects the dignity of service users, relatives, carers and visitors under the Equality Act 2010 and the Human Rights Act 1998.

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

3.0 Duties

3.1 The Board of Directors holds overall responsibility for ensuring an up to date policy is in place, which is fit for purpose and based on best practice. The Board is required to ensure that the Trust is compliant with SSA requirements and has a delivery plan in place, demonstrating the Trust’s continuing commitment to EMSA. The Board is required to monitor Trust’s performance and provide a ‘declaration of compliance’ on the Trust website.

3.2 Executive Director of Nursing and Quality will ensure that training in gender sensitive care including SSA requirements is delivered to all clinical staff at induction. Ensure that compliance with this policy and the required standards are monitored and reported, and best practice achieved and shared.

3.3 Service/ Clinical Directors are responsible for ensuring there is local compliance with the policy and guidelines. On a monthly basis to report SSA compliance to the Nursing and Quality Directorate and ensure any failures to comply with the policy is reported using the Incident Reporting System (Safeguard).

3.4 The Complaints team will record any communication from service users who report an infringement of their privacy and dignity including breaches of SSA.

3.5 Matrons and Service Managers will ensure safety in the investigation of any failure to comply with the policy including all breaches, taking corrective action to prevent a reoccurrence.

3.5.1 Ensure that the policy is available to all clinical members of staff and where required provided in alternative formats such as large print.

3.5.2 Ensure that all aspects of the policy are complied with through supervision and annual appraisal.

3.5.3 Ensure that individual team members understand their roles and responsibilities with regard to privacy and dignity.

3.5.4 Ensure that regular assessments of the environment in relation to safety, privacy and dignity issues are carried out

3.6 Director of Estates is responsible for ensuring that there is a capital development plan in place, that supports the delivery of SSA and ensure compliance with EMSA guidelines in any future estate and buildings programmes.

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

3.7 All Staff Must:

3.7.1 Actively promote and protect the safety, dignity and privacy of patients at all times.

3.7.2 Ensure that all patients are cared for in SSA as defined by this policy and report any breeches of the policy or EMSA to their line manager and on the Trust’s reporting system, Safeguard.

4.0 Procedure/ implementation

4.1 Reporting Breaches in SSA reporting covers sleeping accommodation, bathroom/toilet accommodation (where there is a need for patients to pass through areas for the opposite sex in order to reach their own facilities) and women only day rooms/lounges.

4.2 Mental health and learning disability wards are required to provide same-sex day space, particularly for women who use services (women only lounges are mandatory for services provided in facilities built or refurbished since 2000).

4.3 All breaches must be reported as a ‘Privacy and Dignity-mixed sex accommodation’ incident via the Trust’s incident reporting system, Safeguard. ONLY breaches relating to sleeping accommodation are reportable to NHS England every month (Appendix 2).

4.4 All details relevant to the breach should be completed and logged under the cause group privacy and dignity with the primary cause as single sex accommodation breach. The exact location of the breach should also be recorded such as bathroom or bedroom.

5.0 Special Considerations 5.1 Young People 5.1.1 Young people need special consideration. The hospital standard of the National Service Framework (NSF) for children requires children to be treated in accommodation that meets their needs for privacy and is appropriate to their age and development.

5.1.2 The need to provide gender sensitive care, which promotes privacy and dignity, applies to all ages, and therefore includes children’s and adolescent units. This means that boys and girls must not share bedrooms or bed bays and that toilets and washing facilities should NOT be same-sex.

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

5.1.3 Under the NSF, segregation by age is a more important issue than segregation by gender. This is a particular issue for adolescents, who want primarily to be with patients of a similar age and interests. In addition, they want to be able to choose between being in a single or mixed sex environment. Options should be discussed with young patients who are old enough to understand and with their parents and carers. (DH 2004)

5.2 Transgender/transsexual Service Users 5.2.1 Transsexual people, and individuals who have proposed, commenced or completed treatment for the reassignment of gender, are legally protected against discrimination. In addition, good practice requires that clinical responses should be service user focused, respectful and flexible towards all transgender people who do not meet these criteria but who live continuously or temporarily in the gender role that is opposite to their natal sex.

5.2.2 Where possible transgender patients are accommodated according to their presentation (the way they dress, and the name and pronouns that they currently use). This does not depend on them having a Gender Recognition Certificate (GRC) or legal name change. All transgender patients are cared for in a single room. Transgender patients do not share open shower facilities. The views of the transgender patient take precedence over those of family members if there is disagreement.

5.3 Older Adults It is particularly important for older patients/service users to be accommodated in a same- sex environment. Studies have shown that for people over the age of sixty-five, being accommodated on a same-sex ward scores more highly as something they would consider the most important part of being treated with dignity and respect. Thirty-one per cent of women over 65 say being on a same-sex ward would be the most important factor in them feeling they were being treated with privacy and dignity (DH NHS Confederation, 2010).

5.4 Disabled Service user facilities Some toilets and bathrooms contain specialist facilities (e.g. hoists) to make them accessible for disabled users. Such facilities may be designated unisex as long as they are for use by one person at a time, are lockable from the inside (with external override), a risk assessment has been conducted and, where necessary, the service user is escorted by a member of staff. The ideal remains to have segregated accessible facilities where this is possible.

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

6.0 Development, consultation and ratification

This policy has, since its inception, been consulted upon with a range of stakeholders with an interest, in particular clinical staff working in inpatient areas. This policy has yet to be ratified by the Policy Review Group. This policy is subject to on-going review to reflect changes in guidance from Department of Health, Social Care Institute of Excellence and other organisations.

7.0 Equality impact assessment

This policy has been subject to an equality impact assessment.

8.0 Monitoring compliance

8.1 Any SSA breaches, complaints and the Patient Advice and Liaison service (PALs) reports will be reported to the Trust board monthly and disseminated via the Quality and Performance report.

8.2 Annual audit reports of the Patient Led Assessment of the Care Environment audit (PLACE) and Essence of Care benchmarking and quarterly reporting of the Fundamental Standards of care self-assessment will provide the Trust board with evidence of compliance and improvement.

8.3 A DSSA delivery plan is in place to ensure the Trust is compliant with EMSA requirements, which will be implemented and overseen by the Trust board.

9.0 Dissemination and implementation of policy

10.1 The Governance Support Team will place updated versions of this policy on the Trust’s intranet. The Trust’s Partnership Bulletin will alert stakeholders to the issuing of the policy and any subsequently revised versions. The Executive Sponsor will ensure that clinical staff are alerted to the issue, reissue and review of versions of this policy.

10.2 The implementation of this policy needs to be supported by appropriate guidance and training to enable staff to provide gender sensitive care that promotes service user privacy, dignity and safety.

11.0 Document control including archive arrangements 11.1 Following ratification of this policy the Governance Support Team will allocate an official document number and upload the policy onto the Trust data base and website.

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

11.2 This document will be reviewed as and when required by the actions of the DSSA delivery plan and at least every 3 years in line with Trust processes.

11.2 The front cover indicates the version, date of issue and review date of this document. Following each review the policy will be issued as a new version, whether or not there have been changes to the content. The most recent version will be available on the Trust intranet.

11.3 The Governance Team will maintain previous versions of this policy in an archive and will update the Trust data base and website.

12.0 Reference documents

Care Quality Commission, (2015) New CQC Fundamental Standards [accessed 2.10.2015] http://www.ukqcs.co.uk/new-care-standards

Department of Health (2004) National Service Framework: children, young people and maternity services

Department of Health (2008) High Quality Care for All. NHS Next Stage Review, Final Report, TSO, Norwich.

Department of Health/ NHS Institute for Innovation and Improvement. (2010a) Privacy and Dignity The elimination of mixed sex accommodation Good Practice Guidance and Self- Assessment Checklist. DH, London

Available at [accessed 5.10.2015] http://www.institute.nhs.uk/quality_and_value/introduction/privacy_and_dignity.htm

Department of Health (2010b) Eliminating Mixed Sex Accommodation. PL/CNO/2010/3. DH London.

Department of Health (2001, 2010c) Essence of Care Benchmarks, DH, London

Department of Health, (2010d) NHS Guidance, Delivering Same Sex Accommodation Self- Assessment, Delivery Planning and Assurance, DH London.

Social Care Institute for Excellence (2008) Practice Guide 9, dignity in care, London, SCIE

NHS South East Coast (2010) Delivering same-sex accommodation NHS SEC Mixed-Sex Occurrences Guidance.

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

Royal College of Nursing, (2008) Definition of Dignity, RCN, London.

15.0 Bibliography

NHS Confederation (2010) Delivering same-sex accommodation in mental health and learning disabilities, DH London.

NHS Executive (1999) Safety, privacy and dignity in mental health units: guidance on mixed- sex accommodation for mental health services, DH, London.

Department of Health (2002) Into the Mainstream: Strategic Development of Mental Health Care for Women, DH, London

Department of Health (2003) Mainstreaming Gender and Women’s Mental Health - implementation guidance, DH, London.

13.0 Cross-reference

Chaperoning – clinical guidance

Child visiting policy

Drug & alcohol Use by service Users guidance

Essential training

Incident and Serious Incident reporting Policy and Procedure

Observation Policy

Safeguarding and Child Protection strategy

Safeguarding Adults at Risk

Searching patients and their property policy and procedure

Violence and Aggression (PMVA) the prevention and Management of Policy

Visiting detained patients in hospital

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

Appendix 1

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

Appendix 2 (PL/CNO/2010/3 DH 2010)

What is a breach? Guidance for providers, commissioners, SHAs and regulators Policy statement Mixed-sex accommodation will be eliminated, except where it is in the overall best interest of the patient, or reflects their personal choice.

Definition A breach occurs at the point a patient is admitted to mixed-sex accommodation outside the terms of the policy.

What constitutes a breach? Mixing may be justified (i.e. NOT a breach) if it is in the overall best interest of the patient, or reflects their personal choice. These are separated out below for convenience, although in reality there will often be some overlap.

In the best overall interests of the patient There are situations where it is clearly in the patient’s best interest to receive rapid or specialist treatment, and same-sex accommodation is not the immediate priority. In these cases, privacy and dignity must be protected – e.g. by the enhanced staffing provided in critical care facilities. The patient should be provided with same-sex accommodation immediately the acceptable justification ceases to apply. There is no justification for placing a patient in mixed-sex accommodation where this is not in the best overall interests of the patient and better management, better facilities, or the removal of organisational constraints could have averted the situation.

Acceptable justification – i.e. NOT a breach • In the event of a life-threatening emergency, either on admission or due to a sudden deterioration in a patient’s condition • Where a critically ill patient requires constant one-to-one nursing care, e.g. in ICU • Where a nurse must be physically present in the room/bay at all times (the nurse may have responsibility for more than one patient, e.g. level 2 care). This would be unacceptable if staff shortages or skill mix were the rationale • Where a short period of close patient observation is needed e.g. immediate post- anaesthetic recovery, or where there is a high risk of adverse drug reactions • On the joint admission of couples or family groups

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

Unacceptable justification – i.e. a breach • Placing a patient in mixed-sex accommodation for the convenience of medical, nursing or other staff, or from a desire to group patients within a clinical specialty • Placing a patient in mixed-sex accommodation because of a shortage of staff or poor skill mix • Placing a patient in mixed-sex accommodation because of restrictions imposed by old or difficult estate • Placing a patient in mixed-sex accommodation because of a shortage of beds • Placing a patient in mixed-sex accommodation because of predictable fluctuations in activity or seasonal pressures • Placing a patient in mixed-sex accommodation because of a predictable non-clinical incident e.g. ward closure • Placing or leaving a patient in mixed-sex accommodation whilst waiting for assessment, treatment or a clinical decision • Placing a patient in mixed-sex accommodation for regular but not constant observation It is not acceptable to mix sexes purely on the basis of clinical specialism. For instance, in a stroke unit, it may be acceptable to mix patients immediately following admission (life- threatening emergency, and in need of one-to-one nursing), but not to maintain mixing throughout the rehabilitation phase, simply on the basis that it is easier for staff, or because there are not enough people with the necessary skills.

Reflects patient choice There are some instances when sharing accommodation with the opposite gender reflects personal choice and may therefore be justified. In all cases, privacy and dignity should be assured. Group decisions should be reconsidered for each new admission to the group, as consent cannot be presumed. Acceptable justification – i.e. NOT a breach • If an entire patient group has expressed an active preference for sharing (e.g. renal dialysis etc.) • If individual patients have specifically asked to share and other patients are not adversely affected (e.g. children/young people who have expressed an active preference for sharing with people of their own age group, rather than gender).

Unacceptable justification – i.e. a breach • “Take it or leave it” – i.e. the patient is asked to choose between accepting mixed-sex accommodation, or going elsewhere

An Organisational wide policy for Eliminating mixed-sex accommodation, Maintaining Safety, Dignity and Privacy

• “No-win situation” – i.e. the patient is asked to prioritise same-sex accommodation over another aspect of care (e.g. speed of admission, specialist staff etc.) • Custom and practice – e.g. routine mixing of young people without establishing preferences • If the patient said they didn’t mind (there should always be a presumption of segregation unless patients specifically ask to share) • If the patient did not express a preference It is important to note that the norm is always to aim for segregation – the circumstances in which patients choose to share are expected to be very much in the minority.

Footnote Notwithstanding the above, there will be a very small set of circumstances where mixing is acceptable as an emergency response to extreme operational emergencies. This is limited to unpredictable events such as major clinical incidents e.g. a multiple road traffic accident or natural disaster, and major non-clinical incidents such as fire or flood requiring immediate evacuation of buildings.

Appendix B

Delivering Same Sex Accommodation (DSSA) –Self Assessment Delivery Plan

All provider organisations are required to undertake a self-assessment together with the production of a delivery plan in relation to ‘Delivery of Same Sex Accommodation’ (DSSA). The tasks listed below have been taken from the DH Self-Assessment Delivery Plan

Key areas lead Time scale Actions required 1. Patient experience Ensure a mechanism is in place Director of November To draft and introduce a specific question to be included in ‘Family and which actively seeks the Nursing 2015 friends’ test SU views re. DSSA experiences and views of patients Standards and and service users in relation to Safety/Director SSA specific category to be included in PALs/complaints and peer review same sex accommodation (SSA) of Estates discussions and reported provision. There should be a demonstrable Director of January Communication strategy to be developed, including information leaflets/ commitment by the provider to Communications 2016 posters to be used in staff discussions take follow up action should the patient experience indicators show DSSA Trust objectives to be available on public website and include patient unsatisfactory results feedback 2. Estates The physical environment should Director of December Estates audit (completed appendix A) support the delivery of same sex Estates and 2015 accommodation. There should be Facilities/ good physical separation of Managing Executive Management Team (EMB) to discuss and make decision in context sleeping accommodation and Directors. of capital programme prioritisation segregated toilet and washing facilities.

Providers should take into account the elimination of mixed sex accommodation in any 1 refurbishment or new-build capital schemes. 3. Systems and processes Providers are required to Managing December To revise Bed management procedures to reflect SSA considerations demonstrate that the principles of Director/ Service 2015 delivering same sex Directors accommodation are reflected in the management of patient flow.

Providers should have in place Director of December Revise ‘Delivering Mixed Sex Accommodation’ (Including Safety, Privacy and policies and procedures on the Nursing 2015 dignity) policy for agreement by Trust Board (completed attached) delivery of same sex Standards and accommodation. Safety

There should be systems in place Director of December To ensure that all staff use the Trust reporting system (safeguard) which has to report episodes of mixing and Nursing 2015 privacy and dignity-mixed sex wards reporting line. Staff to be made aware of their rectification. Standards and what constitutes a breach of privacy and dignity including SSA breaches. Safety

Mechanisms are in place to Director of December Governance to be agreed provide the Board with regular Nursing 2015 updates on the progress to Standards and Reports to the Board from complaints, PALs and incidents to be categorised eliminate mixed sex Safety/ Director on the basis of mixed sex accommodation issues. These should also include accommodation and feedback on of Estates and abuse and sexual safety issues. the experience of patients and Facilities service users. Evidence from ‘CQC Fundamental Standards team trackers’, Key line of enquiry: safety, Essence of care ‘Respect and Dignity’ and ‘Patient led assessment of care environment’ (PLACE) ‘Privacy, Dignity and Wellbeing’ to be reported under DSSA to demonstrate improvement to CQC. 4. Staff culture The culture of the organisation is EMB November Board member to be identified as lead on Women’s issues- Clinical Academic one in which there is a zero 2015 Director is currently identified as lead on Board for gender, families and tolerance to the mixing of men and relationships, EMB support for lead to include SSA and women’s issues.

2 women in accommodation. The Board support for ‘Delivering Mixed Sex Accommodation’ policy (Including commitment to the delivery of Safety, Privacy and dignity) (appendix B) same sex accommodation is evidenced by a clear commitment and championing from board to ward. Providers will ensure that there is Executive January Develop Staff training on ‘gender sensitive care’ and DSSA to be delivered at a comprehensive strategy to Director of 2016 induction and as mandatory training. ensure that staff understand the Nursing and behaviours expected of them and Quality To roll out Essence of Care benchmarking across inpatient areas, starting with that appropriate training is ‘Respect and dignity’ essence through Senior Nurse forum. available to provide them with the knowledge, skills and ability to NHS Institute for Innovation and Improvement ‘Privacy and Dignity: the deliver against these expectations. Elimination of mixed sex accommodation’ self-assessment checklist to be completed as a baseline for all inpatient areas led by Matrons

Staff will be compliant with locally Executive December On admission assessment of risk and care plan to be completed to include determined policies and Director of 2015 ‘gender sensitive care’ as well as patients’ potential to be exploited or be a procedures and will be actively Nursing and perpetrator of such behaviour encouraged to report episodes of Quality mixing and ensure rectification. Develop with Matrons, local Staff guidance regarding DSSA, including a card sized ‘Aide memoire’.

Seeking and responding to patients Executive November Matrons to amend Nursing handover sheet for inpatients wards to include and service users feedback will be Director of 2015 DSSA heading to evidence that inpatient staff are actively seeking patient viewed as a fundamental element Nursing and views. of patient care Quality Reference: DH Letter Gateway reference: 13530 ‘Delivering same-sex accommodation, self- assessment Delivery Planning and Assurance’ 8th Feb 2010

Appendix 3 Sussex Partnership Foundation NHS Trust In-Patient Units

Matrons Mitigating Actions

NON COMPLIANT – RAG RATING RED – HIGH RISK

St Raphael

St Gabriel St Gabriel have challenges in that they have created a ‘male’ corridor with the dormitory and toilet, but bathroom and shower room are both at opposite ends of the ward from each other, so both genders have to potential walk along corridor where opposite gender bedrooms are to get to bathrooms. The mitigation for this is that due to dependency of our patients the bathroom and shower room (which are both disabled access and so are for male and female use) are kept locked and patients are escorted to them by a member of staff. The issues of having them locked does also come up but due to risks we are not able to manage safely without doing so. Living accommodation – there is only one main lounge area but there is an activity room, dining room and spiritual (quiet time) room so we have options for providing separate living apace as required. Any risk relating to gender mix with individuals is care planned and we use environmental controls / 1:1 observation if required

Heathfield Patients admitted to Heathfield ward have an individualised care plan which is completed with them to support and manage their needs in relation to the gender separation challenges of the ward environment. Where required, staff escort male patients to bathroom facilities which are accessed via the corridor where female dormitories are situated. Clear signage is in place throughout the ward to indicate gender specific accommodation. There is currently refurbishment work being carried out and following this the Patients and Careers Welcome Packs will be updated by the Ward Manager. These packs will include information about gender separation within the ward environment and will signpost people to discuss any concerns with nursing staff. Patient gender is recorded on the "patient information at a glance" board. Results to be shared with staff.

Bodiam

Beechwood Beechwood – single rooms but not ensuite. Female one end of ward males the other; but again bath/shower room access requires people to walk through corridor where the opposite gender bedrooms are. Again this is managed by staff escorting, rooms are disabled access and for males and females. Toilets – fine for night time, during day or when people are using main dining /living space the closest toilets are in same part of the corridor as the male bedrooms. But looking at the guidance this is I believe seen slightly

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differently as people are fully dressed when accessing these facilities. We have a separate ladies lounge in the ‘female’ part of the ward and also a separate quiet lounge – accessed via female half of ward but can be locked off from female bed area if required. Any risk relating to gender mix with individuals is care planned and we use environmental controls / 1:1 observation if required.

Grove Ward Map of ward includes gender of patient in each bedroom

All wards have ensured that there are separate male and female toilets which are clearly identified

Orchard Ward Orchard Ward – 12 bedded mixed gender ward for older adults. The ward comprises of 8 single rooms and a 4 bedded dormitory, none are en-suite. The dormitory is situated half way down the main corridor with single rooms either side. There is a second corridor with 2 single rooms in. We try and cluster as far as possible the same gender together which can be challenging.

There are 2 bathrooms, one of which is the assisted bath and the other is a normal bath with a shower situated in the bath. There are a further 3 separate toilets all of which are situated in the main bedroom corridor opposite the bedrooms. We have designated the toilet for a particular gender however it cannot be avoided that the opposite sex may need to ass the others toilet to access their own.

Iris Ward Map of ward includes gender of patient in each bedroom

Iris ward to have appropriate security system fitted to bedroom doors to ensure privacy All wards have ensured that there are separate male and female toilets which are clearly identified.

Lindridge The ward has only one bathroom and there is no capacity to create a second Brunswick Ward for gender-specific use. However, due to the severity of illness of the people in the care of Brunswick Ward, the bathroom is designated as an assisted bathroom, therefore staff are with the person at all times. People able to self- care independently are not admitted to the ward. However, in the unlikely event that this should be required, admission would be subject to a rigorous risk assessment due to the nature of the equipment in the assisted bathroom. All patients are risk assessed and where a risk is present in relation to safeguarding or vulnerability of people of the opposite gender, an increased level of observation would be used to mitigate risk. • Gender specific information is recorded on the patient status at a glance and observation record. • The main patient lounge has been divided into separate spaces to allow patients to choose which activity they wish to do for instance watch TV or listen to music/chat. • The Cinema room is designed for all patients to be able to watch a film either by themselves or with relatives. • The garden room is designed for all patients to spend quiet time whether alone or with relatives. This area can be used as a single sex area when required.

Promenade Ward

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Rutland Gardens

The Burrows Map of ward includes gender of patient in each bedroom

All wards have ensured that there are separate male and female toilets which are clearly identified.

NO REPORTABLE BREACH – RAG RATING ORANGE – MEDIUM (Need to be Managed)

Amberstone

Woodlands

Vine Ward Currently closed. Consideration should be given to major refurbishment to provide fit-for-purpose ensuite accommodation. Approx cost £3.0m

Shepherd House

Amber Ward All bedrooms at Langley Green are ensuite and meet privacy & dignity requirements. Staff have been informed verbally and by memo of Coral Ward requirements for maintaining male & female wings wherever possible and mitigating risks where this is not possible. Ward layouts included on the Opal Ward noticeboard with male & female wings labelled.

Jade Ward

Maple Ward At Meadowfield men and women have separate sleeping and bathing accommodation therefore according to the DOH guidelines we do not breach. Rowan Ward There are also female only lounges on each ward. We have though identified on the wards separate male and female bedroom corridors. If there is a Larch Ward greater number of one sex than the other, and for example, a male is placed in a bedroom in the corridor designated for females, then they are placed in the rooms nearest to the nurses base, and if necessary, nursing observations are utilised. Patients all have a risk assessment on admission, which includes an assessment of risk to others which will be taken into consideration in bedroom placements. Patient gender is recorded on the patient information at a glance board. Map of the ward in place which indicates the gender of the person in each bedroom. Ward Manager to complete "Good practice guidance audit- privacy & dignity", the elimination of mixed sex accommodation. Results to be shared with staff. Individualised care plans to support and manage needs in relation to gender separation.

Meridian Ward

Oaklands Ward Oaklands Ward – a 16 bedded mixed gender ward for adults aged 18 – 65 years. There are 2 bedroom corridors each housing 8 rooms, there is a ensuite disabled room in each corridor. There is a designated female corridor and a male corridor, however it is not always possible to ensure there is only that gender in the corridor. There are ‘3 swing rooms’ which are cited at the end of the corridors and can be used for the opposite sex as they would not be required to pass the other sex bathrooms to access their own. There is a

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toilet in each corridor and 2 in the main ward area which are designated to a particular gender. Patient gender is recorded on the "patient information at a glance" board. Map of the ward in place which indicates the gender of the person in each bedroom. Ward Manager to complete "Good Practice Guidance Audit - Privacy & Dignity (the Elimination of mixed sex accommodation. Results to be shared with staff. Individualised care plans to support and manage needs in relation to gender separation.

Selden Centre

South Lodge

Bramble Lodge

COMPLIANT – RAG RATING GREEN – NO RISK

Amberley

Acorn House

Willow Ward

Oak Ward

Ash Ward

Southview

Chalkhill

Elm Ward

Chichester Centre - Pine ward

Chichester Centre - Fir ward

Chichester Centre - Hazel ward

Connelly House

Dove Ward

Lindridge Carehome Plus

Mayfield Court

Caburn Ward

Regency Ward

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Pavilion Ward

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Eliminating mixed Sex Accommodation; Safety, Privacy & Dignity 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: August 2015 1.3 Analysis Submission Date: 9th October 2015 1.4 Analysis Team Members: 1) Author / Editor: Barbara Vincent, Nurse Consultant; Sue Payne, Project Manager 2) Frontline Staff: 1.5 If this is a cross agency policy/service 3) Patient / End-user: Inpatient services including Hostels or strategy please indicate partner 4) I/We, being the author(s), Service Managers, acknowledge in good faith that this analysis uses agencies and their formal title accurate evidence to support accountable decision-makers with due regard to the National Equality Duties, and that the analysis has been carried out throughout the design or implementation stage of 1.6 Completion Statement the service or policy.

To ensure that the trust appropriately monitors, reports against and maintains best practice re :EMSA. 1.7 Policy Aim To provide direction to staff to enable them to provide care and treatment in a way which treats service users with respect and maintains their right to privacy and dignity

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 AC 246

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 Patient / Employee Monitoring Data X Risk Assessments Please provide detailed evidence for the areas Recent Local Consultations Research Findings  Evidence via reporting of breaches, PLACE Complaints / PALS / Incidents X DH / NICE / National Reports assessments & 15 steps challenge  DH guidance for eliminating mixed sex Focus Groups / Interviews Good Practice / Model Policies accommodation X Service User / Staff Surveys Previous Impact Analysis  Risk assessments Contract / Supplier Monitoring Data Clinical Audits  EMSA short life working group to develop Sussex Demographics / Census Serious Untoward Incidents policy and action plan  Data from other agencies, e.g. Services, Equality Diversity and Human Rights CQC inspection findings (Jan 2015) 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 Reassignmen t Pregnancy Maternity & Race & Religion Belief Sex Sexual Orientation Human Rights Ref Age 3.1 + The development of the policy will impact positively on gender separation on inpatient areas. Staff will need to ensure that breaches are avoided by taking mitigating actions for all patients. X

3.2 - The implementation of the policy may impact negatively for patients with a mental health issue X X X X X X X X X requiring admission, as there may not be a bed available which ensures Eliminating mixed sex accommodation policy is adhered to and admission could be delayed. 3.3 + Toilets and bathrooms that are adapted to support disabled service users are designed as X X X X gender neutral and access is managed locally to ensure patient safety and dignity 3.4 + The policy is available in different formats upon request X 3.5 + The policy will have positive outcomes for religious beliefs amongst orthodox practices E.G. X X Muslim and Jewish faiths 3.6 + The policy promotes good practice with Transgender patients and ensures patient dignity and X X safety

4. Monitoring Arrangements Help 4.1 The arrangements to monitor  Breach reporting to Trust Board the effectiveness of the policy,  Staff awareness training in ESMA Policy strategy or service considering  Local ward action plans mitigating risks of ESMA & individual care plans where appropriate relevant characteristics?  To be audited via PLACE assessments and 15 Steps challenge  Use of NHS institute for improvement & Innovation Self-Assessment Checklist

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) 3.1 3.2 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) 3.1, 3.3, 3.4, 3.6 3.2 A9. Freedom of thought, conscience and religion (e.g. Animal-derived medicines/sacred space) 3.5 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) 3.4 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) 3 impacts scored (1-5): 3 = Consequence x Likelihood scores: 9

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 The policy applies equally to all inpatient areas. X B. Improvements made or planned for in section 9 (potential or actual adverse impacts The policy may on occasion adversely affect a removed and missed opportunities addressed at point of design) patient requiring inpatient admission. Mitigating C. Policy, service or strategy continues with adverse impacts fully and lawfully justified action will need to be taken via Bed Management (justification of adverse impacts should be set out in section 3 above and Service Directors 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 3.2 Nursing and Quality Mitigating action will need to be Helen Greatorex On-going N/A taken via Bed Management and Service Directors

Board of Directors: 28 October 2015 – Public Agenda Item:TBP46 .1/15 Attachment: C For information and discussion By: Colm Donaghy, Chief Executive CHIEF EXECUTIVE REPORT

1. Introduction This month I would like to highlight two areas for update to the Board and comment on two aspects of our performance. The two areas for update are:  Development of Care Delivery Services  Care Quality Commission The two areas for comment are:  7 Day Follow Up  Delayed Transfer of Care 2. Context Development of Care Delivery Services (CDS) This month a further two services were accredited, Learning Disability Services and Children and Young People’s Services, making a total of 4 to date. The accreditation meetings are a two way process to highlight opportunities as well as areas for further support or development. In order to provide further clarity on the role of CDSs and their relationship with the Trust Board we are currently drafting planning guidelines that will set out expectations for the CDS plans for 16/17 and 17/18. The timescale for having final agreed plans is March 2016 with draft plans by January 2016. The 2016/17 year will be one of transition where we will be working with CDSs and corporate support services to ensure effective decision making arrangements are in place that maximise the opportunities to have a clinically led and patient focused organisation. Care Quality Commission (CQC) The Executive Team met earlier this month with our new lead inspector Louise Phillips. Louise indicated that CQC will be back to inspect our services early next calendar year. It will be an unannounced inspection and will involve a lot fewer inspectors with a focus on our compliance actions. The Trust will not be re rated as a result of this inspection as that can only happen following a full wave inspection. We have agreed with our CCGs that it would be useful to hold another Quality Summit prior to the re inspection and this will be planned to happen during January. 7 Day Follow Up At our last Board meeting I highlighted our performance on 7 Day Follow Up. I am pleased to report that we are now meeting this Monitor KPI, if only just (95.1% against a target of 95%). The Trust has now decided to implement a “best in class” performance of 3-4 day follow up to avoid situations where appointment are left too late in the 7 day requirement. Delayed Transfers of Care (DTOC) As the Board are aware DTOCs require a system response as opposed to the Trust attempting to resolve the issue in isolation. To that end the Trust is including DTOCs as an item on our meetings with the CCGs and Local Authorities. A paper analysing the current situation and actions required was considered by the Executive Team, a summary of which is included in the performance report.

Page 1 of 3 Adult Services Update  Neil Waterhouse, East Sussex Service Director, has been nominated for a Sussex Police East Sussex Divisional Award for his efforts and achievements above and beyond the call of duty. Specialist Services Update  Secure & Forensic Services have appointed two Co-Chair’s to their Clinical Academic Group, who will take a lead role in developing research and quality activities for the care group. This was an area that Secure & Forensic were asked to development for their accreditation as a Care Delivery Service (CDS).  Woodland Family Project: Reaching to the Outdoors; CAMHS Learning Disability and FISS in East Sussex are working in collaboration with Circle of Life Rediscover, a non-profit organisation, offering the most challenging young people who often have limited opportunities, to experience a relaxing, fun and affirming day with their whole family. This project received highly commended at the recent National Mental Health Awards in Newcastle.  Secure & Forensic Hellingly Centre; The fourth ward at Hellingly is nearing completion, allowing other wards to rotate through and enabling essential remedial works to be completed.

3. Recommendations Board members are invited to note the contents of this report, comment and ask questions.

Page 2 of 3

Board of Directors: 28 October 2015 – Public Agenda Item: TBP46.3/15 Attachment: E For Discussion/Information By: Vincent Badu, Strategic Director of Social Care

Annual Patient Experience Report

SUMMARY & PURPOSE

The Patient Experience Annual Report 2015 provides a summary of the feedback we’ve received over the past twelve months via the Friends and Family Test and of some of the work the differing care groups have undertaken to support service user engagement and thereby improve services. The report also includes an early report on the CQC National Patient Survey 2015 which was published on 21st October 2015.

LINK TO ANNUAL PLAN

This report links particularly closely to Goals 1, 2 & 3 of our 2020 Vision:

1. Safe, effective, quality patient care 2. Local, joined up patient care 3. Put research, innovation and learning into practice

ACTION REQUIRED BY BOARD MEMBERS

The Board of Directors is asked to consider the report and to give their comments/ ask any questions of the Strategic Director Social Care & Partnerships

Patient Experience Annual Report 2015

1.0 Executive Summary

Following feedback in relation to last years’ annual report and the desire to hear more from each care group, this year it is divided into two main sections. The first looks at 4 work- streams/surveys that span across the whole Trust: The FFT, the 15 Steps Challenge, National Patient Survey (NPS) and our work in relation to Carers. In the second section a brief summary for each Care Delivery Service (CDS) is given, which highlights FFT returns and lists some examples of good practice taking place in this care group. Finally our future plans for developing how we listen and involve people, through a revised ‘involvement strategy’, are outlined.

2.0 Introduction

Over the last few years, there has been a growing recognition that achieving good patient experience is not only a ‘nice’ thing to aspire to, but is actually an important factor in determining positive treatment outcomes. Numerous articles and studies have proposed that experience needs to be given equal weight alongside safety and effectiveness and for these to be seen as the ‘3 pillars of quality’ in healthcare. As this study published in the British Medical Journal summarises: “The results show that patient experience is consistently positively associated with patient safety and clinical effectiveness.” (see: http://bmjopen.bmj.com/content/3/1/e001570.full).

Within the Sussex Partnership NHS Foundation Trust (SPFT), there is much evidence to demonstrate that this clear message regarding the importance of patient experience is well understood. This report highlights how we are seeking to hear patients (and carers) feedback through the Friends and Family Test (FFT) and gives an overview and some examples of this feedback. It also describes Trust wide initiatives (such as the 15 Steps Challenge and the Triangle of Care) as well as identifying some of the good practice that local teams have in place.

Whilst all of this work is encouraging and demonstrates a real commitment to improving experience across the Trust, there is still much work to do. To this end, in the final section, ‘Looking Forward’, there is an outline of the emerging involvement strategy which seeks to harness the momentum already in place and to set our sights high, as we look towards 2020.

3.0 Report

The full report is presented with this cover paper, for the Trust Board’s consideration.

4.0 Recommendation/Action Required

The Board is asked to review the report and ask any questions of the Strategic Director Social Care & Partnerships

5.0 Next Steps

The Strategic Director Social Care & Partnerships will advise the Deputy Director of Patient Experience of any feedback/suggestions or actions so that he can take these forward.

Patient Experience Annual Report 2015

Bryan Lynch, Deputy Director of Patient Experience October 2015

Page 1 of 44 www.sussexpartnership.nhs.uk

Contents Page Page

Introduction 3

Executive Summary 3

Section 1: Trust Wide Initiatives/Surveys 4

1.1 Friends and Family Test Overview 4

1.2 CQC National Patient Survey 2015 8

1.3 The 15 Step Challenge 11

1.4 Carers 13

Section 2: Care Group Feedback 16

2.1 Adult Services 17

2.12 Brighton and Hove 17

2.13 East Sussex 20

2.14 Coastal West Sussex 22

2.15 North West Sussex 24

2.2 Specialist Services 26

2.21 Secure and Forensic 26

2.22 Learning Disability 28

2.23 Primary Care Services 30

2.24 Children & Young Peoples Services (Sussex) 32

2.25 Children & Young Peoples Services (Hampshire) 34

2.26 Children & Young Peoples Services (Kent) 37

2.27 Complex Care Services 39

2.28 Nursing Home Services 41

Section 3: Summary and Conclusions 42

3.1 Looking Forward and Conclusion 42

Page 2 of 44

Introduction

Executive Summary

Following feedback in relation to last years’ annual report and the desire to hear more from each care group, this year it is divided into two main sections. The first looks at 4 work-streams/surveys that span across the whole Trust: The FFT, the 15 Steps Challenge, National Patient Survey (NPS) and our work in relation to Carers. In the second section a brief summary for each Care Delivery Service (CDS) is given, which highlights FFT returns and lists some examples of good practice taking place in this care group. Finally our future plans for developing how we listen and involve people, through a revised ‘involvement strategy’, are outlined.

Page 3 of 44 SECTION 1: TRUST WIDE INITIATIVES/SURVEYS

1.1 Friends and Family Test Overview

From January 1st this year, use of the Friends and Family Test (FFT) became a national requirement for NHS mental health trusts. FFT is a short survey, promoted to service users and carers at key points on their pathway through services and is also available for completion at any other time they choose. A broadly equivalent quarterly survey for staff began in April 2014.

The survey consists of two standard questions: Firstly: “How likely are you to recommend our service/ ward to friends and family if they needed similar care or treatment?” on a 6 point scale from extremely likely to extremely unlikely. Secondly, they are then invited to give in their own words a reason for their response. We have chosen to also ask service users and carers for suggestions as to what would have improved their experience with us. These free text responses gives us ‘qualitative’ data and presents a real opportunity to develop our understanding of patient experience at both a local and Trust wide level.

Results are delivered directly to team leads weekly and to CDS leadership teams monthly. The Board and individual teams and services are taking up the opportunity to add bespoke questions to the FFT survey to enable in- depth exploration of patient and carer experience using the text online and tablet FFT methodology that extends across all 200+teams in the Trust.

The FFT implementation was included in the 14/15 CQUIN programme. There is no specific CQUIN target for 2015/16, on the basis that it is now part of the standard NHS contract. The successful introduction of FFT in the Trust marks a significant step in the collection of patient and carer experience data, as for the first time we are achieving routine, timely feedback, disaggregated to a team level.

The Trust has remained very close to, or equal with, the national average for positive and negative ratings. The average national response level is 2.4% of unique patient contacts each month, the Trust average is 1.9%, though there is considerable variation across Care groups. Within our cohort of broadly equivalent mental health trusts, the best performing organisation achieves around 5%, though the majority of our peers report a similar proportion of responses to ourselves.

The following points highlight our main planning intentions for the FFT in the coming year:

1. Set and monitor agreed target response levels in each CDS.

2. Identify poorest performing teams so they can be supported and the best performing teams, so we can share their practice.

Page 4 of 44 3. Support CDS’s to develop autonomy and expertise in the use of FFT data, to support their patient experience objectives and other service development.

4. Develop patient experience and FFT feedback methodology e.g. ‘you said - we did’ boards, so that learning is evidenced and shared.

5. Seek to increase Governor member and peer involvement in delivery and analysis of FFT, to support numbers of returns and encourage respondents to feel able tell us when things are wrong.

6. Develop our communications strategy for FFT, as a part of patient experience feedback, with increased use of trust website and social media.

7. Seek opportunities for the use of FFT results and survey process to support trust business planning. A good example of this is the inclusion of the care plan question in all surveys, which was put in place in response to the results of the 2014 National Patient Survey (NPS).

Below are some graphs to highlight broad performance across the Trust from January (when FFT went ‘live’) to the end of September 2015. Later in this paper, we give CDS specific FFT results.

Page 5 of 44

Page 6 of 44

From January 2015 every service user and carer has had the opportunity to tell us the answer to the following question. This was included in response to the results of the 2014 National Patient Survey, which suggested our performance needed improving in this area:

“Please tell us if you have agreed with someone form NHS mental health services what care you will receive (if you are a carer please answer in your own right).”

Page 7 of 44

The picture that emerges from this longer term and more representative survey is markedly more positive about service users’ involvement in their own care planning, than was evidenced in the NPS. It is also possible to break down the results to CDS/ Division, service and team level allowing us to identify good practice and target areas in need of improvement with precision

1.2 CQC National Patient Survey 2015

CQC NPS SPFT 2015.pdf Background:

The CQC National Patient Survey (NPS) 2015, attached above, was undertaken between February and July 2015 selecting from a random sample of 850 patients, aged 18 or over who had been using our community mental health services between 1st September and 30th November 2014. We had 220 completed responses making a response rate of 28%. The overall national average response rate was 29%.

The demographic breakdown of the respondents was broadly the same as the national CQC sample with the exception of Ethnic Group : All of our respondents who gave their ethnicity, stated they were white (95%) compared to the national average of 87% stating they are in this group. Whilst we may have a lower percentage of black and minority ethnic people compared to many other Trusts, it is still surprising that no one identified as anything other than white in this sample.

CQC use the data from the survey to help inform their system of ‘Intelligent Monitoring’, which provides inspectors with an assessment of risk in areas of care within an NHS trust that need to be followed up. The survey data will also be included in the data packs that they produce for inspections.

Page 8 of 44 Results:

Questions in the survey are divided into 10 key sections, addressing questions that relate to health and social care workers; organising care; planning care; reviewing care; changes in who people see; crisis care; treatments (primarily medication), other areas of life, overall views of care and services and overall experience. The table below shows that for all 10 categories our Trust is in the amber coloured banding, which signifies that we are ‘about the same’ as most other Trusts in the survey:

In terms of comparison with our performance from last year, for all but 3 of the 42 questions asked over the 10 categories, there is no ‘statistically significant’ difference to the response previously given. Interestingly all 3 of these questions are in the section ‘health and social care workers’, and Q6 was the 1 question where the Trust was rated in the ‘worst performing’ category:

Page 9 of 44

In relation to the rest of the survey, although falling within the “about the same” banding, it is encouraging to note that for the series of questions about ‘other areas of life’, the responses have broadly recovered from last year, where we had performed poorly. These responses suggest that we are more effectively signposting people to other services in the community that deal with issues such as finance, employment and housing. This final table highlights how respondents rated their experience overall:

Learning from and responding to the feedback:

Whilst this years’ survey has found the Trust to be ‘about the same’ as others, it does indicate that, compared to last year, we have had a drop in performance in regards as to how we interact with our patients. We cannot know definitively which factors have prompted this outcome: it may be related to increased levels of demand, resource issues, or to a combination of these and other elements. What is clear is that these results strengthen the case for delivering on the main areas of work we are currently undertaking, which can help improve these findings. These include:

 Creation of Care Delivery Services: our belief that devolving services to a more local level will result in more person centred practice  New Care Programme Approach: this seeks again to promote a good clinician/service user relationship, based on recovery principles

Page 10 of 44  Workforce Strategies: which look to recruit the best people, with the right attitudes and to give them the training and support to do the best job they can  Listening Into Action: which recognises that if you want to improve service user experience, you need to listen to the staff delivering services and let them drive improvement  Numerous Patient Experience/Service Improvement Initiatives: as outlined in this report

1.3 The 15 Step Challenge

Introduction

The 15 Steps Challenge is a tool designed by the NHS Institute for Innovation and Improvement to help staff, service users and others to work together to identify improvements, that can be made to enhance the service user experience. It identifies what helps make service users and carers feel welcome and safe on their arrival at a ward, so building confidence about the care that will be provided during the admission.

A ‘challenge team’, consisting of a service user or carer, a staff member and a Trust governor or board member, walk onto the ward and take note of their first impressions using the toolkit, to help structure their observations. After walking around the site, the team feeds back in a meeting with leaders. Feedback focuses upon good practice to share and areas for improvement.

Implementation in 2015

Since January 2015, 5 more Assessment and Treatment Service (ATS) reception areas were visited. There are 2 ATS reception areas remaining and they are scheduled to be visited before the end of 2015.

What the visits found

ATS visits are being conducted using the ‘Clinic & Outpatient Settings Toolkit’, as this focuses more specifically on waiting areas and interactions between reception staff and service users, which previous visits have revealed to be a significant factor in the overall experience. These visits have also emphasised the need to include building managers in the process. This is primarily because the environments are often shared and they are the best placed people to answer queries and share any concerns raised with relevant personnel. In terms of identifying improvement opportunities, these visits showed that in order for reception areas to be welcoming places, more effort is needed in terms of ambience, seating arrangements, interactions between reception staff and service users and up-to-date signposting information.

All the issues raised have been shared with ward and senior managers so that they can be addressed as part of quality improvement work. Positive practice has also been celebrated and shared.

Page 11 of 44 Staff engagement

Awareness of and the value placed on the 15 step programme remains high, though there are on-going challenges to the priority it and other patient experience work is given on a day to day basis. Different staff members have been involved in each of the visits to ATS reception areas.

Service user and carer engagement

The numbers of offers to help in ATS reception area visits and feedback from service users and carers about the programme and involvement in the visits remains excellent. Everyone who has been on a visit has expressed interest in being further involved with the project. People remained attracted to the simplicity and accessibility of the idea of examining first impressions and the opportunity to use their expertise by experience. They continue to comment on how easy it is to become involved and although often feeling nervous at the beginning of the process, it has supported them to feel empowered and thereby confident enough to have face to face conversations with staff.

Governor engagement

Governors have been involved in the majority of the visits to ATS reception areas. They have spoken positively about the access it gives them to front line services and the opportunity to meet staff and hear first-hand about the ways that our teams are trying to improve patient experience. Participating governors have also been instrumental in maintaining the high levels of enthusiasm for the 15 Steps Challenge that exist in the Trust and they have contributed significantly towards the plans for a revision of the way we use this tool.

Reporting

After each visit, written feedback is submitted to the ATS and the relevant General Managers. Results are expected to be discussed in the quality governance arrangements for each team and division. In addition, work has begun to consolidate patient experience reporting including results of 15 steps visits alongside FFT results and feedback from compliments, complaints, patient forums etc… on ‘You Said We Did’ Boards,. on each ward. This will make triangulation of information simpler for staff and make the results more accessible for service user and carers. Wards are being encouraged to display 15 steps visit results and general themes and information about the programme continues to be published on the Trust website.

Going Forward

Several proposals for how best to employ the 15 Steps challenge over the coming year will be taken in a paper to the Better by Experience Steering Group. Among these proposals are the following:

Page 12 of 44  In order to ensure that improvements happen as a result of a visit, it is proposed that the group will contact sites three months after the visit for an update on the actions identified in the feedback report. Where they are concerned that insufficient action has taken place to improve service provision, the group will conduct an unannounced visit with a senior member of staff.

 We are aware that sites and services are also being visited in order to conduct Patient and Peer Safety Reviews and Patient Lead Assessments of the Care Environment (PLACE). In an effort to highlight the differences between and the individual merits of each visit (and to reduce the ambivalence that too many visits can cause) we will work with leads for these other visits to ascertain if they can be joined in any way and look at the possibility of producing a yearly visiting schedule.

 The 15 Steps Challenge team will prioritise visiting sites in Hampshire and Kent. We will recruit more young people to support us with these visits and take the opportunity to strengthen our relationships with Healthwatch in those areas by including them in the visits too.

 The 15 Steps Challenge team have received invitations from a number of sites who are keen to show off their redecorated buildings and rejuvenated teams. The team will seek to respond to these invites, as a way of recognising and promoting positive changes that have taken place.

 The Membership Committee has identified the possibility of promoting a related visit by one Governor and/or member of the Trust, in a ‘mystery shopper’ type approach. Using reception area guidelines, this would not only be comparatively easy to organise, but will also give Members an opportunity to be actively involved in service improvement.

1.4 Carers

Triangle of Care:

We are committed to implementing the Triangle of Care in Adult Mental Health, Secure and Forensic, and Dementia services. The Triangle of Care is a national programme supported by the Carers Trust which promotes improved engagement with carers and awareness of the carer perspective, focussing on the three way relationship between patient, carer and staff. The Triangle of Care approach outlines key areas for development backed up by a self-assessment tool used to identify local issues and develop local actions.

The key six standards identified in the Triangle of Care are:

Page 13 of 44  Carers and the essential role they play are identified at first contact or as soon as possible thereafter  Staff are “carer aware” and trained in carer engagement strategies

 Policy and practice protocols re: confidentiality and sharing information are in place

 Defined posts responsible for carers are in place

 A carer introduction to the service and staff is available , with a relevant range of information across the care pathway

 A range of carer support services is available.

A Trust wide advisory group chaired by the Deputy Director for Social Work oversees the implementation of the Triangle of Care programme. The group is supported by local leads within our services and by the local carers support organisations. We have well established Triangle of Care groups in the majority of inpatient units and community teams in adult mental health, and have implemented Triangle of Care in Secure and Forensic inpatient units. Plans are being developed to address those areas where more work is needed. Implementation in Dementia services has started in East Sussex during 2015 and will be rolled out in other areas going forward.

During the year we have audited the progress of the local Triangle of Care groups and this has shown that considerable progress has been made. This typically includes the development of local carer information packs, provision of carers support groups, improved links with carer organisations, and the provision of carer awareness training to staff. A pilot train the trainer programme is being developed in Secure and Forensic services.

We are also aiming to have undertaken or refreshed the Triangle of Care self- assessment in all areas by the end of 2015/16 in order to enable us to meet the membership requirements for the national Triangle of Care programme. In addition, as an outcome of the 20-20 Vision events, we have identified a need to improve the information available to carers from the Trust and have worked with a local carers project – ICE – to develop new information booklets for carers in adult mental health services.

Other Carer Development Work:

The following gives a few examples to highlight some of the work routinely happening across CDS’s within the Trust, to support the involvement of carers:

Working with carers as partners remains central to the work of the learning disability services. Given the nature of the referrals for people with a Learning Disability to our specialist health teams, we have to work with the system around the person, not just the person referred and this means carers are intrinsic to our facilitating the best outcomes for people. For example,

Page 14 of 44 someone with a complex communication need, who requires a visual communication aid to support their understanding of verbal language, relies on this being developed and used by those who know the client best: the carers.

At a strategic level , parent representatives sit on our ‘Quality Rocks’ groups, which are about quality assurance across the service not issues relation to their individual children. At the Selden centre, carers are actively involved from preadmission, whilst their loved one is an inpatient, through to discharge. There is a carers welcome pack, carers medication pack (bespoke to individual clients) and a questionnaire asking for specific feedback about how carers are finding the service , both during the persons stay, and on discharge . Carers are invited to the multidisciplinary reviews and are seen as active partners throughout.

Within our ‘complex services’ the Eating Disorder specialist team provides regular family and carer workshops. These have an evidence-based approach for families/carers supporting someone with an eating disorder and are skills based. Within the Personality Disorder service, families/carers are encouraged to be part of the ‘reinforcing team’ for people undertaking the skills training to develop ways of managing emotion intensity/dysregulation. A meeting with families is part of the structure of this work. We have also developed an adapted manual for young people with emotion intensity/dysregulation problems and there is a parallel parents group that happens at the same time that young people are learning their skills. The perinatal mental health team are working on an audit that showed they do not routinely ask about the needs of the other (husband/partner/families) and they will be developing resources to make the service more ‘partner friendly’.

Finally we have worked with Healthwatch and the local carers’ organisations to develop a survey of carers experience in adult services, which has been available Sussex wide in online and paper formats, and we will use this to identify key areas for improvement going forward.

Page 15 of 44 SECTION 2 CARE GROUP FEEDBACK

Last year, the Trust’s Quality Committee suggested that it would be helpful if the annual report could have feedback specific to each care group. In order to meet this desire, but not create too lengthy a document, the following section has a brief edited summary of FFT feedback for each care group. It also gives some bullet points gathered from emails received from the various services, which give a flavour of some of the improvement work they have been conducting over the last year.

In regards to the FFT information shown, the following section summarises the results of the survey for the period January (the official start of FFT across Mental Health Trusts) to the end of August 2015. The ‘approximate return level’ is a rough indication of the level of FFT returns within each Care group. It is calculated by looking at the proportion of surveys submitted, against the number of ‘unique patient contacts’ for the period. Similar information is collected by Department of Health, but at a higher Trust wide level.

Page 16 of 44 2.1 Adult Services:

2.12 Brighton and Hove

Approximate return level 1.4%

Service user extremely likely to recommend:

Went the extra mile to see that my problem was solved, really felt like they cared

Carer/ family member extremely likely to recommend:

It has been extremely positive for us as a family and for our family member to know we are not alone.

Service user extremely unlikely to recommend:

Lack of being able to do what you want when you want and having all your liberties taken away

Carer/ Family member extremely unlikely to recommend:

This is the worst mental health service I have ever witnessed.

Improvement Work:

 Experience Based Co-Design: This project is filming ex-patients who have previously been on Pavilion ward and some of their carers and

Page 17 of 44 asking them to talk about their experiences: what was good? What made a difference? How can we do things better? This will be edited into a film which will be shown to all those involved and used as a catalyst to discussing what we can learn from these experiences.  New Service User Group: The Community Team are working to establish a service user group  Triangle of Care has been implemented in Brunswick and there has been a focus on carer engagement which includes regular drop-in sessions and increased opportunities for meeting with carers and family. All carers are also sent information on the ward after admission to try and ensure that they are being provided with updated information.  Co- produced Carers Awareness training: we have been working in partnership with carers of people who use our services to co deliver carers awareness training for the Brighton & Hove community teams focusing on the principals of triangle of care  B&H Peer Support Specialist Bank we are developing a bank for Brighton and Hove and have recruited 3 Peer Support Specialists  We have collaborated with the Research Department to develop a Voices Clinic and Obsessive Compulsive Disorder Clinic.  There are now 3 weekly staff Mindfulness groups for community and acute staff and there is now a new Mindfulness for Dementia Group that is the first of its kind.  The Group Treatment Service has spent the last year evaluating the recovery education group and as a result has just rolled out a new 16 week recovery skills programme across both sites. This group consists of 5 modules around formulation and the self, anxiety, low mood, assertive communication and problem-solving. A new Cognitive Based Therapy focused group will run alongside this course offering weekly goal-setting and practice sessions to reinforce learning. It has also set up a new supervision package for all staff consisting of weekly Reflective Group Supervision and Team Clinical Caseload discussion.  Initiative to improve collaborative, recovery focused care planning on Pavilion ward; care plan has additional prompts in ‘My View’ section to support patients to express their views, identify their own strengths, challenges, risks, need and plans. Also embedded Patient Recovery Review forms to give patients more of a voice during weekly meetings and recovery reviews which can be anxiety provoking  Pavilion ward was short listed for Patient Safety Awards for hard work around reducing restrictive practices  Pavilion activity room risk assessed so can now be accessed by patents unsupervised during evenings and weekends, to increase access to meaningful activity and reduce levels of boredom and distress. Plans to risk assess activity rooms on other wards and work towards making them all more accessible to patients  ‘Wellebration’ event one day arts and activity festival (not sure if this was included in last report)  An animation project is currently being piloted on Caburn ward and it is planned to make this hospital wide and the introduction of an off ward, hospital wide pottery group

Page 18 of 44  Weekly walking and community links groups to promote physical activity and support patients to establish community links such as with local gym, community garden, community arts project.  Rutland gardens garden project – creating new raised beds and a mural  3 hospital wide bake off events; promoting sense of community of wards; raising money for charitable funds and raising awareness

Page 19 of 44 2.13 East Sussex

Approximate return level 1.3%

Service user extremely likely to recommend:

Professional and caring understanding and remembers personal details about me

Carer/ family member extremely likely to recommend:

Without the support of the Crisis Home Treatment Team we would not have coped and would have felt very isolated and out of our depth. It was such a relief to have experienced considerate support on hand and we can't thank them enough.

Service user extremely unlikely to recommend:

Poor service not often enough

Carer/ Family member extremely unlikely to recommend:

No comments

Improvement Work:

 Six month pilot of peer support specialist for Personality disorder to improve the experience of patients with this diagnosis. The steering group developing services for people with personality disorders includes two people with lived experience of personality disorder in the group, bringing patient experience into everything we do. We held a service user consultation about Personality Disorder services on 9th

Page 20 of 44 Sept 2014 and a Carer Consultation on the same subject on 17th November 2014.  Pet therapy on the acute wards - this is about to be launched on St Raphael ward. Susie the dog will be making weekly visits supported by canine concern  Greenhouse re-launched at St Raphael –A regular gardening group has now started and is being enjoyed by many patients in this setting.  Physical activities co-ordinator at Woodlands partnership working with Active Hastings to provide physical activity on the ward - physical activities sessions are running once a week until the end of October. This includes Pilates, aerobics, zumba or chair exercises (depending on client needs/wishes) and on some outdoor activities. It is to ensure physical activity happens for our patients who cannot leave the unit and promotes well-being, plus develops interests they may wish to link with on discharge.  An evaluation of staff satisfaction with working in Intake & service user satisfaction with telephone support. This found that service users valued telephone contact but this wasn’t a consistent experience. Staff had inconsistent levels of satisfaction of their work and effectiveness.  The work of moving from the duty system in Assessment and treatment to holding a ‘Daily Clinic’ and the Wellbeing and Recovery care co- ordinators working in cluster groups with no ‘duty system’ was aimed at improving patient experience.  Partnership work with Active Hastings to involve patients in physical activities in the community and there is now an activity available every day of the week.  We have run monthly service user development forum meetings and Triangle of care meetings. We have organised several events – Christmas tea and Ice Skating, Attendance at the Out of the Blue Sponsored 5km walk/run, Tea and Talk on Carers benefits, Tea and Chat with a psychiatrist.  Increased peer support work and running the peer support work for people diagnosed with Borderline Personality Disorder 6 month pilot.  Nurse led Clinic for the dementia patients. We have received compliments from patients’ carers to say big thank you for providing an excellent care and support to our patients and their families/carers, for professionalism, understanding, caring attitude and making things easier with a good quality time.  The Assertive Outreach Team run a social event with Bramble Lodge and Amberstone patients on a weekly basis, trying to take the lead from them on what and where, encouraging mutual support and friendships.

Page 21 of 44 2.14 Coastal West Sussex

Approximate return level 1.3%

Service user extremely likely to recommend:

They have been extremely helpful and considerate and understanding and all and allowed enough time each visit without being rushed which I have appreciated.

Carer/ family member extremely likely to recommend:

When you're at the point of just not knowing what else you can do to help in a very difficult situation, this group of people give you back the belief in the hope that things can managed.

Service user extremely unlikely to recommend:

Dr X does not listen to his patients and took me off essential medication. The ward is constantly noisy so there is no peace and it does not feel therapeutic .Nurse Y seems completely disillusioned with his job and this rubs off on patients.

Carer/ Family member extremely unlikely to recommend:

No comments

Page 22 of 44 Improvement Work:

 We have established 2 substantive peer roles, one in our assertive outreach team and one in our rehabilitation unit. We are actively looking to use peers wherever possible  In September we held an event to celebrate and promote the use of peers to Band 7 staff  Over the last year the recovery college had become much more firmly established and we have increased the number of courses to 13 this year  The Bognor Assertive Outreach Team has trialled the use of the ‘inspire questionnaire’. This asks service users to give feedback in relation to the recovery focus of their care co-ordinator. This has recently completed and the findings will be used to inform how the Trust takes forward this type of approach.  All clinician based groups seek to have service user and carer attendance. These are set up to focus upon specific conditions, i.e. psychosis, mood disorders etc., where their expertise can help influence decision making.  Partnership Forums’: these groups are now well established, with good attendance across coastal west Sussex, and pull together the Trust with external partners (such as health watch and ccg’s) along with service users/carers/public, to look at how we can improve things together.

Page 23 of 44 2.15 North West Sussex

Approximate return level 1%

Service user extremely likely to recommend:

Excellent, knowledgeable, friendly, kind staff

Carer/ family member extremely likely to recommend:

Friendly service - always managed to contact you when I needed...always patient in explaining things...and for the vast majority of the time appointments were kept in a very timely manner

Service user extremely unlikely to recommend:

Its hell for patients and loved ones. But they should try come

Carer/ Family member extremely unlikely to recommend:

No comments

Improvement Work:

 The development of a service user group has begun with the intention of it creating a forum where service users can give feedback and hear responses directly from service leads and where collaborative working can take place. The group has met twice and will be meeting monthly.  ‘Capital’ (third sector organisation that employs people with lived experience) are working on the wards with SPFT leads to gather patient views. It is felt the use of an external organisation gives patients a greater sense of freedom to say what they think, without concerns

Page 24 of 44 that this may impact on the care they receive. The feedback gained is being used to populate the ‘You Said, We Did’ posters.  The team have begun work on developing a ‘service user performance dashboard’ which will collate information re the feedback being received  A local strategy for involvement is being developed to ensure the service prioritises this work

Page 25 of 44 2.2 Specialist Services

2.21 Secure and Forensic

Approximate return level 20%

Service user extremely likely to recommend:

They have been very helpful in and out of hospital.

Carer/ family member extremely likely to recommend:

Focus on my brother’s needs. Inclusion and readiness to involve us in understanding. Planning.

Service user extremely unlikely to recommend:

Lack of on ward activities, slow at getting the treatment needed and a low engagement overall.

Carer/ Family member extremely unlikely to recommend:

No Comments

Improvement Work:

Service User Involvement: The secure and forensic service incorporates service user involvement increasingly in the planning, delivery and evaluation of the service. Examples include:

Page 26 of 44  ‘Capital’ provide service user experience focus groups (facilitated by community service users). These focus groups provide formal service user experience feedback to the ward and leadership team which is then responded to.  Service User / Patient Consultants as a paid vocational role and various paid roles for service users as required, e.g. Interviewing, Training, etc.  Secure Recovery Implementation Group (SRIG) fortnightly Group meeting, for staff and all Resident Consultants with the aim of co- development and co-delivery of recovery initiatives.  Service User consultants are members of the leadership meetings. The patient representatives attend and participate in the Chichester leadership team meeting, providing feedback from the SRIG.  Membership of Regional Recovery and Outcomes Group – 3 monthly meeting with SRIG equivalents in local secure services.  Service user research looking at successful transitions from secure to community care – participatory study employing service users as co- researchers.  Regular attendance at national conferences for secure service users – the last one was in Birmingham in July  Peer Worker involvement, including substance misuse programme, ‘My Shared Pathway Group’, ‘My Story Group’, and staff training – co- production and co-facilitation of groups.

Page 27 of 44 2.22 Learning Disability

Approximate return level 1.2%

Service user extremely likely to recommend:

Finding out what I'm good at and what's difficult. Having it on paper for my support is useful

Carer/ family member extremely likely to recommend:

The team have a good knowledge and experience with the subject. Very approachable

Service user extremely unlikely to recommend:

No comments

Carer/ Family member extremely unlikely to recommend:

No comments

Improvement Work:

 We have in place quarterly meetings with ‘Powerful Partners’ who are a group of service users who are supported in the role and paid for their time  These meetings have several functions which include reviewing feedback and advising on service and policy developments and most recently input into the new 5 year service plan  Our Domiciliary Care Agency, which supports people with complex behavioural and emotional needs, has recently started convening ‘house meetings’ so residents are involved as is possible in decisions that affect them, overcoming significant barriers in so doing.

Page 28 of 44  At the Selden Centre, our Speech and Language Therapist is developing innovative new ways to help service users to be engaged and give feedback  Whilst using the Friends and Family Test presents a unique challenge to our client group, we are putting resources into looking how best we can overcome these

Page 29 of 44 2.23 Primary Care Services

(unable to calculate % return)

Service user extremely likely to recommend:

I received focused advice and support when I was at a very personal low which helped me to devise strategies to see life more calmly and empowered me to cope once more

Carer/ family member extremely likely to recommend:

Noticed a big change in my daughter she couldn't be happier with the service

Service user extremely unlikely to recommend:

No Comments

Carer/ Family member extremely unlikely to recommend:

No comments

Improvement Work:

 We have set up a service user involvement strategy meeting tasked with working out a strategy, pathways, ideas etc. for service user involvement in Health in Mind - the meeting members are interested staff and a service user consultant.  We have been finding out about peer training initiatives with the intent of finding one that suits our service. We are looking to have some peer support volunteers who might offer some support in a light touch way via e-mail and text etc., and others who might meet with clients -

Page 30 of 44 bearing in mind that this is a brief therapy service and clients will probably only need minimal support.  We have developed a feedback form for clients’ that invites them to be involved in the service. We now have a number of returned forms and are beginning to take this further  The development of an e-mail review group. We have developed an information sheet about this role and have had guidance from the Volunteer Lead about forms that need completing around confidentiality etc.  We are in the process of finalising information for service users interested in joining the strategy meeting – also terms of reference, protocols and guidance on how we make decisions about who is best suited to this role given that a number of people have expressed an interest, how long membership of the meeting would last given that there might be increasing interest etc. We hope to begin meeting people about joining the group soon - our service user consultant is committed to being part of these meetings  We have recently been asked if servicers users would be interested in being involved in training films and have had volunteers for this.  We hope to progress other ideas in the future including having service users involved with interviewing staff and being more involved in service decisions as well as organising local forum meetings.

Page 31 of 44 2.24 Children & Young People Services (Sussex)

Approximate return level 0.6%

Service user extremely likely to recommend:

The whole team has been really supportive and action plans really quickly.

Carer/ family member extremely likely to recommend:

The support given to both me as a friend and to the patient was outstanding. Having no real understanding of mental health issues time was spent explaining things to me, support and advice was given when needed via the phone and regular contact was made. I felt support was available when needed.

Service user extremely unlikely to recommend: No comments recorded

Carer/ Family member extremely unlikely to recommend

Very poor, inadequate service.

Improvement Work:

 Discovery College launched, which mirrors the model of Recovery College, but for young people (YP). We have three courses on offer this term including an innovative project to take a drama event into three schools to raise mental health awareness. The rehearsals and event will also be filmed in order to create a documentary for the remaining East Sussex schools to use. YP are involved in the design and delivery of these courses. We have developed partnerships with TYS- emotional well-being hub to deliver two of the projects. This

Page 32 of 44 partnership provides a unique step-up and step down process between the services.  East Sussex Primary mental health work team run an after office hours training programme for all children’s workers and health professionals. We are just concluding a project to create a film and supplementary resources with children/young people and families, for three of the courses.  ‘Getting to know you’ booklet has been co-designed with young people and offers young people the chance to fill in some info about themselves ahead of their first appointment, with the intention of helping them to share with the clinician. This work has been adopted nationally and received silver positive practice award from the trust.  This year YP are working to design a new ‘Getting to know you’ booklet that is specifically for over 12’s.  There are numerous regular groups that involve a combination of YP and their carers.  The ‘woodland project’ – delivered in partnership with Circle of Life Rediscovery, seeks to engage YP on their own or with their families via teaching them woodland skills. Through a combination of activities and reflective circles, acquisition of new and fun skills, peer support and participation work to improve services are blended into a day’s experience. This year the project expanded to include the LACAMHS, ADCAMHS and CAMHSLD/FISS teams. This work is being recognised in the trust with a Silver Positive practice award and nationally, with the team nominated for a National Positive practice in Mental Health award to be announced in Newcastle on 14th October 2015.  A film has been made in relation to our work with adopted children and this has been shown in Westminster to Edward Timpson (minister).  We have developed partnership working with Rhythmix (music charity) and have adapted the work to be applied in ChalkHill, the Royal Sussex Hospital and CAMHs in East Sussex and the CAMHSLD/FISS team in East Sussex for young people with moderate to severe learning disability.  Completed a project with ADHD team nurses in Hailsham towards end of 2014-2015 to include parents, teachers and young people in training delivered to teachers. Team are currently trialling an ‘All about me’ template that young people complete themselves to aid transition from one teacher to another in primary school.  Improved the waiting area experiences in Highmore, St. Anne’s and Uckfield with clearer ‘you said, we did’ style areas and friendlier children’s areas and staff photo boards.  We hold an annual show for anyone involved in our service come forward to perform a song, poem, display art, give speeches etc.

Page 33 of 44 2.25 Children & Young Peoples Services (Hampshire)

Approximate return level 3%

Service user extremely likely to recommend:

The i2i staff are really good - they are always there to listen to you when you are struggling and are good at encouraging you to face your challenges

Carer/ family member extremely likely to recommend:

Since seeing camhs, our son is getting back to himself. I feel it’s helped a lot for me to understand the way he feels

Service user extremely unlikely to recommend:

Unfortunately I feel that there was a lack of support.

Carer/ Family member extremely unlikely to recommend:

It takes a ridiculous amount of time to get an appointment and then it gets cancelled twice an hour before hand. Then to get told it will be a year before the next appointment.

Improvement Work:

FIT FEST Child and Adolescent Mental Health Services (CAMHS) in Hampshire in cooperation with colleagues from Hampshire Supporting (Troubled) Families, Hampshire Cultural Trust, and the University of Winchester organised a 2 day event called Fit Fest on 10th & 11th July 2015. This youth event held at The

Page 34 of 44 University of Winchester was an inclusive event for all young people and their families across the County. It was an opportunity that focused on non- stigmatising normalised style programme that was in line with other non- mental health style activity that young people engage with, such as festivals. The emphasis was to reduce fear and stigma and demystify CAMHS. It sought to promote a sense of fun and enjoyment accessing workshops that tapped into creativity, exercise as well as learning. A thread running through this whole event was to inspire the young people of Hampshire. This proactive health and wellbeing event driven and led by CAMHS in Hampshire sought to focus on  Engaging young people in taking an active part, interest and responsibility in their own holistic wellbeing.  Provide information in a way that is engaging and non-threatening.  Present information that recognised young people’s physical, spiritual psychological and emotional health and the contribution that each component has on their positive mental health.  To engage young people and families in an event that is fun, inspirational and relevant.  It was a response to feedback from young people who have requested more information that supports their wellbeing and what organisations could support them.  Provide support and advice to parents and carers of young people.

It was an opportunity for organisations to work together and build stronger relationships and recognise and share the common goals that we have in working with young people and families across Hampshire. CAMHS in Hampshire are passionate about and see the relevance of using creative and different ways to reach out to young people and work with schools. An important part of this is using the arts to engage young people, benefit emotional and psychological wellbeing and use as a medium to raise awareness and reduce stigma.

Advise consultancy and Experience (ACE)

CAMHS teams in Hampshire are seeking to increase the involvement of young people, parents and carers in shaping how services are provided, and improving the service we offer. Hampshire CAMHS have formed (ACE). Those young people and families who may be interested in involvement with shaping local services including:

 Interviewing new staff  Supporting training of staff  Commenting on strategy  Supporting CAMHS to achieve meaningful feedback  Presentations at schools / conferences  Budding / Mentoring others

Page 35 of 44 Virtual ACE- V-ACE

CAMHS teams in Hampshire are seeking to increase the involvement of relevant professionals and community participants aged 26 years and above in how services are provided, and improving the service we offer. CAMHS would be interested in involvement from individuals who are involved with or who have a specialist interest in young people and their emotional and psychological wellbeing. Those people seeking to become involved are likely to have;  Knowledge, understanding and lived experience of the needs of young people, who have mental health and emotional difficulties.  Insight into the ways their diagnosis and treatment has affected the young person’s life.  An interest and/or involvement with young people in Hampshire.  Be in a position of representing the views of young people or their needs.  An interest in supporting the emotional and psychological wellbeing of young people and their families.  An understanding of the need to maintain others confidentiality, as required.

Page 36 of 44 2.26 Children & Young Peoples Services (Kent)

Approximate return level 1.5%

Service user extremely likely to recommend:

Because they help you get all your worries and feelings out and they help you with what you need help with.

Carer/ family member extremely likely to recommend:

I feel that we have REALLY been listened to and no quick fix opted for more time to think about what is actually needed

Service user extremely unlikely to recommend:

I have felt like I'm not worth seeing, my appointments are always being cancelled and I'm just left on tablets and expected to cope.

Carer/ Family member extremely unlikely to recommend

Terrible communication-from therapist, doctors and staff in general. Parents are left feeling as 'outsiders', as an inconvenience for wanting support too.

Improvement Work:

 The Art Psychotherapists in Kent had taken a lead in running Art Days for service users and their families to attend the clinics and create art work. The purpose of this was to use the painted canvases to decorate waiting rooms in Chyps clinics so they look friendly and inviting. The young people and their families also said that they felt part of the

Page 37 of 44 service as they had created positive change to the environment. We had intentionally invited the siblings of the service users so they did not feel excluded. The clinics which have taken part are: Georges Turle House, Canterbury, Orchard House, Broadstairs, Knightrider, and Maidstone.  The South Hub have also run creative workshops headed by the Art psychotherapist and other clinicians. These Art Days will remain on- going. Knightrider have held 3 events this year. Other clinicians are now taking active roles in holding creative days; for example, our CPN at Knightrider has been brilliant; very enthusiastic. Our Music Therapist, also contributed his time and experience which the young people loved.  Young People’s forums have been held in some clinics. Although the attendance has been low the key points raised by the young people have been acted upon.  Our areas of discussion and action now centre on ensuring that young people get good, clear information about our services. We have a leaflet in progress aimed at reducing anxiety in young people and their families when they are referred to our service.  Other main aim is to create the possibility for young people to be on our interview panels for Chyps posts. We could give back to them a good training experience so they can have this on their CVs.  We are in contact with ‘Sustainability Consultant’ for Low Carbon Europe, UK to consider ways that young people who use our service can connect with their environment as a possible treatment plan, i.e. making gardens, growing produce, sculptures, etc. to help reduce symptoms of depression and anxiety. Some of our clinics have green spaces attached to them which we could potentially use…… good for staff also re reducing stress  We have recently held an open day at Cherry Tree House South Kent for patients and parents and professionals the focus of the day was to give them a clearer understanding of the service we provide and for them to participate in doing artwork, outdoor activities. We are in the process of evaluating the outcomes.

Page 38 of 44 2.27 Complex Care Services

Approximate return level 3.8%

Service user extremely likely to recommend:

It's been a huge part of my recovery and I cannot even start to describe how much help I've been given.

Carer/ family member extremely likely to recommend:

There is so much understanding and compassion at Sedcas. Aside from all the emotional support available, there is also such good follow-up and hands on approach for your loved one who is ill. This takes a lot of anxiety away from me as a carer and has left me free to be a Mum. I have trust in my daughter's key worker and the team. it is such a relief.

Service user extremely unlikely to recommend:

No comments

Carer/ Family member extremely unlikely to recommend:

No comments

Improvement Work:

 Within the personality disorder pathway, service users have continued to be active in facilitating peer-led groups and co-facilitating joint groups with staff at both Lighthouse and Bluebell House. They have also attended committee meetings in both services, helping make decisions around the treatment programme and other matters related to running the service. Service users are routinely involved in interview

Page 39 of 44 panels for new staff and volunteers. Service users are regular contributors in training events, such as in the recent annual STEPPS training event, where there was also feedback and participation from both young people and their parents who had recently completed STEPPS-YP in our CAMHS service.  Service users have also been involved in developing proposals for new services, including being part of the working groups and helping to run consultation groups for both service users and carers. An active consultation group has been formed to participate in research.  Another example is the 'Patient involvement forum ' in pain management services, which has been involved in the listening in action initiative to feedback patient experience to GP representatives to improve GP awareness of patient experience in medical consultations. Patient representatives have fed back constructively on the proposed new Musculoskeletal pain pathways across some parts of Sussex and commented on proposed assessment protocols. Changes have been made to existing pathways in the new musculoskeletal design on the basis of patient feedback over the years. Patient reps have also been involved in designing and conducting an audit of service user involvement in clinical health services, and this has been submitted with the service user rep as co-author for publication. An audit repeated at the end of last year demonstrated increased patient involvement compared to baseline across services.  The patient rep is now working nationally as they were invited to be a committee member of the British Psychological Society Faculty of Clinical Health and will be involved in national strategy/ policy development of Clinical Health Psychology services.  Brighton & Hove Eating Disorder Service have commissioned ‘men get eating disorders, too’ to develop a peer support group network in Brighton & Hove. This involved creating a women, men and carers group who meet on a monthly basis and use peer support as their main model of operation. We received further funding to develop eating disorder services in West Sussex and based on our positive experiences in Brighton & Hove invested funds to develop two peer support groups in West Sussex. In addition, most recruitment processes have involved highly valuable service user and /or carer representation.

Page 40 of 44 2.28 Nursing Home Services

No returns

Improvement Work:

 We have monthly service user/family meeting which are minuted and where actions are identified feedback given within the minutes which are sent to all.  Sharing ideas – all who use the service/their families are encouraged to put a suggestion in the box as to how we can do it better  We have a service user guide which identifies to residents and families how to raise concerns, suggestions and complaints  We have a local process to provide a paper access version and a suggestions/complaints box to promote engagement and comment (works well)  We have a local complaints/suggestions and concerns protocol on display which is accessible in and signposts all to how and where to get support if required to help make a complaint and suggestions which are captured and discussed for consideration i.e. garden development plans  We have a monthly newsletter which goes out to all the residents and is displayed in the corridors which is well received.  We have a number of established links with the community and plan to look at a social care enterprise lead project to engage with persons living in our community with dementia and their carers.  Service users are involved in our interview process  We host a number of service user/families/friends events  We have excellent links with the local school who are part of our community involvement plan (often visit/sing/will put on a panto at Christmas)  We are planning to run families education and support sessions – such as understanding dementia and how the relative is an important part of the team.  We are looking at widening our dignity/dementia champion roles wider to include families and service users

Page 41 of 44 3. Looking Forward and Conclusion

Looking Forward:

The above report shows us that there is a large breadth of work taking place across the Trust, which seeks to hear people’s experiences and, crucially, do something with this feedback to improve the services we provide. Alongside this, strategically we are moving towards a model where individual care groups will have more autonomy, with the intention that they will be enabled to respond more effectively to meet the needs of their service user and carer population. Whilst both of these factors can very much be seen as positives, there is a need to ensure that future work is supported with a clear vision in regards to patient experience and involvement that works towards the same objectives. This need was also highlighted in discussions with CQC as part of their inspection earlier this year. They saw that we had a wealth of excellent involvement initiatives taking place, but could do more to co-ordinate all of this good work.

With all of the above in mind, the Patient Experience Team began work this summer on a complete review of our existing ‘Service User and Carer Involvement Guidance’. The first steps have been to go to our Trust wide ‘Service User Reference Group’ and to our external partners, to hear their thoughts and suggestions. This feedback is currently being collated, with the intention of using it to form a cohesive strategy with clear goals, that will guide this work over the next 4 – 5 years, in line with the Trusts ‘2020 Vision’. Whilst there is a way to go before the final strategy is produced, there are many ambitions that will clearly have a place within it. Listed below are some of these areas:

 Have regular meetings in each CDS for service users, Trust Members, Health Watch, Clinical Commissioning Groups and other partners, where services can share their plans and they can hear feedback and work collaboratively to seek solutions together. (this is identified in this years’ Business Objectives (2.4))  Develop systems to aid the co-ordination of feedback from the numerous service user involvement groups established throughout the organisation.  Explore and develop the role of ‘Patient Leader’ across the Trust. The ambition is to establish roles that avoid the pitfall of tokenistic involvement and help us to work collaboratively with service users/cares/partners to improve services.  Implement the Triangle of Care programme working closely with carers and carers organisations to ensure greater engagement with carers  Ensure our patient experience feedback mechanisms (i.e. the FFT) are used to maximise their benefit. For instance use tools like ‘You Said- We Did’ Boards to openly highlight this and other feedback and demonstrate what we are doing in response.  Use technology to help improve engagement and accessibility. Develop our Patient Experience website and increase the effective use of social media.

Page 42 of 44  Look at how we can engage our Members more and enhance the opportunities for them to be involved in giving feedback and in service improvement.

3.1 Conclusion:

We can see that over the last year much energy has gone into gathering feedback and into engaging with service users and carers, and that we clearly understand and value the importance of collaborative working. The challenge for next year and subsequent years will be to connect this work, so that we can maximise its potential. If we accept the growing evidence base that argues that experience is equal in importance to safety and effectiveness, then greater focus upon experience will not simply result in higher satisfaction levels, but, more importantly, it will significantly help the overall performance of the organisation.

Page 43 of 44

If you require this document in an alternative format, ie, easy read, large text, audio, braille or a community language please contact: 01903 843000

Contacts: Main switchboard: 01903 843000 Web: www.sussexpartnership.nhs.uk Email: [email protected]

Board of Directors: 28 October 2015 - Public Agenda Item: TBP46 .4/15 Attachment: E For Information By: Helen Greatorex, Executive Director of Nursing & Quality

IN CONFIDENCE

CARE QUALITY COMMISSION COMPLIANCE ACTION UPDATE

SUMMARY & PURPOSE

The Trust continues to ensure that the actions required following the Care Quality Commission’s inspection in January are completed by the end of November.

The Executive Assurance Committee considered progress at its October meeting, and agreed that Clinical and Service Directors would be invited to the November meeting to discuss progress.

The Board of Directors asked to be provided with a brief overview of progress at each meeting. The attached one side overview provides a summary to date. The Governance Support Team and Care Delivery Services all hold the detail relating to each specific item and action, these are closely monitored and any variance to plan addressed.

LINK TO ANNUAL PLAN

The provision of Safe Quality Care.

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to note the dashboard, and the Quality Committee’s continued scrutiny and testing of progress against the detailed action plans. The Quality Committee next meets on X when the issue will be discussed with Clinical Directors.

CQC Action Plan update – October 2015

Progress against CQC Must Do actions is summarised in Table 1.

Table 1 – CQC action plans

Name of Care Group No: of Action Action plans that have Action plans Action plans with outstanding actions and reasons for this. plans in been completed or are on with on-going place. track to be completed by / outstanding end of November 2015 actions AMHS inpatient services 5 4 1 R10.5 - Relates to management of mixed sex environments. Paper going to Board October 2015 and Draft policy out for consultation. Some wards unlikely to meet guidance due to environmental restrictions (for example Iris ward). CAMHS community 6 3 3 R11.1 - Relates to staffing and the team have stated that parts of their services action plan will run from October – December 2015 which is outside of the November deadline. CAMHS inpatient 3 1 2 R.2.2 - Last month we reported that all action plans had been completed services however we have now received confirmation that works being undertaken to address ligature risks will not be completed until the end of January 2016 which is outside of November deadline. R.2.3 – Relates to compliance with essential training and team report that they plan to be compliant by December which is outside of the November deadline. LD inpatient services 3 3 0 Older Peoples inpatient 9 6 3 R9.4 – Relates to protection against unlawful restraint and seclusion. Policy services has now been ratified and uploaded onto Susi. Trust wide review of PMVA has meant that access to training has been restricted. Plans in place to address this but unlikely to be resolved by end of November 2015. R9.6 – As described in R10.5 Also no update on progress in East Sussex regarding review of Dementia care services R9.8 – Meridian Ward have given a completion date of December 2015 re: staff training, supervision and appraisal Rehab services 4 4 0 SMS 2 2 0

Currently 70% of the action plans have either been completed or are on track to be completed by the end of November 2015. More detailed information about the action plans can be found in annexe 1 and annexe 2.

Annexe 1 Detailed CQC action plans

CQC Action Plan v8 - Oct 2015 -HG.xlsx

Annexe 2 Amber rated action plans only

CQC Action Plan v8 - Oct 2015 -HG - amber.xlsx

Board of Directors: 28th October 2015 – Public Agenda Item: TBP46 .5/15 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 – September 2015

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 – September 2015

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 areas of achievement, concerns and emerging concerns are highlighted below. More detail of specific issues and actions taken are described in more detail in the report.

1.1 KEY AREAS OF ACHIEVEMENT IN THE MONTH

1.1.1 The number of external contractual placements in the month has improved significantly from over 400 bed nights in June to none in September.

1.2 AREAS OF CONCERN

1.2.1 Bed Pressures. A seasonal increase in demand is beginning to exert some pressure on the acute care pathway as previously predicted. Work to improve gatekeeping and ensure more effective discharge planning means that bed availability, (including PICU) has improved and in September and October when compared this this period last year. Sustaining this improvement during winter pressures involves sharing best practice in CRHT performance, developing the psychosis care pathway and working effectively with our partners to ensure discharge from hospital is not unnecessarily delayed.

1.2.2 The Trust has not achieved the Delayed Transfers of Care indicator in Q2 at 9.3% and in September and is currently 8.9% against the target of 7.5%, however good progress was made in finalising specialist placements for people with complex needs.

1.2.3 Finance, Financial performance: Overall in the month the Trust is reporting a deficit of £128k for Month 6, taking the year to date deficit to £866k. This now moves the Trust to a Capital Service Cover Rating of 2, however this is only with a small headroom of £18k.

1.2.4 Finance, Cost Improvement Plan (CIP): In the month £352k was saved against the target of £977k, which is £625k less than planned. The savings delivered in month were slightly reduced improved compared to last month. Year to date there is a recurrent shortfall of £3,875k against the target of £5,860k.

1.2.5 Temporary staff costs as a proportion of pay: Temporary staff costs accounted for 12% of the pay bill in September. Of this, agency costs accounted for 5% of the pay bill.

1.3 EMERGING AREAS OF CONCERN

1.3.1 7 day follow ups: The Trust has achieved the target for patients to be followed up within 7 days of discharge from an acute ward in September. 270 of the 284 (95.1%) of patients were followed up in this timeframe. However this was achieved by a narrow margin. A new set of actions have been put in place and are described in the Adult section of the report.

1.3.2 Sickness Absence rates: The Trust sickness absence rates are 3.9% compared to 3.3% for the same period last year. Adult services are reporting 4.6% sickness rates and Specialist services 3.6%.

1.3.3 Serious Incidents: The Trust has established a Serious Incident Review Group to review Sis and identify themes, hotspots and trends. Data and analysis is shared with the emerging Care Delivery Services, each of which has established their own structures and systems and processes for sharing and learning for serious incidents and near misses.

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 Q2 2015/16: Care Programme Approach reviews in the last 12 months, 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).

3.1.2 The Trust has not achieved the target for delayed transfers of care in Q2 and is reporting 9.5%. The Trust is reporting 8.9% delayed transfers of care in September 2015/16, against the Monitor target of 7.5%. 40 patients were delayed at the end of September. A further narrative is provided at 3.4.5 later in this report.

3.2 TRUST WIDE PERFORMANCE DASHBOARD

TRUST WIDE - KEY ACHIEVEMENTS IN THE MONTH

3.2.1 The number of external contractual placements in the month has improved significantly and none were reported in September.

TRUST WIDE - AREAS OF CONCERN

3.2.2 Temporary staff costs as a proportion of pay: Temporary staff costs accounted for 12% of the pay bill in September. Of this, agency costs accounted for 5% of the pay bill. 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.

3.2.3 The Cost Improvement Plan achieved at Month 6 (year to date) was £1,985k against a target of £5,860k, and is therefore reporting a shortfall of £3,250K.

A summary of the year to date planned and actual CIP is shown in the table below.

Year to Date at Month 6 Total Target £k Actual £k Variance £k Corporate 93 50 - 43 Estates and Site Rationalisation 453 443 - 10 Strategic Pay 1,170 170 - 1,000

Operational Services 3,925 1,322 - 2,603 Procurement and Non Pay 219 - - 219

Total 5,860 1,985 - 3,875

As can be seen from the table above there are significant gaps in the Strategic Pay and Operational Services work streams. Specialist Services have found all of their CIP on a non-recurring basis.

It should be noted that the Strategic Pay work stream relates to the planning gap inherent in our CIP, and has been spread equally over each month of the year.

TRUSTWIDE - EMERGING ISSUES

3.2.4 Patient Experience, Complaints: In September 85.7% complaints were responded to within the Trust’s target of 25 working days or other mutually agreed timeframe.

60 new complaints were received in September compared to an average of 60 per month over the last year. (There has been a 28% increase in complaints over the last 12 months). An increase in the number of CAMHS and later life complaints were seen in Q2, compared to Q1, with July showing a high number of CAMHS complaints (28). This coincided with the school holidays and the publication of the CQC report, which may have been a contributing factor.

100 Complaints received 90 80 70 Adult Total 60 Specialist Total 50

40 Trust Total 30 Linear (Trust Total) 20 10

3.2.5 People, Sickness Absence: The Trust sickness absence rates are 3.95% compared to 3.3% for the same period last year. Adult services are reporting 4.56% sickness rates and Specialist services 3.6%

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 continues the actions reported in prior months. 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.

3.2.6 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 significant number of Serious Incidents related to Information Governance Issues has been noticed in CAMHS services over the past 6 months. ( 5 in June, 1 in July and 2 in August and 2 in September) These have been reviewed in detail by the service and an action plan has been developed to ensure lessons are learnt.

An increased number of level 2 serious incidents have been identified in Adult Services during September. (Involving unexpected death or self-harm). There were 3 in north West Sussex, 3 in East Sussex, 2 in Coastal West Sussex and 1 in Brighton & Hove). These will all be reviewed.

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 from next month.

3.2.7 Finance, Financial performance: The Trust is reporting a deficit of £128k for Month 6, taking the year to date deficit to £866k. However, this now moves the Capital Service Cover Rating to a rating of 2. Although, this is only with small headroom of £18k, it does mean that the Trust is now back to reporting an overall Financial Risk Rating of 3.

In the month work was undertaken to utilise a proportion of the unallocated reserves to fund a number of pressures in Adult Services and improve their year to date position, full details of this is set out in the section on reserves. It should therefore be noted that this has skewed some of the in-month pay variances; however it better reflects their year to dates positions and allows the Trust to demonstrate how it has used its additional funding from commissioners.

3.3

SPECIALIST SERVICES PERFORMANCE DASHBOARD – Managing Director for Specialist Services

SPECIALIST SERVICES - KEY ACHIEVEMENTS IN THE MONTH

3.3.1 The Early Intervention service has achieved the monthly Monitor target for Care Programme Approach reviews to be completed every 12 months. Additionally the service is working towards meeting the new waiting times targets in April 2016. The service will begin reporting against those new targets in shadow form from January 2016.

3.3.2 Sickness levels in some Specialist Services are particularly low at less than 2% and across all Specialist Services at 3.6%, just below the Trust target of 3.5%.

3.3.3…As a result of learning from an SI at the Selden Centre, the physio pathway has been developed to clarify and improve access to Physio for the unit.

SPECIALIST SERVICES - AREAS OF CONCERN.

3.3.2 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. 43.7% of patients assessed in September were seen in 4 weeks.

Hampshire CAMHS have been awarded the tender for the coming 5 years and can now begin work on the mobilisation programme.

Alongside this there has been additional in year funding identified to reduce waiting lists which will put the service in an excellent place to begin the new contract. The additional funding is not without risk but the service is confident it can achieve the targets identified in partnership with commissioners. Good quality information has been used to carry out a piece of demand and capacity modelling which has enabled the service to clearly communicate the pressures on the service.

3.3.3 Waiting times to assessment, CAMHS Kent & Medway: 26.7% of assessments were seen in 4 weeks, 46.6% were seen in 6 weeks (the contractual target).It should be noted that some CCG areas are performing better than others. This is expected as a number of areas have recovery plans in place which include seeing those patients who have been waiting the longest as a priority. Seeing these patients has the effect of increasing the average wait reported in the month for those assessed and reducing the average percentage performance reported.

The service is working closely with the commissioner and have been able to give assurance that the Trust is utilising all resources to best effect towards achieving the specified waiting times. West Kent CCG has confirmed that additional investment will be provided on going. The short term delivery of this has begun.

The service is experiencing concerns with the quality of data captured and reported and is reliant on manual processes for some areas of reporting. A

workshop is taking place in October to review the issues and agree a plan to move to electronic reporting. This will have full clinical involvement.

3.3.4 Serious Incidents: A number of serious incidents have occurred 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. CAMHS is no longer reporting bed delays as serious incidents. This has led to a significant reduction in SIs for the CDS.

SPECIALIST SERVICES - EMERGING CONCERNS

3.3.5 Sussex CAMHS Demand & Capacity: Whilst this service routinely meets 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. The service in West Sussex has received additional funds from Commissioners to cover the loss of social workers (£120k). The service is now recruiting to these posts.

The service has completed the demand and capacity work with colleagues from the Performance team and this has been signed off through local Leadership teams. Discussions are being had with each team to enable them to make local adjustments to bring about improved efficiency. The results of this work will then be shared with Commissioners.

3.3.6 Complaints: 24 new complaints were received in September in Specialist Services. 75% 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. Within CAMHS the CDS Leadership Team has been looking at themes and developing plans to address. For example Delivering agreed proactive communication to MPs and other stakeholders about demand and capacity and team and service activity.

3.3.7 Temporary Costs as a proportion of Pay: The Temporary costs as a proportion of pay is 11% in Specialist Services. Agency spend is 5% of the total pay bill.

Learning Disability Services: Temporary staff 14% as a proportion of pay, agency 6%. These pressures exist in the Selden Centre and Mayfield court. Intensive support is being provided by the organisational development team, and focus has been given on the recruitment process. The service has been working with the communications department on a recruitment campaign. Two of the agency nurses have been moved from non-framework agency to bank positions. There has also been improvements reported sickness at Mayfield court.

Secure & Forensic services: Temporary staff 16% as a proportion of pay, agency 5%. Alternative advertising platforms have been explored by these services, including the use of social media, including twitter, to attract new staff. Agency costs have partly been incurred due to increase seclusion and enhanced observation of patients. Two nurses have been appointed this month. The service is looking to better utilise the bank staff available to reduce this spend.

CAMHS: Temporary staff 9% as a proportion of pay, agency 6%. Staff retention has been an issue in Kent. A retention strategy is being developed in this area, and a recruitment day has been successful this month. A media recruitment campaign is expected to run the week following half term.

3.3.8 Sickness absence is 3.4% in Specialist Services. The Secure & Forensic service has reported 7.3% sickness in August. A proportion of the this related to staff on long term sick that have returned to work such that the sickness figure at end September is now 4.6%.

3.3.9 Learning Disabilities services: The service has some Consultant Psychiatrist vacancies which are proving to be difficult to fill. Dr Tim Ojo and Dr Duncan Angus and the Clinical Director are working with Consultants in the service to create greater flexibility in consultant job plans to ensure patients not recently reviewed are seen and gaps filled whilst further recruitment is carried out.

3.3.10 Within our complex pathway service, there are waiting times for the neurobehavioral and neuropsychiatry clinics. This relates to some lack of clarity regarding commissioning and capacity in the system. Conversations with commissioners have taken place to resolve. As a result East Sussex commissioners have agreed to implement an enhanced neurobehavioural service for East Sussex to resolve the waiting times for that clinic.

3.4

ADULT SERVICES PERFORMANCE DASHBOARD – Managing Director for Adult Services

ADULT SERVICES – AREA OF ACHIEVEMENT

3.4.1 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. 96.5% of patients on CPA have had a review in the last 12 month. Information reports that indicate when review dates are due are being used to help clinicians plan effectively and maintain performance levels. This system has been well-received within the organisation and is seen as an enabling factor in improving patient care.

ADULT SERVICES - AREAS OF CONCERN

3.4.2 North West Sussex Performance: A new approach to performance in North West Sussex is being introduced. Unlike other CDSs the turnover of management has been high, with every management post affected over a period of eighteen months, this level of change has had an impact on key performance indicators and it has been difficult to make sustained improvement. To improve engagement and performance a learning set is being introduced to support all new managers.

3.4.3 Bed Pressures / Delayed transfers of care: The pressures on the acute care pathway are likely to continue over the winter months. The current clinically led approach has stabilised the situation and there is a dynamic plan in place to provide greater flexibility.

Initially the plan was to focus on reducing length of stay to increase capacity, however this was not sufficient, in itself, to meet demand and a wider whole systems approach that includes: strengthening our CRHTs to provide assessment and home treatment effectively; engaging community teams in proactive discharge planning and improving the psychosis care pathway, with particular focus on the purpose of hospital admission within the overall care pathway.

The direction and approach taken is underpinned by clinical audits which have reviewed the trends behind our current pattern of demand.

3.4.4 Reducing Inpatient Spend

There is a detailed plan for reducing overspending wards, further to the increase in budget to ensure safer staffing. This has taken a clinically-led approach with the Matrons sharing best practice and developing bespoke plans for their services that address the central themes. The nature of the underlying issues require both short and longer term approaches, these include: supporting all wards to use Rosterpro effectively to plan shifts, and cover gaps proactively without recourse to agency staff wherever possible; working with framework agencies to cover those areas with significant recruitment issues; sharing best practice in effecting therapeutic observation and prevention of slips, trips and falls. Helen Greatorex and Dr Shakil Malik are jointly sponsoring the latter. Areas where recruitment and retention are problematic have specific plans and a concentrated focus which included role re-

design.

3.4.5 Delayed Transfers of Care Indicator

The Trust has not achieved the Delayed Transfers of Care indicator in September and Adult service is reporting 10.9% against the target of 7.5%. 40 patients were delayed at the end of September.

There is a clear focus on timely transfer from acute care and care is being delivered in a more systematic way. Discharge teams are in place in most units and are helping to coordinate care more effectively. This is particularly important in overcoming some of the delays that can arise when accommodation issues might prevent timely discharge or transition. The number of people whose stay has been significantly extended due to issues related to specialist accommodation or placement has been reduced, enabling them to receive the care they need in the right facility.

The Trust is also engaging which Commissioners to ensure that system wide issues are addressed. A weekly trust wide review of all DTCs is now in place, and there is a system for discussing on a case by case basis with commissioners.

Of those patients who were delayed at the end of September, 8 delays started in September, 7 patients delays started in August, 4 started in July, 3 started in June, 5 from January to May and 2 from 2014 and earlier.

Of those patients who were delayed at the end of September

. 5 were awaiting the completion of an assessment . 4 was awaiting public funding . 1 were awaiting further NHS Care . 10 were awaiting residential home placements . 9 were awaiting nursing home placements . 1 was awaiting a package of care in their own home . 1 were due to family choice issues . 9 were awaiting housing

3.4.6 Temporary Costs as a proportion of Pay: The Temporary costs as a proportion of pay is 14.0% in Adult Services, 6% for agency staff. The performance in each area is as follows:-

Temporary Costs as a Agency cost as a proportion of pay proportion of pay North West Sussex 17% 11% Coastal West Sussex 16% 5.9% Brighton & Hove 12% 4.3% East Sussex 15% 3.5% Primary Mental Health Care 2% 0.8% and Wellbeing Total 14.38% 5.56%

3.4.7 Sickness Absence. Sickness absence in Adult Services is 5.1% in August (reported 1 month in arrears). East Sussex 5.2% and Brighton & Hove 5.5% North West Sussex 5.5% ,Coastal West 5.0% and Primary Care and Wellbeing 2.8%

ADULT SERVICES – EMERGING CONCERNS

3.4.8 Complaints. 36 new complaints were received in September in Adult services. 94.6% 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.

3.4.9 7 day follow ups: The Trust has achieved the target for patients to be followed up within 7 days of discharge from an acute ward in September. 270 of the 284 (95.1%) of patients were followed up in this timeframe. However this was achieved by a narrow margin. The Adult Services Performance contract meeting discussed this issue and has decided to take the following actions.

. Introduce a “Best in Class” standard that all patients should be followed up in 3 days of discharge. This is in keeping with the Care Quality Commission concerns about safe discharge. . Introduce proactive reporting to highlight patients who have not been followed up after the third day. This is especially to target the small number of patients who are not followed up due to breakdowns in communication and planning. . Develop a checklist that ensures best practice in following up people moving out of area or with no fixed abode.

3.4.10 Waiting times for assessment in 4 weeks: 96.9% of patients were assessed within 4 weeks in Sussex. 91.8% 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.

3.4.11 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 and use NHS net to eliminate faxing, in line with the new national requirements.  The automation of Discharge Summaries is being planned for the

implementation of Carenotes in Adult Services.

3.4.12 Learning for Serious Incidents

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

Clinical leaders are involved in formulating plans which promote learning from SIs. For example a serious of three master classes is currently being run which focus on the treatment of psychosis, this is aligned to the work on developing care pathways which is led by the Clinical Academic Groups

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

September 2015

Sussex Partnership September 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

September 2015 2 Index September 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

Extra Contractual Referrals (ECRs) 0.14 450 TRUST-WIDE (Local indicator) 400

350

Month: September 2015 300

Month YTD 250 Responsive Number of Bed Nights 01,386 200 150

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 239 250 414 391 92 0 000000

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

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

% Delayed (Adult) 10.9% 11.1% 11.5% 5% % Delayed (TRUST) 8.9% 9.3% 9.6%

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

Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 (inc Dementia). Reported to MONITOR quarterly. TRUST Responsive figure (for MONITOR) includes numbers from S&F. ADULT 6.0% 5.3% 4.4% 4.4% 5.0% 10.0% 11.5% 12.6% 11.3% 11.7% 10.6% 12.1% 10.9% 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%

25% Performance by CCG - September 2015 Month end patient delays % delayed 20% Coastal W Sussex14 14.1% Crawley3 23.1% 15% Horsham & Mid Sx7 14.3% 10% Brighton & Hove14 17.0%

Eastbourne1 0.7% 5% High Weald0 0.8%

0% Hastings & Rother1 4.1% 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 Hampshire1 100.0% % delays Target Other CCGs0 0.0%

September 2015 1 Adult Services September 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

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

95% Month: September 2015 Target: 95%

Month Quarter YTD 90% No. of Admissions 195 610 1,147 85% No. Gate-kept 195 610 1,144

% Gate-kept 100.0% 100.0% 99.7% 80% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

% gatekept Target

AMHS patients under 65 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Responsive TRUST 100.0% 100.0% 98.9% 100.0% 100.0% 100.0% 99.5% 99.4% 100.0% 99.0% 100.0% 100.0% 100.0% 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 - September 2015 100% Admissions Gate-kept % gate-kept

Coastal W Sussex 49 49 100.0% 95% Crawley 8 8 100.0%

Horsham & Mid Sx 24 24 100.0% 90% Brighton & Hove 44 44 100.0% Eastbourne 22 22 100.0% 85% High Weald 18 18 100.0%

80% Hastings & Rother 22 22 100.0% 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 8 8 100.0%

4 week waiting time to assessment 100% Adult Services (Local indicator) 95% Month: September 2015 Target: 95% 90% Month YTD 85% Number of Assessments 1,006 5,475 % assessments <4 Weeks 96.9% 95.6% 80%

Average Wait Days 16.2 16.5 75% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Indicator covers AMHS (exc MAS). % assessments <4 weeks Target Average Wait Days = average wait time from receipt of Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Responsive referral to assessment. ADULT 97.3% 96.6% 96.8% 97.7% 97.1% 96.9% 98.4% 94.5% 93.8% 93.0% 97.6% 97.6% 96.9% 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 - September 2015 100% Assessments <4 weeks Wait Days 90% Coastal W Sussex 326 97.9% 17.8

Crawley 71 93.0% 17.9 80% Horsham & Mid Sx 104 94.2% 21.7 70% Brighton & Hove 110 91.8% 20.8

Eastbourne 160 99.4% 6.7 60% High Weald 107 100.0% 13.9

50% Hastings & Rother 126 97.6% 16.4 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 2 100.0% 12.0 % assessments <4 weeks Target Other CCGs 0

September 2015 2 Adult Services September 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

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

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

4.5%

Month Year Well Led Trust absence rate 3.95% 4.00% 4.0% 3.5% Adult Services absence rate 4.56% 4.85% 3.0%

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

Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 TRUST 3.32% 3.85% 4.10% 4.39% 4.99% 5.30% 5.10% 4.98% 4.10% 3.90% 3.95% 4.10% 3.95% ADULT 3.24% 3.95% 4.23% 4.26% 5.09% 6.24% 5.63% 5.63% 4.60% 4.80% 5.04% 5.25% 4.56%

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

Month YTD 10% Well Led Temporary Spend 14.38% 14.03% Agency Spend 5.65% 5.17% 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% 14.81% 15.37% 14.38% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% AGENCY 4.92% 3.56% 4.81% 6.54% 5.83% 5.65%

Income/Expenditure Budget TRUST-WIDE (Local indicator) £2,000

Month: September 2015 £K Month YTD Well Led (000s) (000s) £1,000

Income/Expenditure Variance 93 2,418 £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

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 Any positive variance against budget is an overspend ADULT 498 1,008 1,726 1,920 2,324 2,418 000000

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

80% Month: September 2015 YTD 60% Well Led

(000s) 40%

CIP Target 2,530 20% CIP Achieved 277 0% CIP % Achieved 10.9% 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 - 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% 10.85% 10.91% 10.95% 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%

September 2015 3 Adult Services September 2015 Sussex Partnership

Key Indicators - Safety NHS Foundation Trust

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

95% Month: September 2015 Target: 95%

Month Quarter YTD 90% Discharged 284 809 1,557 85% Followed-up 270 775 1,502

% Followed-up 95.1% 95.8% 96.5% 80% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

% followed-up Target

All adults aged over 18 discharged from Adult Mental Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 TRUST 97.6% 98.2% 99.2% 98.1% 96.3% 96.2% 94.7% 95.5% 98.7% 97.5% 97.5% 94.6% 95.1%

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 - September 2015 100% Discharged Followed-up % follow-up 90% Coastal W Sussex 78 74 94.9%

Crawley 15 13 86.7% 80% Horsham & Mid Sx 25 24 96.0% 70% Brighton & Hove 71 67 94.4%

Eastbourne 31 29 93.5% 60% High Weald 23 23 100.0%

50% Hastings & Rother 35 35 100.0% 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 1 1 100.0% % followed-up Target Other CCGs 5 4 80.0%

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

Month: September 2015 16

All Serious Incidents Level 1 Level 2 Level 3 8

Adult Services 4

Sussex 4 9 0 0 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

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

Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Level 14822121038155114

Level 2954543810613769 Safety

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

September 2015 4 Adult Services September 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

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

Month: September 2015 Target: 85% 60% Resolved within 25 working days or agreed timeframe 40% Complaints resolved this month 37 Resolved within the agreed timeframe 35 20%

% resolved within agreed timeframe 94.6% 0% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Average number of days to resolution 30.3 TRUST - resolved within timeframe Adult Services - resolved within timeframe Target

Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 TRUST 85.4% 90.0% 96.1% 86.2% 87.9% 85.1% 82.5% 70.5% 70.0% 86.9% 83.1% 84.5% 85.7%

Complaints received (as at month end) 36 ADULT 90.0% 92.0% 93.8% 91.2% 87.2% 83.9% 77.8% 71.8% 61.8% 85.7% 78.4% 80.0% 94.6% Caring

100 Performance by CCG - September 2015

Complaints Resolved Ave Days 80

Coastal W Sussex 9 88.9% 23.3 60 Crawley 3 100.0% 29.0 40 Horsham & Mid Sx 4 100.0% 38.0

Brighton & Hove 5 80.0% 26.0 20

Eastbourne 5 100.0% 20.8 0 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

High Weald 2 100.0% 19.5 Adult new complaints

Hastings & Rother 8 100.0% 48.3 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 S-E Hampshire 1 100.0% 22.0 ADULT35323753394254293443304736 Other CCGs 1 100.0% 23.0

CPA 12 month Formal Review 100% Adult Services (MONITOR indicator) 80% Current Month: September 2015 Target: 95% 60% Month 40% Adults on CPA at end of month 2,478 Last Review within 12 months 2,411 20%

% adults with review <12 months 97.3% 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% 96.5% 95.9% 97.3% 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 - September 2015 Patients Vaild Review % Valid Coastal W Sussex 816 792 97.1% Crawley 109 105 96.3% Horsham & Mid Sx 294 283 96.3% Brighton & Hove 648 637 98.3% Eastbourne 257 255 99.2% High Weald 108 103 95.4% Hastings & Rother 215 205 95.3% S-E Hampshire 9 9 100.0% Other CCGs 22 22 100.0%

September 2015 5 Adult Services September 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

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

Month: September 2015 60% Month Quarter YTD

40% Caring Friends & Family Test 104 268 586

% Positive 92.3% 89.9% 89.6% 20%

% Extremely Likely 53.8% 58.6% 57.2% 0% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 % Negative 3.8% 3.7% 3.4% % Positive Feedback

% Extremely Unlikely 1.9% 1.1% 1.0% Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 ADULT 78.9% 88.1% 83.8% 85.8% 92.9% 85.4% 87.7% 87.7% 87.0% 93.0% 85.2% 92.1% 92.3% 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) 100% Adult Services (Local indicator) 90% Month: September 2015 Target: 95%

Under 65 65 & over TOTAL 80% With a Cluster 11,336 11,932 23,268 70% With a valid Cluster 8,105 10,595 18,700

% valid Cluster 71.5% 88.8% 80.4% 60% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Each cluster has a review period and the cluster is valid if % valid cluster Target the patient's needs are reassessed before the end of the Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 TRUST 83.1% 81.0% 81.1% 80.2% 80.6% 81.4% 80.3% 80.7% 81.1% 81.3% 80.5% 80.4% 80.4%

respective review period and the patient is re-clustered. Caring 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 - September 2015 100% Patients + valid Cluster % valid Cluster 80% Coastal W Sussex 8,608 6,830 79.3%

Crawley 1,774 1,293 72.9% 60% Horsham & Mid Sx 3,468 2,777 80.1% 40% Brighton & Hove 2,997 2,392 79.8%

Eastbourne 2,365 2,001 84.6% 20% High Weald 1,772 1,441 81.3%

0% Hastings & Rother 2,220 1,919 86.4% 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 64 47 73.4% % valid cluster Target

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

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

September 2015 7 Adult Services

Specialist Services Dashboard

September 2015

Sussex Partnership September 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

September 2015 2 Index September 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

4 week waiting time to assessment 100% Specialist Services - CAMHS Sussex (Local Ind) 95% Month: September 2015 Target: 95% 90% Month YTD 85% Number of Assessments 297 2,194

% assessments <4 Weeks 96.0% 96.4% 80%

Average Wait Days 15.1 14.0 75% Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Indicator covers CAMHS Sussex and LDS. % assessments <4 weeks Target Average Wait Days = average wait time from receipt of Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

Responsive referral to assessment. SUSSEX 99.2% 98.5% 99.4% 99.6% 98.5% 98.9% 96.6% 99.5% 97.3% 95.0% 96.1% 93.1% 96.0% 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 - September 2015 100%

SUSSEX Assessments <4 weeks Wait Days 90% Coastal W Sussex 70 90.0% 19.8

Crawley 15 100.0% 13.7 80% Horsham & Mid Sx 26 88.5% 17.5 70% Brighton & Hove 31 100.0% 13.2

Eastbourne 39 97.4% 16.0 60% High Weald 35 100.0% 16.0

50% Hastings & Rother 67 100.0% 9.7 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 14 92.9% 14.9

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

Month: September 2015 Target: 95% 60% Month YTD 40% Number of Assessments 231 1,412 % assessments <4 Weeks 43.7% 40.0% 20%

Average Wait Days 53.9 54.3 0% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Indicator covers CAMHS Hampshire. % assessments <4 weeks Target

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

Average Wait Days = average wait time from receipt of Responsive referral to assessment. HANTS 55.7% 46.0% 45.2% 40.5% 40.0% 45.7% 39.2% 43.5% 35.0% 42.8% 35.2% 40.2% 43.7% 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 - September 2015 100%

HAMPSHIRE Assessments <4 weeks Wait Days 80% Fareham 34 38.2% 45.4 North Hampshire 36 22.2% 81.7 60% N E Hampshire 23 69.6% 55.7 40% S E Hampshire 39 20.5% 65.6 West Hampshire 86 50.0% 50.9 20%

Other CCGs 13 100.0% 6.8 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

September 2015 1 Specialist Services September 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

6 week waiting time to assessment 100% Specialist Services - ChYPS Kent (Local Indicator) 80% Month: September 2015 Target: 95% 60% Month YTD 40% Number of Assessments 290 2,030 % assessments <6 Weeks 45.5% 56.5% 20%

Average Wait Days 63.5 50.6 0% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Indicator covers ChYPS Kent. % assessments <4 weeks % assessments <6 weeks Target Average Wait Days = average wait time from receipt of Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

Responsive referral to assessment. <4 WK 42.5% 47.7% 52.5% 55.6% 51.0% 58.5% 54.5% 60.6% 59.1% 60.5% 63.7% 42.0% 45.5% <6 WK 51.9% 57.1% 70.5% 68.5% 66.9% 69.0% 75.3% 65.8% 59.4% 60.5% 63.7% 42.0% 45.5%

Performance by CCG - September 2015 100%

Assessments <6 weeks Wait Days 80% Ashford 34 82.4% 36.5

Canterbury 34 29.4% 117.3 60% Dartford 42 45.2% 40.1 40% Medway 48 39.6% 57.9

South Kent Coast 28 53.6% 47.4 20% Swale 26 46.2% 52.6 0% Ashford Canterbury Dartford, Medway South Kent Swale Thanet West Other KENT Thanet 28 32.1% 72.5 CCG & Coastal Gravesham CCG Coast CCG CCG CCG Kent CCGs CCG & Swanley CCG West Kent 43 34.9% 88.9 CCG % assessments <4 weeks Target Other CCGs 7 71.4% 25.9

EIS - New Psychosis Cases 200 Specialist Services (MONITOR indicator)

Month: September 2015 150

Responsive

National Target: 48 cases/quarter 100 Month Quarter YTD

50 West Sussex 14 23 48

East Sussex 6 21 44 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 9 19 EIS New Cases - TRUST - YTD Target

TRUST 22 53 111 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 58 76 89 111 Reported to MONITOR quarterly. TARGET 16 32 48 64 80 96 112 128 144 160 176 192

September 2015 2 Specialist Services September 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

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

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

4.5% Month Year Led Well Trust absence rate 3.95% 4.00% 4.0% 3.5% Specialist Services absence rate 3.61% 3.49% 3.0%

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

Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 TRUST 3.32% 3.85% 4.10% 4.39% 4.99% 5.30% 5.10% 4.98% 4.10% 3.90% 3.95% 4.10% 3.95% SPECIAL 3.52% 3.75% 4.08% 4.90% 5.13% 5.57% 5.29% 4.94% 4.03% 3.13% 3.29% 3.38% 3.61%

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

10% Month YTD Led Well Temporary Spend 11.00% 10.26% Agency Spend 5.00% 4.84% 5%

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% 9.64% 10.69% 11.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% AGENCY 4.65% 4.52% 4.37% 4.39% 4.53% 5.00%

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

Month: September 2015 £K

£0

Month YTD Led Well (000s) (000s) -£500

Income/Expenditure Variance -70 -913 -£1,000 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 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 SPECIALIST -80 -257 -413 -664 -843 -913 0 0 0 0 0 0 Any positive variance against budget is an overspend

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

80% Month: September 2015 YTD 60%

Well Led Well

(000s) 40%

CIP Target 1,884 20% CIP Achieved 1,157 0% CIP % Achieved 61.4% 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% 56.13% 60.64% 61.41% 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%

September 2015 3 Specialist Services September 2015 Sussex Partnership

Key Indicators - Safety/Caring NHS Foundation Trust

Serious Incidents - reported in month 24

Specialist Services (Local indicator) 20

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

Specialist Services 8

Sussex 1 0 0 4

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

Kent 2 1 0 Specialist Services Level 1 Sis Specialist Services Level 2 Sis

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Level 1 2 1 4 1 3 6 15 11 10 5 9 3 3 Level 2 5 2 2 1 0 4 5 3 2 2 0 0 1

Performance by CCG - September 2015 Performance by CCG - September 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 0 0 S E Hampshire 0 0 0

Eastbourne 0 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 - September 2015 KENT Level 1 Level 2 Level 3 Ashford 0 0 0 Canterbury 0 0 0 Dartford 2 0 0 Medway 0 0 0 South Kent Coast 0 1 0 Swale 0 0 0 Thanet 0 0 0 West Kent 0 0 0 Other CCGs 0 0 0

September 2015 4 Specialist Services September 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

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

Month: September 2015 Target: 85% 60% Resolved within 25 working days or agreed timeframe 40% Complaints resolved this month 10 Resolved within the agreed timeframe 9 20%

% resolved within agreed timeframe 90.0% 0% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Average number of days to resolution 42.3 TRUST - resolved within timeframe Specialist Services resolved within timeframe Target

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 TRUST 85.4% 90.0% 96.1% 86.2% 87.9% 85.1% 82.5% 70.5% 70.0% 86.9% 83.1% 84.5% 85.7% Complaints received (as at month end) 15 SPECIAL 78.3% 86.7% 100.0% 80.0% 86.2% 86.7% 91.7% 63.6% 83.3% 100.0% 88.9% 90.0% 90.0%

25 Performance by CCG - September 2015

SUSSEX Complaints Resolved Ave Days 20

Coastal W Sussex 2 50.0% 40.0 15 Crawley 0 100.0% 10 Horsham & Mid Sx 2 100.0% 21.0 Caring

Brighton & Hove 1 100.0% 37.0 5

Eastbourne 3 100.0% 67.3 0 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

High Weald 2 100.0% 50.5 Specialist new complaints

Hastings & Rother 0 100.0% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 S-E Hampshire 0 100.0% SPECIAL 5 3 3 3 4 2 5 0 12 15 18 12 15 Other CCGs 2 50.0% 32.5

Performance by CCG - September 2015 Performance by CCG - September 2015 HAMPSHIRE Complaints Resolved Ave Days KENT Complaints Resolved Ave Days Fareham Ashford North Hampshire 1 100.0% 25.0 Canterbury 1 0.0% 44.0 N E Hampshire Dartford S E Hampshire Medway West Hampshire 4 100.0% 51.3 South Kent Coast 2 50.0% 24.5 Other CCGs Swale

Thanet 1 0.0% 38.0 West Kent 1 0.0% 35.0 Other CCGs

September 2015 5 Specialist Services September 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

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

Month: September 2015 60% Month Quarter YTD

40% Caring Friends & Family Test 168 326 495

% Positive 81.0% 77.3% 81.0% 20%

% Extremely Likely 37.5% 37.1% 43.2% 0% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 % Negative 7.7% 9.5% 7.7% % Positive Feedback

% Extremely Unlikely 3.6% 4.9% 3.6% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 SPECIAL 73.7% 82.4% 80.6% 88.8% 93.3% 82.8% 76.8% 98.0% 92.7% 70.5% 83.3% 81.0% 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%

CPA 12 month Formal Review 100% Specialist Services (MONITOR indicator) 80%

Current Month: September 2015 Target: 95% 60% Month 40% Adults on CPA at end of month 232 Last Review within 12 months 224 20%

% adults with review <12 months 96.6% 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% 95.3% 96.6% 96.6% 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 - September 2015 Patients Vaild Review % Valid Coastal W Sussex 72 70 97.2% Crawley 21 20 95.2% Horsham & Mid Sx 21 19 90.5% Brighton & Hove 49 48 98.0% Eastbourne 16 16 100.0% High Weald 23 21 91.3% Hastings & Rother 27 27 100.0% S-E Hampshire 0 Other CCGs 3 3 100.0%

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

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

September 2015 7 Specialist Services

Performance Dashboard

September 2015

Sussex Partnership September 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

September 2015 2 Index September 2015 Sussex Partnership

Key Indicators - Responsive/MONITOR NHS Foundation Trust

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

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

Month Quarter YTD Responsive % Delayed 8.9% 9.3% 9.6% 5%

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

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 TRUST 5.2% 4.4% 3.9% 4.6% 4.7% 8.8% 9.8% 10.5% 9.3% 9.9% 8.7% 10.4% 8.9% 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% 99.4% TRUST-WIDE (MONITOR indicator) 99.2% 98% Month: September 2015 Target: 97% MHMDS Identifier Month Quarter YTD 96% MONITOR Commissioner Code 99.4% 99.4% 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% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Postcode 99.2% 99.2% 99.2% TRUST 99.7% 99.7% 99.4% 99.7% 99.8% 99.7% 99.7% 99.7% 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% 96.1% 94.4% 93.2% TRUST-WIDE (MONITOR indicator) 89.5% 80%

Month: September 2015 Target: 50% 60%

MHMDS Outcome Month Quarter YTD MONITOR 40% Accommodation 96.1% 95.8% 95.8% Employment 94.4% 94.4% 94.4% 20%

HoNOS 89.5% 90.2% 90.2% Accommodation Employment HoNOS TOTAL

TOTAL 93.2% 93.3% 93.3% % valid Target

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 TRUST 90.3% 89.4% 88.5% 88.3% 88.1% 87.4% 86.5% 87.9% 91.4% 94.7% 93.6% 93.2% 93.2% 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%

September 2015 1 Trust-wide Performance September 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

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

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

Month Year 4.5%

Well Led Well Current year absence rate 3.95% 4.00% 4.0% Last year absence rate 3.32% 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. Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15

Trust Absence rate Absence rate (previous 12 months) Target

Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 TRUST 3.32% 3.85% 4.10% 4.39% 4.99% 5.30% 5.10% 4.98% 4.10% 3.90% 3.95% 4.10% 3.95% 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: September 2015 Target: 11%

Month YTD 10%

Well Led Well Temporary Spend 12.00% 12.51% Agency Spend 5.00% 5.04% 5%

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% 11.75% 13.50% 12.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% AGENCY 4.26% 3.68% 4.28% 5.14% 5.31% 5.00%

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

Month: September 2015 £1,000 Month YTD £K

Well Led Well (000s) (000s) £500

Income/Expenditure Variance 128 866

£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

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 300 435 819 695 737 866 0 0 0 0 0 0

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

80% Month: September 2015 YTD 60%

Well Led Well

(000s) 40%

CIP Target 5,860 20% CIP Achieved 1,985

0% CIP % Achieved 33.9% 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% 31.89% 33.42% 33.87% 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%

September 2015 2 Trust-wide Performance September 2015 Sussex Partnership

Key Indicators - Safety/Caring NHS Foundation Trust

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

Month: September 2015 25

All Serious Incidents Level 1 Level 2 Level 3 20

Sussex (Adult) 4 9 0 15 Sussex (Specialist) 1 0 0 10 5 Hampshire (Specialist) 0 0 0 0 Kent (Specialist) 2 1 0 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 TRUST Level 1 SIs TRUST Level 2 SIs Corporate 0 0 0 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 TRUST 7 10 0 Level 1 6 9 7 3 4 9 26 14 18 21 14 14 7 Level 2 14 7 6 6 4 7 13 13 8 15 7 6 10 Safety

July August September

Serious Incident Category Level 1 Level 2 Level 3 Total Level 1 Level 2 Level 3 Total Level 1 Level 2 Level 3 Total

Accidental Event 0 0 0 0 1 0 0 1 0 0 0 0 AWOL 0 0 0 0 0 0 0 0 0 0 0 0 Breach of Mental Health Act 0 0 0 0 0 0 0 0 0 0 0 0 Drug Error 0 0 0 0 0 0 0 0 0 0 0 0 Fall, Slip, Trip 2 0 0 2 2 0 0 2 0 0 0 0 Fire 0 0 0 0 0 0 0 0 0 0 0 0 Ill Health 0 0 0 0 1 1 0 2 0 0 0 0 Privacy and Dignity (inc Bed Delay) 3 0 0 3 0 0 0 0 0 0 0 0 Security & Information Governance 1 0 0 1 2 0 0 2 3 0 0 3 Self Harm 8 0 0 8 7 0 0 7 4 1 0 5 Unexpected Death 0 7 0 7 0 5 0 5 0 9 0 9 Violent Incident 0 0 0 0 1 0 0 1 0 0 0 0 Violent Incident (Homicide) 0 0 1 1 0 0 0 0 0 0 0 0

Complaints resolved in month 100% (Local indicator) 80% Month: September 2015 Target: 85% 60% Resolved within 25 working days or agreed timeframe Complaints resolved this month 63 40%

Resolved within the agreed timeframe 54 20% % resolved within agreed timeframe 85.7% 0% Average number of days to resolution 34.5 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 TRUST - resolved within timeframe Target

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Complaints received (as at month end) 60 TRUST 85.4% 90.0% 96.1% 86.2% 87.9% 85.1% 82.5% 70.5% 70.0% 86.9% 83.1% 84.5% 85.7% 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

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

Trust new complaints

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 TRUST 51 53 49 78 63 62 89 58 59 79 66 71 60

September 2015 3 Trust-wide Performance September 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

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

Adults on CPA at end of month 2,710 40% Caring

Last Review within 12 months 2,635 20%

% adults with review <12 months 97.2% 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% 96.4% 95.9% 97.2% 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: September 2015 60% Month Quarter YTD

Friends & Family Test 272 594 1,081 40% Caring % Positive 85.3% 83.0% 85.7% 20%

% Extremely Likely 43.8% 46.8% 50.8% 0% % Negative 7.0% 8.2% 6.8% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 % Positive Feedback % Extremely Unlikely 2.9% 3.2% 2.2% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Figures reported from September 2014 onwards TRUST 78.9% 86.4% 83.4% 84.0% 90.7% 89.3% 85.7% 83.4% 91.1% 92.9% 76.7% 89.3% 85.3% 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%

September 2015 4 Trust-wide Performance

Board of Directors: 28 October 2015 – Public Agenda Item: TBP46 .5/15 Attachment: I For Decision By: Helen Greatorex, Executive Director of Nursing & Quality

SUMMARY & PURPOSE

The Trust made a public commitment in April this year, its commitment to join the national Sign up to Safety campaign.. Supported by both Monitor and the Care Quality Commission and launched at the end of June 2014, Sign up to Safety is designed to help realise the ambition of making the NHS the safest healthcare system in the world by creating an approach devoted to continuous learning and improvement.

Sign up to Safety aims to deliver harm free care for every patient, every time, everywhere. It champions openness and honesty and supports everyone to improve the safety of patients. Its 3 year objective is to reduce avoidable harm by 50% and save 6,000 lives. The attached paper includes an extract taken from the Sign up to Safety website in addition to our proposed pledges in relation to each of the five Sign up to Safety headings.

The attached update provides the Board of Directors with an outline of progress made in the first six months of work.

The report has been enhanced through the addition of an overall rating for each goal.

In addition, a summary of remedial action where the rating is amber or red has been provided.

LINK TO ANNUAL PLAN

This work links in particular to the Trust’s primary objective:

1.0 Safe Effective Care

ACTION REQUIRED BY BOARD MEMBERS

Members of the Board are asked to progress made to date and endorse the role of the Quality Committee in monitoring the detail of delivery against each pledge.

The areas we Our Goal The Measures Action we need to Timescales Status at end of Q1 Status at End of Rating/ believe could take 2015/16 Q2 2015/16 Rationale make the most difference

Put safety first Put safety first Put safety first Put safety first Put safety first Put safety first Put Safety First Put Safety First Building on  A clinically lead  A reduction  Establish a task  Strategy to be  Executive Medical  Strategy  Reduction national best Sussex in the and finish group to completed by Director leading. developed and in rate of practice, reduce Partnership incidence of develop the November  Task & Finish endorsed by suicide not the rate of suicide suicide suicide. strategy 2015 and Group established Sept Board of yet evident across the Trust prevention  Establish links with launched. and first meeting Directors. strategy national and  Baseline data held in June.  Implementation understood and international established  Key partners now being owned by leaders in the field and shared identified developed. everyone, and  Establish our by end Q1.  Contact made with  Links developed in baseline and set national trail established with partnership with the target for blazers in key partners people who use reduction Merseycare and and national our services Devon trail blazers Partnership.  First outline of strategy drafted  Baseline data established and informing the identification of the reduction target Reduce the  A reduction by  A month on  Draw upon the  Roll out of  Executive Director  Roll out to all  50% number of slips, 25% in 2015/16 month benchmarking from pilots to of Nursing and wards reduction trips and falls in overall reduction Q3 2014 and wards by end Quality leading completed. although on our wards compared to success of the Q4 of Q1  Roll out to all wards  Target of 50% track not 2014/15 pilot sites across 2015/16 complete. reduction yet the Trust.  Monthly  Monthly reporting agreed. delivered.  Work with the pilot reporting and template in pilot  Steering group sites as Expert monitoring stage overseeing Partners to working  Reduction by 42%  Reporting in The areas we Our Goal The Measures Action we need to Timescales Status at end of Q1 Status at End of Rating/ believe could take 2015/16 Q2 2015/16 Rationale make the most difference

implement the towards year of slips trips, falls place. successful practice end reduction seen on pilot everywhere. by at least wards. 25%. Ensure all staff  A clear rolling  Monthly  Monitor our  Clinical Academic  Reports by  Planned are up to date programme reports performance Director leading service in place. trajectory with core leading to all showing against the clear Trajectory agreed and  Trust-wide not met for mandatory staff being up to improve- programme with shared dashboard now Q1 and training. ments to an metrics and Monthly progress published Q2. agreed milestones reported to Executive  37% of staff Escalation trajectory  Provide reports to Assurance Committee are fully plans in all staff compliant. place.  Share  Corrective  EAC improvements and action in place overseeing support continued to ensure . focus shortfall against target is resolved. Continually Continually Continually Continually Learn Continually Continually Learn Continually Learn Continually Learn Learn Learn Learn Learn Improve our  Review and  A  Identify national  Review SI  Executive Director  First annual  Good approach to revise our streamlined best practice, liaise policy and of Nursing and Report & Learn progress learning from approach, process and learn from revise by end Quality leading Live event held made. Serious Incidents learning from informed by their experience September  Policy review in September.  SI policy across the Trust. the national practitioner  Adjust our 2015. underway  SI Policy review in best practice feedback approach and test  National links review hand but with easy to it  Establish established complete. not yet audit Trust- links with field  Learning event  SI closure complete. wide leaders by booked and timescales  Timescale learning and end Q1 advertised. improved. on tracki. improving  Trust-wide  Positive following Report and feedback from incidents Learn, annual staff and SI learning CCGs. event by end Sign up to Safety Improvement Plan 2015 – 17 Page 2

The areas we Our Goal The Measures Action we need to Timescales Status at end of Q1 Status at End of Rating/ believe could take 2015/16 Q2 2015/16 Rationale make the most difference

September

Honesty Honesty Honesty Honesty Honesty Honesty Honesty Honesty Ensure that  Efficient and  Performance  Establish a rolling  Training  Executive Director  Training  Performan everyone effective reports to programme of programme of Nursing and continues. ce understands and systems to Care training for all staff. established. Quality leading  Duty of improved meets the Duty of ensure duty is Delivery  Agree a clear  Training rolling Candour  Training Candour always met. Services, mechanism for out. performance deliver4ed Divisions, capturing and  Monitoring and reports in  Monitoring Executive reporting reporting system place. in place Assurance compliance with established and in Committee the Duty use and the Board. Foster a culture  Ensure all staff  Feedback  Confirm the Trust’s  Agree Trust’s  Executive Medical  Speak up  All actions of safety and are able to from Freedom to Speak Freedom to Director leading Guardian meeting learning in which easily raise Listening Up Guardian Speak Up identified time all staff feel safe concerns at any into Action,  Ensure that every Guardian by  Programme of (Medical scales. to raise a time. appraisals, member of staff end Q1 discussions and Director)  Positive concern. supervision knows how to reflections using  Regular feedback and staff speak up and feels  Agree existing meetings updates on from staff survey. able to do so development in development Listening into  Evidence of  Ensure that programme, Action staff induction, informed by  Board paper in presented to speaking up appraisal, Listening in to development the Board. and action supervision and Action  Induction being taken Listening in to feedback by  Induction training training revised to resolve Action all reflect end Q2 content review to include ‘How issues as a the importance of initiated to Raise result establishing a  Board of Concerns’. listening, Directors to responsive and formally open culture receive and consider Sir Robert

The areas we Our Goal The Measures Action we need to Timescales Status at end of Q1 Status at End of Rating/ believe could take 2015/16 Q2 2015/16 Rationale make the most difference

Francis QC’s report, Freedom to Speak up. Collaborate Collaborate Collaborate Collaborate Collaborate Collaborate Collaborate Collaboration Reduce the  To improve the  A reduction  Identify baseline  Baseline  Wards with high  Baseline  Reduction incidence of safety of our by 50% of activity and identified by activity identified. identified. target patients going patients. incidents of highlight hotspots. September  Project scope  Wards with (50% BY Absent without AWOL by  Review our policy 2015. agreed. high activity April 2016) Leave (AWOL) April 2016 against national  Revised identified. not yet best practice. Process.  Caburn ward delivered. piloting quality  Evidence initiative from first 6 programme months  On-going data not yet collection analysed  Meetings with team booked to explore driver diagrams  Team day booked for 11th November 2015 to share findings and agree steps for moving forward. Support Support Support Support Support Support Support Support Use Listening into  Every member  Services  Champions and  Clear  Champions and  Values and  Good Action to release of staff feeling shaped by sponsors milestones network in place. behaviours progress the Trust’s full valued for their staff throughout the month by  Quick wins work underway across all potential. contribution Trust. month. identified.  Progress with actions.  Positive quick Wins  Value and Sign up to Safety Improvement Plan 2015 – 17 Page 4

The areas we Our Goal The Measures Action we need to Timescales Status at end of Q1 Status at End of Rating/ believe could take 2015/16 Q2 2015/16 Rationale make the most difference

feedback being shared behaviour  People work not Committee yet reviewing real finalised. changes evident. Celebrate and  Create a new  Award  Clear criteria and  First award to  Discussions under  Award criteria  All actions share excellent annual safety created, support from Chief be made at way. agreed complete. practice in award multiple Exec Staff awards  Comms plan in relation to safety nominations ceremony place. received. 2016

` Sussex Partnership NHS Foundation Trust Board of Directors: 28 October 2015 - Public Agenda Item: TBP46 .5/15 Attachment: H For Information By: Sally Flint Executive Director of Finance and Performance

IN CONFIDENCE

PERFORMANCE REPORT – Quarter 2, 2015-16

Trust Corporate Business Objectives Report – Q2 2015/16

SUMMARY & PURPOSE

This report reviews the Trusts performance against the Trusts Corporate Business Objectives. At the end of September 2015, of the 31 corporate business objectives for 2015/16, 12 are fully met, 15 are partially met and 4 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 2 update

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.

The Quality Improvement Plan was presented to the September Board of Directors and its contents were endorsed. A detailed update on all elements of the CQC action plan

Q2 was also presented and progress was noted, with the intention for all compliance actions to have been closed by the end of November. Position

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

The Trust’s Suicide Prevention Strategy was agreed by the Board of Directors in September 2015. Active monitoring has commenced with oversight from the Suicide and Homicide Prevention Strategy Group chaired by the Executive Medical Director. Local action plans are being developed by Clinical Delivery Services, working with public health Q2

Position teams, and will be reported to the Board in April 2016.

A 1.1.3 EDNQ Safety Thermometer in active use in all wards Fully complete over next 12 months.

The Trust is on target to have all wards and community areas completing the 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 of Nursing Standards and Safety has visited ward areas to discuss how the Safety Thermometer is used. In Q2 the Trust has continued to increase the uptake of the use of the tool throughout the Trust. There is a continued focus on how the information can be used to improve care. Q2 Position Q2

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

The revised Falls Protocol is on target for full implementation by the end of October 2015. This is being produced in place of a Strategy. The Chief Pharmacist has developed a staff guide "Medicines and Falls – Guidance on Causes and Risks" and this has been added to the Falls Bundle. An example of how this is connected to practice is that falls risks have been added to the agenda of mulitidiciplinary patient reviews on Larch Ward, and are now discussed for every patient. Progress continues to identify assistive technologies most appropriate for mental health settings and several falls risk sensors, some with built in continence alarms, are being trialled at Millview - a lead pilot site. In Q3, Procurement, the Deputy Director of Nursing, the Director of Occupational Therapy and Senior Clinicians are meeting preferred suppliers to ensure that the approach is Q2 Position Q2 standardised and added to the NHS Supply Chain.

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 5 Action Plans submitted for SIs that occurred in Quarter 2 15-16, there were 14 actions identified. Of those actions there are 8 on-going actions and 6 that have been

Q2 completed in the agreed timeframe. 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 (DoC) requirements has now been established and is in use. This includes a robust alert system and weekly status report which is shared with Service Directors. Compliance has significantly improved this quarter with 35 out of 47 meeting the full standard of complinace. Of the 12 cases in which DoC was overdue 6 were due to late reporting of the incident and a further 4 were due to a delay in the response from clinical services. Q2 Position Q2

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

Ref Lead Deliverable Target

Share learning from serious incident reports with key partners R 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 SI reports signed‐off internally within agreed regarding these has been very positive. All SI reports have offered the SI reports submitted to commissioners in 60 timeframes days opportunity to both families and GP for their contribution. Timeliness of the completion of SIs has improved but there continues to be delay particularly at 100% 100% allocation stage by services, this is currently under review. 15 serious incident reports due for internal sign-off in Q2 were signed off within the agreed 50% 50% Q2 Position Q2 timeframe. 30 of the 56 serious incident reports due to be shared with 0% 0% commissioners in Q2 were shared within the 60 day target, (for serious Q1 Q2 Q3 Q4 incidents that occurred after 1st April 2015). Q1 Q2 Q3 Q4

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?”

Responses to this question are being monitored and will be specifically highlighted for each CDS in the forthcoming Patient Experience Annual Report. Going forward the Patient Experience Team will highlight this in quarterly patient experience reports that go to the Board and will include a timeline to show whether improvement is up or down. Q2 Position Q2

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

Ref Lead Deliverable Target

Carers: 1.2.2 SDSC A 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 survey was designed in partnership with carers organisations and healthwatch groups across Sussex and was launched in both paper and online versions in early September. The survey has been widely publicised and has raised the profile of the work we are undertaking with carers. With regard to CHYPS the revised Friends and Family Test question regarding carers has been used and the data will be analysed in Q3. The survey period has been extended into October. The action plan will now be developed in Q3 in conjunction with carers organisations and Healthwatch. Q1 Position Q1

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 continues to be championed as a vital monitoring tool for recognising changes in a patients physical health and in Q2, local meetings have taken place to raise awareness and shift the focus to improving integration of physical and mental health observation. A MEWS Steering Group has been established and the first meeting has taken place in order to review the current tool format. A bespoke tool has been developed and implemented for Children and Young Peoples services following best practice guidance and PEWS-(Paediatric Early Warning Scoring System). Initial feedback is that the PEWs tool meets the needs of the patient age group and will be audited in Q3 to

Q2 Position Q2 evaluate clinical effectiveness. A repeat master MEWS Master class "Managing the Patient, not the task" is booked for November due to demand.

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.

All Adult Clinical Delivery Services continue to contribute and respond to the local System Resilience Groups and Crisis Concordats in each locality. Further to the Trust-wide Crisis Pathway meeting in Q1, each locality has set up crisis workshops to develop further the cross cutting relationhips and pathways that support people in crisis. The review of the internal mental health helpline has been initiated in Q2 and will report in Q4. Q2 Position Q2

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.

By Q2, 75% of priority re-audits show improved or maintained compliance and 37% of improvement actions have been implemented by the agreed date. Improvements are being made by implementing SMART action plans, through communications/ shared learning such as the 'report and learn' bulletin and integrated audit and SI action plans. Q2 Position Q2

1.6 Successful implementation of Care Notes

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

CHYPS Services go live August 2015: Carenotes succesfully went live across CHYPS Service (Kent, Sussex and Hampshire) on 13th July 2015. Adults and other services by December 2015 The September Carenotes Programme Board agreed to move the go live for Adults and Specialist Services to February 2016. This shift reflects lessons learnt from CHYPS and the level of change for the Adults services identified during workshops held over the summer.

Q2 Position Q2 All Services by March 2016 The Health in Mind Service is likely to remain on their current local solution (PCMIS) until the Carenotes Patient Portal is available. Currently patients can access their records through PCMIS and this functionality is liked by staff and patients. Date for Patient Portal being confirmed with Carenotes’ supplier.

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

Quality Improvement Plan was endorsed by September Board, and detailed Compliance Action overview presented. A meeting between new CQC Relationship Manager and Regional Inspector took place on Monday 5th October and an overview of progress shared.

Q2 Regular quarterly meetings now established and a Trust-wide system to monitor compliance with Fundamental Standards introduced. 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

All Adult Clinical Delivery Services (five) have drafted outline business plans for the next year and two to five years. These plans are dynamic and iteritive and pull together the outputs from partnership working in each commissioned locality. The outline business plans will be used as a tool to support the Clinical Delivery Service (CDS) 'state of readiness' Q2

Position and 'accreditation' process for each CDS.

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 Secure and Forensic Services, Primary Care and Wellbeing Service, East Sussex Adult Services, Learning Disabilities and Childrens and Young Peoples Services have all now been accredited as Clinical Delivery Services (CDS). Corporate Services have carried out a workshop with the Clinicial Delivery Services to develop how support services will be Q2

Position delivered in partnership.

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 Specialist Services: Clinical pathways have been identified for each Clinical Delivery Service (CDS) / Care Group. These will be ratified by the respective Clinical Academic Group or CDS /Care Group Governance Forum in Q3.

Adult Services: The Adult Services Transformation Group continues to monitor and seek governance assurance on the development of the core clinical care pathways and the

Q2 Position development of the Clinical Academic Groups during Q2.

Page 6 of 13 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 A Units to establish community engagement and listening fora for each local population.

The Patient Experience Team (PET) has looked at how best to meet this target given limited resources within the team and across CDS's. A project plan has been pulled together which scopes out the task and identifies key milestones. All CDS's have been contacted and the PET has attended both adult and specialist leadership meetings to highlight this objective and suggest how CDS's can be supported to achieve it. It seems clear that adapting existing meetings is the most realistic way of meeting this goal and Q2-3 we have begun mapping this and working with identified leads to support progression. The PET will in addition be drawing up guidance/toolkit to support CDS's and ensure consistency so

Q2 Position these meetings, when established, are able to form part of a Trust wide feedback system that supports continuous improvement.

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)

Specialist Services: Each CS/Care Group has produced a Service Plan which incorporated the service priorities and objectives for 2015/16. As further guidance is being released the CDS'/Care Groups will be developing next years service plan.

Adult Services: All five Adult Service Clinical Delivery Services (CDS) have completed the initial phase of development workshops during Q1 & Q2. All CDSs have drafted outline business plan for the next year and years two to five. These business plans are the core tool used to support the 'state of readiness' and' accrediation' process that take place Q2 Position during Q2 & Q3. Each CDS will have achived accreditation by end of Q3.

Page 7 of 13 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

91% of staff have now been allocated to the correct team hierarchy in My Learning, allowing 91% accurate reporting on compliance at all levels of hierarchy (Division, Department and Team). These reports are now published on the front page of My Learning for all to see and to allow simple local level and performance contract reporting. Compliance continues to improve, but this needs to speed up. September figures show 5/23 courses show achievement of Q2 target of 50% compliance. 8/23 now show they have achieved the Q1 target of 40% compliance (up from 7/23 in June). Current rate of completions will need to go up significantly if we are to

Q2 Position achieve the Q4 target.

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 an expectation that all groups will be established by the end of the year. Formal agreement of the chairs of the CAGs is almost complete, backfill for this work is being Q2 Q2

Position identified through job planning and other operational solutions. Executive management Board has agreed some funding for service user and carer engagement .

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

R 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 was presented to the Transformation Board on the 28th July on the Lean Programme / Continuous Improvement. Support for business case development was given and is being developed by Lean Practitioners. Q2 Q2

Position Strategic partner to be included in business case.

Page 8 of 13 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 A 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

The response rate for Q2 was approx 10% (400 Staff) and the survey was sent Staff Friends and Family Test ‐ Response rate to all employees and bank workers. The Q1 survey was sent to all Corporate 100% staff and 107 responses were received (32%). 50%

The test score for Q2 was 56% (approx 224 staff) compared to 64% (approx 68 0% Q2 Position staff) in Q1. Q1 Q2 Q3 Q4

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.

As ‘MyLearning’ is not yet fully embedded, the data for Q2 has been collected again by means of an audit. 75% of those audited reported that they have had an appraisal. The Learning and Development Team are working on communications for staff to highlight the need to upload the information regarding completed appraisals onto ‘My Learning’. ‘MyLearning2’ is being launched soon which includes a more intuitive appraisal recording function.

Q2 Position 110 leaders have taken part in the Leadership Development Programme by the end of Q2.

Page 9 of 13 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 A 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.

The percentage of leavers with less than 2 years' service in Q2 was 21.5%. Q2

Position The time to hire was 14.35 weeks in Q2

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.

The Trust-wide sickness rate was 4.12% at the start of Q2. Q2

Position The staff survey results will be available in Q4.

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

Q2 debate. A team level heatmap has also now been produced for each CDS, to show performance against KPIs by team against a rolling three months to enable identification of Position specific areas of good performance or concern.

Page 10 of 13 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 we were just £18k away from a rating of 2. This is due to the deficit position. Q2 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 £1,984k of recurrent savings compared to the planned level of £5,862k, therefore a shortfall of £3,878k. Non recurrently we have saved a further £3,013k. The

Q2 main variances relate to the following three areas: 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 penalties or remedial action plans have been approved with Commissioners in Q2. Details of underachieving performance are highlighted in the monthly performance reports

Q2 to the Trust Board. Position

5.4 To improve effectiveness and efficiency of our office services

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

The Admin Services review was put on hold during Q2 and further consultation with Clinical Delivery Services is underway in Q3. Q2 Position

Page 11 of 13 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 13

Board of Directors: 28 October 2015 – Public Agenda Item: TBP46.5/15 Attachment: G 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, have some positive results This work continues, supported and informed by the developing Care Delivery Services’ engagement and focus on their areas of highest need.

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.

Sussex Partnership NHS Foundation Trust Board of Directors: October 2015 Agenda Item: Attachment: For Information By: Helen Greatorex, Executive Director of Nursing & Quality

SAFE STAFFING APPENDIX 1

Set out below are the 22 wards whose returns for September prompted questions about levels of staffing. This included shift where the RMN fill rate is below 95%.

Ward staffing levels are reviewed every shift and an overview and required action taken by the responsible Ward Manager and Matron. This month report included the additional funding given to some wards to increase their staffing level to support patients’ safety. The report outlines the ward’s establishment, shift pattern; the current Nursing vacancies; fill rate and incidences to help us review and support the wards in order to deliver safe, effective and quality care.

Ward / No. of Beds Staffing Current Nursing Shift Pattern Fill Rate Action Plan Incidences Establishment * Vacancies includes allied professionals 5. Woodlands 44 WTE All vacancies Long day - 2 RMNs and Overall fill rate (126%)  Daily monitoring and Incidences: 18 recruited. 4 HCA review of 1:1 by MDT 23 mixed acute Funding increased by Had 1 patient on 1:1 constantly as staff. 2 Self-harm beds 6 WTE this month. well as three other patients on  3 pm bed call to review Night - 2 RMNs and 3 1 intermittent 1:1 throughout observation level. 1 Choking HCA September. 7 Ill health 1 RMN 9-5  Review of ward safety at handover and 1 Verbal abuse (pt on Overall fill rate for RMNs on day duty monitor during shift. public) (94%)  Support at ward manager and Matron 3 Physical assault, pt on Patients’ safety prioritised. Level. staff

4 Physical assault, pt on Additional WTE: pt. (1 near miss)

4.00 HCA for day shifts 2.35 HCA for night shifts

6. Amberley 36 WTE 4 WTE Early - 2 RMNs and Overall fill rate (111%)  Daily reviews of 1:1 by Incidences: 12 2 HCA ward staff and MDT. 14 female acute Funding increased by 3 WTE RMN High volume of 1:1 observations in  Monitoring by Matron 3 AWOL (1 attempted) beds 5 WTE this month. Late - 2 RMNs and September.  Daily report to GM on

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1 WTE HCA 3 HCA 3pm bed call giving 2 Self-harm Additional WTE: detail of 1-1s and how Recruitment in Night - 2 RMN and many extra staff on 3 Near miss (security, process for both 2 HCA 0.85 HCA for day shifts shift per 24hours. accidental event, assault posts. 1.56 HCA for night shifts pt on staff)

3 Verbal abuse pt on staff

1 Physical assault pt on staff

8. Jade 28 WTE 7.5 WTE Early – 2 RMN and 2 HCA Overall fill rate (110%)  Daily reviews of the Incidences: 8 eyesight observation 19 mixed acute Had 1 pt on eyesight observation by staff. 3 Self harm 0.91 WTE RMN Late – 2 RMN and 2 HCA beds daily throughout September.  Support and monitoring at ward 1 Incorrect storage of 2.59 WTE HCA Night – 1 RMN and 2 HCA manager level. expired items

Additional WTE: 1 Asphyxiation Recruited 2 WTE RMN and 3 WTE 1.16 HCA for day shifts 1 Failed to return after HCA waiting for 0.33 HCA for night shifts unescorted leave clearance from HR

process. 2 Physical assault pt on staff (1 unintentionally)

12. Beechwood 27 WTE 9 WTE Early – 2 RMN and 2 HCA Overall fill rate (121%)  Review of ward safety Incidences: 31 at handover and 14 mixed dementia High dependency and 1:1 / 2:1 monitor during shift. 2 Falls 1.5 WTE RMNs Late – 2 RMN and 2 HCA beds therapeutic engagement resulted in  Support at ward high staffing numbers per shift. manager and matron 1 Slip 7.5 WTE HCA Night – 1 RMN and 3 HCA level. Fill rate for RMN day is 76%. 13 Physical assault (4 pt on pt, 1 pt on public, 8 pt Merging with St Qualified staff low as low patient on staff) Gabriel and numbers. waiting for CCG 4 Violent incidences confirmation of Patients’ safety prioritised. approval for New 1 Ill health Service Model. Additional WTE: 1 Pre-existing medical 3.88 HCA for day shifts condition 1.36 HCA for night shifts 1 Contraband item

1 Attempted to leave

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ward

13. St Gabriel 26 WTE 2.5 WTE Long Day – 1 RMN and 3 Overall fill rate (116%)  Review of ward safety Incidences: 7 HCA at handover and 14 mixed dementia Increase in numbers due to periods monitor during shift. 1 Deliberate alarm No RMN vacancy beds of high dependency with use of 1:1 activation only HCA. Night – 1 RMN and 2 HCA  Support at ward therapeutic engagement manager and matron level. 1 Pt found on floor Merging with Beechwood and 1 Prescribing error – waiting for CCG incorrect dose confirmation of approval for New 1 Record – blank Service Model. administration

1 Medical scrutiny

identified error – not amendable

1 Section expired – pt not informed and treated

1 Physical assault pt on pt

14. Burrowes 29 WTE 8 WTE Early – 1 RMN and 3 HCA Overall fill rate (97%)  Review of ward safety Incidences: 19 at handover and 10 mixed dementia Fill rate for RMN on day is 80%. monitor during shift. 1 Trip 2.5 WTE RMNs Late – 1 RMN and 3 HCA beds  Support at ward Patients’ safety prioritised. manager and matron 2 Falls 5.5 WTE HCA Night – 1 RMN and 3 HCA level. Fill rate for RMN on night is 127%. 3 Persons found on floor

Matron aware. 1 Personal This is a hard to recruit area. Plan 1 Cuts in general is to set up rolling

recruitment. 1 Violent incident

9 Physical assault pt on staff (2 near miss and 1 unintentional)

1 Physical assault pt on pt.

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15. Grove 28 WTE 6 WTE Early – 1 RMN and 3 HCA Overall fill rate (100%)  Review of ward safety Incidences: 14 at handover and 10 mixed dementia Fill rate for RMN on day is 63%. monitoring during shift. 10 Physical assaults 5.21 WTE RMNs Late – 1 RMN and 3 HCA beds  Support from Ward (8 pt on staff, 1 visitor on Patients’ safety prioritised and manager. staff, 1 pt on pt) 0.79 WTE HCA Night – 1 RMN and 3 HCA maintained. 2 Persons found on floor

Matron aware. 2 Cuts in general This is a hard to recruit area. Plan

is to set up rolling recruitment.

16. Brunswick 34 WTE Vacancy to be Early – 2 RMN and 2 HCA Overall fill rate (156%)  Daily review and Incidences: 24 reviewed monitoring of 15 mixed dementia Funding increased by following observations. 3 Persons found on floor Late – 2 RMN and 2 HCA beds 7 WTE this month. additional Had up to 5 patients requiring 1:1  Review care needs. 2 Falls funding. throughout September. Night – 1 RMN and 2 HCA 4 Medication Additional staffing level required for administration errors other patients on enhanced (3 unintentionally omitted,

observations due to falls risk and 1 meds to wrong patient) poor physical health.  Review of ward safety 4 Near miss security Fill rate for RMN on day is 63% and at handover and night is 82%. monitoring during shift. 1 Violent incidence  Support from Ward Patients’ safety prioritised and manager. 1 Record – Blank maintained.  Covered with administration additional support workers. 1 Absconded Additional WTE: 8 Physical assaults 8.10 wte HCA for day shifts ( 6 pt on staff, 1 pt on pt, 3.53 wte HCA for night shifts 1 near miss pt on staff)

17. Iris 29 WTE 5 WTE Early – 2 RMN and 3 HCA Overall fill rate (111%)  Daily review of 1:1 and Incidences: 14 eyesight obs by MDT 12 mixed dementia Had 3-4 Intermittent and at handover. 2 Falls All RMN posts Late – 2 RMN and 3 HCA beds observations, 2-3 eyesight (1 near miss) recruited.  Support at Matron observations with fluctuating Level. Night – 1 RMN and 3 HCA 2:1 eyesight obs. 3 Persons found on floor HCAs recruitment process in place. Some patients needing 3 1 Cut with sharp object

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staff for personal care intervention at nights. 1 Manual handling Matron aware.

This is a hard to Escort for appointments. 1 Dispensing incorrect recruit area. Plan supply for is to set up rolling leave/discharge recruitment.

4 Physical assault (2 pt on staff, 1 pt on pt, 1 near miss pt on staff)

3 Near misses (1 self-harm, 1 accidental event, 1 fall, slip and trip)

19. Larch 29 WTE 6 WTE Early – 2 RMN and 2 HCA Overall fill rate (98%)  Review of ward safety Incidences: 8 at handover and 18 mixed integrated Fill rate for RMN on night is 93%. monitor during shift. 2 Ill health 1 WTE RMN Late – 2 RMN and 2 HCA beds starting in Oct.  Support at ward Patients’ safety prioritised and manager and matron 2 Persons found on floor Night – 2 RMN and 1 HCA maintained. level. 5 WTE HCA 1 Cut with sharp object

1 Slip Meadowfield is rolling out VBR 1 Near miss – self-harm (value based recruitment) days, 1 Fall from standing supported by HR and Recruitment.

20. Meridian 27 WTE 7 WTE Early – 2 RMN and 3 HCA Overall fill rate (126%)  Daily review and Incidences: 12 monitoring of 19 mixed integrated Additional staffing level for high observations. 1 Missed footing 1 WTE RMN Late – 2 RMN and 2 HCA beds number of patients on eyesight  Regular planning of observations and complex staffing level to support 1 Fall from standing

6 WTE HCA Night – 2 RMN and 1 HCA healthcare needs. ECT treatments. 1 Pt handling

Both posts will be Escorts for physical health OPA and 1 Cut with sharp object recruited at the ECT (Tuesdays and Fridays). VBR (Value based 1 Contact with a recruitment) day in stationary object October.

 Review of ward safety 1 Violent incident Additional WTE: at handover and

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monitoring during shift. 1 Policy not adhered to 1.40 wte RMN for day shifts  Support at ward manager and matron 3 Near missed 2.39 wte HCA for day shifts level. (1 self-harm, 1 accidental, 2.54 wte HCA for night shifts 1 security) 1 Physical assault pt on pt

1 Absconded 22. Orchard 28 WTE 8 WTE Early – 2 RMN and 3 HCA Overall fill rate (83%)  Review of ward safety Incidences: 2 at handover and 12 mixed integrated Fill rate for RMN on day is 52%. monitor during shift. 1 Absconded 2 WTE RMN Late – 2 RMN and 3 HCA beds currently being  Support at ward Patients’ safety prioritised and 1 Alcohol advertised. manager and matron Night – 1 RMN and 2 HCA maintained. level.

Recruited 2 WTE

HCA in September.

5.3 HCA vacancies.

23. St Raphael 27 WTE 10 WTE Long Day – 2 RMN and 2 Overall fill rate (116%)  Review of ward safety Incidences: 19 HCA at handover and 15 mixed integrated Had 3 patients on 1:1 throughout monitor during shift. 3 Ill Health 1 WTE RMN beds September. recruited. Night – 2 RMN and 2 HCA  Support at ward manager and matron 1 Slip Fill rate for RMN on night is 95%. level. 5 WTE RMN 1 Cut with sharp object Patients’ safety prioritised and maintained. 1 Head Banging 4 WTE HCA 2 Contact with stationary Matron aware. object

1 Verbal threat This is a hard to recruit area. 1 person found on floor Support from HR and Recruitment. 1 Attempted to leave

4 Near miss (2 accidental, 1 harassment, 1 security)

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1 Self-harm

3 Medication errors (2 Prescribing incorrect dose, 1 administered incorrect dose)

25. Fir 30.19 WTE No current Long Day – 2 RMN and 2 Overall fill rate (106%)  Review of ward safety Incidences: 1 vacancy HCA at handover and 15 male low secure Fill rate for RMN on day is 92%. monitor during shift. Breach of security beds Night – 2 RMN and 2 HCA  Support at ward Fill rate for RMN on night is 65%. manager and matron level. Currently supporting and redeploying their RMN to ensure there is an RMN on night duty at Hazel ward when required.

Patients’ safety prioritised and maintained.

27. Pine 30 WTE 2 WTE RMN Long day – 2 RMN and 3 Overall fill rate (110%)  Review patients 1:1 Incidences: 1 HCA daily. 16 male low secure Had new staff requiring Induction Section 17 issue Recruitment in beds and PMVA training over a three process. Night – 2 RMN and 2 HCA weeks period.

Fill rate for RMN on night is 57%.  Review of ward safety Patients’ safety prioritised and at handover and monitored on each shifts. monitor during shift.  Support from ward Able to request for help within manager and matron. Chichester Centre from other wards  * Unfilled RMN night onsite if required. shifts covered by additional HCA.

Additional WTE:

1.23 wte HCA for day shifts 2.93 wte HCA for night shifts *

28. Southview 36 WTE 4 WTE RMN Long Day – 2 RMN and 3 Overall fill rate (91%)  Review of ward safety Incidences: 0 HCA at handover and 15 male low secure Fill rate for RMN on day is 92% and monitor during shift. Rolling recruitment rehab ward on night is 57%. in place. Night – 2 RMN and 2 HCA  Covered with

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additional unqualified Patients’ safety prioritised and staff. This is a hard to maintained.  Support from ward recruit area. manager and Matron. Support from HR Able to call for support within the and Recruitment. Hellingly Centre for redeployment if required.

30. Oak 41 WTE 4 WTE RMN Long day – 3 RMN and 4 Overall fill rate (107%)  Daily review and Incidences: 20 HCA monitoring of patients 15 medium secure Funding increased by Fill rate for RMN on night is 72%. 1:1. 1 Slip Rolling recruitment male ward 2.15 WTE from this in place. Night – 2 RMN and 3 HCA month. Patients’ safety prioritised. 1 Contact with a moving . object This is a hard to Able to call for support within the  Review of ward safety recruit area. Hellingly Centre for redeployment if at handover and 1 Med error Support from HR required. monitor during shift. (administration and Recruitment.  Support from ward unintentionally omitted) manager and matron Additional WTE:  * Unfilled RMN shifts 3 Breaches covered by additional (2 security, 1 1.73 HCA for day shifts * HCA. confidentiality) 1.43 HCA for night shifts * 1 Verbal threat

4 Violent incident Physical assault

9 Physical assaults (1 near miss pt on staff, 8 pt on staff)

32. Amber 42 WTE 9.7 WTE Early – 3 RMN and 4 HCA Overall fill rate (94%)  Review of ward safety Incidences: 8 at handover and 12 mixed PICU Fill rate for RMN on day is 81%. monitor during shift. 1 Theft of Trust property 4.2 WTE RMN Late – 3 RMN and 4 HCA beds  Support from ward Patients’ safety prioritised and manager and matron 1 Contact with moving 5.5 WTE HCA Night – 2 RMN and 4 HCA supported. vehicle interview on 22/9/15 2 Med error – (1 Administration unintentionally omitted, 1 Matron is aware. prescribing incorrect This is a hard to dose) recruit speciality. Support from HR 4 Physical assaults pt on and Recruitment. staff (1 near miss)

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36. Connolly House 15.2 WTE No Vacancy Early – 2 RMN and 1 HCA Overall fill rate (95%)  Ensure and maintain Incidences: 2 patients’ safety on 15 Rehabilitation Patients’ safety prioritised and each shift. 1 Personal Late – 2 RMN and 1 HCA beds maintained. 1 Fainting Night – 1 RMN and 1 HCA

37. Rutland 15 WTE 1 WTE HCA Early – 2 RMN and 1 HCA Overall fill rate (93%)  Ensure and maintain Incidences: 0 patients’ safety on 10 Rehabilitation Patients’ safety prioritised and each shift. Late – 1 RMN and 1 HCA beds maintained.

Night – 1 RMN and 1 HCA

39. Dove 19 WTE 5 WTE RMNs Long Day – 2 RMN and 1 Overall fill rate (97%)  Ensure and maintain Incidences: 2 HCA patients’ safety on 12 Substances Fill rate for RMN on day is 93%. each shift. 1 Seizure Hard to recruit Misuse beds area. Advertised Night – 1 RMN and 1 HCA  Support at General Patients’ safety prioritised and 1 Person found on floor 4 times but no Manager level. maintained. applicants.

Support from

General Manager.

40. Promenade 21 WTE 4 WTE Early – 2 RMN and 1 HCA Overall fill rate (98%)  Ensure and maintain Incidences: 8 patients’ safety on 13 Substances Fill rate for RMN on day is 91%. each shift. 2 Loss of Trust properties 3 WTE RMN and Late 2 RMN and 1 HCA Misuse beds 1 WTE HCA  Support at General Patients’ safety prioritised and Manager level. 2 Incorrect storage – Night 1 RMN and 1 HCA maintained. access by pts or visitors Recruitment in progress and 2 Meds errors 9-5 1 RMN interviewing (1 Administration of meds planned. no longer prescribed, 1 Prescription Med)

1 Overdose of prescribed med

1 Seizure

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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 1 Bodiam Acute 900 900 900 915 630 630 630 630 100% ‐ 102% 0.09 100% ‐ 100% ‐ 100% 0.09 2 Maple Ward Acute 900 900 900 900 300 300 600 600 100% ‐ 100% ‐ 100% ‐ 100% ‐ 100% ‐ 3 Oaklands Ward Acute 900 900 900 900 645 645 645 647 100% ‐ 100% ‐ 100% ‐ 100% 0.01 100% 0.01 4 Rowan Ward Acute 900 893 900 915 300 300 600 600 99%‐ 0.04 102% 0.09 100% ‐ 100% ‐ 100% 0.05 5 Woodlands Centre Acute 915 862 1,035 1,680 690 679 1,035 1,415 94% ‐ 0.33 162% 4.00 98%‐ 0.07 137% 2.35 126% 5.95 6 Amberley Ward Acute 900 863 1,125 1,263 630 630 630 882 96%‐ 0.23 112% 0.85 100% ‐ 140% 1.56 111% 2.19 7 Coral Ward Acute 900 899 900 938 600 600 320 380 100%‐ 0.01 104% 0.24 100% ‐ 119% 0.37 104% 0.60 8 Jade Ward Acute 900 900 900 1,087 300 321 615 668 100% ‐ 121% 1.16 107% 0.13 109% 0.33 110% 1.61 9 Caburn Ward Acute 1,013 1,013 1,077 1,199 600 600 480 540 100% 0.00 111% 0.76 100% ‐ 113% 0.37 106% 1.13 10 Regency Ward Acute 900 908 908 900 600 600 300 320 101% 0.05 99%‐ 0.05 100% ‐ 107% 0.12 101% 0.12 11 Chalkhill CAMHS 1,095 1,067 1,095 1,038 600 597 600 595 97%‐ 0.17 95%‐ 0.36 99%‐ 0.02 99%‐ 0.03 97%‐ 0.58 12 Beechwood Dementia 900 687 900 1,526 300 310 900 1,120 76% ‐ 1.32 170% 3.88 103% 0.06 124% 1.36 121% 3.98 13 St Gabriel Ward Dementia 345 474 1,035 1,155 345 345 690 840 137% 0.80 112% 0.74 100% ‐ 122% 0.93 116% 2.47 14 Burrowes Ward Dementia 900 722 1,350 1,364 300 313 600 642 80% ‐ 1.11 101% 0.09 104% 0.08 107% 0.26 97%‐ 0.68 15 Grove Ward Dementia 900 565 1,350 1,472 314 399 645 789 63% ‐ 2.08 109% 0.75 127% 0.53 122% 0.89 100% 0.10 16 Brunswick Ward Dementia 900 952 1,125 2,431 600 490 600 1,170 63% 0.32 216% 8.10 82% ‐ 0.68 195% 3.53 156% 11.27 17 Iris Ward Dementia 900 876 1,350 1,331 300 300 600 1,001 97%‐ 0.15 99%‐ 0.12 100% ‐ 167% 2.49 111% 2.22 18 Heathfield Ward Integrated 900 775 900 930 315 357 630 588 86%‐ 0.78 103% 0.19 113% 0.26 93%‐ 0.26 97%‐ 0.59 19 Larch Ward Integrated 900 885 900 863 600 560 300 330 98%‐ 0.09 96%‐ 0.23 93% ‐ 0.25 110% 0.19 98%‐ 0.39 20 Meridian Ward Integrated 900 1,125 1,125 1,510 610 590 300 710 125% 1.40 134% 2.39 97%‐ 0.12 237% 2.54 134% 6.20 21 Opal Ward Integrated 900 837 900 899 300 300 600 620 93%‐ 0.39 100%‐ 0.01 100% ‐ 103% 0.12 98%‐ 0.27 22 Orchard Ward Integrated 900 465 1,350 1,245 323 323 645 634 52% ‐ 2.70 92%‐ 0.65 100% ‐ 98%‐ 0.07 83% ‐ 3.42 23 St Raphael Ward Integrated 690 713 690 918 690 656 690 909 103% 0.14 133% 1.41 95% ‐ 0.21 132% 1.36 116% 2.69 24 Selden Centre LD 360 379 1,800 1,917 360 360 720 732 105% 0.01 107% 0.73 100% ‐ 102% 0.07 105% 0.92 25 Fir Ward Low Secure 690 635 690 958 690 449 690 932 92% ‐ 0.34 139% 1.66 65% ‐ 1.49 135% 1.50 108% 1.33 26 Hazel Ward Low Secure 690 694 1,035 1,130 690 393 690 1,139 101% 0.02 109% 0.59 57% ‐ 1.84 165% 2.78 108% 1.55 27 Pine Ward Low Secure 690 804 690 832 690 472 345 552 117% 0.71 121% 0.88 68% ‐ 1.36 160% 1.28 110% 1.51 28 Southview Low Secure 690 634 1,380 1,255 690 460 690 805 92% ‐ 0.35 91%‐ 0.78 67% ‐ 1.43 117% 0.71 91% ‐ 1.84 29 Ash Medium Secure 690 863 1,380 1,204 345 426 1,035 916 125% 1.07 87%‐ 1.09 123% 0.50 88%‐ 0.74 99%‐ 0.27 30 Oak Ward Medium Secure 1,035 991 1,380 1,659 690 495 1,035 1,266 96%‐ 0.27 120% 1.73 72% ‐ 1.21 122% 1.43 107% 1.68 31 Willow Ward Medium Secure 690 702 1,725 1,656 345 564 1,380 1,070 102% 0.07 96%‐ 0.43 163% 1.36 78%‐ 1.93 96%‐ 0.93 32 Amber Ward PICU 1,350 1,088 1,800 1,813 600 580 1,200 1,170 81% ‐ 1.63 101% 0.08 97%‐ 0.12 98%‐ 0.19 94% ‐ 1.86 33 Pavillion Ward PICU 900 900 1,350 1,358 600 590 600 600 100% ‐ 101% 0.05 98%‐ 0.06 100% ‐ 100%‐ 0.02 34 Amberstone Rehab 900 874 900 855 300 310 554 535 97%‐ 0.16 95%‐ 0.28 103% 0.06 97%‐ 0.11 97%‐ 0.49 35 Bramble Lodge Rehab 345 374 690 667 345 345 345 345 108% 0.18 97%‐ 0.15 100% ‐ 100% ‐ 100% 0.03 36 Connolly House Rehab 780 791 570 454 323 323 323 323 101% 0.07 80%‐ 0.72 100% ‐ 100% ‐ 95% ‐ 0.65 37 Rutland Gardens Rehab 615 653 450 300 300 320 300 280 106% 0.23 67%‐ 0.93 107% 0.12 93%‐ 0.12 93% ‐ 0.70 38 Shepherd House Rehab 450 465 900 908 300 300 300 300 103% 0.09 101% 0.05 100% ‐ 100% ‐ 101% 0.14 39 Dove Ward Substance Misuse 690 630 345 352 345 345 345 345 91% ‐ 0.38 102% 0.04 100% ‐ 100% ‐ 97%‐ 0.33 40 Promenade Ward Substance Misuse 983 915 450 473 310 300 300 310 93% ‐ 0.42 105% 0.14 97%‐ 0.06 103% 0.06 98%‐ 0.28 TRUST TOTAL 32,806 31,567 41,150 45,164 18,814 17,873 24,506 28,246 96% 110% 95% 115% 105%

Board of Directors: 28th October 2015 - Public Agenda Item: TBP46.6/15 Attachment: I 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 25th September 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.

Given the Trust’s current financial position, in September the Committee’s main area of focus was the Trust’s financial recovery plan. The Committee received updates on the progress being made to deliver the work plan. The Committee also received a detailed paper on the work that is being undertaken to address the level of overspend on the in-patient wards in Adult Services. The Trust’s Executive Director of Nursing & Quality attended the meeting to support this work.

The other key discussion for the Committee was the Trust’s Estates & Facilities Services Strategy.

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. Due to the timing of the Council of Governors meeting in October, the Council received this paper ahead of the Board meeting. 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 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 25th September 2015. It should be noted that Michael Decker was the governor representative at the meeting.

The Committee Received papers on a number of current topics including:-  Month 5 Financial position  Update on Cost Improvement Programme for 2015/16 and Financial Recovery Plan  Themed Review on the Ward Expenditure Action Plan  Quality & Operational Performance Reports  Capital Expenditure Report  Estates & Facilities Services Strategy  Sustainability Strategy  Commercial Report  Future of 78 Crawley Road  Update on Strategy for Substance Misuse Services

2.0 Introduction

The Finance and Investment Committee meet in the week before the Board meeting. The next Committee meeting is due to be held on the 23rd October 2015. This report provides a summary of the meeting held on the 25th September 2015, the main areas of discussion are set out in the body of the report below.

3.0 Report

Month 5 Financial Report and Delivery of the Financial Recovery Plan

The Committee received a report on the Trust’s financial performance for month 5 noting that the Trust is reporting a deficit of £42k for Month 5, after committing £250k of reserves, taking the year to date deficit to £737k. This now moves the Trust to only £7k away from improving its Capital Service Cover Rating from a rating of 1 to a 2.

The Committee were updated on the changes to Monitor’s Risk Assessment Framework, which came into effect from August, with the re-introduction of financial metrics to assess income and expenditure margin and variance from plan in relation to the income and expenditure margin. The override rule has also been re-instated, where if any one metric is a score of 1, then the Trust’s overall financial risk rating is capped at a rating of two, potentially leading to investigation. It is therefore imperative that the Trust improves its position on the Capital Service Cover Rating at the end of Quarter 2 (Month 6) otherwise the Trust will be receive a Financial Risk Rating of 2.

The Committee noted that in the month there was a significant improvement in the use of external beds and the funding for the s75 agreement in Brighton. However, there still continues to be a high use of agency staffing and overspend across the Adult in-patient services, together with concerns around the financial performance in North West Sussex, which was £269k overspent in the month.

Good progress continues to be made in Specialist Services and there were also some improvements in Corporate Services.

The Committee expressed their concern regarding the Trust’s financial position and a significant part of the meeting was used to discuss the financial recovery plan and seek assurance that this was being delivered with the rigour and pace to ensure that the Trust reports a break-even position by the end of the financial year.

The Committee noted that good progress is being made across a number of areas of the financial recovery plan. However, the main areas of concern continue to be the overspend on in-patient staffing which increased from a forecast overspend of £173k in the month to an overspend of £246k and maintaining the current levels of staffing in Adult Community Teams, ahead of the community services redesign, where the level of underspend was forecast at £212k, but only a £156k underspend was achieved. Based on the delivery of the financial recovery in Month 5, the Trust is now forecasting a shortfall againt the financial recovery plan of £876k, and therefore a further savings plan, mainly driven by savings in Corporate Services had been identified. Slow progress had been made in meeting these additional savings in the month.

As part of the Financial Recovery Plan, the Committee received a paper on the work that is being undertaken to address the level of overspend on the in-patient wards in Adult Services. The Trust’s Executive Director of Nursing & Quality attended the meeting to support this work, which includes:-

 compliance with using Rosterpro, the electronic rostering system to plan shifts effectively  use of reporting from Rosterpro to track planning of annual leave  master classes on use of observations and compliance with the Trust’s policy  increased focus on recruitment, particularly in North West Sussex

In addition, the daily bed call is being extended to include discussions on in-patient staffing, which will be clinically led to provide the right level of scrutiny, mirroring the approach taken to address bed pressures.

The Committee also received two further papers setting out work that is being undertaken to address staffing issues, these were the update of the work in progress to reduce the level of agency staff and the progress being made on the use of Rosterpro, the Trust’s electronic staff rostering system. The Committee were updated on the guidance and compliance reporting being introduced by Monitor on the use of non-framework agency staff. It was noted that a supplier day had been held with the main suppliers of agency staff and that the Trust was now sourcing between 60 to 65% of its agency staff from framework agencies.

As part of the Committee’s assurance process it was agreed to have themed review on the working being undertaken to on the redesign of Adult Community Services and Corporate savings at the meetings in October and November.

Operational Performance Report The Committee received the Performance Reports for Adult and Specialist Services for Month 5, which highlighted the following key areas of concern:

 The Trust continues to experience pressures on the acute care pathway. However, work to improve gatekeeping and discharge planning is beginning to stabilise the situation, with the number of bed days in external placements reducing from 400 in June to 92 in August, and no external placements used since the middle of August.  Delayed Transfers of Care continue to be an issue, with the Trust currently not meeting its Monitor target. The Committee were updated on the work being undertaken to ensure that performance is improved in this area  Waiting Times – the Committee noted the on-going issues around waiting times in Children and Young People’s Services and were updated on the demand and capacity work that has

been undertaken to inform commissioners that the resources in the service are inadequate to cope with the levels of demand. This work has resulted in additional funding in Hampshire and on-going discussion with commissioners in Kent.

Estates Strategy The Committee received a paper setting out the work that has been undertaken to develop a 5 year estates strategy for the Trust. The work has been undertaken through the process of strategic site reviews, with the purpose of the reviews being to maximise the use and value of the estate, deliver savings to contribute the cost improvement plan and to release cash for future capital developments and to ensure that future estate changes meet both current and future operational needs.

The Committee welcomed the review and hard work in getting the Trust’s Estates Strategy to this position. However, they requested that further work is required to develop an overarching estates strategy for each service and that the 5 year plan is modelled to test its affordability against the Trust’s financial strategy.

The Committee also received a paper setting out the Trust’s Sustainability Strategy and Travel Plan, which gave examples of initiatives already in place in, for example the use of power assisted bikes and electric cars.

Contract Update The contract report provided the Committee with the final details of the contract negotiations with commissioners and provided a summary of the contract values for 2015/16. The Contract Update also set out the details of the Trust’s CQUIN schemes for 2015/16 and development of plans for the 2016/17 contracting round.

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.

4.0 Recommendation/Action Required

The 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 23rd October 2015 and the Chair of the Committee will be able to provide a verbal update on the discussions held at the October Committee meeting, highlighting any matters for action or ratification by the Trust Board.

IN CONFIDENCE

Board of Directors: 28 October 2015 - Public Agenda Item: TBP46 .7/15 Attachment: L For Discussion By: Sue Morris, Executive Director of Corporate Services

OUR PEOPLE

SUMMARY & PURPOSE

The Board of Directors is asked to consider the information and analysis provided in the October 2015 report and ask any questions of the Executive Director of Corporate Services.

LINK TO ANNUAL PLAN

The need to retain a strong focus on reducing agency to improve quality of care remains a priority whilst at the same time maintaining focus on the longer term strategic solutions of service re-design and workforce transformation.

ACTION REQUIRED BY COMMITTEE MEMBERS

The Board of Directors is asked to note progress against the update progress under each of the 7 workforce programmes as well as the areas identified of concern and ask any questions of the People Director.

IN CONFIDENCE

Our People

1.0 Executive Summary

The People report for October 2015 aligns with the Trust’s 2020 Strategy and Vision, in particular, goal four, ‘To be the provider, employer and partner of choice’ and is structured to reflect the 7 programmes outlined in the Workforce Strategy to achieve this goal.

The aim of the report is to inform the Trust Board of developments across the 7 key programmes of work, to highlight areas of concern or risk and provide a high level overview of the key workforce metrics to assure the Committee and the Trust Board of the safety and sustainability of our workforce.

Three key areas are currently being monitored, turnover rate, monthly sickness absence and the monthly vacancy rate. These inform our workforce plans.

In terms of recruitment and retention, there were 108 starters in September (77 External and 31 Internal) and 48 leavers. This is a marked improvement in our appointment figures. The WTE percentage turnover rate for September was 15.10% compared to 14.90% in August.

The average time to hire for September was 15.07 weeks compared to 14.04 in August, this slight increase was partly attributable to interview result forms not being returned in a timely way after the interviews had taken place.

Recruitment Campaigns have been developed for the Selden Centre, the Eating Disorder Centre in CAMHS and Hampshire ChYPS in conjunction with the communications team. These campaigns are due to be launched in November 2015.

Consultation on the proposed organisational values and behaviours has been a key focus of the 6 Leadership Forums across Kent, Hampshire and Sussex this month. Feedback from over 150 senior leaders has helped us to refine and amend the document ready to share with the Board for their feedback on 21 October before it goes out to all staff for their contribution through team meetings.

Agency spend decreased to £703k in September from £768k in August. Medical agency decreased by £72k and nursing agency spend decreased by £41k whilst other agency costs in community services increased by £47K. Total agency now equates to 4.59% of the total month's pay bill, 4.94% in the previous month, with the target being 2-3%.

2.0 Introduction

Please see attached full report

3.0 Report

Please see attached full report.

4.0 Recommendation/Action Required

The Board of Directors is asked to consider the information and analysis provided in the September report and ask any questions of the People Director.

5.0 Next Steps

As outlined in previous months, the key operational priorities will remain focussed on improving and tackling the issues that lead to high agency spend and impact on the quality of services.

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Our People Report July-2015 Our People October 2015

Overview

Sussex Partnership NHS Foundation Trust

1. Overview

1.1 Sussex Partnership 2020 Strategy and Vision sets out a clarity of purpose, a set of stretching objectives and an aspirational culture that define the experience that patients, carers and families, staff and our partners should expect from working with us.

1.2 Goal 4: Be the provider, employer and partner of choice sets the context and aims for which

the People Directorate directly align and work towards to accelerate the achievement of this Overview strategic goal.

1.3 The People Directorate Workforce Strategy sets out 7 key areas of work that provides an architecture for the work we carry out to achieve Goal 4: Resourcing and Workforce Planning; Organisational Development and Cultural Change; Improving People Management Systems and Workforce Information; Developing the People Directorate to Support the Delivery of the Workforce Strategy; Developing the Medical Workforce; Performance, Re- ward and Recognition and; Leadership, Management and Staff Development.

1.4 Our People Report is one part of the key monthly strategic reports. The other element is the CDS reports, which have a greater level of workforce detail and are discussed at performance contract meetings and local multi-disciplinary leadership meetings.

1.5 Our aim is to inform the Board of developments across our 7 key programmes of work, to highlight areas of concern or risk. Also to provide a high level overview of the key metrics required to inform the Board of the safety and sustainability of our workforce.

1.6 The People Report is presented to the People Committee bi-monthly before it is presented to the Executive Assurance Group and then the Board. The CDS reports are presented at CDS board and divisional leadership teams.

2 Performance Summary

Sussex Partnership NHS Foundation Trust

Dashboard

The latest Trust figures are as follows:

Substantive Staff in Post (wte) as at 30 September 2015 3731 ▼ PerformanceSummary Vacancy Rate (wte funded vacancies) - September 2015 13.9% ▲

Vacancy Rate (wte vacancies with HR) - September 2015 6.1% ▼

Average Time to Hire (weeks) - September 2015 15.07 ▲

Monthly Sickness Absence Rate - August 2015 4.1% -

Agency Spend - September 2015 703K ▼

Agency Spend - September 2015 % of Paybill 4.59% ▼

DBS Compliance % 97% -

Staff Retention Rate (wte 12 months ending September 2015) 87% -

Staff Turnover Rate (wte 12 months ending September 2015) 15% ▲

WTE—Whole Time Equivalent

3 Performance Summary

Sussex Partnership NHS Foundation Trust

Exception Reporting

Workforce Metrics Exception Reporting Three key areas are currently being monitored: annual turnover % rate, monthly sickness absence % rate and the monthly vacancy % rate. The exceptions are reported below.

CDS Areas of Action Concern PerformanceSummary

Adult East 5.25% Sickness Sickness – There has been targeted interventions supported by HR at Amberstone, AOT St Mary’s and Bram- ble Lodge. Short term absences have reduced by 64% from the previous month due to intensive intervention. Of the 28 LTS cases, 8 cases were closed in August and 13 will close in September and October, which will reduce LTS by 75%. 22.2% Vacancy rate Vacancy - Of the 60 vacancies with Recruitment, 13 have start dates and 14 are undergoing employment checks. Bank workers have been converted to substantive posts as part of the recruitment initiatives for Has- tings. The Division is looking to advertise within the RCN Bulletin and attend upcoming RCN Job Fairs.

Adult Coastal 5.15% Sickness Sickness : Senior HR Advisor working closely with areas that need additional support. The LTS cases are being closely managed.

15.2% Vacancy rate Coastal Vacancy Rate : The Matrons for Dementia and Meadowfield are working closely with the HR team to bring in new recruitment practices that have worked well elsewhere in the Trust. They are also working closely with the trust-wide initiatives such as reviewing skill mix to address short-falls in recruitment. In the meantime, Grove Ward has been in discussion with a framework agency to source permanent and long term temp qualified staff.

Adult North 5.3% Sickness Sickness – Improved in the division from 6.22 to 5.37 % over a 3 month period. Bradford Score introduced and managers supported and trained in its application. Regular absence meetings are attended conducted by the senior HR Advisor with managers reviewing action plans, meeting with employees and taking appropriate steps in accordance with policy including the use of absence cautions, and ill health retirement where appropriate. 17.8% Vacancy rate Recruitment— Challenging in Crawley and Horsham, whereas Mid Sussex is fully recruited. LGH experienced difficulties with the recruitment of HCA’s which is unusual. The hospital had two interview dates for HCAs which resulted in only 4 offers due to poor attendance and calibre. Recruitment co-coordinator is now in post and will be undertaking a review. Actions on the recruitment strategy plan being implemented and reviewed regularly. 22.3% Turnover High turnover of staff with under 12 months service, General Manager for LGH and HRBP invited those staff members to meet and discuss their experiences of recruitment, induction and being a new member of staff at LGH during the first 6 months. 6 employees attended the meeting. One who was unable to attend provided a written response . The meeting encouraged positive and negative feedback and actions for the hospital to take on board particularly around Trust induction, PMVA training , communication during the recruitment process, and supervision . This exercise will be repeated in 6 months’ time and feedback will be provided to staff who attended this session on progress.

CHYPS—Hants 18.2% Turnover The retention strategy for ChYPS has been completed and will be launched in November. The strategy focuses CHYPS - Kent 19.2% on values-based recruitment, advertising campaigns, wellbeing, staff engagement, and training and development. A new Project Manager will be leading on the recruitment campaign for the waiting list management and Eating Disorder Service.

Corporate 20.5% Turnover The number of leavers in September rose to 8 including 7 voluntary resignation and one MARS. Exit data is being analysed to identify and address areas of concerns.

Facilities & Estates 19.1% Vacancy rate Vacancies continue to be held whilst the DTZ review is underway.

4.6% Sickness New long-term cases

Prison 22.7% Turnover There are a decreasing amount of leavers in Prison services however the turnover will remain high as the Services calculation takes into account staff movement in the last 12 months.

Learning Disabili- 15.5% Vacancy Rate The nursing vacancies at Selden remain hard to recruit to posts. A detailed recruitment action plan has now ties been agreed in conjunction with finance and the Recruitment Account Manager who is working onsite one day a week.

Secure & 7.3% Sickness The sickness rate remains high however 7 staff have now returned to work which will impact on the sickness Forensic rate from November.

16.7% Vacancy Rate A social media campaign has reached 2,000 people through Twitter and applicants are encouraged to indicate where they saw the job advertised.

4 Summary

Sussex Partnership NHS Foundation Trust Overall Monthly Absence Percentage 6.00%

5.00%

4.00% 2014 Summary 3.00% Target

2.00% 2015

1.00%

0.00% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 4.16% 4.10% 3.93% 3.89% 3.71% 3.44% 3.66% 3.45% 3.99% 4.18% 4.38% 5.08% 2015 5.40% 5.09% 5.00% 4.13% 3.91% 3.94% 4.12% 4.06%

The sickness absence rate for August remained the same at 4.1%. Comparable to the chart below we are below the average sickness rate for other Mental Health Trusts.

Average Sickness rate for the Year Mental Health Sussex Partnership Trusts NHS Trust 2013 4.77% 4.24% 2014 4.83% 4.00% 2015 5.14% 4.71%

Top 5 Sickness Reasons - Aug-15 WTE Days Lost

278 376 1,235 Anxiety/stress/depression Musculoskeletal problems 404 Cold, Cough, Flu - Influenza Gastrointestinal problems

981 Injury, fracture

5 Summary

Sussex Partnership NHS Foundation Trust

Staff Turnover

WTE % Turnover Rate

18.00% 15.10% 16.00% 13.79% 14.19% 14.00%

12.00% Summary

10.00%

8.00%

6.00%

4.00%

2.00%

0.00% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Median

12 Months ending

External Starters & Leavers - September 2015

External New Starters - Sept-15 Starters & Leavers Sept-15 45 100 40 80 35 60 30 40 77 25 20 20 0 15 Leavers (Headcount) Starters (Headcount) 10 -20 -48 -40 5 0 -60 Adult Services Specialist Services Corporate & Miedical & Dental Estates

Add Prof Scientific & Technical - Clinical Psychologists, Psychotherapists, Pharmacists

Allied Health Professionals - Occupational Therapists, Therapists

Additional Clinical Services - Healthcare Assistants, Occupational Therapy Assistants, STAR Workers

Compliance DBS Renewals

14 The total number of staff with expired 118 DBS as at 1st October is 132. Of these With Capita some have yet to respond or are on long Maternity/Long Term Sick/No response term sick or maternity leave and have In Date been passed to the HR Business Part- 3762 Compliance ners to take further action.

Revalidation There were a total of 8 doctors due for Revalidation in September, 5 Consultants and 3 Specialty Doctors. 6 doctors were recommended and 2 deferred.

Whistleblowing We currently have one Whistleblowing case in North West Sussex.

6 Recruiting and Retaining the Right People with the Right Skills and Val- ues for the Right Roles Sussex Partnership NHS Foundation Trust

Programme One Summary • Supporting CDS to produce local workforce plans • Recruiting and retaining the right people with the right skills and values for the right roles • Improving the recruitment experience • Promoting our rewards option to attract and deploy a flexible workforce • Developing a retention strategy Programme1

Recruitment Campaigns Recruitment Campaigns have been developed for the Selden Centre, the Eating Disorder Centre in CAMHS and Hampshire ChYPS in conjunction with the communications team. These campaigns are due to be launched in November 2015.

Exit Questionnaire The on-line Exit Questionnaire has now gone Live and staff leaving the Trust are being asked to complete the survey. The findings from surveys completed in Sept show that 43% of leavers had worked for the Trust for 2 years or less, with the main reasons for leaving being: not feeling valued by the Trust (71.5%); lack of job satisfaction (57%); and to broaden experience (42%). 57% of leavers were going to other NHS Trusts with 42% to same graded NHS positions. More detailed analysis is under way.

University Careers Fairs The Trust has attended a careers fair at Surrey University on the 14 th October 2015. Feedback will be provided at the next People Committee.

Open Days Mill View held an open day on the 22 nd September and recruited 2 Register Mental Health Nurses and 22 HCA’s. Lindridge had an open day on the 2 nd October and recruited 1 x RMN and Kent CAMHS had one on the 6th October and recruited 4 x Band 6 RMN’s and 1 x Band 7.

Return to Practice Health Education England (HEE) have re-launched their Return to Practice Campaign and the Trust is linking in with HEKSS and the University of Brighton to promote opportunities within the Trust. We are launching an advertising campaign to attract RtP nurses to our Trust.

Time to Hire The time to hire from requisition raised to start date has increased from 14.04 weeks in Au- Reasons for Leaving Sept-15 gust 2015 to 15.07 weeks in September 2015. End of Fixed Term Contract

The increase is due to delays in the Interview Mutually Agreed Resignation - National Scheme with Repayment 2 Results Forms being returned after interview. 4 2 2 Retirement - Ill Health

7 Retirement Age 6 Voluntary Resignation - Adult Dependants

Voluntary Resignation - Better Reward Package 1 4 Voluntary Resignation - Health 2 Voluntary Resignation - Lack of Opportunities 2 Voluntary Resignation - Other/Not Known 4 12 Voluntary Resignation - Relocation

Voluntary Resignation - To undertake further education or training

Voluntary Resignation - Work Life Balance

Average Time to Hire in Weeks - Oct-14 to Sep-15

15.04 15.07 15 14.96 14.99 14.81 15 14.73 14.65 14.5 14.46 14.35 14.04 13.82 Bank – New Starters Satisfaction Survey 14 The findings from this month’s survey show that 83.5% of new bank starters were either very satisfied, or extremely

13 satisfied with their pre-employment experience and, based on their first impressions of the Trust, 100% would recommend it as a place to work. 75% of those new starters have already started work with the Trust.

7 Organisational Development and Cultural Change Sussex Partnership NHS Foundation Trust

Programme Two Summary • Improving staff experience and staff engagement • Developing strong team practices • Introducing new roles • Recruiting for values • Promoting equality, diversity and human rights • Improving the health and wellbeing of our staff • Improving communications and embedding LiA

Programme2 Values and Behaviours Consultation on the proposed Organisational Values and Behaviours at each of the 6 Leadership Forums across Kent, Hampshire and Sussex this month.

Feedback from over 150 senior leaders has helped us to refine and amend the document ready to share with the Board for their feedback on 21 October before it goes out to all staff for their contribution through team meetings.

Team Away Days and OD formulation days Design and facilitation of Medical Away Day; Team Development - Selden Centre, Mayfield and Acorns and; Governance Team. CDS Development - Sussex CHYPS; LD; NWSX and; CAMHS. Formulation sessions with the Service Director of Brighton and Hove and CHYPS services.

Appraisal Figures Appraisal figures stand at 75% against a target of 85% for Q2. There is intensive focus on geng staﬀ to register appraisals informaon on My Learning.

Health and wellbeing CAMHS have created a Health and wellbeing working group in Kent to analyse the stress audit recently carried out and devise an action plan.

Improving People Management systems and Workforce information

Programme3 Programme Three Summary • Improving the quality of the data held in Electronic Staff Record (ESR) • Utilising e-systems to improve efficiency • Maximising e-rostering • Establishing workforce planning • Introduce Annex W • Reviewing the workforce reports we produce • Establishing robust governance frameworks

ESR ESR Self-Service for employees will be available from early November. Staff will be able to look up and amend their personal details and check the information we hold about them. Manager self-service will come online in early 2016 to enable managers to directly amend their staff data without the need for forms.

In order to prepare for nursing revalidation, the team are cleansing the data held in ESR and removing bank workers not taking up shifts in the last 12 months.

Nursing workforce planning Following the workshop, an action plan has been drafted which will support the recruitment, retention and training of RMNs in the Trust and promote the Sussex Partnership brand.

Disclosure and Barring Service Based on the recent decision to continue 3-yearly checks for all eligible staff within S&F, Prison, and ChYPS, with all other staff in ‘regulated activities’ to be checked upon joining and thereafter in the form of an annual declaration. Work is under way to develop new processes around this for both substantive and bank workers to ensure a continued high level of governance.

8 Developing the People Directorate Sussex Partnership NHS Foundation Trust 9

Programme Four Summary • Becoming a highly customer focused team • Becoming a sustainable and efficient service • Increasing the skills and knowledge of all people services staff • Embedding the business partner model • Enhancing our services to the organisation Programme4 Level 3 Award in Education and Training Members of the HR team will undertake the training in the coming months to further develop their facilitation skills and support the management development programme now in place.

Bank cross-training Following the recent merger of the bank booking and bank recruitment teams, the staff have been trained across both functions and developing their skills in each area.

Development of HR skills Staff in the department are taking part in shadowing with colleagues in other HR functions to develop their knowledge of employment law, and policies and procedures.

Support Services Workshop Representatives of the People Services team have presented their visions, priorities and activities to the CDSs on 14th October to ensure that the directorate continues delivering services which are aligned to clinical services.

Developing sustainable terms and conditions

Programme Five Summary • Ensuring that the terms and conditions of staff fit the Trust’s vision, values and objectives • Ensuring that they meet the needs of services and deliver workforce flexibility • Ensuring clinical resources are used effectively and improve clinical engagement

CONSULTANTS JUNIOR DOCTORS - Removal of current contractual barriers to facilitate seven day - Pay will no longer be time based incremental progress working sion and instead increases in basic pay will be deter - Introduction of a schedule of safeguards to ensure staff are mined by changes in level of responsibility as the doctor appropriately protected when they move to a seven day service Progresses through training Programme5 - Revised pay structure that rewards staff that contribute the - Out of hours pay based on the number of hours and most and work the most onerous work patterns by: when these house are worked (different rates of pay for - Bringing to an end incremental pay progression based on time Sundays and night shifts) served by introducing two fixed payment points equating to two - Working pattern managed similarly to job planning levels of consultant (newly appointed and established) - Leave, private professional practice, and termination of - The introduction of new pay rates employment are simplified - Linking progression to higher levels of responsibility and - Expenses provisions brought in line with Agenda for competence with progression being contingent on performance Change with an additional section incorporating discre - Bringing local Clinical Excellence Award arrangements to an tionary provisions on relocation and excess travel end and replacing them with a new locally determined, non- - An absolute maximum of 72 hours worked in any seven consolidated payment for excellence in which three categories consecutive calendar days (current contract allows a of award would be considered 1) Individual 2) Team 3) Organi scenario where it is possible to work up to 91 hours in a sational level single week)

CURRENT STATUS The BMA has re-entered in to negotiations with NHS Employers The health secretary wrote to the chair of the BMA Jun- ior Doctors’ Committee (JDC) on the 8 th October 2015 summarising the key discussion points, following this the BMA JDC has been asked to return to talks to help ne- gotiate the best deal for junior doctors and the health secretary has asked for a decision by the 14 th October 2015 PROPOSED IMPLEMENTATION DATE April 2016 for new consultants and existing consultants to be 9 August 2016 moved across by 2017 Performance, Reward and Recognition Sussex Partnership NHS Foundation Trust

Programme Six Summary • Embedding Trust values and behaviours in our operational structures for performance management and development • Developing an integrated approach to reward recognition and performance • Improving overall performance and productivity

The Values and behaviour “blueprint” describe our staffs thoughts about what you will experience as service user, carer, partner, commissioner and anyone else who works with us when we are at our best and the types of behaviour we are moving away from and do not want others to experience. These core val- Programme6 ues and behaviours enable our staff to deliver the best care and describe the aspirational culture we want to see across Sussex Partnership NHS FT.

How will these be used? The behavioural Framework provides an architecture and consistency to enable quality:

• Performance Management • Appraisal and 1-1 • Talent Management • Supervision • Succession Planning • Values Based Recruitment • For consistent cultural audit across the organisation

A Project group is being set up to look at performance and productivity linked to the launch of Annex W. Leadership Management and Staff Development

Programme Seven Summary • Behavioural Feedback • Identifying priority areas to support Care Delivery Services development • Improving leadership and management capacity • Prioritising clinical leadership development • Recognising different roles and needs of managerial levels • Creating a learning organisation

Management Training Programme7 A 5 module training programme has been written to develop and up-skill any managers in the Trust who have line management responsibility. The 5 modules focus on the main areas of advice sought from the HR team and aim to educate managers on the various elements of the employee lifecycle and how this ultimately impacts on employee engagement and the quality of care providing by staff. This training programme will complement the Leadership Development Programme by providing an operational focus and will be accessible to those managers who are not currently eligible to attend the LDP.

The 5 modules are: employee lifecycle, work life balance, managing concerns raised by employees managing concerns raised about an employee and investigation training. The investigation training has been shared and commented on by staffside to maintain partnership working.

The training will be delivered by the Senior HR Advisors. 4 training sessions have been run in East Sussex and were well received by attendees and more training sessions are being arranged across the Trust. These will be advertised on SUSI and promoted at divisional leadership teams.

Leadership Development

Leadership Development Programme Cohort 6 launches in November as Cohort 4 prepares to present their projects.

Planning is under way for the SPFT Leadership Conference in November as we invite LDP alumni to present the outcomes of their project.

SPFT Leadership Development Programme has been short-listed as a finalist in the 2015 Training Journal Awards https://www.trainingjournal.com/articles/sponsored_article/tj-awards-2015-open-entries

Other organisations in the Best Public Sector Programme category include The Civil Service, University Hospitals Birmingham, University of Surrey and University of St Andrews.

Board of Directors: 28 October 2015 – Public Agenda Item: TBP47.1/15 Attachment: M For Decision By: Peter Lee, Head of Corporate Governance & Sally Flint, Executive Director of Finance & Performance

Q2 IN-YEAR GOVERNANCE STATEMENT TO MONITOR

SUMMARY & PURPOSE

As part of the quarterly return, Monitor requires the Board of Directors to confirm the In- Year Governance Statement, found at appendix 1. This asks whether, in-year, the Trust anticipates maintaining a financial sustainability risk rating of at least 3 and that it has on- going compliance to meet existing performance targets.

1. Financial sustainability risk rating Sussex Partnership currently has a financial sustainability rating of 3. However, it should be noted that while previously the liquidity of the Trust meant that it was almost certain to maintain a financial sustainability rating of 3, the way Monitor now limits the overall rating to 2 where any metric is 1 means that the Trust is at greater risk than before of not being able to maintain this rating.

2. Compliance to meet existing performance targets Board members will see from the Performance Reports that in Q2, like in Q1, the Trust missed one of the eight performance targets set out by Monitor in the Risk Assessment Framework. The Trust is reporting 8.9% delayed transfers of care for Q2, against the Monitor target of <7.5%. This has reduced from 9.9% in Q1. The action being taken to address this is set out in section 3.4.5 of the Performance and Quality Report.

Monitor has updated its Risk Assurance Framework in response to the increasingly challenging financial context facing the NHS. A report detailing these changes can be found at Appendix 2.

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to:

1. Agree that the Trust should confirm the two finance statements set out in Appendix 1 2. Agree that the Trust should not confirm the governance statement in Appendix 1 and by way of explanation include in the ‘notes’ section the narrative set out in section 3.4.5 of the Performance & Quality Report. 3. Note the changes to the Risk Assessment Framework set out in Appendix 2

Page 1 of 7

Page 2 of 7

Appendix 2

CHANGES TO MONITOR’S RISK ASSESSMENT FRAMEWORK

1.0 Executive Summary

Monitor has made changes to its Risk assessment Framework that came into effect from August 2015.

These changes were made in response to the increasingly challenging financial context facing the sector. They are intended to strengthen Monitor’s regulatory regime so that it can help foundation trusts live within their means and support improvements in financial efficiency across the sector.

The key changes are as follows:-

 monitoring in-year financial performance and the accuracy of planning

 combining these two measures with the previously used continuity of services risk rating to produce a new four-level financial sustainability risk rating

 introducing a value for money governance trigger.

The Trust’s Financial Sustainability Rating is currently ‘3’.

2.0 Introduction

All NHS foundation trusts need a licence from Monitor stipulating the specific conditions they must meet to operate, including financial sustainability and governance requirements. Monitor’s Risk Assessment Framework sets out the assessment framework used to assess each NHS foundation trust’s compliance with two specific aspects of its provider licence: the continuity of services and governance licence conditions.

Monitor’s assessment of a foundation trust under the Risk Assessment Framework aims to identify:

 significant risk to the financial sustainability of a provider of key NHS services that endangers the continuity of those services and/or

 poor governance at an NHS foundation trust, including poor financial governance and inefficiency.

NHS foundation trusts are assigned a financial sustainability risk rating calculated using a capital service metric, liquidity metric, income and expenditure (I&E) margin metric and variance from plan metric.

A foundation trust’s governance rating is determined using information from a range of sources including national outcome and access measures, outcomes of Care Quality

Page 3 of 7

Commission (CQC) inspections and aspects related to financial governance and delivering value for money.

The ratings indicate when there is a cause for concern at a provider. It is important to note they do not automatically indicate a licence breach or trigger regulatory action. Rather, they prompt Monitor to consider where a more detailed investigation may be necessary to establish the scale and scope of any risk.

3.0 Revisions to the risk assessment framework in August 2015

In June 2015 Monitor consulted on a number of proposed changes to the Risk Assessment Framework to reflect the challenging financial context in which foundation trusts are operating and to strengthen their regulatory regime to support improvements in financial efficiency across the sector. The changes include:-

 monitoring in-year financial performance and the accuracy of planning

 combining these two measures with the previously used continuity of services risk rating to produce a new four-level financial sustainability risk rating

 introducing a value for money governance trigger.

Monitor also reviewed the appropriate reporting requirements and as a result from August 2015 NHS foundation trusts are required to submit financial information monthly as well as quarterly.

4.0 Introduction of a financial sustainability risk rating

Under the new Risk Assessment Framework Monitor has replaced the previously used ‘continuity of service risk rating’ with the ‘financial sustainability risk rating’. This risk rating represents Monitor’s view of the likelihood that a licence holder is, will be, or could be in breach of the continuity of service licence condition 3 and/or the provisions of the NHS foundation trust licence condition 4 (governance ) which relates to finance.

The financial sustainability risk rating will be calculated using the following measures:-

 Liquidity: days of operating costs held in cash or cash-equivalent forms, including wholly committed lines of credit available for drawdown  Capital servicing capacity: the degree to which the organisation’s generated income covers its financial obligations  Income and expenditure (I&E) margin: the degree to which the organisation is operating a surplus/deficit. The I&E margin is defined as surplus/ (deficit)/total operating and non-operating income. Surplus / (deficit) should be calculated before impairments, transfers by absorption, gains/losses on asset disposal and restructuring costs.  Variance from plan in relation to I&E margin: variance between a foundation trust’s planning I&E margin in its annual forward plan and its actual I&E margin within the year.

The table below outlines how the risk rating will be calculated:

The overall score will inform Monitor’s regulatory approach. The table below outlines the regulatory implications of each score.

5.0 Introduction of monthly reporting

Monitor notified foundation trusts that from month 4 (July 2015/16), it would be collecting monthly financial data from all foundation trusts.

The monthly collection will not supersede the quarterly reporting process; which will remain a comprehensive review of both financial and governance positions and ratings will continue to be published on a quarterly basis. The intention is to provide additional visibility between the quarterly monitoring process and allow Monitor to identify areas of concern sooner. The monthly data collection requires selected information in the same template return as the quarterly collection for ease of use and board sign off is not needed for the monthly submission, prior to submission.

6.0 Value for money governance measure

Monitor is introducing a measure within the existing governance rating to assess whether foundation trusts are delivering value for money. If a provider demonstrates inefficient / uneconomical spend (actual or likely) compared to published benchmarks, this may trigger an investigation.

Where appropriate national benchmarks are not yet available, Monitor may also consider investigating a trust if there is other material evidence to suggest a trust is delivering poor value for money. For example, Monitor may look at whether a foundation trust is adhering to good practice regarding agency and management consultant spend. Where this is the case Monitor will discuss the evidence with the foundation trust in question.

7.0 Changes to the Accounting Officer memorandum

Monitor has updated the accounting officer memorandum to strengthen the requirement to consider value for money. The following changes have been made to paragraph seven of the memorandum: -

• “the accounting officer must ensure financial systems and procedures promote the efficient and economical conduct of the business and safeguard financial propriety and regularity throughout the NHS foundation trust”

Amended to: • “the accounting officer must ensure the foundation trust delivers efficient and economical conduct of its business and safeguards financial propriety and regularity throughout the organisation”

And

• “the accounting officer must ensure financial considerations are fully taken into account in decisions on NHS foundation trust policy proposals”

Amended to: • “the accounting officer must ensure financial considerations are fully taken into account in decisions by the NHS foundation trust”

The accounting officer is held to account on the commitments made by signing the memorandum by the Public Accounts Committee via the Comptroller and Auditor General

(C&AG) who leads the National Audit Office. Therefore if a foundation trust is found not to have delivered on the commitments set out within the memorandum the accounting officer may be required to appear before the PAC to provide an explanation on why the commitments have not been met.

8.0 Recommendation/Action Required

The Board is asked to note the changes to Monitor’s Risk Assessment Framework. . 9.0 Next Steps

The Finance Report and the Quarterly In-Year Governance Statements has been updated to include details of the Trust’s Financial Sustainability Rating, which is an overall rating of 3.

Performance against Monitor’s revised Risk Assessment Framework will be monitored through the Executive Assurance Committee and Finance & Investment Committee.

Sussex Partnership NHS Foundation Trust Board of Directors: 28 October 2015 – Public Agenda Item: TBP47.2/15 Attachment: N For: Information By: Peter Lee, Head of Corporate Governance

NOTIFICATION OF SEALED DOCUMENTS REPORT FOR Q2 – 01 JULY 2015 TO 30 SEPTEMBER 2015

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 Q2 summary report of sealed documents between 01 July 2015 and 30 September 2015.

2.0 SEALED DOCUMENTS

No. Date Document 290 21.07.15 Deed of Surrender relating to land and buildings known as Pepperville House, Fort Road, East Wick, Littlehampton, West Sussex, BN17 7QZ between 1) Arun District Council and 2) Sussex Partnership NHS Foundation Trust.

291 21.07.15 Lease relating to land and buildings known as Pepperville House, Fort Road, East Wick, Littlehampton, West Sussex, BN17 7QZ between 1) Arun District Council and 2) Sussex Partnership NHS Foundation Trust.

292 21.09.15 Land Registry Transfer of whole of registered title for 1 & 2 Primrose Cottages and 1 & 2 Foxholme Cottages, Summersdale Road, Chichester between 1) Sussex Partnership NHS Foundation Trust and 2) Mirillion Properties Limited.

Sussex Partnership NHS Foundation Trust Board of Directors: 28 October 2015 - Public Agenda Item: TBP47 .3/15/15 Attachment: O For: Information By: Rebecca Huth, Corporate Governance Administrator

MATTERS ARISING: ACTION POINTS FROM THE COUNCIL OF GOVERNORS MEETING HELD IN PUBLIC ON MONDAY 19 OCTOBER 2015 Date of Action Action Min. No. Action Points from previous meeting Lead Action Taken

19.10.2015 Action CG 36/15 CDS Suicide Prevention Plans to be added to April Helen Complete: Added to Council of Council of Governor’s agenda. Greatorex/Tim Governors January 2016 Agenda. Ojo 19.10.2015 Action CG 38.1/15 Council of Governors to receive a report in January Simone Complete: Added to Council of 2016 giving a further update on how CDSs will operate. Button/Lorraine Governors January 2016 Agenda. Reid 19.10.2015 Action CG 38.4/15 Undertake a review of the steps being taken to ensure Helen Greatorex adequate provision of dietary advice in both acute and community services. 19.10.2015 Action CG 38.4/15 Involvement Strategy to be included on January 2016 Vincent Badu Complete: Added to Council of Council of Governors Agenda. Governors January 2016 Agenda. 19.10.2015 Action CG 39.1/15 Internal Auditors to audit and test the OT activities on Sally Flint wards and obtain input from governors to help design the audit 19.10.2015 Action CG 39.3/15 Briefing note to council members setting out the liaison Sam Allen with HOSCs and other stakeholders in the development of the quality improvement plan. 19.10.2015 Action CG 40.1/15 Circulate the top risks from the Board Assurance Helen Greatorex Framework.

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