Council of Governors Meeting
16 June 2014
11.00 – 14.00
(Pre-meeting for Governors only commences at 10.00)
Overline Lounge, American Express Community Stadium, Village Way, Brighton, BN1 9BL
For copies of papers, queries or further information, contact: Natalie Hennings, Corporate Governance Business Manager (01903 843078) [email protected]
MEETING OF THE COUNCIL OF GOVERNORS IN PUBLIC
To be held in the Overline Lounge, American Express Community Stadium, Village Way, Brighton, BN1 9BL
Monday 16 June 2014 at 11.00am Time
11.00 CG25/14 Introductions and apologies for absence
11.03 CG26/14 To receive any declarations of interest
11.05 CG27/14 Minutes of the meeting held on 14 April 2014, action points and matters A arising Verbal update on the review of out of date policies Helen Greatorex, Executive Director of Nursing and Quality
CG28/14 PERFORMANCE
11.15 CG28.1/14 Chief Executive’s Report B Lisa Rodrigues, Chief Executive
11.25 CG28.2/14 Finance and Performance Report C Sally Flint, Executive Director of Finance and Performance
To receive an update on the Board’s response to The Survey initiative D 11.35 CG28.3/14 Report Sue Morris, Executive Director of Corporate Services
11.40 CG28.4/14 Complaints Progress and Performance Update VERBAL Helen Greatorex, Executive Director of Nursing & Quality
11.45 CG28.5/14 Patient Experience Quarterly Report Vincent Badu, Strategic Director of Social Care & Partnerships E
11.50 CG28.6/14 To receive a report on Safe Staffing Helen Greatorex, Executive Director of Nursing & Quality F
11.55 CG28.7/14 To receive a report on the Care Plan Audit Kay Macdonald, Clinical Academic Director G
Coffee Break
CG29/14 STRATEGY
12.05 CG29.1/14 To receive an themed report on Specialist Services H Lorraine Reid, Managing Director of Specialist Services
12.10 CG29.2/14 To receive an update report on Adult Mental Health Services I (to include an update on Langley Green CQC inspection) Anna Lewis, Managing Director of Adult Mental Health Services
12.20 CG29.3/14 Sussex Partnership’s 5 Year Business Plan Update - Presentation J Sally Flint, Executive Director of Finance and Performance Sam Allen, Commercial Director
12.30 CG29.4/14 Discussion on the Trust approach to the Smoking Policy/Review K Sue Morris, Executive Director of Corporate Services
12.40 CG29.5/14 Membership Development Strategy L Vincent Badu, Strategic Director of Social Care and Partnership & Karen Braysher, Interim Chair of Membership Committee
12.50 CG29.6/14 Charitable Funds Vision and Plan for 2014-16 M Rachael Duke, Head of Fundraising
13.00 CG29.7/14 To receive a presentation on Musculoskeletal Services - Presentation N Sam Allen, Commercial Director
CG30/14 GOVERNANCE
13.15 CG30.1/14 The FTGA Annual Subscription O Peter Lee, Head of Corporate Governance
13.20 CG30.2/14 General Elections 2014 Update VERBAL Peter Lee, Head of Corporate Governance
13.25 CG30.3/14 An update from Task Force 1 P Martin Jeremiah, Lead Governor
13.30 CG30.4/14 An update from Task Force 2/Establishing a Training and Development Q Committee Martin Jeremiah, Lead Governor and John Bacon, Chair
CG31/14 REPORT BACK FROM COMMITTEES
13.35 CG31.1/14 Governors Activities R Martin Jeremiah, Lead Governor
13.40 CG31.2/14 Feedback from the Audit Committee VERBAL Tim Masters, Non Executive Director and Chair of the Audit Committee
13.45 CG32/14 Questions or comments from members of the public (Chair to be notified in advance of the meeting)
13.50 CG33/14 Any Other Business
CG34/14 Date of next meeting: Monday 20 October 2014 11.00 – 13.30 Overline Lounge, American Express Community Stadium (Governors’ Meeting 10.00 – 10.45; Lunch & Networking 13.45 – 14.15)
CG35/14 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 Council of Governors: 16 June 2014 - Public Agenda Item: CG27/14 Attachment: A For Decision By: Natalie Hennings, Corporate Governance Business Manager
SUSSEX PARTNERSHIP NHS FOUNDATION TRUST
Minutes of the Council of Governors meeting held in public on Monday 14 April 2014 at 11.00am in the Overline Lounge at the American Express Community Stadium, Village Way, Brighton, BN1 9BL Present: John Bacon, Chair, Sussex Partnership NHS Foundation Trust (Chair)
Elected Governors Rodney Ash, Service User Governor, East Sussex Diana Byrne, Service User Governor, East Sussex Jane Tatum, Service User Governor, East Sussex Nic Allen Service User Governor, West Sussex Paul Burris, Service User Governor, West Sussex Elizabeth Hall, Service User, West Sussex Karen Braysher, Service User Governor, Brighton & Hove Giles Wright, Service User Governor, Brighton & Hove Tony Moore, General Public Governor, East Sussex Mick Burtenshaw, General Public Governor, West Sussex Howard Pearce, General Public Governor, West Sussex Cliff Buckland, Carer Governor Martin Jeremiah, Carer Governor Steve Malone, Staff Governor
Appointed Governors: David Standing, Chief Executive of Sussex Central YMCA Stephen Trask, Assistant Director of Operational Services, Richmond Fellowship Professor David Taylor, Universities of Brighton & Sussex Andy Winter, Chief Executive of Brighton Housing Trust Graham Taylor, Headteacher, West Kent Health Needs Education Service
In attendance Melloney Poole, Non Executive Director Diana Marsland, Non Executive Director Lisa Rodrigues, Chief Executive Sue Morris, Executive Director of Corporate Services Sally Flint, Executive Director of Finance & Performance Lorraine Reid, Managing Director of Specialist Services Helen Greatorex, Executive Director of Nursing and Quality Vincent Badu, Strategic Director of Social Care & Partnerships Peter Lee, Head of Corporate Governance Natalie Hennings, Corporate Governance Business Manager (minutes)
CG13/14 Introductions and apologies for absence
John Bacon welcomed Governors, Board members and members of the public to the meeting.
John welcomed two new Governors, Nic Allen and Mick Burtenshaw who were elected following the recent West Sussex by-election.
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Apologies for absence Phyllida de Salis, General Public Governor, East Sussex Christopher Masters, Carer Governor Denise D’Souza, Brighton & Hove City Council Debbie Kennard, West Sussex County Council
CG14/14 To receive any declarations of interest
None
CG15/14 Minutes of the meeting held on 20 January 2014, action points and matters arising Minutes
Helen Greatorex advised she was present at the meeting but not noted in the attendence list.
The Council agreed to accept the minutes as a true reflection of the meeting.
Actions
CG03/14 – Jane Tatum asked why the names of policies under review had not been circulated to Governors. John Bacon explained that Helen Greatorex would be giving an update later in the meeting.
CG36/13 – Karen Braysher asked when the care planning audit was happening and Martin Jeremiah confirmed that it was due to be completed by tomorrow.
CG05.4/14 – Rodney Ash gave Governors an update on his participation with complaints and advised he’d attended a training day and organised for one of the Case Managers to visit the Sussex Police Professional Standards Department. Rodney had also met with the Executive Director of Nursing and Quality and the Director of Nursing Standards and Safety on an informal basis and was pleased to report that work in the complaints department was progressing well.
CG05.3/14 – Martin Jeremiah advised that Rachael Duke, Head of Fundraising attended the recent Governors Training Day on 14 March 2014 and gave a good presentation on her vision and plan going forward. Martin reminded Governors that the Spring Cycling Challenge was taking place in May and the event had been reduced to now take place over one day.
CG16/14 Chief Executive Recruitment Update John Bacon, Chair John Bacon gave an update on the Chief Executive recruitment. He confirmed that following approval by the Council on 5 March the Trust finalised the details of Colm’s appointment. Colm is due to join Sussex Partnership on 1 July 2014, with Lisa Rodrigues handing over her Chief Executive duties on 11 July 2014. Colm is scheduled to visit the Trust later this month to have a prelimary meeting with Executive colleagues and meet staff. John advised he was looking forward to welcoming Colm on 1 July 2014.
Jane Tatum asked whether Colm would have a probationary period as part of his contract. John advised it is not standard practice for appointments at this level..
Karen Braysher expressed disappointed that incidents reported by the BBC recently relating to the Trust Colm Donaghy currently manages were not raised during the recruitment process. These reports included concern about patients waiting for long periods on trolleys in A&E leading to 5 patients who sadly died in one year. The BBC made suggestions that this was linked to staff shortages. John advised that the appointment of Colm Donaghy had gone through a very thorough recruitment process, which included obtaining the usual references, which were all very
Page 2 of 15 positive. John had also personally spoken to the Chairman at the Trust in Belfast who gave a strong endorsement. Karen asked the Chair that her disappointed be included in the minutes.
CG17/14 PERFORMANCE
CG17.1/14 Chief Executive’s Report Lisa Rodrigues, Chief Executive
Lisa Rodrigues presented her report and spoke about the continued pressure on all services over the past three months. Lisa explained the pressures are due to a number of different reasons, together resulting in mental health services seeing a considerable increase in demand.
Lisa referred to her latest weekly message and noted the pressures on acute adult mental health services have become so severe that Sussex Partnership has moved into ‘business continuity’. The Trust wrote to commissioners last week and they are working on a recovery and improvement programme to tackle the pressures. Although resources are limited the Trust must ensure funds are spent in the most effective way. Given the challenges Lisa thanked staff for working tirelessly in 2013/14, and acknowledged whilst the Trust doesn’t get everything right all of the time, staff always try their very best, and on behalf of the Board and Council Lisa was extremley grateful for their tremendous work.
The appointment of Colm Donaghy was approved by the Council of Governors last month, and Lisa has been discussing a handover with Colm which will take place the week commencing 7 July 2014.
From personal contact with service users and their families, Jane Tatum was concerned that there are not enough support services available, and as a result service users reach crisis point which must be contributing to the increased pressure on services. Jane noted that the Sanctuary in Hastings had been set up by a charity and asked whether more facilities such as this could be made available. Lisa advised the facility Jane was referring to is funded by Commissioners, and suggested inviting Commissioners to future Council meetings so they could explain to Governors what services they commission in each area.
Jane challenged whether the Trust was doing enough with Commissioners to ensure the right services were available. Lisa assured Governors that we regularly provide evidence to Commissioners and explained why it is unfair to expect staff to provide services that have not been commissioned. Sally Flint also gave assurance about these discussions with Commissioners, and advised the system needed to be less reliant on inpatient facilities but instead look at the whole care pathway from primary to specialist services.
Action: Invite Commissioners to future Council meetings.
Rodney Ash suggested to Jane that if she wanted to challenge Commissioners she should attend her local Clinical Commissioning Group to submit questions and hold them to account through their meetings held in public. John Bacon confirmed Governors could challenge Commissioners through the publlic forum suggetsed by Rodney and confirmed representatives from the seven local Clinical Commissioning Groups would be invited to attend future Council meetings.
Lisa reported on the fabulous work of Recovery Colleges and explained it is a pioneering way of supporting people with mental health challenges to live their lives to the full. It uses education in a supportive learning environment to help people to become experts in their own self-care and recovery. Following an open day held last week the programme for May is almost full, and there will be four more colleges being launched in September 2014.
Elizabeth Hall advised she had attended a day session at Brighton University on Recovery Colleges and found what they are trying to achieve extremley uplifting.
Martin Jeremiah referred to the bed crisis and advised Governors were surprised at the quick progress in solving issues last November and expected a longer term solution. Martin questioned Page 3 of 15 whether the hub was still in place. Lisa advised when Sussex Partnership moved into business continuty there were 22 people in external placements. The impact on quality of care and the financial implications mean it is crucial patients are brought back into Sussex Partnership services as soon as possible. As of today, 8 people are in external placements; this is a result of the extensive focus being given over the last six days. Lisa reminded members that the Easter Holiday was approaching so the Trust must not be complacent, and continue to work closely with Commissioners and partners in preparation for the bank holiday.
Lisa confirmed the Executive Team was meeting tomorrow to look at the recovery plan and long term solutions. These will be shared with Governors at an appropriate time but in the meantime Lisa confirmed she would continue to share updates on bed pressure through her weekly message.
CG17.2/14 Finance and Performance Report Sally Flint, Executive Director of Finance and Performance
Sally Flint presented the report and explained the paper was a summary of Sussex Partnership’s financial performance and progress up until the end of February 2014. Sally felt it was important to note that the Trust’s achievements on finance and performance given the pressures and challenges. At the end of February the Trust is reporting a surplus of £1.5k which is £674k under plan, with a good year end forecast of £2.2k after taking into account contingency reserves. Sussex Partnership has seen considerable bed pressures through the financial year, which has resulted in over £1m being spent on external placements. The other areas contributing to the underperformance are the continuing use of agency staff, the pressure on in-patient services and the slippage on the cost improvement plan. Going forward into 2014/15 the financial pressures will continue so the Trust needs to ensure the right balance of quality.
Sally advised the Trust has continued to make good progress in delivering its performance indicators throughout the year and highlighted some of the key areas. In regard to the new indicators for specialist services, Sally noted that while the Trust has struggled with waiting times in the past, sustained progress is now being seen in all areas. In Hampshire additional funding has been provided by Comissioners which will increase the capacity of teams to further improve waiting times and response rates.
Sally acknowledged given the challenges 2013/14 has been a successful year.
Andy Winter referred to 3.1.4 and asked whether the Board had set a target on the average time it takes to recruit staff, and sought confirmation the Board is satisifed there are measures in place to monitor this target. Sue Morris confirmed this was a key performance indicator reported to the Board monthly; at the time of writing the report the average was 18 weeks, and this has since been reduced to 17 weeks with a target to reach 15 weeks by September 2014. Andy directed his question to John Bacon and asked whether the Board was content with the 15 week target. John confirmed the Board were not content with this timescale but had to be realistic in the context of the process that needs to be undertaken in order to recruit. The Trust’s first objective is to reach 15 weeks, following that a further review will take place to see whether the target can be further reduced. Work is being undertaken to see whether we can anticpate and predict staff turnover in certain areas. The recruitment issue is a contributing factor to agency costs so finding a solution is esstential. Sally Flint assured the Council that the Trust always seeks to use bank staff in the first instance, but there are times when it is nessecary to use agency staff.
Mick Burtenshaw noted the Trust’s target on agency spend is 1% of the total paybill and asked what it was currently. Sally Flint confirmed spend was currently 4-5% but that the aim is to achieve 1% which has been achieved in the past. Mick questioned whether there were any plans to increase internal bank resources to help reduce agency spend. John confirmed the Board are not satified with the current spend on agency staff, and the Non Executive Directors are regularly challenging the Executive Team to address the issue. John explained the current situation is unsatisfactory as it affects quality and continuty of care. Given the severity of this issue, John recommended that Governors receive a full understanding of the issues and processes in place to resolve at either a future Council meeting or Governors training day. Page 4 of 15
Action: Governors to fully understand agency issues either at a future Council meeting or a Governors Training Day.
Graham Taylor was pleased to see indictors for specialist services in the report, in particular children and young peoples services, but questioned why these were not presented by CCG area and asked if a timescale has been set to reach 95% four week waiting time to assessment target.
Elizabeth Hall asked how much an agency nurse cost per week versus a permanent member of staff. Sally Flint confirmed on average agency staff costs 25% higher than permanent staff. Elizabeth asked whether permanent staff could be employed to work in various services as and when demand required. John advised this was an area of flexibility that is being explored.
Elizabeth asked why there is a delay on the completion of appraisals and thought this gave the wrong impression to staff. Sue Morris set out the focus given to regular supervision, and confirmed Sussex Partnership achieved slightly higher than the national target for completion of appraisals. The appraisal documentation is reviewed every year, and the Trust is aware it needs to improve the quality of appraisals and additional training is being put into place.
Rodney Ash asked why in East Sussex when you go for a consultation your next appointment is not given before leaving the building. Steve Malone advised this varies and does happen in some areas. Rodney was concerned this was starting to cause problems with people’s recovery.
Rodney referred to the figures relating to serious incidents and asked whether Sussex Partnership was any different from other mental health trusts. Helen Greatorex confirmed the Trust was very simular to others but its reporting is more proactive. Lorraine Reid advised Kent children and young people’s services had agreed with Commissioners to report as an SI any wait over 4 hours in the tier 4 service which has contibuted to the number being reported.
Rodney referred to liaison services response times and asked how many members of staff Sussex Partnership has providing this service to acute hospitals across Sussex. John advised the number would be circulated to Governors in due course.
Action: Circulate the number of staff providing liaison services into acute hospitals across Sussex.
Howard Pearce asked why no further appraisals had been completed since September. Sue Morris confirmed that appraisals should be completed between April and June, and the Trust wouldn’t expect an appraisal for the previous year to be completed in the last six months of the following year. Those who have not completed an appraisal by the end of June are followed up. Martin Jeremiah noted that the quality of an appraisal is harder to measure but more valuable. When Governors discussed the staff engagement report at their training day in March they questioned whether there are any quarterly measures that can be introduced for staff satisfaction. Sue Morris advised last year an audit was introduced on the quality of appraisals and this is due to be presented to the Audit Committee and can then be shared with Governors.
Action: Share the audit on the quality of appraisal questions with Governors.
Nic Allen noted the increase in sickness leads to an increase in agency which then reduces the time for managers to undertake appraisals. Nic asked whether the staff engagement report included any further detail to help address these issues. John confirmed the detail of the report is being considered very carefully. Sue advised there is range of information that can be shared with Governors and she would consider the best way to do this.
Jane Tatum was concerned about the introduction of 12 hour shifts and requested the Trust relook at this. Helen Greatorex advised that this is being reviewed and a report will be presented to the Board for further discussion on the best way forward. John confirmed the system was very varible, some staff like it whereas others don’t, and so a systematic review needs to be undertaken to see whether it is appropriate. Helen assured Governors the system was researched very carefully
Page 5 of 15 before it was implemented, and nationally it has shown to work very well in some orgnsations. Jane pointed out there was also evidence to suggest it doesn’t work well and John confirmed it would be reviewed from both a service and staff point for view.
CG17.3/14 Feedback from the Mental Health Act Committee Melloney Poole, Non Executive Director and Chair of the Mental Health Act Committee Melloney Poole gave the Council an overview of the specific areas looked at by the Mental Health Act Committee, how these related to the Trust Board and how they carry paramount importance for patients. Melloney described the duties of the Committee as set out in her paper. She advised it is the Board’s responsibility to ensure strong effective governance, and explained the role of Associate Hospital Managers (AHM). AHMs are trained and supported by the Mental Health Act Manager and Mental Health Act office. Sussex Partnership currently has 47 AHMs, 30 of who are active members, and the Trust is extremley grateful for their independent judgement. The AHMs elect members to attend the Mental Health Act Committee and participate in discussions on the working of the Act.
Melloney explained sections 2, 3 and 5 of the Mental Health Act and the process of patients’ hearings. Article 5 of the European Convention of Human Rights provides the right to liberty. For people detained under the Mental Health Act this is a limited right. Tribunals have the power to review all decisions to detain a person and, if the hospital is unable to provide sufficient evidence that the person should remain detained, their detention should be discharged.
In order to ensure a fair and independent hearing, a patient can generally appeal to one, or both, of two bodies: the Hospital Managers and the Mental Health Review Tribunal. In 2013, there were 224 Managers’ hearings held compared with 239 in 2012. 259 Tribunal hearings were held compared with 222 in 2012. The Tribunal made 21 discharges in 2013. The Mental Health Act Committee receives an extensive breakdown of these figures, and the Committee provides a summary to the Board after each meeting and an annual report once a year.
Jane Tatum asked how many patients have an advocate. Melloney advised the request for support was variable, and Jane understood the Trust can request an advocote on the patient’s behalf if they feel it is nessecary. Melloney confirmed ensuring patients are supported is hugely important.
CG17.4/14 Complaints Progress and Performance Update Helen Greatorex, Executive Director of Nursing and Quality
Helen Greatorex updated Governors on action CG03/14 and advised the Trust has an extensive number of policies, many of which are out of date. Richard Ford, Projects Director is working exlusively on policies to ensure they are up to date, easy to use in practice and easy to follow. Richard will also be making sure the renewal dates on each policy are not too short, as in the past the Trust has found it needs to continually update policies when it is not always needed. Helen anticpated this work would be completed by the end of May and the Governors will receive a further update in June.
Action: Governors to receive a verbal update on the review of out of date policies.
Helen went on to present the complaints report and was pleased to advise a new Complaints Manager is now in post, this is a brand new position to run alongside the 2 Complaint Case Managers who have a nursing background. A third case manager will be in post shortly. These appointments strengthen the complaints team considerably, and the main focus for the team is to ensure complaints are resolved in the first instance. Feedback so far on this approach has been very positive from both complainants and staff in services.
Rodney Ash agreed positive progress has been made in the Complaints Department, and once all new staff are in place he would arrange for each of them to visit Professional Standards. He would
Page 6 of 15 also be visiting the new team in Worthing. John Bacon thanked Rodney for his continued help and support with the new structure on handling complaints.
CG17.5/14 Patient Experience Quarterly Report Vincent Badu, Strategic Director of Social Care & Partnerships
Vincent Badu presented the report and welcomed Bryan Lynch, Deputy Director for Patient Experience who was sitting in the audience. The main focus of the report is on the Friends and Family Test, a national programme being rolled out to mental health trusts by January 2015. All service users will be asked on discharge and at regular intervals, whether they would recommend the Trust’s service to a friend or family members. Vincent felt this test was very positive and would provide very valuable information to help identify areas for improvement.
The planning for implementation is underway, and once national guidance has been issued in June the Trust will start to roll out the programme in an incremental way. The feedback received will be published for members of the public to view in the Trust monthly performance report presented to the Board. A simular test for staff commences this month.
Vincent gave an update on the 15 steps challenge that was implemented last year and explained that follow up visits are being undertaken across all wards and are due to be completed by the end of May. Vincent thanked Governors for particpating in a number of challenges. The feedback received from these visits has led to meaningful changes being made in services; the detail of these changes will be published on a ward by ward basis including key themes and actions taken.
Jane Tatum asked whether carer involvement is measured in the family and friends responses. Vincent Badu confirmed this was the case, and highlighted the triangulation of care work which had been discussed at the Council meeting in January.
Martin Jeremiah asked whether the feedback from the staff friends and family test can be reported back to the Governors quarterly. Vincent advised he would include information from the programme as part of the patient experience quarterly report; the Trust was looking at what performance framework would be used to monitor feedback.
John Bacoon advised the friends and family test for mental health services is under trial and suggested the Council were given time to understand how the scoring system works.
CG17.6/14 Update on Care Plan Audit Kay Macdonald, Clinincal Acadmic Director
Sally Flint presented the update on behalf of Kay Macdonald.
Sally reminded Governors that they were informed at the last meeting that the care plan audit was being reviewed and once completed a report would be presented; first to the Board of Directors before coming back to the Council of Governors meeting in June.
Action: CPA review to be presented at the Council of Governors meeting in June.
Karen Braysher referred to the minutes of the Council of Governors meeting in January 2014 and asked why patients were not being sent a copy of their notes and correspondence relating to their care as agreed by Kay Macdonald. Sally Flint advised she would take specific details from Karen, and follow this up. Rodney Ash confirmed he had received a personal copy of his correspondence recently. This practice seemed to be varible and the Trust needed to ensure it was happening as a matter of standard practice.
Giles Wright advised that he’d attended a service user focus group on care planning, where an interesting point was made from another attendee about how the recovery plan is spoken about to patients. For someone being diagnosed with mental health the recovery plan can be very scary
Page 7 of 15 prospect. Giles gave an example, as given at the focus group, of how someone with diabetites has the diagnosis and a contact in health service for life whereas a mental health diagnosis is for life but a recovery plan, which commonly involves getting back into work can seem threatening for many service users.
Karen Braysher disagreed and advised she was proof that someone with a mental health illness can return to work, and although she has a life enduring illness she has managed her illness in a way in which she can continue her professional career. Giles advised he wasn’t suggesting that people couldn’t work but he felt recovery plans can put unnecessary pressure on service users.
Jane Tatum noted there are people to specifically deal with employment for those with a mental health illness and look at ways of slowly progressing into the working environement. Steve Malone confirmed that Sussex Partnership have people in teams specifically to help and support service users back into work.
CG18/14 STRATEGY CG18.1/14 To receive an themed report on Specialist Services Lorraine Reid, Managing Director of Specialist Services
Lorraine Reid presented her paper and advised the way in which the pathway is commissioned is critical for the structure. Lorraine explained that CAMHS is commissioned through consortium arrangements with a lead clinical commissioning group in Kent & Medway and in Hampshire. In Sussex there are separate commissioning arrangements for East Sussex, Brighton & Hove and West Sussex.
As with any new contract, it can take up to 18 months or so for a new service model to be embedded. Particular pressures at the moment are on tier 4 services where commissioning responsibility moved from local commissioners to NHS England in April 2013. The current issues are subject to a national review. In Kent and Medway, reporting indicates there has been a significant increase in urgent and emergency referrals and this has had a significant impact on routine activity. Lorraine gave an example where 60 hours of input was needed for two urgent referrals, and explained the amount of routine activity that could have taken place within this time.
In spite of all the pressures, feedback from young people and their families has been very positive. In summary, Lorraine advised if Sussex Partnership were to tender for another service outside of Sussex they would take a different approach on staff consultation and implementation of new service models. The Trust would also look to build in a review process with Commissioners where progress could be reviewed after six months and then again after a year. There is growing competition in the provision of CAMHS and the Trust’s aim is to work closely with third sector partners and other agencies to ensure a more integrated care pathway across all providers, into and through all tiers of provision.
Lorraine noted she and Lisa Rodrigues had attended the Health Overview and Scrutiny Committee (HOSC) meeting on 11 April 2014 and the discussion of this meeting could be heard via a webcast available on Kent County Council’s website. Those at the meeting acknowledged the lessons learnt from dividing services, and attendees understood the need to have a more integrated approach, but this could only be achieved from integrated commissioning. Sussex Partnership is fortunate in Sussex as they currently provide tier 4 services; this makes it much easier to manage the care pathway. If this was the same in Kent & Medway and in Hampshire managing the care pathway would much easier.
John Bacon informed Governors that the Board has been concerned about access to tier 4 services outside of Sussex. A national review of this situation is being undertaken, and the Trust is waiting for the outcome of this review.
Rodney Ash asked whether taking on services outside of Sussex has caused concerns. John advised when taking on any major service there are envitably always issues, and the transistion Page 8 of 15 process can take up to 18 months. In this particular case taking on a service that was previously managed by a number of organisations has discovered some unpredicted issues. John reassured Governors that Sussex Partneship undertook a thorough due diligence process, but no matter how good the due diligence you can only see what is evidenced. There have been some issues in Kent that nobody knew about, and the learning from this mean that the Trust will ensure any future contracts have triggers for renegotation if issues come to light that were not identified. Rodney confirmed the contract he had worked on with another organisation had encountered similar problems, and the Trust was not alone.
Graham Taylor suggested when taking on future contracts the Trust should consider speaking to service users who may be able to identify issues and problems based on their own experiences of using the service. Graham acknowledged the Trust has worked hard to decrease waiting times, but he was concerned about the current waiting time to treatment and the inconsistency in times across the county. For example, the waiting time in Dartford is considerably more than other areas. Given it has been a difficult 18 months, Graham questioned when the Trust envisaged meeting standard targets. Lorraine advised during February 2014, Kent & Medway CAMHS went into business continuity and a more robust approach to demand and capacity management for routine referrals and treatment was put in place. The Trust is confident that targets will be delivered by August 2014. Graham acknowledged the improvements and recognised there is still work to do, and advised the Trust should try to promote their achievements more.
John reinforced this and reminded Governors that although there have been some issues to overcome, Sussex Partnership has made significant improvements to CAMHS in Kent and this should not be forgotten.
Tony Moore asked whether Sussex Partnership has had any dialogue with Greg Clark MP. Graham advised he had a meeting scheduled next week, and noted he’d heard Mr Clark on the radio suggesting a new provider for CAMHS in Kent. Lisa confirmed she has been in regular contact with Mr Clark. Lisa advised she had written to all 17 elected members of parliament in Kent setting out the facts on treatment times and the improvements that Sussex Partnership has implemented to overcome the problems that it inherited.
Jane Tatum asked for an explaination on market testing as referred to in the paper. John advised this term was used in the NHS for when a Commissioner wants to put a service out to tender and went on to explain the tender process.
The Governors were content to note the paper.
CG18.2/14 To receive an Update Report on Adult Mental Health Services Anna Lewis, Managing Director of Adult Mental Health Services
Lisa Rodrigues presented the report on behalf of Anna Lewis and advised the pressures in Adult Services had already been discussed in great detail and she had nothing further to add to the report.
The Council of Governors agreed to note the contents of the report.
CG18.3/14 Annual Business Plan Update Sally Flint, Executive Director of Finance and Performance
Sally Flint presented the Annual Plan for 2014-2016 and the Annual Budget for 2014/15 and highlighted the Governor’s involvement in the plan. Sam Allen reminded the Council about Monitor’s planning requirements. The Trust’s plan was submitted on 1 April, and an additional 5 year plan and sustainability statement needs to be submitted to Monitor by the end of June, which will require sign off from the Board.
Page 9 of 15
Sally confirmed the plan presented to the Council is based on the context of continued financial pressures, and a continue drive for providing high quality services. The sections of the plan have been aligned to those in the Trust’s new strategy published in June 2013 and Sally went on to highlight each section as detailed in the paper.
Sally gave an overview of the finances in the plan and explained the Trust had taken the decision to reduce the level of surplus to £1.2m with a contingency of £1.2m and deliver a more achievable £12.5m cost improvement programme.
Sally asked the Council to review and formally approve the Annual Plan for 2014-2016 and the Annual Budget for 2014/15.
Rodney Ash referred to page 15 and asked whether the Trust plans to replace the Department of Psychiatry. John Bacon advised this would form part of the detailed review and is being considered very carefully.
Karen Braysher referred to 3.2.2 and asked for a further explaination on the review of service provision on Caburn Ward at Mill View Hospital. Helen Greatorex explained that Caburn Ward is women only ward and will form part of the annual review. Karen asked when she would be able to see a copy of the review. Helen advised a report would be presented to the Quality Committee, and she would seek approval from the Committee that it can be shared. Lorraine noted that as a single sex unit, Caburn has impacted on bed pressures at times.
John Bacon asked the Council of Governors to vote on whether they were in favour of approving the Annual Plan for 2014-2016 and the Annual Budget for 2014/15.
Those in favour = 18 Those against = 0 Those abstained = 1
John confirmed the 5 year plan will be brought to the Council meeting in June.
Action: 5 Year Plan to be presented to the Council in June.
CG18.4/14 Staff Engagement and Staff Survey Results 2013 Sue Morris, Executive Director of Corporate Services
Sue Morris presented the report and explained that following The Survey Initiative report the Trust initiated the start of a change process in the organization; a two year programme that aims to engage with staff to change the culture of Sussex Partnership.
Appendix 4 refers to the improvement workplan, this has deliberately not been called an action plan as the Board wants to engage with staff and enable them to further contribute and develop the plan. The process has already started with discussions at leadership forums, board meetings and forums with staff. Sue read through the 5 headings of the improvement workplan as detailed in the paper.
Rodney Ash referred to section 6 in the report and asked whether the external data on benchmarking with other mental health trusts was available. Sue confirmed this information was available on the public website, and she would circulate a link to governors.
Action: Sue Morris to circulate a link to governors with the external data on benchmarking with other mental health trusts.
Martin Jeremiah advised that Governors had discussed The Survey Initative report in great detail at their training day, and observed the report was good at identifying problems but did not offer any solutions. Governors have thought through some possible solutions they would like the Board to consider and feedback. John confirmed he would take the governors ideas on solutions to the Board and formulate a response. Page 10 of 15
Action: John Bacon to take governors ideas on solutions to the findings of The Survey initiative report to the Board and provide a response.
The Governors were content to receive the report.
CG19/14 GOVERNANCE
CG19.1/14 The Board’s response to the Francis Report (Presentation) Helen Greatorex, Executive Director of Nursing & Quality Helen Greatorex introduced the item and gave a presentation on the Board’s response to the Francis Report.
The presentation gave Governors a reminder of the timetable and an outline of how the Trust has responded:
Reminder of the timeline The Board and Governors met for a Joint meeting in February 2013 to discuss the content of the report and its recommendations.
An outline of how we have responded The Board received a paper in January 2014 setting out all the 290 recommendations and highlighted 73 recommendations that applied specifically to Sussex Partnership. The paper detailed which Board Committee would monitor each action, and the Quality Committee agreed to oversee all actions made against each recommendation, which would then be subject to an internal audit to ensure the actions are robust.
Governors shaping our response Governors have played a big part in shaping the Board’s response. At the Joint Board and Council Day in February 2013, Howard Pearce made an observation about Sussex Partnership’s responses to complaints being very bureaucratic. Following this, a small working group was established and Rodney Ash joined the Quality Committee as a Governor representative. The Quality Committee met in December 2013 to discuss complaints as a single agenda item. Trust is grateful to Rodney for providing a route into seeing how Sussex Police effectively and efficiently deals with their complaints. A new structure and continued focus is being given to the Complaints Department and things are progressing well.
Next steps The Council of Governors will be provided with a quarterly update on complaints, and Rodney will continue to attend the Quality Committee and help shape the new complaints structure.
Helen advised a hard copy of the presentation had been made available to Governors before the meeting and would be available as part of the papers online.
Action: Load a copy of the presentation on the public website.
Rodney Ash advised an employee from Professional Standards would be happy to come and speak to Governors if this would be useful.
The Council of Governors were content to note the presentation
CG19.2/14 General Elections 2014 Peter Lee, Head of Corporate Governance
Peter Lee presented the paper and advised the general election this summer would consist of 16 elected positions and 5 appointed positions. Work is underway on various methods of
Page 11 of 15 communication to ensure the election is well advertised. The Council is currently running at 7 vacancies and the hope is that each constituency will be contested, so the Council will be running at full strength.
John Bacon asked Governors to stimulate members’ interest and encourage them to stand.
CG19.3/14 Register of Declaration of Interests 2013/14 Peter Lee, Head of Corporate Governance
Peter Lee presented the report and reminded Governors that some forms are awaited and these should be completed and returned as soon as possible.
The Council of Governors agreed to note the register for information and to inform the Corporate Governance Business Manager of any changes to the register as soon as these arise.
CG20/14 REPORT BACK FROM SUB COMMITTEES CG20.1/14 Governors Activities Martin Jeremiah, Lead Governor
Martin Jeremiah presented the report and advised the Task and Finish Groups that were set up earlier in the year have adopted the Health and Social Care Act recommendations and driven significant change on compliance. The Training and Development Task and Finish Group have developed a Code of Conduct that Governors were asked to approve. Martin noted the group was grateful to Peter Lee, Head of Corporate Governance for reviewing the Code of Conduct from a compliance perspective.
John Bacon asked the Council of Governors to vote on whether they were in favour of approving the Governors Code of Conduct
Those in favour = 18 Those against = 0 Those abstained = 1
CG20.2/14 Nomination and Remuneration Committee John Bacon, Chair
John Bacon presented the paper and reminded Governors that he is Chair of the Nomination and Remuneration Committee. At their last meeting on 27 February 2014 the Committee reviewed and amended its terms of reference and agreed the appraisal process for the Chair and Non Executive Directors. Other items discussed by the Committee would form part of the Council’s private meeting today.
Governors agreed to approve the Nomination and Remuneration Committee’s amended terms of reference.
John outlined the appraisal process and reminded Governors that it is the Council responsibility to receive and agree the Chair and Non Executive Directors appraisals at their meeting in June. The new process enables Governors to give feedback on the Chair and Non Executive Directors, and the points raised will be summarised by the Lead Governor. Martin Jeremiah confirmed a summary of the feedback received has been shared with the Nomination and Remuneration members over the weekend, and they will also have the opportunity to further discuss this with him before the appraisals take place. Martin noted that Governors’ understanding of the Non Executive Directors’ role has evolved over the last year and so it is very positive, for the first year, they have had the opportunity to comment on their performance
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CG20.2/14 Membership Committee Karen Braysher, Interim Chair of the Membership Committee
Karen Braysher presented the report and advised that sadly Sue Taylor had resigned as a Governor a few months ago and she had taken on interim chairmanship of the Membership Committee until the end of July. Karen went on to advise that the Committee met on 20 March 2014, and the meeting, as always, was well supported by Governors. The Committee discussed the two forthcoming Members Meetings taking place on 24 April in West Sussex and 20 May in East Sussex, and asked her fellow Governors for their help at these meetings. Continued focus was also given to the Membership Strategy, which will be presented to the Council in June.
Action: Membership Development Strategy to be presented at the June Council meeting.
The Committee has also spent considerable time changing the format of Membership Matters and is now seeking suggestions and ideas for content from members themselves in order to further develop and ensure it is user friendly. Karen noted she had attended the Proud to Care Awards with the Chief Executive and will be writing an article on the event for the next edition of the magazine.
Karen advised the number of Foundation Trust members has increased to 13,705.
Karen felt strongly that the freedom of choice for patients wishing to use designated smoking areas was being taken away. Karen then handed over to Martin Jeremiah, Lead Governor to talk through the detail. Martin advised that Governors had discusseed this matter at their pre-meeting and, after a vote, felt strongly that they want to support patients’ right to smoke in designated areas. Cliff Buckland highlighted the role of Governors was to support the views of their members and the conclusion of the pre-meeting showed a fair representation of support for allowing patients the choice to smoke in designated areas. Karen had prepared some literature on the subject. John thanked Karen for alerting members to this issue of great concern and advised he would investigate and carefully consider this matter, and update Governors at their next meeting.
Action: To update Governors on the smoking review programme at the Council meeting in June.
Elizabeth Hall shared her attendance at an FTGA event in March where the Chair of University Hospitals Birmingham NHS Foundation Trust gave a talk on membership. Every patient there who has been treated by the Trust is autmoatically enrolled into their Foundation Trust programme, and new members of staff joining the Trust are also automatically enrolled. The Chair advised the advantage of having a large number of members meant that at the time of an election there are at least 1000 members voting in each constituency. John confirmed that Peter Lee would liaise with Elizabeth on this matter in prepartion for the forthcoming general election.
Action: Peter Lee and Elizabeth Hall to discuss the talk at the FTGA event taking into consideration the forthcoming elections.
Elizabeth went on to advise there would be a membership stool at the Shoreham Health and Wellbeing Day on 14 June 2014, and asked for volunteers from her fellow Governor to help rn the stool.
The Council of Governors agreed to note the report.
CG21/14 Questions or comments from members of the Public (Chair to be notified in advance of this meeting) Peter Lee confirmed that the answers to questions 1-3, received from a member of public in advance of the meeting, were provided by Rachael Duke, Fundraising Manager, and then read out each question in turn, followed by the answer;
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Question 1 Why are Members and service users being encouraged to support the Bike Ride through sponsorship and gifts in kind i.e. donations of cakes? This request - on the website and Membership Matters - is at odds with the Big Conversation video which is also on your website.
Answer We are encouraging the general public as a whole, including members and service users, to support the bike ride as volunteers as it is a charitable event that will raise monies to establish a charitable fund that will support the physical wellbeing of our patients and service users. This fund is part of the charity, Sussex Partnership NHS Trust Charity (Reg. Charity No 1051736) rather than the Trust. The Bike Ride is largely dependent on volunteers for its success and so far our volunteers are a mixture of individuals with a link to the Trust, including members and staff, and those who have no link and are just members of the public.
The Big Conversation deals with professional boundaries in respect of the therapeutic relationships patients have with the Trust’s staff but doesn’t give guidance on any donations a patient may wish to make to the Sussex Partnership NHS Trust Charity.
Question 2 Could you please clarify why the Trust is now asking for patients to support the Bike Ride - again in the website and Membership Matters - by offering massages to staff? Could you please explain the reasons why service-users and Members, some of whom are children, are being asked to get 'hands-on, touchy-feely' with yourselves?
Answer Our request for volunteers is to the general public as a whole and includes members and service users if they wished to get involved. Volunteers are sought in a variety of capacities including cake bakers, marshals, vehicle support, bike mechanics and massage therapists. It is common for sporting fundraising challenges to recruit volunteer sports therapists and massage therapists to offer treatments to participants at the end of the event. Volunteers in this capacity would need to be adult professionals working in this field with relevant experience. For any Charitable Funds event we would always be careful to make sure that volunteers were placed in an appropriate role that they felt able to undertake. All volunteers for the Cycling Challenge must be aged 16 and over.
We have not used the phrase ‘hands-on, touchy feely’ in any publicity documentation.
Question 3 Given that Members and service users cannot make donations in money or in kind, and that SPT has to be 'careful', could you clarify how a Fund Raiser can raise funds when these avenues are forbidden?
Answer Members and service users can make donations of cash or in-kind support to Sussex Partnership NHS Trust Charity and the Charity has a long history of this kind of support. However, it would not be appropriate for members or service users to make donations to individual members of staff and these would be refused.
Question 4 Given that the Trust spends £650 on hiring the Amex (plus £8pp for Lunch) and £10180 publishing material such as Making Breakthroughs Together with the glamour photos ("which no one wants" - staff survey) and printing and sending out Christmas Cards is there a need to also look at how money is currently being spent?
Answer Peter Lee explained that Sussex Partnership continually reviews how it uses its resources.
A member of public in the audience referred to action CG05.3/14 and asked why Rachael Duke was
Page 14 of 15 not at the meeting presenting her vision and plan to the Council. Martin Jeremiah confirmed the point he made earlier, when he explained that Rachael had presented her plan at the Governors Training Day due to the pressures on today’s agenda. Martin went on to advise alternative venues had been investigated for the Council of Governors meeting, but due to ease of transport and access Governors had requested to continue using the American Express Stadium. Martin also confirmed that as volunteers it is standard that refreshments and lunch are provided.
CG22/14 Any Other Business
Andy Winter suggested questions from members of the public were brought forward and taken at the beginning of the agenda.
Andy noted some Governors are restricted on the number of meetings they are able to attend, and was disappointed that action CG05.3/14 was completed at the recent Governors Training Day as he was not able to be present. As such, Andy requested that Rachael Duke was invited to the June Council meeting to present her vision and fundraising plan. John explained due to todays agenda being very busy, Governors had decided to take this action forward as part of the Training Day, but recognised not all Governors were able to attend and therefore confirmed Rachael would be invited to the next Council of Governors meeting in June.
Action: Invite Rachael Duke to present her vision and fundraising plan to the June Council of Governors meeting.
Paul Burris advised he was a presenter on the Hospital Radio station at the Princess Royal Hospital and welcomed advertising any Trust news or events during his show.
Diana Byrne thanked Diana Marsland, Non Executive Director for having an open discussion with service users and staff when she visited Cavendish House recently. John explained that Board members now have a system and process in place for ensuring regular visits to services across all sites and care groups. John suggested bringing a summary of scheduled visits to future Council meetings.
Action: To add a regular item for Governors to receive a summary of Board site visits. CG23/14 Date of next meeting Monday 16 June 2014 11.00 - 13.30 Overline Lounge at the American Express Community Stadium, Village Way, Brighton, BN1 9BL CG24/14 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). The meeting closed.
……………………………………………………………………………. John Bacon, Chair, Sussex Partnership NHS Foundation Trust
NB Those present at the meeting should be aware that their name will be published in the notes of this meeting which may be released to members of the public on request.
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Sussex Partnership NHS Foundation Trust Council of Governors: 16 June 2014 - Public Agenda Item: CG27/14 Attachment: A For: Information By: Natalie Hennings, Corporate Governance Business Manager
MATTERS ARISING: ACTION POINTS FROM THE COUNCIL OF GOVERNORS MEETING HELD IN PUBLIC ON 14 APRIL 2014
Date of Action or Min. No. Action Points from previous meeting Lead Action Taken Action Agenda Item
14.04.14 Action CG17.1/14 Invite Commissioners to future Council meetings Peter Lee To follow up
14.04.14 Action CG17.2/14 Governors to fully understand agency issues either at a Sue Esser Sue Esser gave a presentation at future Council meeting or a Governors Training Day the Governor Training Day in May.
14.04.14 Action CG17.2/14 Circulate the number of staff providing liaison services Peter Lee Email from Peter Lee sent to all into acute hospitals across Sussex Governors on 03 June 2014 14.04.14 Action CG17.2/14 Share the audit on the quality of appraisal questions Sue Morris To be circulated before the meeting with Governors 14.04.14 Action CG17.4/14 Governors to receive a verbal update on the review of Helen Greatorex Update to be given under CG27/14 out of date policies at the June Council meeting 14.04.14 Action CG17.6/14 CPA review to be presented at the Council of Kay Macdonald Added to the June agenda Governors meeting in June
14.04.14 Action CG18.3/14 5 Year Plan to be presented to the Council in June Sally Flint/ Sam Added to the June agenda Allen
14.04.14 Action CG18.4/14 Circulate a link to governors with the external data on Sue Morris To follow up benchmarking with other mental health trusts
14.04.14 Action CG18.4/14 John Bacon to ensure governors’ ideas on solutions to John Bacon Added to June agenda the findings of The Survey initiative report are considered by the Board and update the Council
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Date of Action or Min. No. Action Points from previous meeting Lead Action Taken Action Agenda Item
14.04.14 Action CG19.1/14 Load a copy of the presentation on the public website Natalie Hennings Completed
14.04.14 Action CG20.2/14 Membership Development Strategy to be presented at Vincent Badu Added to the June agenda the June Council meeting
14.04.14 Action CG20.2/14 To update Governors on the smoking review Sue Morris Added to the June agenda programme at the Council meeting in June
14.04.14 Action CG20.2/14 Peter Lee and Elizabeth Hall to discuss the talk at the Peter Lee Discussed on 7 May 2014 FTGA event taking into consideration the forthcoming elections
14.04.14 Action CG22/14 Invite Rachael Duke to present her vision and Natalie Hennings Added to the June agenda fundraising plan to the June Council of Governors meeting
14.04.14 Action CG22/14 To add a regular item for Governors to receive a Peter Lee To follow up summary of Board site visits
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CHIEF EXECUTIVE REPORT Council of Governors meeting 16 June 2014 By: Lisa Rodrigues, Chief Executive Agenda Item: CG28.1/14
1. Introduction
This is my regular Chief Executive report to the Council of Governors. It aims to provide some context to the work of Sussex Partnership, and a brief résumé of issues we have been managing since the Council last met in April. As always, I am happy to discuss it with members of the council at the meeting, and to answer questions or arrange for other directors to do so at the meeting or afterwards.
2. Context
At the last three Council meetings there has been considerable discussion about the increasing pressures on the majority of our services, so this does tend to be at the centre of everything we are doing currently. The pressures are most acute in our adult mental health services in Sussex, and children and young people services across the three localities in Sussex and in Medway, Kent and Hampshire.
The Board of Directors and its Committees have been working with senior clinical and managerial leaders to get the right balance between the need to make better use of resources, and ensuring we maintain focus on our longer term strategic priorities. Only in doing both will be able to assure ourselves and support our staff to provide safe and effective care. Therefore, our three main priorities are currently;
1. Ensuring people who need to be in hospital are admitted to their local hospital and stay there only for as long as they need to. We have a number of activities underway in each of our localities with our partners in other parts of the NHS, justice agencies, local authorities and third sector organisations. We want to make sure that hospital is not used as a backstop because better alternatives haven’t been developed in the community, or if they have, are not properly resourced or it is complicated for our staff to access them for patients. 2. Reducing demand on temporary staff by speedily filling posts that need to be filled, and having an effective bank of our own staff so we don't have to rely on expensive agency. The less we use agency staff, the better for patients because it improves continuity and, if we don't spend money on fees, we can pay for more clinical staff. 3. Continuing with our service redesign and transformation programme. We want all our patients to receive care from the right clinician, in the right place and at the right time, based on the best evidence, with compassion and in ways that promote independence, recovery and choice. Although we achieve this most of the time, we have more to do to improve effectiveness and efficiency. We are committed to a cycle of continuous improvement in all our services.
A couple of months have now passed since Council members began observing each Board Committee and the part of our Board meeting which is held in private. I feel confident that this increased transparency will prove increasingly valuable to all concerned.
I know the Council is keen to explore progress being made, particularly against the priorities I mention, and during the meeting members will have opportunity to hear about what has been done since April and the expectations for the next part of the year. In my weekly messages, I have mentioned the booklets Our Year Ahead 2014/15 which précis our business plan and we have given to all our staff. We will have copies available for governors to take away at the meeting.
Page 1 of 2 3. Key issues since the Council last met
Shortly after the last Council meeting it was announced that we are to be part of a ground-breaking new approach to providing holistic assessment and treatment for people with any kind of bone, joint or muscular problem requiring referral from a GP in the Brighton and Hove, Mid Sussex, Horsham and Crawley areas. The Sussex MSK Partnership includes Brighton Integrated Care Service (BICS), Horder Healthcare, Sussex Community NHS Trust and Sussex Partnership, working closely with Rheumatoid Arthritis UK and acute providers Brighton and Sussex University Hospitals NHS Trust and Surrey and Sussex Healthcare NHS Trust. This is an extraordinary opportunity, as for the first time, mental health and wellbeing will be fully integrated with physical health services. The new service will start in October 2014. The agencies involved are all currently working together to agree the fine details which will set out exactly how this partnership will work; a decision paper will go to each of our Boards later in June. In the meantime, we can share with the Council the broad vision and role Sussex Partnership has in the Sussex MSK Partnership, which Sam Allen covers in her paper. We could not be more pleased to be playing our part in this partnership, recognising that so many problems with pain, particularly back pain, have a major psychological component.
In May we decided to agree to talk to national media about pressures in adult mental health services. They were going to run a story about patients being sent hundreds of miles away, based on responses to FOI requests to all 58 mental health trusts. We felt we had a duty to explain that the story should be about people who are mentally ill and the hardships they are facing, including stigma, rather than beds. Our "bed problem" isn't really about beds, it is about making sure patients receive the right help at the right time to stay at home, and that those who need admission don't stay in hospital any longer than they need, because doing so is proven to be detrimental to recovery.
To help with this issue we met our commissioners at the beginning of last month. We provided them with details of all the patients who are ready for discharge but who either have no home, no suitable care package to enable them to go home safely or need somewhere else to go that is more suitable than an acute mental hospital. If all the people who were ready to leave were able to go, we would be back to having a small number of empty beds and our immediate problems and the human misery for the people affected would be over. Our commissioners acknowledged the point and have shown their commitment to working alongside us to improve the situation. We will give an update at the meeting.
The Council heard in April about the CQC inspection of Langley Green Hospital. Anna Lewis’ paper outlines the continued focus being given to support Langley Green and the associated community services in northern West Sussex, where we have a high number of long term staff vacancies and a relatively new, committed leadership team. At the same time, the CQC also inspected the Selden Centre, in Worthing. If you want the antidote to Winterbourne View, this is it. The compassion and expertise of staff as they care for challenging but also extremely vulnerable patients is a source of pride and joy to us. This good news story was completely overshadowed by the story about Langley Green Hospital, and serves to prove the point that, because bad news travels faster and tends to be remembered longer than good news; we all need to talk more about the many positive stories about our services and the people who use them.
It is with sadness but also anticipation about my new life beyond Sussex partnership that I remind you that this will be my last Council meeting. I am leaving at a time when there are many challenges ahead for Sussex Partnership, but we are a strong organisation and we are very well placed to meet them. Colm Donaghy will be starting next month, and our handover will take place during the week of 7 July 2014. I am sure the Council will offer Colm a warm welcome and will support and challenge him, as they have me, to lead Sussex Partnership to become an even better provider of health care services in the coming years.
I would like to take this opportunity to thank members of the Council for the commitment and passion you show for the services Sussex Partnership provides. It has been my honour to work with you all.
4. Recommendation
Governors are invited to note the contents of my report and ask any questions arising from it.
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COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title Agenda Item: CG28.2/14 Attachment: C Finance and Performance Report Author Sally Flint, Executive Director of Finance and Performance Section Performance Presented by Sally Flint, Executive Director of Finance and Performance
Purpose This report provides the Council of Governors with a summary of the Trust’s financial performance and progress being made in delivering its regulatory and contractual performance indicators for month 1 of the new financial year.
Paper Summary The financial position for Month 1 is indicative of the significant financial challenge facing the Trust in 2014/15. The Trust is reporting a deficit of £961k against a breakeven plan for the first month of the new financial year. Given the financial pressures reported in March it is disappointing, but inevitable that the Trust’s performance is considerably under plan in April. Despite of the Trust’s strong cash position, the deficit in the month has meant that Trust’s Continuity of Services Risk Rating has dropped to a 3, against a planned rating of 4.
Based on the performance in April the executive team are fully engaged with the business continuity and financial recovery plan to give ensure that the Trust delivers its financial plan for 2014/15.
The Trust continues to make good progress on meetings its regulatory, contractual and other performance indicators.
Specific points for The areas of concern contributing to the financial position continue to be those Governors to note that challenged the Trust throughout last year, these being expenditure on agency staff, the pressure on adult in-patient beds and resulting cost of external placements and delivery of cost improvement plans, which are all contributing to significant overspending particularly across the adult service divisions.
It should be noted that from the new financial year the format of the performance dashboards have been revised in order to provide a Trust wide performance dashboard and separate dashboards for Adult and Specialist Services.
Points for discussion The Council of Governors is asked to discuss the Trust’s performance. at meeting
Recommendation The Council of Governors is asked to note the finance and performance report for Month 1 and the actions the Trust is taking in developing and implementing a financial recovery plan as a matter of urgency to ensure that the Trust delivers its financial plan in 2014/15.
Sussex Partnership NHS Foundation Trust Council of Governors: 16 June 2014 - Public Agenda Item: CG28.2/14 Attachment: C For Information By: Sally Flint, Executive Director of Finance and Performance
FINANCE & PERFORMANCE REPORT
1.0 PURPOSE AND RECOMMENDATION
1.1 The Council of Governors is asked to note the finance and performance report.
2.0 INTRODUCTION
2.1 This report summarises the financial and performance position of Sussex Partnership for Month 1 of the new financial year, 2014/15.
3.0 FINANCE
3.1 The financial position for Month 1 is indicative of the significant financial challenge facing the Trust in 2014/15. The Trust is reporting a deficit of £961k against a breakeven plan for the first month of the new financial year. Given the financial pressures reported in March it is disappointing, but inevitable that the Trust’s performance is considerably under plan in April. Despite of the Trust’s strong cash position, the deficit in the month has meant that Trust’s Continuity of Services Risk Rating has dropped to a 3, against a planned rating of 4.
3.2 The areas of concern contributing to the financial position continue to be those that challenged the Trust throughout last year, these being expenditure on agency staff, the pressure on adult in-patient beds and resulting cost of external placements and delivery of cost improvement plans, which are all contributing to the significant overspending particularly across the adult service divisions. These issues, together with details of the overall financial position are set out in the section below.
3.3 Income – in the month income was £95k under plan. The main under performance was on cost per case income, with underperformance in both the Nursing Home and Selden Centre. However, it is pleasing to report a significant improvement in Substance Misuse Services, with activity in Promenade Ward being in line with plan.
3.4 Pay budgets – overall pay expenditure was overspent in the month by £369k. Expenditure in the month totalled £15,443k compared to £15,121k in March. However, the Trust made good progress in reducing agency spend in April with agency costs decreased in the month to £766k (Month 12, £1,029k). This was against a forecast spend for the month of £810k, with medical agency usage being £15k high than forecast, however non-medical agency was £59k under forecast, which is a significant improvement on previous months.
3.5 Significant attention is being given to reduce the level of agency usage both from a financial and quality aspect. The actions that are being undertaken include:-
Regular meetings are being held between the in-patients units, finance and HR, which in future will be supported by an executive director The in-patient nursing establishments and rosters are under review A new policy for observations is being piloted in Chichester and Woodlands. Work also continues to fill all current in-patient vacancies and to recruit to the in- house bank.
3.6 The cost of bank staff also reduced in the month to £1,087k (Month 12, £1,195k), which equates to 476 wte. The bank fill rate increased in the month to an average of 137% (Month 12: 109%), with a number of areas using temporary staff was in excess of 100% of the number of vacancies. Work is on-going to review this over establishment which in the main is being used to cover observations.
3.7 At the end of April there was an improvement in the level of vacancies being reported, which reduced to 347 wte (Month 12: 417) and substantive posts were underspent by £1,484k in the month (Month 12 £1,664k).Of these vacancies 288wte are due to be recruited to, with 56 posts out to advertisement, 165 awaiting shortlisting or the outcome of an interview, 5 people were waiting to start in post and 62 posts were at the pre- advertisement stage.
3.8 Non-pay budgets – overall in the month non-pay was overspent by £457k. Expenditure in the month totalled £3,559k compared to £3,648k in March. The reasons for the overspend were the use of external placements £199k, the overspent on the cost of properties for the Kent Children’s and Young People’s Service (£75k) and slippage on cost improvements plans for non-pay (£75k). The Trust is continuing to operate a Gold Command approach to managing the issues around the pressure on adult in-patient beds and has set a target of having no external placements by the end of May. In addition full analysis of non-pay expenditure is being undertaken as part of the financial recovery plan and controls are being enhanced around the requisition of goods and services.
3.9 In terms of operational performance, Operational Services were over spent by £721k in the month (Month 12: £988k), with Adult Services accounting for £527k (Month 12 £861k) of the overspend. Corporate Services were overspent by £218k in the month (Month 12: £293k), as a result of the overspend in estates and facilities, mainly due to the slippage of cost improvement plans.
3.10 Cost Improvement Plan - Overall in the month £252k was saved against a target of £752k, which is £499k less than planned. Work is continuing in all of these areas to address the shortfalls and the Finance & Investment Committee will be undertaking a themed review of cost improvement plans on a monthly basis.
3.11 Details of income and expenditure and the financial risk rating for Month 1 are shown in the performance dashboard attached to this paper.
4.0 PERFORMANCE
4.1 This section of the report details the Trust’s performance in relation to an agreed set of key performance indicators, including indicators mandated by Monitor, contractual indicators and other indicators relating to quality, people and performance. The reports have been also developed to include a summary of how the Trust performs against key quality indicators in each Clinical Commissioning Group (CCG) area. It should be noted that from the new financial year the format of the Performance dashboards have been revised in order to provide the following:-
A Trust wide performance dashboard covering Quality, Finance and People indicators that are appropriate to report for the Trust as a whole.
An Adult Services performance dashboard covering the performance of the Adult Services directorate.
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 Intermediate Care Services
4.2 TRUST WIDE DASHBAORD
4.2.1 Monitor Indicators - The Trust has achieved the following indicators in April: Delayed Transfers of Care, 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).
4.2.2 7 day follow ups - 94% of patients discharged from acute psychiatric wards were followed up within 7 days in April. This equates to 249 patients followed up in the month. The circumstances for the 15 patients who are reported as not being followed up are being reviewed by the Adult Community teams to ensure that lessons are learnt where possible.
4.2.3 Patient Experience: Recording patient experience feedback -- The Trust uses a combination of questionnaires in adult mental health services and service specific postcards within other services to record patient satisfaction feedback. The postcards include questions related to the Better by Experience values. The questionnaires are related to themes identified from the Care Quality Commission (CQC) National Patient Survey and the NICE guidance for service user experience in mental health. Health in Mind is not included in these figures as they use patient experience questionnaires as part of the Improving Access to Psychological Therapies data collection. In April, 86% of the feedback was positive.
4.2.4 Patient Experience, Complaints - 60 new complaints were received in April.
All complaints are taken extremely seriously. They must be fully investigated with care and consideration and the findings reported to the complainant.
There is a clear correlation between satisfaction and responsiveness and the Trust has taken the decision that complaints must be responded to within 25 working days, or within a different agreed timeframe when the complaint is particularly complex. The target is 85% of all complaints are responded to within 25 working days or different agreed timeframe.
Although performance in April has improved, it is anticipated that with the new Complaints and PALS Manager now in post, and the recent appointment of our third Case Manager, previous improvements will be regained and further improvements shown from Quarter 2.
4.2.5 People, Time to Hire: The average time to hire in the Trust was 16.8 weeks in April. This is an improvement on the previously agreed target of 17.6 weeks.
4.2.6 People, Sickness Absence: The sickness absence rate for March 2014 was 3.97%, which compares to 4.25 in February. This is the lowest the rate has been since May 2013. Over the last 12 months the top two reasons for absence continue to be stress/anxiety and muscular-skeletal conditions. In the month, ten of our fifteen services reported a decrease in sickness levels compared to the previous month. However, ten services are still reporting sickness levels in excess of our 3.5% target, of which three areas, namely the Nursing Home, Prison Services and Secure and Forensic Services have sickness rates in excess of 6%. These services continue to be supported by HR to provide additional support and monthly sickness surgeries. Detailed action plans are reviewed routinely at all management meetings and individual case monitoring between HR Business Managers and appropriate operational managers. Detailed reports are available for all managers to support improvements required.
4.2.7 People, Agency Spend: Total agency spend now equates to 5.0% of the total month's pay bill compared to 6.8% in the previous month. Projections for reducing agency spend are in place for each service with ratification at Performance review days. Detailed analysis of individual service issues associated with plans together with intense activity to speed recruitment into posts. Recovery plans have been scrutinised by the People Committee.
4.2.8 Data Quality: The Trust has achieved the Monitor data quality indicators relating to the completeness of key fields and the completeness of information relating to key outcome measures. This section will be developed in future months to include data quality metrics which are relevant in ensuring the quality of patient care is measured and reported accurately and also to ensure the quality of information held in Trust clinical systems is accurate prior to the replacement of the systems in 2014/15.
4.3 SPECIALIST SERVICES PERFORMANCE DASHBOARD
4.3.1 Safety, Serious Incidents: No grade 2 Serious Incidents (SI) were reported during April in Specialist Services. (Grade 2 is the most serious category). From April last year trusts were obliged to report Grade 1 incidents in addition. There were 3 grade 1 incidents reported in Specialist Services in April.
4.3.2 Effectiveness, Urgent Referrals: 100% of urgent referrals were seen within the required contractual timeframe in Sussex, Hampshire and Kent & Medway in April.
4.3.3 Waiting times to assessment, Sussex: 99% of patients in CAMHS and Learning Disability services were assessed within 4 weeks in Sussex.
4.3.4 Waiting times to assessment, Hampshire: In month assessment appointments continue within 12 weeks of referral with 100% of referrals (excluding ASC) seen being offered appointments within 12 weeks and 84% being seen within 8 weeks. Additional funding has been provided by Commissioners in Hampshire for 2014/15, which will increase the capacity of teams to improve waiting times response rates.
4.3.5 Waiting times to assessment, Kent & Medway: A business continuity plan has been agreed with Commissioners which includes improving the waiting times for children and adolescents in this area. The service is ahead of the targets that were agreed within this plan in January. The number of patients waiting for treatment has reduced by 45% since the plan was agreed. This is a reduction from 1087 to 598 against a target of 748 at the end of April. The waiting list for assessment has been reduced by 93 patients over the same period, over which time the service has received an additional 2,703 referrals. 4.3.6 Effectiveness Average Length of stay (CAMHS): The average length of stay for patients accommodated in Sussex Partnerships facilities at Chalkhill was 64 days for patients discharged in Q4 2013/14. 4.3.7 Effectiveness Prison Transfer: Access to Mental Health Services for adult patients – transfer times from prison: Transfer times from prison to the mental health bed for individuals under section 7/48 of the Mental Health Act should be no more than 14 days from the date that the transfer warrant was issued by the Ministry of Justice (MOJ). Two prisoners were transferred in April, both within the 14 day target. 4.3.8 Patient Experience – Long Term Service Users, Sussex CAMHS: The Trust offers rapid re-assessments to patients who have received services from the Trust within the last two years. In April all of the patients referred for reassessment were assessed within the target of 7 days. 4.3.9 Activity and Data Quality: This section is being developed to describe the service activity. This will include referral numbers, bed days and community contact activity as well as the development of data quality metrics which is likely to include duplicate referrals. 4.4 ADULT SERVICES PERFORMANCE DASHBOARD 4.4.1 Safety, Serious Incidents: One grade 2 Serious Incident (SI) was reported during April in Adult Services. (Grade 2 is the most serious category). From April last year Trusts were obliged to report Grade 1 incidents in addition. There were 13 grade 1 incidents reported in Adult Services in April.
4.4.2 Effectiveness, Gatekeeping of Admissions: In April there were 191 admissions to Trust psychiatric acute inpatient services. All of these admissions were gate-kept by the Crisis & Home Treatment teams prior to admission. In gatekeeping patients, these teams look to provide home treatment whenever possible to avoid unnecessary acute admissions.
4.4.3 Effectiveness, 4 hour response to urgent referrals: 99% of urgent referrals meeting the required definition were responded to within 4 hours in April.
4.4.4 Effectiveness, 5 working days to priority assessment: 40 priority referrals were received in Brighton & Hove during April. 75% of these were seen within 5 working days in April.
4.4.5 Effectiveness, 4 weeks waiting time to assessment: In Sussex Adults services, 95% of referrals received were assessed within 4 weeks during April. In the month, 1,167 assessments were carried out.
4.4.6 Effectiveness, Liaison services response rates: Sussex Partnership provides Mental Health Psychiatric Liaison services in Acute Hospitals across Sussex. The Trust plans to respond within 2 hours to emergency referrals and 24 hours to urgent referrals. 98% of emergency referrals and 100% of urgent referrals met the targets in April.
4.4.7 Effectiveness, Length of stay. The report shows that there has been an increase in Q4 2013/14 of the average length of time a patient stays admitted during an acute episode. An increased length of stay is one of the key factors that impacts on the demand for psychiatric inpatient beds in Sussex. An Acute inpatient work-stream is looking at the reasons for increases in length of stay, including delayed transfers of care, and is working with key stakeholders to ensure unnecessary delays are avoided.
4.4.8 Effectiveness, Emergency Readmissions: This report shows that 13.6% of discharges were re-admitted within 28 days of discharge. The reasons for these readmissions are also being reviewed by the acute inpatient work-stream described above.
4.4.9 Patient Experience, Delayed Transfers of Care: 4.2% of applicable adult bed days and 3.4% of applicable beds days Trust wide were delayed in April. 13 patients were delayed in adult services. Details of patients who have a delayed transfer of care are being shared with Trust Commissioners to ensure any blockages are resolved in a timely manner.
4.4.10 Rapid Reassessment of long term service users: The Trust offers rapid re- assessments to patients who have received services from the Trust within the last two years. 90% of the assessments carried out in April happened within 7 days. (There were 202 people who met the criteria in the month). A multi-disciplinary team is reviewing the construct of this indicator in light of the introduction of the 5 day priority access target to ensure that it is still effective in its current form.
4.4.11 Payment By Results (PbR) Reassessments: The Trust is preparing for the introduction of Payment by Results for Mental Health, which also forms a significant CQUIN (Commissioning for Quality and Innovation) scheme for the Trust in 2013/14. The Trust is working towards an internal target of 95% of patients having their needs reassessed according to the cluster specific timeframes by the end of the financial year. At the end of March, 85% of adult patients had received a PbR reassessment within the required timeframe.
Through the CQUIN mechanism, lead clinicians across Sussex Partnership have defined optimal treatment pathways for patients in each PBR cluster. In 2014/15 the Trust will continuing to focus attention on the implementation of Payment by Results. This will include the implementation of cluster treatment pathways. The Trust will continue contractually in 2014/15 in shadow format, with a plan to operate actual PBR in an agreed form during 2015/16.
5. SUMMARY AND CONCLUSION
5.1 The financial position for Month 1 is indicative of the significant financial challenge facing the Trust in 2014/15. The Trust is reporting a deficit of £957k against a breakeven plan for the first month of the new financial year. Given the financial pressures reported in March it is disappointing, but inevitable that the Trust’s performance is considerably under plan. Despite of the Trust’s strong cash position, the deficit in the month has meant that Trust’s Continuity of Services Risk Rating has dropped to a 3, against a planned rating of 4.
5.2 The areas of concern contributing to the financial position continue to be those that challenged the Trust throughout last year, these being expenditure on agency staff, the pressure on adult in-patient beds and resulting cost of external placements and delivery of cost improvement plans, which are all contributing to significant overspending particularly across the adult service divisions.
5.3 Based on the performance in April the executive team are fully engaged with the business continuity and financial recovery plan to give ensure that the Trust delivers its financial plan for 2014/15.
5.4 The Trust continues to make good progress on meetings its regulatory, contractual and other performance indicators.
5.5 The Council of Governors is asked to note the finance and performance report for Month 1 and the actions the Trust is taking in developing and implementing a financial recovery plan as a matter of urgency to ensure that the Trust delivers its financial plan in 2014/15.
Council of Governors Performance Dashboard
April 2014
April 2014 Sussex Partnership Trust Dashboard NHS Foundation Trust
Page PATIENT EXPERIENCE
Reporting patient experience feedback - at least 80% positive responses 1 G
Complaints responded to within 25 working days - target 85% 1 R PEOPLE
Time to Hire 2 G
Sickness absence - 3.5% or less 2 A
Agency spend - maintain spend at less than 1% of pay bill 2 R DATA QUALITY
MHMDS Data Completeness Identifiers - target 97% MONITOR 3 G
MHMDS Data Completeness Outcomes - target 50% MONITOR 3 G FINANCE
Financial Risk Ratings (3 or above) 4 A
Achievement of Cost Improvement Plan 4 R
Income and Expenditure Account (£2.5m surplus by year end) 4 R GOVERNANCE
MONITOR Governance Risk Rating G
April 2014 Sussex Partnership Key Indicators - Patient Experience NHS Foundation Trust
100% G 93% Patient Experience 89% 90% 90% 89% 86% 86% 84% 84% 84% 84% (Local indicator) 82%
80% Patient Experience 80% Month: April 2014 Target: 80% positive Month Quarter YTD 60% Postcards 163 163 163 % Positive response 88% 88% 88% % Strongly Agree 61% 61% 61% 40% Questionnaries 35 35 35 20% % Positive response 84% 84% 84% % Strongly Agree 34% 34% 34% 0% Total % Positive 86% 86% 86% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% Positive Feedback Target
100% R Responding to Complaints 88.9% (Local indicator) 80% 80.9% 80.5% Month: April 2014 Target: 85% 76.0% 69.7% 67.6% 66.7% 70.3% 69.8% 66.7% Complaints responded to within 25 working days or within a 60% 62.1% 63.0%
different agreed timetable 55.6%
Complaints responded to this month 33 40% Responded to within the agreed timeframe 22 % responded to within agreed timeframe 67% 20% Average number of days to response 25.2 0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
Total number of complaints received by Trust 60 TRUST - completed within timeframe Target
Performance by CCG - current month Performance by CCG - current month SUSSEX ComplaintsResponse rate Ave Days HAMPSHIRE ComplaintsResponse rate Ave Days Patient Experience R Coastal W Sussex 9 6 67% 40.4 G Fareham & Gosport 0 0 100% 0.0 A Crawley 5 4 80% 13.6 G North Hampshire 1 1 100% 17.0
R Horsham & Mid Sx 3 1 33% 30.0 G N E Hampshire 1 1 100% 20.0
G Brighton & Hove 1 1 100% 7.0 G S E Hampshire 0 0 100% 0.0
A Eastbourne 4 3 75% 12.5 R West Hampshire 5 3 60% 27.4
G High Weald 0 0 100% 0.0 R Other CCGs 1 0 0% 26.0 G Hastings & Rother 0 0 100% 0.0 G Other CCGs 0 0 100% 0.0
Performance by CCG - current month KENT ComplaintsResponse rate Ave Days G Ashford 0 0 100% 0.0 R Canterbury 1 0 0% 37.0
G Dartford 1 1 100% 4.0
G Medway 0 0 100% 0.0
G South Kent Coast 0 0 100% 0.0
G Swale 0 0 100% 0.0
G Thanet 11100%12.0
G West Kent 0 0 100% 0.0
G Other CCGs 0 0 100% 0.0
1 Performance Indicators Trust-wide
April 2014 Sussex Partnership Key Indicators - People NHS Foundation Trust
20
18.6 Time to Hire G 18.0 (Local indicator) 16 16.8 16.8 Month: April 2014 Target: <=17.4 weeks
Month YTD 12 People
Time to Hire (weeks) 16.8 17.6 Weeks
8
4
0 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
Time to Hire Target
5.0% Sickness Absence A
(Local indicator) 4.61%
4.5% Month: March 2014 Target: <=3.5% 4.37% 4.28% 4.37% 4.38% Month Year 4.26% 4.29% People
4.0% 4.06% 2013-14 absence rate 4.4% 4.2% 4.04% 4.03% 4.00% 3.95% 2012-13 absence rate 4.2% 4.3%
Reported one month in arrears 3.5%
3.0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Trust Absence rate Trust Absence rate (previous 12 months) Target
8% Agency Spend R (Local indicator) 7% Month: April 2014 Target: 1% 6%
Month YTD 5% 5.08% People
Agency Spend (2014-15) 5.08% 5.08% 4%
Agency Spend (2013-14) 3.45% 4.40% 3%
Agency spend as a proportion of the total pay bill. Target is 2% to maintain this below 1%. Last year's YTD figure is for the whole year (2013-14). 1%
0% Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 % Agency spend (Current Year) % Agency spend (Last Year) Target
2 Performance Indicators Trust-wide
April 2014 Sussex Partnership Key Indicators - Data Quality NHS Foundation Trust
G 100% Data Completeness Identifiers 100.0% 100.0% 99.8% 99.9% (MONITOR indicator)
Month: April 2014 Target: 97% 98% 98.2% Data Quality 97.6% G MHMDS Identifier Month Quarter YTD
G Commissioner Code 99.8% 99.8% 99.8% 96% G Date of Birth 100.0% 100.0% 100.0%
G Gender 100.0% 100.0% 100.0% 94%
G GP Code 99.9% 99.9% 99.9%
G NHS Number 97.6% 97.6% 97.6% 92% Commissioner Date of Birth Gender GP Code NHS Number Postcode Code G Postcode 98.2% 98.2% 98.2%
% valid Target Linear (Target)
100% G Data Completeness Outcomes 96.3% (MONITOR indicator) 86.8% 87.2% 80% Month: April 2014 Target: 50% Data Quality MHMDS Outcome Month Quarter YTD 60% G Accommodation 86.8% 86.8% 86.8%
G Employment 87.2% 87.2% 87.2% 40%
G HoNOS 96.3% 96.3% 96.3%
20%
0% Accommodation Employment HoNOS
% valid Target
3 Performance Indicators Trust-wide
April 2014 Sussex Partnership Key Indicators - Finance NHS Foundation Trust
Financial Risk Rating A
Continuity of Service Risk Ratings Financial Risk Rating April has resulted in a continuity Year to Date Apr-14 Year to Date Rating Plan Rating Apr-14 Plan 2014/15 Apr-14 2014/15 of service risk rating of 3, due to Earnings Before Interest, the strong liquidity position, and a Revenue Available for 0.03 13.2 Taxation, Depreciation and 0.14% 1 5.40% 3 Capital Service Amortisation (%) financial risk rating of 1, due to -0.54 -6.5 Earnings Before Interest, Capital Service Taxation, Depreciation and 3% 100% the in month deficit. Capital Service Cover 1 5 0.06 2.03 Amortisation Plan vs metric Actual (%) Capital Service Cover Rating 13 Return on Assets (%) -6.95% 1 2.90% 4
Cash for CoS liquidity 14.909 24.9 purposes Income & Expenditure -5.05% 1 0.52% 2 Operating Expenses within Margin (%) -19.00 -218.8 EBITDA, Total
Liquidity metric 23.54 41.0 Liquid Ratio (times) 23.54 3 63.87 5 Liquidity rating 44
Continuity of Service Risk 34 Financial Risk Rating 24 Rating
Cost Improvement Plans R
Total Savings 2014-15 The year-to-date savings amount-
14,000 ed to £252K against a target of £751K. 12,000 10,000 CIP 8,000 Savings Achieved 6,000 £000 Savings Achieved 2013-14 4,000 2,000 -
123456789101112 Month
Income and Expenditure Account R
Income and Expenditure ANNUAL In Month - Apr-14 Year to Date - Apr-14 Account BUDGET Budget Actual Variance Budget Actual Variance £000's £000's £000's £000's £000's £000's £000's Revenue from Activities
Total operating Revenue (226,790) (19,123) (19,028) 95 (19,123) (19,028) 95
Operating Expenses
Total Pay Costs 177,148 15,075 15,443 369 15,075 15,443 369
Total Non Pay Costs 37,547 3,101 3,559 457 3,101 3,559 457
Total Operating Costs 214,695 18,176 19,002 826 18,176 19,002 826 Reserves 0 0 0 0 0 0 0
Earnings Before Interest, Taxes, (12,095) (947) (27) 921 (947) (27) 921 Depreciation and Amortisation Total other Items 10,895 947 987 40 947 987 40
Retained Surplus For the Year (1,200) 0 961 961 0 961 961
Non Trading (Gains)/Losses (880) 0 0 0 0 0 0
Retained Surplus For the Year (2,080) 0 961 961 0 961 961
April has resulted in a retained deficit of £961K, against an in month break even target. The main in month issues relate to the shortfall of cost improvement targets within pay, high agency usage and ECR costs.
4 Finance Indicators Trust-wide
Council of Governors Specialist Services Dashboard
April 2014
April 2014 Sussex Partnership Specialist Services Dashboard NHS Foundation Trust
Page SAFETY
Serious Incidents - Reporting on and demonstrating learning 1 EFFECTIVENESS
New cases of psychosis - Effective treatment - 48 new cases each quarter MONITOR 2 A
Emergency referrals responded to in 4 hours (Sussex) - target 95% 2 G
Emergency referrals responded to in 4 hours (CAMHS Hampshire) - target 95% 3 G
Emergency referrals responded to in 24 hours (ChYPS Kent) - target 95% 3 G
Routine assessments within 4 weeks of referral (Sussex) - target 95% 4 G
Routine assessments within 4 weeks of referral (CAMHS Hampshire) - target 95% 4 R
Routine assessments within 4 weeks of referral (ChYPS Kent) - target 95% 5 R
Appropriate Placement of Prisoners - prisoner transfer times - target under 2 weeks 5 G PATIENT EXPERIENCE
Complaints responded to within 25 working days (Sussex) - target 85% 6 R
Complaints responded to within 25 working days (CAMHS Hampshire) - target 85% 6 R
Complaints responded to within 25 working days (ChYPS Kent) - target 85% 6 R
Long term service users reassessed in 7 days (CAMHS Sussex) - 95% threshold 7 G PEOPLE
Time to Hire - Trust-wide 17.6 weeks 8 G
Sickness absence - 3.5% or less 8 A
Agency spend - maintain spend at less than 1% of pay bill 8 R ACTIVITY & DATA QUALITY
External Referrals (CAMHS Sussex) 9
MHMDS Data Completeness Identifiers - target 97% MONITOR 9 G GOVERNANCE
MONITOR Governance Risk Rating G
April 2014 Sussex Partnership Key Indicators - Safety NHS Foundation Trust
Serious Incidents 24 23 23 TRUST-WIDE (Local indicator) 20 19 Month: April 2014 All Serious Incidents Month YTD 16 16 13 Sussex 13 13 14 12 13 13 10 Hampshire 0 0 11 11 10
8 Kent 0 0 6
4 TRUST 13 13 4 5 2 2 2 1 11 1 0 00 0 0 Grade 2 (TRUST-WIDE) 1 1 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Safety
TRUST SIs (All Incidents) TRUST SIs (Grade 2)
Serious Incidents 10 Specialist Services (Local indicator) 8 Month: April 2014
6 All Serious Incidents Month YTD 6 Specialist Services 3 3 5
4 4 4 Sussex 3 3 4 333 3 Hampshire 0 0 3 3 3 3 2 2 Kent 0 0 2 1 Grade 2 (Specialist Services) 0 0 1 00000000000000 0 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
Sussex SIs (Specialist Services) Hampshire SIs Kent SIs
1 Performance Indicators Specialist Services
April 2014 Sussex Partnership Key Indicators - Effectiveness NHS Foundation Trust
EIS - New Psychosis Cases A 200 Specialist Services - Early Intervention (MONITOR)
Month: April 2014 Effectiveness 150 National Target: 48 cases/quarter Month Quarter YTD 100 West Sussex 6 6 6 East Sussex 4 4 4 50 Brighton & Hove 5 5 5 TRUST 15 15 15 15 0 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Reported to MONITOR quarterly. EIS New Cases - TRUST - YTD Target
G 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 4 hour response to urgent referrals 100% Specialist Services - CAMHS Sussex (Local indicator)
Month: April 2014 Target: 95% 95% 95.2% Month YTD Urgent GP referrals received 57 57 90% Referrals meeting definition 24 24 % response under 4 hours 100% 100% 85% Urgent GP referrals presenting an immediate risk either to
the patient or others require an immediate response and Effectiveness 80% meet the "4 hour response" definition. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% response <4 hours Target
Performance by CCG - current month 100% GP Referrals Definition % <4 hours 80% Coastal W Sussex 16 0 100%
Crawley 7 2 100% 60% Horsham & Mid Sx 14 8 100%
Brighton 7 1 100% 40% Eastbourne 6 6 100% High Weald 0 0 100% 20% Hastings & Rother 7 7 100% 0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST Other CCGs 0 0 100% Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
% response <4 hours Target
2 Performance Indicators Specialist Services
April 2014 Sussex Partnership Key Indicators - Effectiveness NHS Foundation Trust
G 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 4 hour response to urgent referrals 100% Specialist Services - CAMHS Hants (Local indicator) Month: April 2014 Target: 95% 95% Month YTD Urgent GP referrals received 51 51 90% Referrals meeting definition 9 9 % response under 4 hours 100% 100% 85%
Urgent GP referrals presenting an immediate risk either to Effectiveness Effectiveness the patient or others require an immediate response and 80% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 meet the "4 hour response" definition. CAMHS Hampshire.
CAMHS Hants % response <4 hours Target
Performance by CCG - current month 100% GP Referrals Definition % <4 hours 80% Fareham & Gosport 00100%
North Hampshire 00100% 60% N E Hampshire 75100%
S E Hampshire 13 0 100% 40% West Hampshire 31 4 100% Other CCGs 00100% 20%
0% Fareham & North Hampshire NE Hampshire South East West Hampshire Other CCGs HAMPSHIRE Gosport CCG CCG & Farnham Hampshire CCG CCG CCG CAMHS Hants % response <4 hours Target
G 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 24 hour urgent referrals 100% CHYPS Kent & Medway Month: April 2014 Target: 95% 95% Month YTD Emergency referrals received 66 66 90% Emergency referrals seen 66 66 % seen under 24 hours 100% 100% 85%
Emergency referrals presenting an immediate risk either to Effectiveness Effectiveness the patient or others must be seen within 24 hours, 80% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 irrespective of whether within normal or out-of-hours. ChYPS Kent and Medway. ChYPS Kent % seen <24 hours Target
Performance by CCG - current month 100% Referrals Definition % <24 hours 80% Ashford 33100% Canterbury & Coastal 10 10 100% 60% Dartford 66100%
Medway 10 10 100% 40% South Kent Coast 10 10 100% Swale 33100%20% Thanet 99100% 0% Ashford Canterbury Dartford, Medway South Kent Swale Thanet West Other KENT West Kent 88100% CCG & Coastal Gravesham CCG Coast CCG CCG CCG Kent CCGs CCG & Swanley CCG CCG Other CCGs 77100% ChYPS Kent % seen <24 hours Target
3 Performance Indicators Specialist Services
April 2014 Sussex Partnership Key Indicators - Effectiveness NHS Foundation Trust
100.0% 100.0% 100.0% 100.0% 99.8% 99.8% 99.7% 99.8% 99.5% 100% 99.2% 99.1% 4 weeks waiting time to assessment G 98.9% 98.6% Specialist Services - CAMHS Sussex & LDS (Local ind.)
95% Month: April 2014 Target: 95% Month YTD 90% Number of Assessments 485 485
% assessments <4 Weeks 99% 99% 85% Average Wait Days 31.0 31.0 Indicator covers CAMHS Sussex and LDS. 80%
Average Wait Days = average wait time from receipt of Effectiveness 75% referral to assessment. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% assessments <4 weeks Target
Performance by CCG - current month 100% Assessments <4 weeks Wait Days 90% Coastal W Sussex 116 96% 32.6 Crawley 22 100% 16.4 80% Horsham & Mid Sx 63 98% 33.6
Brighton & Hove 73 100% 27.7 70% Eastbourne 66 98% 36.8 High Weald 67 100% 33.2 60% Hastings & Rother 77 100% 22.4 50% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST Other CCGs 1 100% 12.0 Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG CCG Seaford CCG Havens CCG
% assessments <4 weeks Target
100% 4 weeks waiting time to assessment R Specialist Services - CAMHS Hants (Local indicator) 80% Month: April 2014 Target: 95%
61.8% 59.8% Month YTD 60% 56.7% 51.8% 50.0% Number of Assessments 181 181 50.3% 45.9%
47.6% 47.2% % assessments <4 Weeks 46% 46% 40% 41.6%
36.0% Average Wait Days 35.2 35.2 31.9% 33.2% Indicator covers CAMHS Hampshire 20%
Average Wait Days = average wait time from receipt of Effectiveness 0% referral to assessment. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% assessments <4 weeks Target
Performance by CCG - current month 100% Assessments <4 weeks Wait Days 80% Fareham & Gosport 27 30% 46.2
North Hampshire 16 38% 41.8 60% N E Hampshire 31 68% 22.1
S E Hampshire 29 41% 46.5 40% West Hampshire 76 45% 31.9 20% Other CCGs 2 100% 0.0
0% Fareham & North NE Hampshire South East West Other CCGs HAMPSHIRE Gosport CCG Hampshire & Farnham Hampshire Hampshire CCG CCG CCG CCG % assessments <4 weeks Target
4 Performance Indicators Specialist Services
April 2014 Sussex Partnership Key Indicators - Effectiveness NHS Foundation Trust
4 weeks waiting time to assessment R 100% Specialist Services - ChYPS Kent (Local indicator)
80% Month: April 2014 Target: 95% Month YTD 60% 54.7%
No. of Assessments 379 379 47.4% 46.0% 42.5% 38.8% % <4 Weeks 38% 38% 40% Ave Wait Days 63.4 63.4 38.6% 38.3% 28.2% 25.8% Indicator covers ChYPS Kent 20%
Average Wait Days = average wait time from receipt of Effectiveness 0% referral to assessment. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% assessments <4 weeks Target
Performance by CCG - current month 100% Assessments <4 weeks Wait Days 80% Ashford 30 37% 60.1
Canterbury & Coastal 19 42% 73.4 60% Dartford 86 27% 53.8
Medway 61 31% 65.9 40% South Kent Coast 32 56% 56.6 20% Swale 19 47% 83.4 Thanet 37 51% 59.2 0% Ashford Canterbury Dartford, Medway South Kent Swale Thanet West Other KENT West Kent 86 37% 74.1 CCG & Coastal Gravesham CCG Coast CCG CCG CCG Kent CCGs CCG & Swanley CCG CCG
Other CCGs 9 67% 22.6 % assessments <4 weeks Target
100% Appropriate Placement for Prisoners G 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Specialist Services - Secure & Forensic (Local ind.) 80%
Month: April 2014 Target: 100% Effectiveness
Month YTD 60% Under 2 weeks 2 2
TOTAL 2 2 40%
20% Prisoner transfer time from receipt of Ministry of Justice warrant to hospital bed. Target is under 2 weeks. 0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% transferred in under 2 weeks
5 Performance Indicators Specialist Services
April 2014 Sussex Partnership Key Indicators - Patient Experience NHS Foundation Trust
100% R Responding to Complaints 88.9% Specialist Services (Local indicator) 80% 80.9% 80.5% 69.7% Month: April 2014 Target: 85% 76.0% 67.6% 68.8% 70.3% 69.8% 66.7%
Complaints responded to within 25 working days or within a 60% 66.7% 62.1% 63.0% different agreed timetable 55.6%
Complaints responded to this month 16 40% Responded to within the agreed timeframe 11 % responded to within agreed timeframe 69% 20% Average number of days to response 19.4 0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
Total number of complaints received by Trust 60 TRUST - completed within timeframe Specialist Services completed within timeframe Target
100% Performance by CCG - current month SUSSEX ComplaintsResponse rate Ave Days 80% Coastal W Sussex 0 0 100% 0.0
Crawley 1 1 100% 9.0 60% Horsham & Mid Sx 1 0 0% 29.0
Brighton & Hove 1 1 100% 7.0 40% Eastbourne 2 2 100% 6.0 High Weald 0 0 100% 0.0 20% Patient Experience Hastings & Rother 0 0 100% 0.0 0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & Other SUSSEX Other CCGs 0 0 100% 0.0 Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG CCGs CCG Seaford CCG Havens CCG
Sussex - complaints completed within timeframe Target
Performance by CCG - current month 100% HAMPSHIRE ComplaintsResponse rate Ave Days 80% Fareham & Gosport 0 0 100% 0.0
North Hampshire 1 1 100% 17.0 60% N E Hampshire 1 1 100% 20.0
S E Hampshire 0 0 100% 0.0 40% West Hampshire 5 3 60% 27.4 Other CCGs 1 0 0% 26.0 20%
0% Fareham & North Hampshire NE Hampshire South East West Hampshire Other CCGs HAMPSHIRE Gosport CCG CCG & Farnham Hampshire CCG CCG CCG
Hampshire - complaints completed within timeframe Target
Performance by CCG - current month 100% KENT ComplaintsResponse rate Ave Days 80% Ashford 0 0 100% 0.0
Canterbury 1 0 0% 37.0 60% Dartford 1 1 100% 4.0
Medway 0 0 100% 0.0 40% South Kent Coast 0 0 100% 0.0 Swale 0 0 100% 0.0 20% Thanet 11100%12.0 0% Ashford Canterbury Dartford, Medway South Kent Swale Thanet West Other KENT West Kent 0 0 100% 0.0 CCG & Coastal Gravesham CCG Coast CCG CCG CCG Kent CCGs CCG & Swanley CCG CCG Other CCGs 0 0 100% 0.0 Kent - complaints completed within timeframe Target
6 Performance Indicators Specialist Services
April 2014 Sussex Partnership Key Indicators - Patient Experience NHS Foundation Trust
G 100.0% 100.0% 100.0% 100.0% 100.0% Long Term Service Users (LTSU) 100% 100.0% 98.2% Specialist Services - CAMHS Sussex (Local Indicator) 98.1%
97.5% 96.8% 96.2% 96.9% Month: April 2014 Target: 95% 95% Month YTD LTSU Referrals 39 39 92.3% 90% Seen within 7 days 39 39 % seen within 7 days 100% 100% 85% Patient Experience This is a 7 day response indicator for people in CAMHS
Sussex who have previously used our services. 80% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% seen <7 days Target
Performance by CCG - current month 100% Referrals <7 days % <7 days 80% Coastal W Sussex 7 7 100%
Crawley 1 1 100% 60% Horsham & Mid Sx 5 5 100%
Brighton & Hove 10 10 100% 40% Eastbourne 6 6 100% High Weald 5 5 100% 20% Hastings & Rother 5 5 100% 0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST Other CCGs 0 0 Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
% seen <7 days Target
7 Performance Indicators Specialist Services
April 2014 Sussex Partnership Key Indicators - People NHS Foundation Trust
20
18.6 Time to Hire G 18.0 TRUST-WIDE (Local indicator) 16 16.8 16.8 Month: April 2014 Target: <=17.4 weeks
Month YTD 12 People
Time to Hire (weeks) 16.8 17.6 Weeks
8
4
0 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
Time to Hire Target
5.0% Sickness Absence A
Specialist Services (Local indicator) 4.61%
4.5% Month: March 2014 Target: <=3.5% 4.37% 4.28% 4.37% 4.38% Month Year 4.26% 4.29% People
Trust absence rate 4.0% 4.4% 4.2% 4.04% 4.03% 4.06% 4.00% 3.95% Specialist Services absence rate 4.3% 3.67%
Reported one month in arrears 3.5%
3.0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Trust Absence rate Trust Absence rate (previous 12 months) Specialist Services Absence rate Target
10% Agency Spend R 9% Specialist Services (Local indicator) 8% Month: April 2014 Target: 1% 7% Month YTD 6% People
Agency Spend (2014-15) 4.72% 4.72% 5%
4.72% Agency Spend (2013-14) 3.70% 5.70% 4%
Agency spend as a proportion of the total pay bill. Target is 3% to maintain this below 1%. 2%
Last year's YTD figure is for the whole year (2013-14). 1%
0% Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 % Agency spend (Current Year) % Agency spend (Last Year) Target
8 Performance Indicators Specialist Services
April 2014 Sussex Partnership Key Indicators - Activity & Data Quality NHS Foundation Trust
External Referrals 1,400 CAMHS Sussex 1,200 Month: April 2014 989 962 1,000 929 932 929 Month YTD 851 891 Number of External Referrals 761 761 800 769 763 757 761 718 Brighton & Hove Locality 130 130 600 591 East Sussex Locality 268 268 400 West Sussex Locality 363 363 200
CAMHS Sussex only 0 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Activity
CAMHS Referrals
Performance by CCG - current month 300
Month YTD 250 Coastal W Sussex 222 222 200 Crawley 45 45 Horsham & Mid Sx 96 96 150 Brighton & Hove 130 130 100 Eastbourne 83 83 50 High Weald 80 80
Hastings & Rother 105 105 0 Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
External referrals
G 100% Data Completeness Identifiers 100.0% 100.0% 99.9% TRUST-WIDE (MONITOR indicator) 99.8%
Month: April 2014 Target: 97% 98% 98.2% Data Quality MHMDS Identifier Month Quarter YTD 97.6%
Commissioner Code 99.8% 99.8% 99.8% 96% Date of Birth 100.0% 100.0% 100.0%
Gender 100.0% 100.0% 100.0% 94% GP Code 99.9% 99.9% 99.9%
NHS Number 97.6% 97.6% 97.6% 92% Commissioner Date of Birth Gender GP Code NHS Number Postcode Postcode 98.2% 98.2% 98.2% Code
% valid Target Linear (Target)
9 Performance Indicators Specialist Services
Performance Indicators 2013 - 2014 Sussex Partnership NHS Foundation Trust
Early Intervention Services - New Psychosis Cases (page 2) Early Intervention services work with young people aged between 14 and 35. Patients referred to the Service are usually ei- ther at risk or are experiencing a first episode of psychosis. Research has shown that the longer an episode of psychosis goes untreated, the poorer the outlook. Research has also indicated that early intervention services may reduce hospital stays, reduce relapses and lower suicide rates. Monitor requires that the agreed Commissioner contract figures for new cases, either those on extended assessment or those added to the three-year caseload, are met on a quarterly basis. The contractual target is 48 new cases per quarter. 4 hour response to urgent GP referrals (pages 2 & 3) All Urgent GP referrals are carefully screened by clinicians, to ensure they are responded to in the most appropriate way. Where, in the view of the clinician, the patient is presenting an immediate risk to themselves or others; an immediate re- sponse is required. The response that the Trust makes must be adequate to address the level of risk described above. This could be either assessment, or other actions, to ensure the safety of the patient and others appropriate to the particular cir- cumstances. This may not necessarily mean meeting the patient face-to-face. This could be achieved through discussion with the GP or patient. The clinical responsibility is to ensure that the GP’s request has been responded to and the patient is safe. 100% of all urgent GP referrals that meet the definition must be responded to within 4 hours. 4 weeks waiting time to assessment (pages 4 & 5) This indicator addresses the patient pathway from referral (from external source) to first assessment. It describes the num- bers of external referrals achieving the 4 week target across the Trust. The indicator is expressed as the number of patients waiting less than 4 weeks between referral and first assessment. It takes the first contact following referral to represent assessment. The contractual target is that at least 95% wait under 4 weeks to first assessment following referral. Responding to Complaints (page 6) All complaints are taken extremely seriously. They must be fully investigated with care and consideration and the findings reported to the complainant. There is a clear correlation between satisfaction and responsiveness and the Trust has taken the decision that complaints must be responded to within 25 working days, or within a different agreed timeframe. The target is 85% of all complaints are responded to within 25 working days or different agreed timeframe. Long Term Service Users (LTSU) (page 7) People discharged to primary care after a long period of being supported by secondary services, may feel insecure about what will happen if their mental health should deteriorate. A rapid re-assessment will increase their confidence to live more inde- pendently. 95% of patients meeting the criteria below should be offered an assessment within 1 week. Patients in receipt of services for six months or more in their last episode. Patients were discharged no more than two years before the referral. The Monitor threshold is 95%. The Trust’s aim is a target of 100%. MHMDS Data Completeness Identifiers and Outcomes (page 9) The Mental Health Minimum Data Set (MHMDS) is a nationally defined framework of data held locally by Trusts around the country. Each record in the data set looks at the whole period an individual is cared for by the provider from the initial referral to the final discharge. The MHMDS is central in providing information for clinical audit and for the assessment of patient out- comes. At a local level the MHMDS data completeness enables monitoring of outcomes for individuals in terms of morbidity, quality of life and user satisfaction with services. The latest version (4.0) of MHMDS is used. Identifier - 6 selected data items Date of birth Patient’s current gender Patient’s NHS number Postcode of patient’s normal residence Organisational code of patient’s registered General Medical Practice Organisational code of Commissioner The Monitor target for is set at 97% overall.
10 Performance Indicators Specialist Services
Council of Governors Adult Services Dashboard
April 2014
April 2014 Sussex Partnership Adult Services Dashboard NHS Foundation Trust
Page SAFETY
Serious Incidents - Reporting on and demonstrating learning 1
7 Day Follow-up - All acute inpatient discharges followed up in 7 Days - 95% threshold MONITOR 1 A EFFECTIVENESS
Crisis team gate-keeping - Avoiding unnecessary inpatient admissions - 95% threshold MONITOR 2 G
Emergency referrals responded to in 4 hours - target 95% 2 G
Routine assessments within 4 weeks of referral - target 95% 3 G
Liaison Services reponse times - target 95% for emrgency and urgent referrals 3 G
Length of Stay 4
Readmissions within 28 days 4 PATIENT EXPERIENCE
Delayed Transfers of Care - Timely discharge of patients - less than 7.5% MONITOR 5 G
Long term service users reassessed in 7 days - 95% threshold 6 A
Care Programme Approach reviews (At least every 12 months) - target 95% MONITOR 6 G
Complaints responded to within 25 working days - target 85% 7 R
Payment By Results - Reassessment frequency in accordance with patient needs 7 A PEOPLE
Time to Hire - Trust-wide 17.6 weeks 8 G
Sickness absence - 3.5% or less 8 A
Agency spend - maintain spend at less than 1% of pay bill 8 R ACTIVITY & DATA QUALITY
External Referrals 9
MHMDS Data Completeness Identifiers - target 97% MONITOR 9 G
MHMDS Data Completeness Outcomes - target 50% MONITOR 9 G GOVERNANCE
MONITOR Governance Risk Rating G
April 2014 Sussex Partnership Key Indicators - Safety NHS Foundation Trust
Serious Incidents 24 23 23 TRUST-WIDE (Local indicator) 20 19 Month: April 2014 All Serious Incidents Month YTD 16 16 13 Sussex 13 13 14 12 13 13 10 Hampshire 0 0 11 11 10
8 Kent 0 0 6
4 TRUST 13 13 4 5 2 2 2 1 11 1 0 00 0 0 Grade 2 (TRUST-WIDE) 1 1 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Safety
TRUST SIs (All Incidents) TRUST SIs (Grade 2)
Serious Incidents 24 23 23 Adult Services (Local indicator) 20 19 Month: April 2014 17 16 16 16 All Serious Incidents Month YTD 14 13 13 Adult Services 10 10 14 12 13 11 10 11 10 10 West Sussex 7 7 11 10 10 East Sussex 4 4 8 9 9 7 6 5
Brighton & Hove 2 2 4 5 4 SUSSEX 13 13 0 Grade 2 (Adult Services) 1 1 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
TRUST SIs (All Incidents) Sussex SIs (Adult Services)
7 Day Follow-ups A 100% 99.3% 99.3% 99.2% 98.1% 98.3% Adult Services (MONITOR) 97.1% 97.2% 97.5% 96.9% 96.6% 95.6% Month: April 2014 Target: 95% 95% 95.1% Month Quarter YTD 94.0% Discharged 267 267 267 90% Followed-up 251 251 251 % Followed-up 94% 94% 94% 85%
All adults aged over 18 discharged from Adult Mental Health 80% inpatient units. Reported to MONITOR quarterly. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Safety
% followed-up Target
Performance by CCG - current month 100% Discharged Followed-up % follow-up 90% A Coastal W Sussex 68 64 94% A Crawley 15 14 93% 80% A Horsham & Mid Sx 27 24 89%
A Brighton & Hove 56 51 91% 70% G Eastbourne 44 42 95%
G High Weald 27 27 100% 60%
G Hastings & Rother 27 27 100% 50% R Other CCGs 3 2 67% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG % followed-up Target
1 Performance Indicators Adult Services
April 2014 Sussex Partnership Key Indicators - Effectiveness NHS Foundation Trust
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5% 99.5% 99.5% G 100% 99.1% Gate-keeping of Admissions 98.5% Adult Services (MONITOR)
Month: April 2014 Target: 95% 95% Month Quarter YTD No. of Admissions 191 191 191 90% No. Gate-kept 191 191 191 % Gate-kept 100% 100% 100% 85%
Adult Mental Health patients under the age of 65 only. Effectiveness 80% Reported to MONITOR quarterly. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% gatekept Target
Performance by CCG - current month 100% Admissions Gate-kept % gate-kept G Coastal W Sussex 43 43 100% 95% G Crawley 14 14 100%
G Horsham & Mid Sx 21 21 100% 90% G Brighton & Hove 44 44 100%
G Eastbourne 32 32 100% 85% G High Weald 11 11 100%
G Hastings & Rother 22 22 100% 80% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST G Other CCGs 4 4 100% Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
% gatekept Target
G 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 4 hour response to urgent referrals 100% 98.6%
Adult Services (Local indicator) 98.7% 98.7% 98.2% Month: April 2014 Target: 95% 95% 96.1% 95.5% Month YTD Urgent GP referrals received 214 214 90% Referrals meeting definition 73 73 % response under 4 hours 99% 99% 85% Urgent GP referrals presenting an immediate risk either to
the patient or others require an immediate response and Effectiveness 80% meet the "4 hour response" definition. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% response <4 hours Target
Performance by CCG - current month 100% GP Referrals Definition % <4 hours 80% G Coastal W Sussex 66 17 100% G Crawley 20 5 100% 60% A Horsham & Mid Sx 75 15 93%
G Eastbourne 15 14 100% 40% G High Weald 21 18 100%
20% G Hastings & Rother 17 4 100%
G Other CCGs 0 0 100% 0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST Brighton & Hove CCG is covered by the Brighton Urgent Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG Referral Service (BURS). % response <4 hours Target
2 Performance Indicators Adult Services
April 2014 Sussex Partnership Key Indicators - Effectiveness NHS Foundation Trust
G 100% 4 weeks waiting time to assessment 97.8% 97.1% 97.1% Adult Services (Local indicator) 96.3% 96.1% 95.2% 95.5% 95% 94.2% Month: April 2014 Target: 95% 92.3% Month YTD 90.5% 91.2% 90% 90.7% Number of Assessments 1,167 1,167 89.1%
% assessments <4 Weeks 96% 96% 85% Average Wait Days 12.8 12.8 Indicator covers AMHS (inc Dementia) 80%
Average Wait Days = average wait time from receipt of Effectiveness 75% referral to assessment. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% assessments <4 weeks Target
Performance by CCG - current month 100% Assessments <4 weeks Wait Days 90% G Coastal W Sussex 352 97% 13.3 G Crawley 74 97% 13.0 80% G Horsham & Mid Sx 149 99% 11.3
A Brighton & Hove 249 90% 13.4 70%
G Eastbourne 124 97% 15.4
60% G High Weald 118 99% 9.3
G Hastings & Rother 95 99% 13.0 50% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST G Other CCGs 6 100% 12.0 Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG CCG Seaford CCG Havens CCG
% assessments <4 weeks Target
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 99.6% 99.7% 99.6% Liaison Services response times G 100% 99.3% 99.6% 100% 98.8% 98.7% 99.2% 99.3% 98.7% 98.5% 98.8% Adult Services (Local indicator) 98.2% 97.9% 97.7% 97.8% 97.3%
Month: April 2014 Target: 95% 95% 95% 95.0% Month YTD Emergency referrals 314 314 90% 90% % responded to within target time 98% 98%
85% 85% Urgent referrals 253 253
% responded to within target time 100% 100% Effectiveness
80% 80% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
Emergency Referrals Urgent Referrals Target
Performance by locality - current month 100% Emergency Urgent Referrals response Referrals response G 95% West Sussex 79 96% 73 100% G East Sussex 173 98% 73 99% G Brighton & Hove 62 98% 107 100% 90% Referrals fr om A&E, A&E linked and general war ds
St Richards Hospital West Sussex Acute Hospitals The Princess Royal Hospital Worthing District General Hospital 85%
Eastbourne District General Hospital East Sussex Acute Hospitals The Conquest Hospital
80% Brighton Acute Hospitals The Royal Sussex County Hospital West Sussex East Sussex Brighton & Hove Trust
Emergency Referrals Urgent Referrals Target
3 Performance Indicators Adult Services
April 2014 Sussex Partnership Key Indicators - Effectiveness NHS Foundation Trust
Readmissions within 28 days 25% Adult Services (Local indicator) 20% Month: April 2014 18.1% 16.5% 16.6% 15.7% 15.4% 16.4% Month YTD 15%
11.9% 14.0% 13.9% AMHS <65 Patients Discharged 256 256 13.2% 13.2% 12.9% 12.6% 12.3% 9.5% % AMHS <65 Readmitted 16.4% 16.4% 10% AMHS 65+ Patients Discharged 74 74 7.0% 6.9% 5.3% 6.6% 5% 6.1% 4.1% % AMHS 65+ Readmitted 4.1% 4.1% 3.1%
1.6% 3.8%
All AMHS Patients Discharged 330 330 1.5% Effectiveness 1.9% 0% % all AMHS Readmitted 13.6% 13.6% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
AMHS <65 % Readmitted AMHS 65+ % Readmitted
30% Performance by CCG - current month
AMHS <65 AMHS 65+ AMHS 25% Coastal W Sussex 11.9% 4.3% 9.8% 20% Crawley 30.0% 0.0% 28.6%
Horsham & Mid Sx 5.0% 0.0% 3.3% 15% Brighton & Hove 13.2% 0.0% 10.9% 10% Eastbourne 22.5% 0.0% 18.4%
High Weald 23.8% 18.2% 21.9% 5% Hastings & Rother 26.1% 0.0% 18.8% 0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST Other CCGs 5.0% 0.0% 5.0% Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
% AMHS Patients Readmitted
Length of Stay 100 Adult Services (Local indicator)
80 Current Quarter: Q4 (January - March) Benchmark Quarter 2013-14 60 Adult - 18 - 65 28 40.3 34.4
Adult - 65+ Functional 50 59.3 57.6 40 Adult - Organic 60 70.3 72.5
Length of Stay is measured in days for patients discharged 20 during last quarter. Effectiveness Effectiveness
0 Q1 - 2013/4 Q2 - 2013/4 Q3 - 2013/4 Q4 - 2013/4
AMHS <65 AMHS 65+ Functional AMHS 65+ Organic
100 Performance by CCG - current quarter 18-65 65+ Functional 80 Coastal W Sussex 29.2 51.5 Crawley 24.1 22.3 60 Horsham & Mid Sx 40.7 83.0
Brighton & Hove 42.3 66.1 40 Eastbourne 52.3 67.5 High Weald 33.4 38.8 20 Hastings & Rother 59.8 88.8 0 Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST Other CCGs 39.5 10.0 Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
AMHS <65 AMHS 65+ Functional
4 Performance Indicators Adult Services
April 2014 Sussex Partnership Key Indicators - Patient Experience NHS Foundation Trust
15% Delayed Transfers of Care (DTC) G Adult Services (MONITOR) Month: April 2014 Target: <=7.5%
10% Month Quarter YTD
% Delayed (AMHS) 3.5% 3.5% 3.5% 7.4% 6.7% 6.2% 6.2% 6.2%
% Delayed (TRUST) 2.8% 2.8% 2.8% 5.2% 4.9% 5% 4.2% 4.3% 3.8% 3.6% 3.3% 3.5% Non-acute adult patients aged 18 and over from AMHS (inc Dementia). Reported to MONITOR quarterly. TRUST figure
(for MONITOR) includes numbers from LDS and S&F. 0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% delays Target
25% Performance by CCG - current month Month end patient delays % delayed 20% G Coastal W Sussex3 4.7%
R Crawley4 18.4% 15% A Horsham & Mid Sx5 8.8%
G Brighton & Hove0 1.2% 10%
GG Eastbourne0 0.0% 5% GG High Weald0 0.0% Patient Experience GA Hastings & Rother1 0.9% 0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST G Other CCGs0 0.0% Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
% delays Target
R
5 Performance Indicators Adult Services
April 2014 Sussex Partnership Key Indicators - Patient Experience NHS Foundation Trust v A Long Term Service Users (LTSU) 100% 99.1%
Adult Services (Local indicator) 97.6%
95.1% Month: April 2014 Target: 95% 95% 94.6% 93.1% Month YTD 93.7% 93.4% 92.2% LTSU Referrals 202 202 89.6% 90% 90.2% Seen within 7 days 181 181 89.7% 87.8% % seen within 7 days 90% 90% 85% 85.6% Patient Experience This is a 7 day response indicator for people in AMHS (inc
Dementia) who have previously used our services. 80% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% seen <7 days Target
Performance by CCG - current month 100% Referrals <7 days % <7 days 80% G Coastal W Sussex 67 64 96%
G Crawley 11 11 100% 60% G Horsham & Mid Sx 24 23 96%
R Brighton & Hove 26 10 38% 40%
GG Eastbourne 24 23 96% 20% GG High Weald 26 26 100%
GA Hastings & Rother 23 23 100% 0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST G Other CCGs 1 1 100% Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
% seen <7 days Target
CPA 12 month Formal Review G 100% Adult Services (MONITOR indicator)
98% Current Quarter: Q4 (January - March) Target: 95% 97.4% 97.5% Quarter YTD 96% Adults on CPA at end of quarter 2,984 3,220 95.3% Last Review within 12 months 2,845 3,104 95.1% 94% % adults with review <12 months 95.3% 96.4%
92% Patient Experience This indicator is currently reported quarterly. A manual audit is completed at the end of the quarter. 90% Q1 - 2013/4 Q2 - 2013/4 Q3 - 2013/4 Q4 - 2013/4
% <12 month Review Target
100% Performance by CCG - current quarter Patients Vaild Review % Valid G Coastal W Sussex 964 920 95% 95% G Crawley 182 179 98%
A Horsham & Mid Sx 337 312 93% 90%
G Brighton & Hove 719 682 95%
G Eastbourne 342 339 99% 85% G High Weald 141 136 96%
A Hastings & Rother 277 256 92% 80% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST GR Other CCGs 22 21 95% Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
% <12 month Review Target
6 Performance Indicators Adult Services
April 2014 Sussex Partnership Key Indicators - Patient Experience NHS Foundation Trust
100% R Responding to Complaints 88.9% Adult Services (Local indicator) 80% 80.9% 80.5% Month: April 2014 Target: 85% 76.0% 69.7% 67.6% 66.7% 70.3% 69.8% 66.7% Complaints responded to within 25 working days or within a 60% 62.1% 63.0% 60.0% different agreed timetable 55.6%
Complaints responded to this month 15 40% Responded to within the agreed timeframe 9
20% % responded to within agreed timeframe 60% Patient Experience Average number of days to response 32.7 0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
Total number of complaints received by Trust 60 TRUST - completed within timeframe Adult Services - completed within timeframe Target
Performance by CCG - current month 100% ComplaintsResponse rate Ave Days 80% R Coastal W Sussex 7 4 57% 47.6
A Crawley 4 3 75% 14.8 60% R Horsham & Mid Sx 2 1 50% 30.5
G Brighton & Hove 0 0 100% 0.0 40%
R Eastbourne 2 1 50% 19.0
20% G High Weald 0 0 100% 0.0
G Hastings & Rother 0 0 100% 0.0 0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & Other SUSSEX G Other CCGs 0 0 100% 0.0 Sussex CCG CCG Mid Sussex Hove CCG Hailsham & Lewes, Rother CCG CCGs CCG Seaford CCG Havens CCG
% complaints completed within timeframe Target
Payment by Results (PBR) A 100% Adult Services (Local indicator)
Month: April 2014 Target: 95% 90% 86.9% 86.3% 85.8% Under 65 65 & over TOTAL 83.6% 83.5% 82.9% 83.2% 83.1% 85.1% 84.9% 84.7% 83.2% With a Cluster 11,443 11,130 22,573 80% 82.1% With a valid Cluster 8,835 10,310 19,145 % valid Cluster 77% 93% 85% 70%
Each cluster has a review period and the cluster is valid if the Patient Experience patient's needs are reassessed before the end of the respective review period and the patient is re-clustered. 60% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
% valid cluster Target
Performance by CCG - current month 100% Patients + valid Cluster % valid Cluster 80% A Coastal W Sussex 7,844 6,733 86% R Crawley 1,480 1,237 84% 60% R Horsham & Mid Sx 3,084 2,573 83%
R Brighton & Hove 3,393 2,604 77% 40% A Eastbourne 2,601 2,347 90%
R High Weald 1,963 1,645 84% 20%
A Hastings & Rother 2,208 2,006 91%
0% Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & TRUST Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG % valid cluster Target
7 Performance Indicators Adult Services
April 2014 Sussex Partnership Key Indicators - People NHS Foundation Trust
20
18.6 Time to Hire G 18.0 TRUST-WIDE (Local indicator) 16 16.8 16.8 Month: April 2014 Target: <=17.4 weeks
Month YTD 12 People
Time to Hire (weeks) 16.8 17.6 Weeks
8
4
0 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
Time to Hire Target
5.0% Sickness Absence A
Adult Services (Local indicator) 4.61%
4.5% Month: March 2014 Target: <=3.5% 4.37% 4.28% 4.37% 4.38% 4.33% Month Year 4.26% 4.29% People
4.0% 4.06% Trust absence rate 4.4% 4.2% 4.04% 4.03% 4.00% 3.95% Adult Services absence rate 4.3%
Reported one month in arrears 3.5%
3.0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Trust Absence rate Trust Absence rate (previous 12 months) Adult Services Absence rate Target
8% Agency Spend R Adult Services (Local indicator) 7% Month: April 2014 Target: 1% 6%
5.53% Month YTD 5% People
Agency Spend (2014-15) 5.53% 5.53% 4%
Agency Spend (2013-14) 3.39% 4.26% 3%
Agency spend as a proportion of the total pay bill. Target is 2% to maintain this below 1%. Last year's YTD figure is the average for the whole year. 1%
0% Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 % Agency spend (Current Year) % Agency spend (Last Year) Target
8 Performance Indicators Adult Services
April 2014 Sussex Partnership Key Indicators - Activity & Data Quality NHS Foundation Trust
External Referrals 6,000 Adult Services (Local indicator) 5,000
4,185 Month: April 2014 4,073 4,145 3,947 4,000 3,748 Month YTD 3,814 3,672 3,664 3,652 3,552 3,351 3,342 Number of External Referrals 4,145 4,145 3,000 3,287 Brighton & Hove Locality 951 951 2,000 East Sussex Locality 1,207 1,207
West Sussex Locality 1,987 1,987 1,000
AMHS only 0 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Activity AMHS Referrals
Performance by CCG - current month 1,500
Month YTD 1,250 Coastal W Sussex 1,227 1,227 1,000 Crawley 267 267 Horsham & Mid Sx 493 493 750 Brighton & Hove 951 951 500 Eastbourne 514 514 High Weald 296 296 250
Hastings & Rother 397 397 0 Coastal West Crawley Horsham & Brighton & Eastbourne, High Weald, Hastings & Sussex CCG CCG Mid Sussex CCG Hove CCG Hailsham & Lewes, Rother CCG Seaford CCG Havens CCG
External referrals
G 100% Data Completeness Identifiers 100.0% 100.0% 99.8% 99.9% TRUST-WIDE (MONITOR indicator)
Month: April 2014 Target: 97% 98% 98.2% Data Quality 97.6% MHMDS Identifier Month Quarter YTD
Commissioner Code 99.8% 99.8% 99.8% 96% Date of Birth 100.0% 100.0% 100.0%
Gender 100.0% 100.0% 100.0% 94% GP Code 99.9% 99.9% 99.9%
NHS Number 97.6% 97.6% 97.6% 92% Commissioner Date of Birth Gender GP Code NHS Number Postcode Postcode 98.2% 98.2% 98.2% Code
% valid Target Linear (Target)
100% G Data Completeness Outcomes 96.3% Adult Services (MONITOR indicator) 86.8% 87.2% 80% Month: April 2014 Target: 50% Data Quality MHMDS Outcome Month Quarter YTD 60% Accommodation 86.8% 86.8% 86.8%
Employment 87.2% 87.2% 87.2% 40% HoNOS 96.3% 96.3% 96.3%
20%
0% Accommodation Employment HoNOS
% valid Target
9 Performance Indicators Adult Services
Performance Indicators 2013 - 2014 Sussex Partnership NHS Foundation Trust
7 Day Follow-up (page 1) Patients are most at risk of suicide within the first seven days after being discharged from an inpatient unit. The 7 day follow- up process attempts to reduce the number of suicides within this time frame. Every adult patient, including those on the Care Programme Approach (CPA) receiving secondary mental health services should be followed up, either in person, or by phone, within 7 days of discharge. The Monitor and Contractual target is 95%. A schedule of working principles has been agreed to define expected practice.
Gate-keeping of Admissions (page 2) A key role of the Crisis Resolution Home Treatment Team is to gate-keep admissions to inpatient services to reduce inappro- priate inpatient admission and provide crisis care in the home or in the community where this is more appropriate. They should provide a mobile 24 hour, seven days a week response to requests for assessment and be actively involved in all requests for admission. For the avoidance of doubt, this should involve face-to-face contact unless it can be deemed that this was not appropriate, or possible. For each case where face-to-face is deemed to be inappropriate, a self-declaration is re- quired. In relation to Mental Health Act assessments the team should be notified of assessment; be assessing all these cases before admission happens; and be central to the decision making process in conjunction with the rest of the multi disciplinary team. The Monitor and Contractual target is 95%. 4 hour response to urgent GP referrals (page 2) All Urgent GP referrals are carefully screened by clinicians, to ensure they are responded to in the most appropriate way. Where, in the view of the clinician, the patient is presenting an immediate risk to themselves or others; an immediate re- sponse is required. The response that the Trust makes must be adequate to address the level of risk described above. This could be either assessment, or other actions, to ensure the safety of the patient and others appropriate to the particular cir- cumstances. This may not necessarily mean meeting the patient face-to-face. This could be achieved through discussion with the GP or patient. The clinical responsibility is to ensure that the GP’s request has been responded to and the patient is safe. 100% of all urgent GP referrals that meet the definition must be responded to within 4 hours. Urgent GP referrals for adult patients in Brighton & Hove are managed by the Enhanced Brighton Urgent Response Service. 4 weeks waiting time to assessment (page 3) This indicator addresses the patient pathway from referral (from external source) to first assessment. It describes the num- bers of external referrals achieving the 4 week target across the Trust. The indicator is expressed as the number of patients waiting less than 4 weeks between referral and first assessment. It takes the first contact following referral to represent assessment. The contractual target is that at least 95% wait under 4 weeks to first assessment following referral. Liaison Services response times (page 3) Psychiatric liaison services provide mental health care to people being treated for physical health conditions in general acute hospitals. The co-occurrence of physical and mental health problems is very common and often leads to poorer health out- comes for these patients. It also has a detrimental effect on health care costs. The Centre for Mental Health issued a report in 2011 (Economic Evaluation of a Liaison Psychiatry Service) which estimated that an acute hospital could save £3.5m a year in shorter lengths of stay and lower readmission rates through the use of high-quality psychiatric liaison services. This represent- ed a cost-benefit ratio of 4:1. The targets for patients to be seen are: 2 hours for emergency referrals (A&E wards, A&E linked wards, general wards) 24 hours for urgent referrals (A&E linked wards) 48 hours for urgent referrals (general wards) For non-urgent referrals (general wards) the aspirational target is 72 hours 95% of patients should wait no more than indicated. Delayed Transfers of Care (DTC) (page 5) A delayed discharge occurs when a patient is assessed as medically ready to be discharged from an inpatient bed but remains due to non medical delays. These include, awaiting public funding, awaiting a housing placement or a package of care in their own home. A patient is ready for transfer when: A clinical decision has been made that patient is ready for transfer and A multi-disciplinary team decision has been made that patient is ready for transfer and The patient is safe to discharge/transfer. A multi-disciplinary team in this context includes nursing and other health and social care professionals, caring for that patient in an acute setting. For patients of no fixed abode, the council responsible for the patient is the council whose area they reside. This is irrespec- tive of whether the patient lives on the street or in a hostel. Asylum seekers and others from overseas are listed under the council in which they currently reside. It is the responsibility of this council to decide whether they are eligible for social ser- vices. Delays attributable to social care are excluded. The Monitor target is that DTCs should be no more than 7.5%.
10 Performance Indicators
Performance Indicators 2013 - 2014 Sussex Partnership NHS Foundation Trust
Long Term Service Users (LTSU) (page 6) People discharged to primary care after a long period of being supported by secondary services, may feel insecure about what will happen if their mental health should deteriorate. A rapid re-assessment will increase their confidence to live more inde- pendently. 95% of patients meeting the criteria below should be offered an assessment within 1 week. Patients in receipt of services for six months or more in their last episode. Patients were discharged no more than two years before the referral. The Monitor threshold is 95%. The Trust’s aim is a target of 100%. CPA 12 month Formal Review (page 6) “The Care Programme Approach (CPA) is at the centre of the personalisation focus, supporting individuals with severe mental illness to ensure that their needs and choices remain central in what are often complex systems of care.” - from the Foreword to ‘Refocusing the Care Programme Approach—Policy and Positive Practice Guidance’ Dept of Health (2008). In identifying what a service user, who has the support of a CPA, should expect, the need for a comprehensive formal written care plan features prominently. This care plan should include a risk and safety/contingency/ crisis aspect. An on-going, formal multi-disciplinary, multi-agency review is required at least once a year (but likely to be needed more regularly). The 12 month review is a key Monitor performance indicator. It is expressed as a percentage of adult patients having had a formal review in the past 12 months from the total number of adults on the Care Programme Approach at any time in the past 12 months. Responding to Complaints (page 7) All complaints are taken extremely seriously. They must be fully investigated with care and consideration and the findings reported to the complainant. There is a clear correlation between satisfaction and responsiveness and the Trust has taken the decision that complaints must be responded to within 25 working days, or within a different agreed timeframe. The target is 85% of all complaints are responded to within 25 working days or different agreed timeframe. Payment by Results (PbR) cluster reassessment (page 7) Under the Department of Health Guidance for Payment By Results, there is a requirement that patients, whose needs are defined in terms of Payment By Results clusters, are re-assessed in accordance with defined review periods. The defined re- view periods vary in length according to the cluster concerned. Clusters are considered as “valid” if the patients’ needs have been re-assessed in the review period and the patient has been re-clustered. There are a number of possible reasons as to why a patient may have an EXPIRED cluster including: Patients with no current activity that have not been discharged from the system. (these patients need to be discharged). Patients whose clusters have not been reviewed within the defined review periods. (all patients need to be clustered in accordance with the review periods guidance). MHMDS Data Completeness Identifiers and Outcomes (page 9) The Mental Health Minimum Data Set (MHMDS) is a nationally defined framework of data held locally by Trusts around the country. Each record in the data set looks at the whole period an individual is cared for by the provider from the initial referral to the final discharge. The MHMDS is central in providing information for clinical audit and for the assessment of patient out- comes. At a local level the MHMDS data completeness enables monitoring of outcomes for individuals in terms of morbidity, quality of life and user satisfaction with services. The latest version (4.0) of MHMDS is used. The indicator measures the completeness of the mental health minimum data set in two parts: 1. Identifier - 6 selected data items Date of birth Patient’s current gender Patient’s NHS number Postcode of patient’s normal residence Organisational code of patient’s registered General Medical Practice Organisational code of Commissioner The Monitor target for is set at 97% overall. 2. Outcomes - 3 selected data fields (using the most recent entered for adult patients aged 18-69 on CPA in the last 12 months) Settled accommodation Employment HoNOS The Monitor target for is set at 50% overall.
11 Performance Indicators
Sussex CCG Map Sussex Partnership NHS Foundation Trust
© Graham Ainsworth - Sussex HIS - April 2012 Population Number of CCG (2012) GP Practices Coastal West Sussex CCG 482,300 59
Crawley CCG 124,000 13
Horsham & Mid Sussex CCG 222,500 23
Brighton & Hove CCG 299,400 48
Eastbourne, Hailsham & Seaford CCG 183,400 23
High Weald, Lewes, Havens CCG 163,100 22
Hastings & Rother CCG 182,600 35
12 Performance Indicators Sussex Partnership NHS Foundation Trust Council of Governors – 16 June 2014 – Public Agenda Item: CG28.3/14 Attachment: D For Discussion By: Sue Morris, Executive Director of Corporate Services
STAFF ENGAGEMENT - UPDATE
1.0 PURPOSE AND RECOMMENDATION
The Council of Governors is asked to note the progress made against the improvement plan presented to the Board in March 2014 and ask any questions of the Executive Director, Corporate Services.
2.0 OVERVIEW
The improvement plan attached was produced as an outcome of the focus groups held with staff in 2013 and considerable discussion with Board members, governors, staff representatives and staff across the trust. This update was reviewed by both the Board and People Committee at the May meetings.
The improvement plan was designed to define accountable actions for Board members but also to promote discussion across the trust and provide a focus on the importance of positive staff engagement.
The update focusses on some early actions and will continue to be revised to reflect current feedback that will be measured through quarterly surveys, focus groups and regular feedback through leadership forums, governors and staff representatives. A briefing on progress has been shared this week with staff and a monthly update will be produced inviting feedback and suggestions on positive practice.
The overarching theme of all plans for improvement is the need to listen more and this needs to be modelled in all of our behaviours and across the organisation.
The most significant focus has been placed on the following areas:
Production of the Trust vision and values in a simple format which has been completed and circulated with payslips together with business objectives Regular visits programme of Board members with feedback in Board meetings Seminar on behaviour expectations held as part of Board development Development of the Leadership Development Programme approved by the Executive Management Board and People Committee in May with roll out commencing in June 360 degree feedback process for Executive Team in progress Development of ongoing surveys to include friends an family test to commence in June Ongoing discussion sessions every month in Leadership forums, focussed on listening, with agenda guided by leadership group Progress on improving working lives through the technology and recruitment developments
3.0 PERFORMANCE MONITORING
The improvement plan, together with business objectives are being used to drive key changes that arose from the feedback from the focus groups. These are reviewed regularly through People Committee and the Board.
4.0 GOVERNANCE Progress on the elements of this plan is reviewed through the People Committee regularly and the Board. As the objective is to achieve culture change this is a long term programme thought is being given to the reporting plan over the coming months.
5.0 STRATEGIC DEVELOPMENT AND CONTROL
The impact of the programme on staff engagement will be assessed through the EMB, People Committee and Board. The impact will be assessed from the results of the staff surveys through the year, feedback direct from staff governors and staff representatives.
6.0 SUMMARY AND CONCLUSION
Council of Governors members are asked to note progress against the improvement plan to date and ask any questions of the Executive Director, Corporate Services
Focus groups and staff survey outcome - Improvement Workplan – short/medium term priorities (0 – 12 months)
Update May 2014
Activity Who Outcomes By when
1. Two - way Communications
Review, refresh and publish Trust Vision and Values. This is not a new piece of work but a review of the Executive Director of Better By end April current values to ensure they remain fit for purpose. Corporate , People understanding by Director and staff around the Communications direction of travel; Director better fit within their roles
Update: Complete and published
Incorporate demonstration of Trust values (as described in the Better By Experience values) in Trust Board Chair for CEO and Trust Board models By end April objectives which include description of behaviours: team to ‘live’ the values CEO for Directors. the behaviours expected by staff
Update: Behaviour expectations produced through consultation and presented to People Committee. To be incorporated into Leadership Development Programme. Board seminar held on behaviours to be taken forward in Board development.
Devise template for Monthly/Weekly/Fortnightly Leadership Brief for managers to use for team meetings Communications Consistent and End April with staff. (consistent messages via partnership bulletin) – 3 key messages regular message supporting and promoting values and behaviours;
Update: 3 key messages produced in CE message weekly and through Partnership Bulletin for staff
Create an ‘Ideas forum’ on the website for staff to post ideas and comments and ensure that these are Communications plus Engagement with Forum responded to/considered/acted on where appropriate and details published CEO to nominate a staff on living the available. To Director to lead values and showing be refined by the correct end April. behaviours;
Update: Launched a Facebook site and more routinely requesting feedback on Trust communications.
CEO Trust Partnership Bulletin to staff once a month setting out key developments at the Trust and Communications and Provide a forum In place for incorporating updates on this program. Define markers of change since the report was published. HR/CEO where staff can find March developments to date and keep up with progress To inform staff of key changes; make a contribution and give feedback;
Update: First briefing for staff produced in May, monthly updates to follow .
Surveys including Friends and Family test questions being prepared to run first survey in June followed by three more during the year.
Ensure that the messages that go out via all media – electronic, notice-boards, payslips and others, are Director of Improve the quality Immediately consistent and reach the entire workforce across all sites and bands. Communications and means of staff receiving communication; reach out to those who have less access to technology, etc.
Update: business objectives, vision and values also produced in a booklet this year and being distributed to all staff via payslips.
Ongoing review of all communications and use of relevant media
2. Leadership and management
Unscheduled visits to the service by Board members and direct reports to Board members. Each Board Board Members To provide direct Plan drawn member/direct report should anticipate carrying out at least 4 unscheduled visits a year. Feedback to staff contact between up for year post-visits to be given by the board member who carried out the visit and reported at the People Committee the Board and ahead by front-line staff mid-March
Update: in place. Visits reported to the Board in public part of meeting regularly
Clarify how the Trust Board work together, their roles/responsibilities and behaviours. Board Members Improve team Set in place All members of the Trust Board to have access to an external coach to particularly prioritise: working and mutual for April • Use of appreciative enquiry model (building on strengths, amplifying what is working, able to understanding at articulate expectations and able to build on skills to hold people accountable via a positive Board level framework) • Coaching leadership skills for their own direct reports Update: Board seminar held on behaviours. Development programme to commence on appointment of new Chief Executive.
Increasing capacity to Executive Team and direct reports to focus on strategic priorities. CEO Improve delivery of By April key objectives
Update: Being discussed as part of each individual appraisal
Visibility and time spent in the service with front-line staff and patients to be added to all Board members’ Chair for CEO and Improve staff Immediate formal annual objectives. To include unscheduled visits and opportunities for staff to shadow Executive NEDs. Patient and Board Team. CEO for all Executive understanding and Directors. respect. Engage with all staff groups
Update: visits recorded and fed back. Expectation on all Executive Team to visit services regularly, no less than once per month.
Offers made to staff to shadow Executives and some already taken place.
Listening exercises to be organised for Executive members to visit teams and listen to feedback. To be Managing Directors Listening in action; Plan drawn planned and jointly run with relevant service lead/CD/Matron as appropriate. Agree how we capture and People Director forums for staff to up for year current and new feedback and ensure this is happening Exec team (feedback contribute to ahead by at people committee) changes; mid-Mar improvement in services; engagement and two-way problem solving
Update: Executives meeting in all ward units as part of the recovery plans to address agency spend and bed management. This approach will continue to be developed.
Develop a framework of competencies for “managing for sustainable employee engagement” - (to be used People Director- Competency By end April in selection and retention of staff; supervision, staff development; management and leadership Framework to be framework to development programmes; etc) (Business Objectives 2014/15) approved by People ensure Committee engagement becomes embedded in the Trust culture and is measured
Update: See previous reference to behaviour expectations.
‘People skills for Leaders’ development program, using tools such as coaching and action learning, People Director with Ensure a high To launch 1 st appreciative enquiry to include: support from Staff standard of cohort by • Courageous conversations; Performance improvement; Managing conduct; Effective supervision & Side managerial skills, May 2014 appraisal; Workforce planning; Building resilience. (Business Objectives 2014/15) behaviours and values employed in leading staff
Update: Leadership Development programme designed and being presented to Executive Management Board and People Committee in May with first cohort end of June.
Leadership Development Programme for Trust Board to be commissioned. Initial work to be carried out New CEO and Set a high standard Initial scoping now and programme agreed with CEO. To include: People Director. for team and and • Individual leadership including MBTI or similar diagnostic and 360 degree; Development of team individual identification leadership model; Team decision-making; Group dynamics; positive challenging; Managing leadership to carry of providers meetings effectively. the Trust forward by end of Aug. Update: 360 degree feedback agreed for Executive Team using NHS Leadership Academy model. This will be piloted for rollout for more staff.
Trust Board joint strategy seminars run by external facilitator at least 2 times a year. CEO and To ensure that Begin in Commercial Director adequate time and March. focus is provided by the Board to the strategic direction of the Trust.
Update: Next Board away time booked for September.
3. Risk management and organisational responses to incidents
Review the staffing levels and skill mix on acute wards and medium secure units and the use of the three- Director of Nursing Examine the Report to day, twelve ½ hour shift rota and Governance with appropriate and Executive by clinical leads, affordable safe end of March Managing Directors; staffing level and Staffing HR and Finance ensure appropriate levels (End of support staffing resource in April) place; create opportunities for reflective practices
Update: Outcome of review presented to EMB in April 2014. Ward establishment and rota reviews taking place ward by ward to meet individual needs commencing with dementia wards.
Review outcomes of past 12 months Serous Incidents to determine level of action in relation to staff and Director of Nursing To obtain a clear By June publish findings e.g. suspensions/dismissals, etc. and understanding of Governance(support the relationship from People Director between staff and staff side) competence and Sis
Introduce the incident decision tree tool prior to suspensions/disciplinary action People Director/ To show clarity of By April Nursing /Quality process and Director/Staff Side provide assurance of compliance with procedures and the law
Update: Complete. this is available in the Policy
Run two lessons learned seminars each year as a minimum (incidents/ SIs/ ETs/ Hearings) and continue Various Directors or To ensure that By June to report them via the lessons learned bulletin. Deputy Directors errors are under their remit i.e. understood and Nursing Director, explored Medical Director, People Director ; staff side
4. Staffing, HR and employee relations issues
Review employment policies with direct impact on improving working lives and how ER issues are People Director with Provide simple, April – managed staff side clear and December transparent procedures to assist managers and staff in their correct interpretation and implementation; improve prevention and reduce disciplinary action/grievances
Update: ongoing
Substantially improve the recruitment process to reduce time to hire (to be defined by banding) and monitor People Director Reduce time to Achieve excellent customer services. (Business Objectives 2014/15) recruit to an Target by acceptable level to September ensure ‘full staffing’ and reduce agency costs
Update: April 16.8 weeks reducing to 15 by September
Reduce the level of agency staff. Project already underway. (Business Objectives 2014/15) Executive Reduce agency Project will team/Finance and staff by reducing be ongoing. HR working through sickness absence, budget holders unplanned absence, vacancies and addressing workload over establishment issues. Improve quality levels of care
Update: reported through People Committee and F & I Committee. HR/Finance teams working locally with ward managers to support in terms of management of resources, sickness absence case management and recruitment to vacancies
Promote internal workplace resolution by introducing internal mediation services, harassment advisors and People Director Reduce conflict in By June other methods with the support from ACAS and other relevant external bodies. the workplace with early interventions where possible
5. Service improvements
Ensure the approach to service reviews includes all start with staff involvement in the project, i.e. allocate Executive Openness and Immediate one or two local staff to be part of the management of change project. This should also include sharing a Team/Project Leads consultation prior to monitoring of proposal with a staff group prior to a consultation document so they can input, etc. /Staff Side change giving staff change the opportunity to programmes comment prior to a final decision being made
Update: In the two service re-design projects (Adult Services and Specialist services) the workstreams involve large numbers of front line staff contributing to the plans.
Explore the use of Governors especially in service improvement and staff involvement. E.g. internal Head of Governance Deploying June cultural change, recruitment exercises, etc and Head of members of the Governors governing body as an additional resource in the dialogue with staff about change
Update: Recruitment of new staff governors currently underway. People Director presenting to Governors on recruitment and potential for Governors input in May.
Introduce protected reflection time for all clinicians across the Trust (e.g. OTs, qualified and non-qualified Executive Directors Building stronger All Directors nurses; etc.) -Ensure regular away days take place across all departments (clinical and non clinical) to for their relevant teams through have plans in enable staff to build strong team skills; have space for reflection and development. areas ensuring reflective place for practice, stronger achieving by communications May. and an investment in team development
Update: Feedback on progress in June
Processes- IT and electronic forms/ recruitment improvements and working environment (e.g. space Direct reports to Exec Producing a less Review utilisation) (Business Objectives 2014/15) Corporate Director stressful work progress environment by monthly via improvement of the People working space, Committee technology and simplified processes; reduce time spent by staff on administrative tasks
Update: Project in place in Brighton and Hove (3 months) to match concerns of staff about lack of access to interview rooms etc. with space utilisation survey showing underutilisation. Solutions to be shared across the trust .
IT programme benefits realisation reported through business objectives.
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG28.5/14 Attachment: E Patient Experience Update Author Bryan Lynch, Deputy Director of Patient Experience and Customer Care Section Performance Presented by Vincent Badu, Strategic Director of Social Care & Partnerships
Paper Summary Verbal update of progress made in key aspects of the patient experience programme.
Specific points for The Friends and Family Test (FFT) implementation continues on schedule and Governors to note the programme lead is working jointly with the external provider (Fr3dom Health Solutions), Trust corporate teams (i.e. Information and Performance), operational teams, service user and carers groups and Healthwatch, to ensure it remains so. The current expectation is that FFT will be launched in all in- patient services from July this year, and that over the remainder of the calendar year it will be rolled out to all community teams.
The 15 Steps Challenge revisits of all adult in-patient services continue, with an expectation that these are all completed in June. The first visits of Children and Young Peoples Services reception areas have commenced in May, and the intention is to visit all adult Assessment and Treatment Services in autumn 2014.
Patient Experience Reporting has an opportunity to develop significantly in depth and richness as a consequence of the above programmes. FFT will give greater levels of qualitative feedback than the current system of questionnaires is able to, and this will be used to triangulate against the emergent themes of 15 Steps, as well as other sources, such as complaints/plaudits/serious incident reports/peer reviews etc. These changes will begin to become evident in Quarterly Patient Experience Reports from the end of quarter two.
Points for discussion Council of Governors are invited to note the contents of this update for at meeting information and discussion.
Recommendation(s) Council of Governors are invited to note the contents of this update for information and discussion.
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG28.6/14 Attachment: F To receive a report on Safe Staffing Author Helen Greatorex, Executive Director of Nursing and Quality Section Performance Presented by Helen Greatorex, Executive Director of Nursing and Quality
Paper Summary The Francis Inquiry in to failings at Staffordshire Hospital highlighted significant issues in relation to the number and quality of staff caring for patients. In particular, the importance was recognised of every ward having the right number and calibre of nursing staff on duty.
As a result, and following publication of the ‘Hard Truths’ document by the Department of Health in January 2014, NHS trusts were informed that they would be required to take a series of actions to ensure that they were openly sharing information about nurse staffing numbers by ward.
Attached at Appendix 1 is the letter sent by the Chief Nursing Officer and Chief Inspector of Hospitals to all NHS Trusts on 31 March 2014. The letter sets out the expectations of trusts with the timeline required for action.
Specific points for The actions set out in Appendix 1 are nationally mandated. Compliance with Governors to note the required actions is being overseen at national level by NHS England and at a local level by Clinical Commissioning Groups. The People, Quality and Audit Committees, as well as the Board of Directors, will require assurance that actions are delivered as required and on time and a template for reporting is in development.
A regular report to the Board of Directors will be presented in June 2014 addressing the requirements and setting out progress against next steps.
Points for discussion Governors are asked to discuss the Safer Staffing report and at meeting recommendations going forward.
Recommendation(s) The Council of Governors is asked to formally note progress made against the requirements to publically share information on ward staffing levels following publication of the Francis Inquiry and subsequent national reports.
Citygate Quarry House Gallowgate Quarry Hill Newcastle upon Tyne Leeds NE1 4PA LS2 7UE
31st March 2014
To: CEOs of Trusts and Foundation Trusts with inpatient areas CC: Monitor CEO NHS TDA CEO and Director of Nursing Health Education England CEO and Director of Nursing Regional Directors and Regional Chief Nurses Area Team Directors CCG Accountable Officers Trust Directors of Nursing and Directors of HR
Dear Colleague,
Re: Hard Truths Commitments Regarding the Publishing of Staffing Data
As you know the National Quality Board (NQB) issued guidance in November to optimise nursing, midwifery and care staffing capacity and capability. Research demonstrates that staffing levels are linked to the safety of care and that staff shortfalls increase the risks of patient harm and poor quality care. Patients and the public have a right to know how the hospitals they are paying for are being run, and so the Government has made a number of commitments in Hard Truths: The Journey to Putting Patients First to make this information more publically available.
We are writing to give you clear guidance on the delivery of the Hard Truths commitments associated with publishing staffing data regarding nursing, midwifery and care staff.
There are a number of milestones ahead in this first phase, which will focus on all inpatient areas; including acute, community, mental health, maternity and learning disability. The commitments are to publish staffing data from April and, at the latest, by the end of June 2014 in the following ways (see appendix one and NQB Guidance for full details):
• A Board report describing the staffing capacity and capability, following an establishment review, using evidence based tools where possible. To be presented to the Board every six months • Information about the nurses, midwives and care staff deployed for each shift compared to what has been planned and this is to be displayed at ward level • A Board report containing details of planned and actual staffing on a shift- by-shift basis at ward level for the previous month. To be presented to the Board every month • The monthly report must also be published on the Trust’s website, and Trusts will expected to link or upload the report to the relevant hospital(s) webpage on NHS Choices
We will be undertaking two stock-takes of progress. These will require minimal data entry and will take place on the dates set out below. They will be undertaken jointly with the NHS Trust Development Authority (TDA) for NHS trusts. We would encourage you to ensure that a member of your team is primed to respond on your organisation’s behalf. Specific details will be sent in due course.
Date Issued: Date to be Returned:
Stock-take 1 23rd April 2014 30th April 2014
Stock-take 2 28th May 2014 6th June 2014
The NQB guidance is designed to assist providers in fulfilling their commitments, made in Hard Truths, with regard to publishing nurse, midwife and care staff levels. The guidance sets out ten expectations of commissioners and providers in relation to getting nursing, midwifery and care staffing right so that high quality care and the best possible outcomes for patients can be achieved.
Please find attached a table containing an overview of the key actions that you should take and the timeframes. We also attach a set of Frequently Asked Questions in anticipation of some of the queries that these expectations might raise. These documents will also be put on the NHS England website. If the FAQs do not provide an answer to your question, or you would like to discuss further support, please contact either the Chief Nurse’s Office in your region or the NHS TDA:
• NHS England: North – Hazel Richards • NHS England: Midlands and East – Sylvia Knight • NHS England: London – Bronagh Scott • NHS England: South – Deborah Wheeler • NHS TDA: Jacqueline McKenna
Boards must, at any point in time, be able to demonstrate to their commissioners that robust systems and processes are in place to assure themselves that the nursing, midwifery and care staffing capacity and capability in their organisation is sufficient to provide safe care. All NHS Trusts are accountable to the NHS TDA and, as stated in the Accountability Framework 2014-15, will be expected to provide the NHS TDA with assurance that they are implementing the NQB staffing guidance and that, where there are risks to quality of care due to staffing, actions are taken to minimise the risk. Monitor has worked with us in the development of this guidance and expects Foundation Trusts to have the right staff, in the right place at the right time. The Care Quality Commission will be looking for compliance with all the actions outlined in this letter as part of their inspection regime. Monitor will act where the CQC identifies any deficiencies in staffing levels in Foundation Trusts.
We hope that this outline of the required next steps and associated milestones has been helpful.
Yours sincerely,
Jane Cummings Professor Sir Mike Richards Chief Nursing Officer England Chief Inspector of Hospitals NHS England Care Quality Commission
Hard Truths Commitments Regarding the Publishing of Staffing Data
Timetable of Actions
Action Required by Trusts : By When: Periodicity : National Quality Further Guidanc e: Board Expectation(s):
A The Board receives a report every six months on staffing June 2014 Every Six 1, 3 and 7 NQB pages 12, 18- capacity and capability which has involved the use of an Months 22 and 42 evidence-based tool (where available), includes the key points set out in NQB report page 12 and reflects a realistic expectation of the impact of staffing on a range of factors.
This report: • Draws on expert professional opinion and insight into local clinical need and context • Makes recommendations to the Board which are considered and discussed • Is presented to and discussed at the public Board meeting • Prompts agreement of actions which are recorded and followed up on • Is posted on the Trust’s public website along with all the other public Board papers
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B The Trust clearly displays information about the nurses, From April and Each shift 8 NQB pages 48-51 midwives and care staff present and planned in each clinical by June 2014 setting on each shift. This should be visible, clear and at the latest accurate, and it should include the full range of patient care support staff (HCA and band 4 staff) available in the area during each shift. It may be helpful to outline additional information that is held locally, such as the significance of different uniforms and titles used.
To summarise, the displays should: • Be in an area within the clinical area that is accessible to patients, their families and carers • Explain the planned and actual numbers of staff for each shift (registered and non-registered) • Detail who is in charge of the shift • Describe what each member of the team’s role is • Be accurate
C The Board: From April and Monthly 1 and 7 NQB pages 12, 13 • Receives an update containing details and summary by June 2014 and 45 of planned and actual staffing on a shift-by-shift basis at the latest • Is advised about those wards where staffing falls short of what is required to provide quality care, the reasons for the gap, the impact and the actions being taken to address the gap • Evaluates risks associated with staffing issues • Seeks assurances regarding contingency planning, mitigating actions and incident reporting • Ensures that the Executive Team is supported to take
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decisive action to protect patient safety and experience • Publishes the report in a form accessible to patients and the public on their Trust website (which could be supplemented by a dedicated patient friendly ‘safe staffing’ area on a Trust website).
D The Trust will ensure that the published monthly update report By June 2014 Monthly 1 and 7 specified in Row C [i.e. the Board paper on expected and actual staffing] is available to the public via not only the Trust’s website but also the relevant hospital(s) profiles on NHS Choices.
The latter can be achieved either by placing a link to the report that is hosted on the Trust website on the relevant hospital(s)’ newsfeed on their NHS Choices webpage or by uploading the relevant document to the relevant hospital(s)’ NHS Choices newsfeed. For Trusts with multiple hospital sites that have their own NHS Choices webpages, this will require the separate posting of the Trust Board report to each hospital newsfeed. However, this is likely to reach more patients given that patients tend to review hospital, not Trust, NHS Choices webpages. This approach will also allow you to highlight hospital-specific plans and achievements, which may be of particular interest to a public audience.
Given these requirements, the update reports should be written in a form that is accessible and understandable to patients and the public. This is likely to include ensuring that the information on staffing is not embedded within hundreds
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of pages of other Board papers.
Your own NHS Choices web editor(s), who already provide your Trust and hospital-specific content to NHS Choices, will be able to advise you further on their preferred mechanism for making these documents available on NHS Choices – either via a link or by uploading a .pdf of the Board paper. NHS Choices will also be liaising directly with each Trust’s web editors with further information.
E The Trust: Immediate Each Shift 2 NQB pages 16 and • Reviews the actual versus planned staffing on a shift 17 by shift basis • Responds to address gaps or shortages where these are identified • Uses systems and processes such as e-rostering and escalation and contingency plans to make the most of resources and optimise care
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COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG28.7/14 Attachment: G To receive a report on the Care Plan Audit Author Wendy Harlow, Clinical Audit Team Leader Section Performance Presented by Dr Kay Macdonald, Clinical Academic Director
Paper Summary To receive the final report on the Trustwide clinical audit of the Care programme approach (CPA) policy.
Specific points for Sussex Partnership NHS Foundation Trust sets out clear expectations for the Governors to note management and on-going implementation of the Care Programme Approach (CPA) within its policy. This audit formed part of the Trust clinical audit forward plan 2013-14 and aims to identify if improvements have been made, previous good practice is sustained and areas of concern with non-compliance. The Divisions represented are Adult Mental Health Service, Dementia and Later Life Service, Children and Young People and Secure and Forensic.
Points for discussion Governors are asked to consider this report’s conclusions and at meeting recommendations.
Recommendation(s) Governors are asked to receive tis report and ask any questions of the Clinical Academic Director.
Care Programme Approach Re-Audit Report
May 2014
Clinical Audit Team
Author: Sussex Partnership NHS Foundation Trust – Clinical Audit Team
1 1. Contents
Executive Summary
2. Section 1 Pg 4 1.1 Background Information Pg 4 1.2 Aims & Objectives Pg 4 1.3 Standards Pg 5
3. Section 2 Pg 6 2.1 Sample Pg 6 2.2 Overall Sample Pg 6 2.3 Data Collection Pg 6
4. Section 3 Pg 7 3.1 Overall Results Pg 7
5. Section 4 Pg 8 4.1 Conclusion Pg 8 4.2 Recommendations Pg 8
2 1. Executive Summary
Sussex Partnership NHS Trust sets out clear expectations for the management and ongoing implementation of the Care Programme Approach (CPA) within its policy. An annual audit is set as a requirement of the policy to monitor compliance and ensure care delivery standards, whether local or national, are met.
The Divisions represented are Adult Mental Health Service (AMHS), Dementia and Later Life Service (D&LL) Child and Adolescent Mental Health Services (CAMHS) and Secure and Forensic (S&F)
The re-audit results show:
The overall result Trust wide compliance is 72% (n=201 2013/14 The overall result Trust wide compliance is 76% (n=198 2012/13). The overall result Trust wide compliance is 75 %( n=130 2011/12).
Recommendations: Individual service leadership teams are required to demonstrate in their action plans that areas of poor compliance are addressed. In particular, where compliance is significantly less than in previous years. Action plans will undergo audit on a quarterly basis to ensure that actions are implemented and that improvements to the quality of service user experience take place. A Trust wide re-audit of CPA is planned for Quarter 4 2014-15.
Conclusion: There have been significant improvements in compliance in standards of the Trust policy for CPA. This is particularly apparent in adult services where good practice has been maintained or significant improvements have been made. Carer’s assessment have improved in adult services but compliance of 70% remains low and should be addressed. Where there has been a decrease in compliance overall, services must take action to make improvements.
3 SECTION 1
1.1 Background Information The Care Programme Approach (CPA) is used when service-users pose a current or potential risk, have complex needs, and require health and social care authorities to work together to meet these needs. The approach was first introduced in 1990 and, since then, has been “modernized” (NHSE & SSI, 1999) and refocused (Department of Health, 2008). An annual audit is set as a requirement of the CPA policy to monitor compliance and ensure care delivery standards, whether local or national, are met.
The CPA framework for mental health care consists of four essential elements:
A systematic assessment of health and social care needs. An agreed care plan. The appointment of a named care co-ordinator. A regular review to reconsider need and/or risk and to adapt and change care plans as necessary.
Sussex Partnership NHS Foundation Trust is committed to providing a high quality service to its users, demonstrating this by auditing key areas of its services. The results of such audits enable the Trust to meet the requirements of internal and external regulations, such as objective five of the Trust Business Plan, the Care Quality Commission standards and the legal requirements of equality and diversity legislation and the Human Rights Act (Trust’s Clinical Audit Policy).
This Trust wide re-audit was identified as part of Sussex Partnership NHS Foundation Trust’s Clinical Audit Forward Plan 2011-2014. The specific driver for this audit is the Care Quality Commission.
1.2 Aims & Objectives The aims of the audit: To evidence compliance to the Care Programme Approach Trust Policy. To provide assurance and demonstrate compliance with NHS Litigation Authority (NHSLA). o Standard 4.9: Clinical handover of care. o Standard 6.2: Patient Information. o Standard 6.3 Clinical risk assessments. o Standard 6.10: Medicine management. To provide assurance and demonstrate compliance with Care Quality Commission Outcomes: o Outcome 1: Respecting and involving people who use services. o Outcome 4: Care and welfare of people who use services. o Outcome 6: Cooperating with other providers. o Outcome 7: Safeguarding people who use services from abuse. o Outcome 16: Assessing and monitoring the quality of service provision. o Outcome 21: Records.
The objectives of the audit are: To carry out data collection in all Divisions with the designated electronic audit tool. Clinical Audit Team to receive Division reports, collate and produce Trust wide report of findings. Clinical Audit Team to report the results and action plan to the Effective Care Domain and Trust Quality Group for approval and sign off.
4 1.3 Standards
Table 1 – Standards of CPA re-audit. Assessing needs Standard 1. Where appropriate particular attention has been given to issues relating to diversity. Standard 1a. Where appropriate particular attention has been given to issues relating to housing. Standard 1b. Where appropriate particular attention has been given to issues relating to employment. Standard 1c. Where appropriate particular attention has given to issues relating alcohol and or drug abuse. Standard 1d. Where appropriate, particular attention has been given to issues relating to parenting. Carers assessment. Standard 2. Documented evidence that Carers have been made aware of their entitlement to a carer’s assessment. Standard 2a. Documented evidence that Carers have undergone a carer’s assessment. Standard 2b. If carer’s assessment has been completed, documented evidence that the carer is offered a written care plan of their own. Standard 2c. There is evidence that the carer has been provided with crisis contact information. Care Planning. Standard 3. The service user care plan is recovery focussed. Standard 3a. The service user care plan is person-centred. Standard 3b. There is documented evidence the service user has been actively involved in care planning. Standard 3c. There is documented evidence the carer has been actively involved in care planning. Standard 3d. The care plan clearly specifies the care coordinator/named practitioner. Standard 3e. The care plan specifies the contributions of all agencies involved. Standard 3f. The care plan includes agreed goals of intervention. Standard 3g. The service user care plan is written in language/and or format accessible to the service user. Standard 3h. The care plan includes date of the next planned review (no more that six months ahead for Adult Services and good practice for CHYPMHS) Standard 3i. The latest care plan is no more than six months old. Standard 3j. The care plan documents discussions with the service user about their diagnosis. Standard 3k. The care plan documents discussion with the service user about medication and side effects/concerns. Standard 3l. If appropriate, the care plan details discussions with the carer about a service user’s diagnosis. Standard 3m. If appropriate, the care plan details discussions with the carer about a service user’s medication and side effects. Crisis and contingency planning. Standard 4. The crisis plan contains information about who to contact in a crisis 24 hours a day/ 7days a week. Standard 4a. The crisis plan contains phone numbers for crisis contacts. Standard 4b. The crisis plan addresses coping skills, triggers or relapse prevention. Standard 4c. Contingency plans provide information about alternative strategies should the agreed care plan not be implemented in some way. Review on discharge from Acute Inpatient care. Standard 5. Where a person has been discharged from hospital, the care plan includes detailed community /crisis contacts. Standard 5a. Where a person has been discharged from hospital, the care plan includes the name of the care coordinator/ named practitioner. Standard 5b. Where a person has been discharged from hospital, the care plan includes who will undertake the 7 day follow up.
5 SECTION 2 - Methodology 2.1 Sample
In total n=201 health records were audited Trust wide.
The Trust wide audit took place during quarter four 2014. Eligibility criteria for the sample are as follows:
Service users with complex mental health needs. Service users on full CPA. Service users in receipt of mental health care services for a minimum of six months. A proportion of recently discharged patients from Trust inpatient units. A proportion of patients with dual diagnosis of mental health needs, learning disability and substance misuse.
The following Divisions were eligible for the audit:
AMHS, D&LL, CHYPS and S&F.
2.2 Overall Sample
Table 2. - Overall sample size per Division. Division. Total Total number of Total number of service Total number of community users discharged from sample teams. service users. in-patient care within size. last 12 months. AMHS n=10 n=60 n=20 n=80 D&LL n=7 n=31 n=16 n=47 CHYPS n=7 n=38 n=6 n=44 S&F n=2 n=18 n=12 n=30 Total n=26 n=147 n=54 n=201
2.3 Data Collection Data collection was conducted within each Division with the Clinical Audit Team taking responsibility for delegation to each team and collation of Division results. All audit samples were chosen at random and met the eligibility identified for CPA identified sample.
6
SECTION 3 - Results The results section outlines the overall performance in relation to the agreed audit standards.
Graph 1. – Overall compliance by standard and by service
Overall Comments
Standard one, assessing needs, shows improvement for all services and a significant increase in compliance overall from 87% to 96% Standard 2, carers assesment,compliance has seen a decrease of compliance from 52% to 32%. In adult’s services this has improved from 56% to 70%, however, in CAMHs this has reduced from 45% to 20% and in D&LL from 75% to 39%. S&F reported 0% compliance with this standard as a result of no carers assessment documentation available for staff to use in practice which is embedded within Web ecpa. Standard 3, care planning, has seen a slight drop in compliance. In D&LL this has decreased form 83% to 62%. In all other services there has been an increase in compliance. Standard 4, crisis and contingency planning, has seen an overall drop in compliance from 83% to 68%. Adult services have seen an improvement in compliance from 75% to 86%. In all other services compliance is lower this year than in previous audits. In S&F this was reported as 76% this year as oppose 94% 2012-13, in D&LL this was reported as 68% as oppose 74% in 2012-13 and in CAMHs this was reported as 42% as oppose 47% in 2012- 13. Standard 5, review on discharge form acute inpatient care, saw an overall improvement in compliance from 84% to 88%. In D&LL there has been a significant decrease in compliance from 100% to 80%. In all other services this has shown improved compliance.
SECTION 4
4.1 Conclusion There have been significant improvements in compliance in standards of the Trust policy for CPA. This is particularly apparent in adult services where good practice has been maintained or significant improvements have been made. Carer’s assessment have improved in adult services but
7 compliance of 70% remains low and should be addressed. Where there has been a decrease in compliance overall, services must take action to make improvements.
4.2 Recommendations Individual service leadership teams are required to demonstrate in their action plans that areas of poor compliance are addressed. In particular, where compliance is significantly less than in previous years. Action plans will undergo audit on a quarterly basis to ensure that actions are implemented and that improvements to the quality of service user experience take place. A Trust wide re-audit of CPA is planned for Quarter 4 2014-15.
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COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG29.1/14 Attachment: H Overview of Complex Care Pathways Author Lorraine Reid, Managing Director, Specialist Services Section Strategy Presented by Lorraine Reid, Managing Director, Specialist Services
Paper Summary This paper provides an overview of complex care pathways provided by the Trust. It outlines the services within the care group and illustrates their work with two vignettes.
Specific points for Complex care pathways care group is managed by Dr Brian Solts Governors to note Previously known as specialist services, complex care pathways has recently become a care group in its own right. Services provided relate to both core adult and specialist services as many of the services involve specialist support or are for people who are in transition. Brian and his team work closely with commissioners in Sussex and with NHS England The guiding ethos is that mind and body cannot be separated and every interaction is an opportunity to promote this connection Clinical excellence is the driver for growth or expansion
Points for discussion The challenging nature of managing and promoting these services at meeting
Recommendation(s) This paper is for information and discussion.
Sussex Partnership NHS Foundation Trust Council of Governors: 16 June 2014 - Public Agenda Item: CG29.1/14 Attachment: H For Information By: Lorraine Reid, Managing Director of Specialist Services
SPECIALIST SERVICES THEMED REPORT
1.0 INTRODUCTION
My update this quarter is in the form of a themed report. I am currently in the process of introducing a development programme for specialist services which will improve staff engagement and create robust business plans for the future. Working very closely with corporate services, I hope to introduce more autonomy for services in the specialist services group. I want to do this by putting clinical excellence at the heart of everything we do. In this way all our ventures, service models, growth research and development will improve outcomes and enhance service user experience. This is an exciting project which will influence everything we do in specialist services. The project structure and plan is in place and the corporate reference group has developed a tool kit for leadership teams to use to develop their plans.
2.0 OVERVIEW OF ISSUES IN SPECIALIST SERVICES
The business continuity plan for children and young people’s services in Kent is demonstrating good progress in reducing waiting times for assessment and treatment and remains on target and in line with our activity forecasts. Pressures in the system continue, consistent with the national picture within these services, however, the issues around a place of safety in relation to Section 136 of the Mental Health Act are being resolved. However, we are working in a productive way with commissioning colleagues and hope that a more integrated approach to commissioning services in the future will prevent some of the challenges we have been experiencing. We reported back to the Health and Overview Scrutiny Committee (HOSC) in April. Since January discussions between stakeholders have resulted in a clearer representation of the complexity of the situation and better understanding. The progress we have made since the last meeting was noted and we were invited to provide a further progress report in six months. Over the coming months we will be working with another provider to review the service model in Kent, in line with the recommendations made by the HOSC in January.
In inpatient services, matrons have introduced a system for displaying and reporting staffing data in line with the national requirement to do so.
Mayfield Court, in Eastbourne is now open and has received the first few tenants. This facility is for people who have a learning disability and complex needs. It offers one bedroom flats where people can live within their local community, while being supported to gain greater independence, it is an alternative to more traditional forms of care often provided at a distance from home. We feel that it meets the recommendations of the Winterbourne View Inquiry and is an innovative model offering bespoke care. Karen Braysher and I had a very informative visit in May, about which Karen has written an article for Membership Matters.
3.0 THEMED REPORT
Complex Care Pathways: Care Group Director Dr Brian Solts
Introduction
Complex care pathways was recognised as a care group when the specialist services directorate was formed in 2013. Dr Brian Solts, provides overall clinical leadership assisted
1 of 4 by Alison Rhodes, General Manager. This change represented a real milestone for this group of services, previously known as specialist services. The renaming of these services as complex care pathways was intended to avoid confusion and provide greater clarity over their clinical function.
The biggest common denominator for the care group is that the constituent services do not fit easily into core adult services or geographical trust structures. These services always interface with mainstream teams and cut across a number of traditional service boundaries such as primary or secondary care, psychiatric or acute hospitals. The people who use the services tend to be ‘in transition’ one way or another: either moving through as a step up or a step down or in receipt of a specialist assessment to try to clarify diagnosis or to help them move into a more sustainable period of recovery. These services also are set up to be a clinical resource for adult services, providing additional input for complex patients when they are most in need.
Service provision
There are 15 direct clinical services with approximately 60 whole time equivalent staff, a commissioning team and a budget of around £2.25m. Teams are clinically led; in addition to direct clinical services they are involved in education, training and research, as well as consultation and supervision. Examples of the work include:
specialist assessments by neuropsychiatrists and neuropsychologists for neurodevelopmental or neuropsychiatric conditions services for people with severe eating disorders intensive day treatments for people with complex recovery needs and a diagnosis of personality disorder services for people with co-existing mental and physical health problems including HIV/AIDS interventions in acute hospitals such as pain management programmes (key to muscular skeletal care pathway) stroke and other highly specialized areas
In summary, these are a diverse range of small services, spread across Sussex, providing highly specialist services that would not otherwise be available within local mainstream teams across the whole of Sussex.
Strategy
1. Clinical excellence should drive all opportunities for growth and expansion. 2. Working closely with Clinical Commissioning Groups (CCGs) to develop constructive relationships with lead GP commissioners 3. To be known for creative models of partnership working that add value: within the trust, with third sector and acute hospital trusts. 4. To develop a marketing strategy that demonstrates the value in terms of quality of outcomes 5. To develop the relationship with NHS England 6. Continuing to develop a national and international profile through teaching and research – ensuring we have adequate succession plans for the leads of our services and continue to develop new talent for the future
Quality
Mechanisms are in place to ensure positive experience and high quality outcomes. These include: A quarterly team reporting structure that provides an overview of team activity including direct clinical work, outcomes, teaching and training provided, compliments & complaints. The quarterly clinical reports of activity feed into quarterly governance meetings. Working in this way, issues can be picked up and addressed where there are difficulties, teams can be commended for their work and innovation rewarded. Page 2 of 4
These quarterly reports go to CCGs as part of the overall performance reporting to commissioners for service level agreements.
In addition to quarterly reports, the care group also feeds into the trust audit department. During 2012-2013, the care group took part in mandatory trust audits, such as record keeping and patient experience. The latter audit on patient experience was adapted slightly for these services and showed that earlier improvements in patient satisfaction were maintained, with good standards for treatment planning for instance, but that there is a need to focus on the needs of carers. Other audits were carried out for the benefit of the service, for instance an eating disorder audit focused specifically on outcomes for Payment by Results (PbR) reporting and compared team evaluations of PbR clusters with general services. This showed inconsistencies in how decisions were made in clustering and led to a training plan to improve the consistency of PbR decision making for people with eating disorders.
Research
There is some variability across teams with regards to research activity. For some teams, research has become integral to their activity and there are good links with the Research Department. There are three neuropsychiatrists on honorary contracts with the neurobehavioural and neuropsychiatry services, who are employed by the Brighton & Hove Medical School. In addition, the care group has supported the clinical lead for personality disorders to undertake research and this is presently focusing on patient outcomes within Tier 3 services, early intervention for borderline personality disorder, and an intervention for young people. Other research activity includes evaluation of a new group therapy service for adults with attention deficit hyperactivity disorder, a focus attachment styles within complex trauma, and several small scale projects.
Clinical vignettes
“Your heart & mind safe in our hands”
The care group believes that it is impossible to separate mental health from physical health. Whether this is the physical impact of severe eating disorders and the associated medical risks, or the consequences of long term self harm, the aim is to try to work across the mental health – physical health interface. This also applies in the direct services provided within in acute medical settings, for example within pain management services where opportunities for growth rely on promoting greater understanding of this connection.
Sammy: Diagnosed with severe depression and a personality disorder Sammy is in her late 20s and was first referred for help about 7 years ago following the breakdown of her work life brought about by the onset of a severe depressive illness. She was cutting her body regularly and severely. At 12 she started damaging her body in response to overwhelming feelings of anxiety about being bullied, and it seemed to also provide a great distraction from her difficulties at home – her mother had severe mental health problems and she was also grieving the loss of a close family member.
Over the course of her treatment, mental health services worked closely with physical health teams. This was not an easy process. Tensions emerged at regular intervals over how best to work together with Sammy and manage acute medical crises when she was refusing help. It was challenging to get all the teams into the same room to talk directly about her care. The mental health teams, accident & emergency services and her GP have had to ensure close liaison to prevent knee jerk reactions while trying to manage the risk, but over time staff consistency and positive attitudes has enabled Sammy to feel able to begin to use psychological approaches to enable her to make choices about her own recovery and to begin to challenge her immense fear of people and rejection.
Page 3 of 4 Laura: Chronic pain Laura was in her early 60s when she presented to the pain service with persistent pain in the lumbar region of her spine radiating down into her left leg. She experienced constant chronic pain, which impacted on her mobility, social activities, sleep, mood and ability to self care. She was also recently involved in a road traffic accident resulting in whiplash injuries with further sleep disruption caused by nightmares about the accident. She also developed chronic obstructive pulmonary disease (COPD) 5 years ago and was trying to give up smoking. She was desperately struggling to maintain her work as a nurse, her husband having recently left her saying she was no longer the person he married, leaving her with considerable financial pressures. Her 4 children thought she just needed to pull herself together and she provided financial support to their families in addition to childcare.
During her first psychology appointment, she reported that her quality of life was now significantly affected by her health conditions and knew this would only get worse over time. She wondered if it would just be easier to take a handful of her numerous medications and not wake up. She was overwhelmed by her problems and did not know where to start in tackling her difficulties. Additionally, her medication for pain made sustaining concentration very hard. Over time, these appointments helped Laura to understand the relationship between her personal history, life events, her medical conditions and the physical and mental distress she was experiencing. She recognised work as a priority, without this she would lose her home and spiral into debt. She did some individual work with the psychologist to deal with her psychological arousal and re-experiencing trauma symptoms following her accident. As her mood improved, her suicidal feelings declined.
A joint assessment with a pain service physiotherapist suggested adaptations she might make at work, and Laura worked with her manager and occupational health to support her make adaptations to the workplace. She also had to learn to be assertive when colleagues at work forgot about her needs, which was difficult as she had always put others first. After this, she joined a pain management programme, and began to pace activities to manage her pain and was also taught how to improve her sleep. She also tackled her over reliance on analgesics Pacing activity reduced the number of flare ups she experienced and eventually she was able to reduce her medication enabling her to concentrate better at work. Gentle exercise and breathing techniques learnt on the programme helped her manage her COPD as well as her pain. Another goal was to stop smoking which her GP was able to help her with.
4.0 RECOMMENDATIONS
Governors are invited to note the contents of the report and ask any questions and offer any suggestions for future themed reports.
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COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG29.2/14 Attachment: I To receive an update on Adult Mental Health Services Author Anna Lewis, Managing Director of Adult Mental Health Services Section Strategy Presented by Tbc (Anna Lewis on annual leave)
Paper Summary The paper provides on update on key issues in Adult Services, including: - operational service pressures - quality improvement
Specific points for To note progress against key operational and strategic priorities Governors to note
Points for To provide comments and feedback on the content of the report discussion at meeting
Recommendation(s) For the Council of Governors to note the contents of the report and ask any questions arising.
Sussex Partnership NHS Foundation Trust Council of Governors: 16 June 2014 - Public Agenda Item: CG29.2/14 Attachment: I For Information By: Anna Lewis, Managing Director of Adult Services
ADULT SERVICES UPDATE FOR COUNCIL OF GOVERNORS
1. Purpose of the Report
This report provides an overview of the key issues and challenges in Adult Services over the last quarter, and the actions we are taking to address them. In addition, it highlights areas of good practice which we are seeking to spread across all services. Please accept my apologies that I cannot be present to report in person, due to annual leave.
2. Operational Service Pressures
Since my last report in March 2014, Adult Services has been faced with sustained pressure in its acute care pathway. For the majority of the last quarter, we have been reliant on bed capacity outside our Trust to accommodate the demand we have seen, particularly for psychiatric intensive care (PICU). North West Sussex (Langley Green Hospital) has seen greatest pressure, which then has had a knock-on impact on the rest of Sussex. At its worst, the number of ‘out of area’ placements was in the region of 25. Following intensive work throughout May, the position at the time of writing is zero use of independent sector beds, and two NHS PICU Care beds outside Sussex. We were able to cease the short term contract we put in place with the Priory Group after 4 weeks as planned. This is a huge improvement and achievement, which our staff have shown real commitment to deliver, yet the challenges associated in sustaining this position are significant. There is a wide-ranging action plan in place, tackling both operational and strategic measures, internally and externally. This covers all aspects of our service delivery, on the understanding that use of acute care is influenced largely by the ease of access to community-based alternatives in both crisis and non-crisis situations. We are very conscious of the impact that an out of area admission can have on individual service users and so we are focussing hard on the quality aspects of this pressure in our dialogue with commissioners and other partners.
While North West Sussex gets to grips with the pressure in its acute care pathway, it is simultaneously progressing its action plan in response to the CQC inspection in February 2014. Mindful of the CQC challenge about the pace at which we have been able to deliver change at Langley Green Hospital, we have been providing specific Executive support to unblock barriers, facilitate solutions and provide encouragement and support to the local team. We have also put in place additional assurance to test progress. We are planning an open day in early July, targeted towards clinical commissioners, as an opportunity for colleagues to meet the clinical leadership team, see the hospital in action, and present the work we have been doing in response to the CQC concerns. This is consistent with the ‘open door’ approach we have been encouraging at the hospital. For service users and carers, a regular newsletter is being produced, and easy access to senior staff, including the Director of Nursing and Quality, has been publicised on the wards.
3. Quality Improvement
Dementia and later life services are continuing to work on pathway developments to ensure that people get smooth access to the skills and expertise that can most help them, and thus
Page 1 of 2 overcome unhelpful service boundaries. This is a complex piece of work which has the full engagement of our Clinical Directors.
Our new improved urgent access pathway in West Sussex went live in April. This means that GPs have easy access, over extended hours, to ‘phone consultation with expert practitioners and the ability to refer someone to be seen within five days. This is in addition to longstanding access targets of 4 hours and 4 weeks respectively.
Rapid improvement work continues in Crawley and Horsham, despite ongoing problems with vacancies in the local teams, which we are addressing. The work has facilitated closer collaboration with GP colleagues as well as the third sector, and progress is steady.
A strategic ward staffing review of our core inpatient services has been initiated. This is designed to review the quality of experience we are able to provide on the wards as they are currently staffed, and explore how we might organise staffing differently to improve the therapeutic experience. This looks at skill mixes, shift patterns, continuity of care and other aspects of our operation. It will report back later in the summer.
A fundamental review of our CPA policy and practice was launched recently, with service users, carers, governors, frontline clinicians and managers coming together in a workshop held at Mill View Hospital. We have real ambition for this work, to ensure that a recovery- oriented approach to care delivery is embedded in our policies and that in turn those policies support collaborative practice which put service user needs at the forefront of care.
At the end of May we were delighted to host a two day visit from the leaders of the national Positive Practice in Mental Health Collaborative, Angie and Tony Russell. They visited a broad range of our specialist and adult services and were very positive in their feedback to us. We have submitted several applications for the annual awards they organise too.
Finally I am pleased to announce that we are embedding a quality improvement approach within our ways of working. An important step forward is the establishment of Service Improvement lead roles for each of our major improvement initiatives – for acute, rehabilitation and personality disorder pathways, community pathways, and dementia pathways. These are the priorities for development that we identified as part of our 2014/15 planning process. The postholders provide facilitation for clinicians in redesigning pathways of care so that we deliver better outcomes and value for money. The early stages of this work are showing much improved clinical engagement, and a sense of re-energising people who have felt the impact of major change over recent years. We have a long way to go in delivering our programme of work, yet feel hopeful for its impact in the long term. We are also in early development in terms of our co-production of this programme with service users and carers, and have received some very positive feedback about this recently.
4. Summary
As this report illustrates, we have a very ambitious programme of work, and at times the immediate service pressures do conflict with our medium to long term goals. We are mindful of these risks and working proactively to mitigate them as far as we are able. We continue to work with optimism and confidence that we can and will fulfil our ambitions for consistently excellent care for the people of Sussex.
Anna Lewis Managing Director Adult Services
Page 2 of 2
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG29.3/14 Attachment: J Sussex Partnership’s 5 Year Business Plan Update Author Sally Flint, Executive Director of Finance and Performance Sam Allen, Commercial Director Section Strategy Presented by Sally Flint, Executive Director of Finance and Performance Sam Allen, Commercial Director
Paper Summary The purpose of the presentation is to outline Sussex Partnership’s 5 year business plan and to give council members the opportunity to ask questions and provide feedback.
Specific points for The plan will be submitted to the Board for approval when it meets on 25 June, Governors to note in time for submission to Monitor by the 30 June deadline.
Points for discussion at meeting
Recommendation(s) The Council is recommended to note the presentation and ask any questions of the Executive Director of Finance and Performance and the Commercial Director.
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG29.4/14 Attachment: K Discussion on the Trust approach to the Smoking Policy/Review Author Neil Jackson, Director of Estates Section Strategy Presented by Sue Morris, Executive Director of Corporate Services
Paper Summary The purpose of the policy review is to refresh current policy and existing compliance with the policy. The review brings together current initiatives and best practice from other NHS organisations in meeting the requirements of national policy, improving health and wellbeing and reducing fire risk. Staff and service users will be involved in developing solutions and implementation plans.
The policy review will recognise current position and set out the terms of reference and actions for an implementation group oversee any required changes to current practice.
The review will include e-cigarettes which will be treated in the same way as traditional cigarettes unless significant government policy guidance directs the Trust to do otherwise. This is not only from a heath perspective but from the fire risk posed by these devices (three fire incidents caused by e-cigarettes on trust premises to date).
In England in 2011, an estimated 79,100 adults aged 35 and over died as a result of smoking, accounting for 18% of all deaths. An estimated 462,900 hospital admissions of people from the same age group were attributable to smoking, accounting for 5% of all admissions (Health and Social Care Information Centre 2013).
The National Institute for Health and Clinical Care Excellence (NICE) guidance “Smoking cessation in secondary care: acute, maternity and mental health services” (2013 p5) states:
“Secondary care providers have a duty of care to protect the health of, and promote healthy behaviour among, people who use, or work in, their services. This duty of care includes providing them with effective support to stop smoking or to abstain from smoking while using or working in secondary care services. This guidance aims to support smoking cessation, temporary abstinence from smoking and smoke free policies in all secondary care settings. It recommends: Strong leadership and management to ensure secondary care premises (including grounds, vehicles and other settings involved in the delivery of secondary care services) remain smoke free – to help to promote non-smoking as the norm for people using these services.”
Conclusive evidence identifies that exposure to second hand smoke (breathing other people’s tobacco smoke) causes fatal illnesses including lung cancer and heart disease. Major reviews of the evidence by bodies including the International Agency for Research on Cancer, the UK Scientific Committee on Tobacco and Health, the US Surgeon General (2006) and the US Environmental Protection Agency have concluded that second hand smoke is a major health hazard.
Smoking is also not allowed by law in any enclosed workplace, public building or on public transport in the UK (Prohibition of Smoking in Certain Premises Regulations 2006)
Secure and Forensic Services has taken the initiative to be the first major service within the trust to adopt a smoke free environment based on the best practice model from the Bracton Centre Forensic Services. The service has engaged with its staff and patients to develop a smoking cessation plan with the aim of becoming smoke free by October this year.
Each clinical service will have its specific issues and challenges in working towards meeting the trust wide policy aims and objectives. Each service would be expected to work with its staff and patient group to develop implementation plans relevant to that service.
Specific points for The current policy is only partially compliant with national policy. The review Governors to note will need to focus more on the approaches to improving compliance and promoting healthy lifestyles.
This is a policy that forms a part of the wider public health agenda of preventing premature death as a result of smoking. National policy sets the expectation that health providers will promote healthy lifestyles and take specific action to promote non-smoking as the norm.
It is recognised that whilst achieving a smoke free environment is the overall national aim no one solution fits all and some services may take significantly longer to achieve this outcome.
Points for discussion Whist recognising that the whole of the Public Health, Social Care and NHS at meeting has a responsibility to make non-smoking the norm, what could the trust do to help staff and patients make these sorts of lifestyle changes?
Recommendation(s) To review the findings and best practice in other similar organisations with a smoking policy group. This best practice and other feedback are then to be used to inform any amendments to the policy.
Understand the current position on the ground and develop improvement plans in each service which will include input from staff and patients of that service.
Undertake a post implementation review of the ‘pathfinder’ project in Secure and Forensic Services and share lessons learnt with other services.
Recognise that working to achieve the aim of making ‘non-smoking the norm’, even if this take time to achieve, is a very worthy aim as every step we make to reduce smoking is not only a benefit to that individual but to those around them.
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG29.5/14 Attachment: L Membership Development Strategy Author Andy Porter, Deputy Director of Social Work Section Membership Development Strategy 2014 Presented by Andy Porter, Deputy Director of Social Work
Paper Summary The Membership Development Strategy 2014 gives an overview of our membership structures and confirms the importance of membership within the organisation. The paper looks at achievements in 2013/14 and sets priorities for 2014/15.
Specific points for The paper gives a detailed breakdown of membership data and shows an Governors to note increase in the combined public membership of 388 during the year.
Points for discussion The paper illustrates the important role that governors play in supporting at meeting membership involvement. How can we build on this in 2014/15?
Recommendation(s) The Council of Governors is asked to agree the Membership Development Strategy 2014.
Membership Development Strategy 2014/15
Andy Porter: Deputy Director Social Work
Introduction
Sussex Partnership NHS Foundation Trust provides NHS mental health , learning disability, substance misuse and prison healthcare services across Sussex , and a developing range of specialist services across the south east of England and beyond. We became an NHS Foundation Trust in 2008.
The Trust and its Council of Governors recognise and highly value the important role and function members have in making the Trust a success. Our Membership Development Strategy outlines our plans to maintain, grow and inform a representative and active membership. These plans continue to evolve and grow as our Foundation Trust matures. The Council of Governors, via the Membership Committee, has responsibility for the membership strategy. It reviews the strategy annually and supports its development to ensure the continuous growth of and engagement with the membership.
The appointed members of the Council of Governors reflect and represent our extensive partnerships across the statutory and voluntary sectors. Alongside our staff, the elected membership is drawn from constituencies which represent our patients, their carers and the local residents of Sussex and the other areas we serve.
In developing this strategy we have been particularly mindful of service developments that have already changed us to an organisation operating across a much wider area than Sussex. A key element of the strategy is to ensure that Foundation Trust Membership and representation through the Council of Governors genuinely reflects our staff, patients and carers and the wider public in every area where we operate. Currently we have very few public members from outside of Sussex.
What is Membership?
Through our membership, Sussex Partnership can be closer to the people we serve and more accountable to them than ever before. Membership builds on existing partnerships and also supports new partnerships.
Our membership policy is inclusive. No special skills or experience are required to be a member of our Foundation Trust but members should be interested in our services and compassionate towards people with mental health, learning disability or substance misuse problems. We are committed to encouraging everyone who is eligible to become active members of Sussex Partnership.
We currently have three constituencies:
Constituency Criteria Service User For people who have within 5 years preceding the date of application attended the Trust as either a service user or as the carer of a service user. The constituency is sub-divided into 5 classes to represent geographical areas (West Sussex, Brighton & Hove, East Sussex, An Area Outside of Sussex serviced by the Trust) a carers’ class.
Public For people interested in our services who live in West Sussex, Brighton & Hove, East Sussex, An Area Outside of Sussex serviced by the Trust Staff All Sussex Partnership permanent staff, those on a fixed term contract of at least 12 months and social care staff who work in the Trust are automatically offered membership. (Membership is not mandatory for staff)
Our members:
Can elect other members as governors and stand for election as governors themselves Are able to take part in surveys, questionnaires and discussions about our services, helping to develop them and comment on how we can improve Can tell us about the needs and expectations of local communities and groups Receive preferential invitations to seminars and members’ meetings, where they can meet governors and senior Trust staff Are encouraged to recruit new members and spread the word about Sussex Partnership, the importance of our services and the need to tackle stigma and discrimination Receive a regular newsletter and have access to a members’ area on our website Can interact electronically with the Trust Chair and other members
Our members:
Are a valuable resource, bringing knowledge, enthusiasm and time Assist in determining our values and developing our services. Provide a potential pool of recruitment to paid employment and volunteering opportunities within the Trust.
It is our aim to link membership with our wider patient and public involvement work. When we need to consult the public, or a section of the public we will look to our membership in the first instance. When we are seeking to involve patients, carers and the public in the life of the organisation for example in the development of strategy and policy, we will draw on our membership as the way of identifying people interested in these opportunities. When we are creating opportunities for volunteering we will make sure that our members have every opportunity to participate and be involved.
We are also aware that as our services for children and young people expand there is an increasing need to find ways of making membership available and meaningful to the young people who are using our services.
Our Membership base
Detailed information about our membership is included in the data tables at the end of this report.
As of 1st April 2014 our total membership is 13,675, with a combined public membership of 9,972. This represents an increase of 388 in the combined public membership from April of 2013. Analysis of the data tells us that compared to the local population we have an under representation of young people, an under representation of people aged over 75 years, and an under representation of men. With regards to black and minority ethnic members in most categories our membership is broadly the same as the local demography. However, we currently have only one member who identifies as a Gypsy and Traveller, and one member who defines as Arabic.
Data about sexual orientation, transgender, and disability has only been collected since 2011 and so for the majority of members we do not currently have this information.
This strategy identifies key actions that address the issues identified above.
The Membership office and the Membership Committee
The Membership function is managed within the Social Care and Partnerships Directorate reflecting the increased emphasis on linking membership to wider engagement activities.
The Membership office team works closely with the Chief Executives Office, the Governors support team, Charitable funds, and the Marketing and Communication department.
The Membership office maintains an extensive members data base. This enables us to keep track of our extensive membership and to analyse data in order to identify trends in membership. The data base has new functions and capabilities including the capacity to send emails to members which is a function we are now using regularly.
The Membership office is based at Aldrington House in Hove.
The Membership Committee is comprised of elected governors and plays an important role in the development of membership and in the planning and commissioning of our Membership magazine.
The Membership office is keen to support governors in developing initiatives in the community for example events and meetings.
The Membership Committee was involved and consulted on the development of this strategy.
Communicating with members
Communicating effectively with a large and diverse membership will always be a challenge and we seek to do this through a range of different approaches.
Members receive a quarterly newsletter and the Membership Committee plays an important role in determining the content and direction of the magazine. Recent issues have aimed to have a more informal approach and to carry more articles written by members themselves.
We also hold members meetings which are advertised in Membership Matters.
As well as our four page Membership brochure we have also designed a simple Membership postcard which will be more accessible for recruitment at public events and forums. The Membership brochure has been amended to take into account the wider area we serve.
For the future our aim is to make much greater use of social media and new technology as a way of maintaining an active relationship with our membership across the wider area that we now cover and may cover in the future.
Achievements in 2013/14
During 2013/14 we have regularly attended community events in order to promote membership and the wider work of Sussex Partnership. This has included events as a part of World Mental Health week, and events linking with carers, with Healthwatch and with the Recovery College. We also played an active part in the work of the Worthing Mayors Charity. All of these events have had the support and involvement of our FT governors. We have worked closely with the governors in the Membership committee to involve them in our wider patient and public involvement work. Over 40 members attended the Trust AGM in July.
We have also used Twitter to promote events and activities throughout the year.
We have regularly taken the opportunity to contact members by email to inform them of events and opportunities. These are listed below. Each reaches over 7000 members with email addresses.
1. Albion in the Community - Game Changers 2. Hastings and Rother Recovery College pilot ready to launch! 3. Service User Stakeholder Engagement Events 4. Invitation to seminar: Involvement in Mental Health Research and launch of Voicing Care giving Experiences 5. Equality Performance Scheme - Your Feedback is Important to Us 6. Interested in being a Governor? 7. Review of Sussex Partnership public website 8. Request for help – Service User and Carer views on bed numbers at Mill view 9. Dementia Strategy Engagement Event for Patients and Carers 10. Albion in the Community - Could You Be a Human Book?
Members have been asked to respond to two surveys throughout the year. One was as online questionnaire to support the public consultation with regards to our new equality strategy, and the other was a specific survey linked to Membership Matters which asked for readers’ views and ideas for the future. We worked with the Communication team to review the style and format of the magazine and this informed the survey undertaken
Following the Health and Social Care Act 2012 all Foundation Trusts were required by Monitor to make changes to their constitutions. At this time, the Council of Governors took the opportunity to review their current composition and agreed to reduce the overall size of the Council from 41 to 32, introduce an Outside of Sussex class within the Service User and Public constituencies and introduce an appointed governor position for an organisation that supports Children and Young People with a Mental Health Problem. This ensures that our Council of Governors reflects the membership across the whole organisation.
The Membership Office regularly responds to telephone and email inquiries from members and members of the public about a diverse range of issues.
Priorities for 2014/15
Our main priorities for 2014/15 as reflected in this report are outlined below:
To ensure that membership reflects the wider geographical area that we cover and that we are flexible enough to allow membership to expand to cover new areas and new developments. To ensure that membership is open and attractive to all and to take steps to encourage active involvement from those groups who are currently underrepresented. To ensure that there are strong links between membership and our wider strategies for patient and public involvement and the promotion of social inclusion. To employ social media and new technologies as an effective means of maintaining a large membership across a wide geographical area. To ensure that membership supports the delivery of Trust strategy and policy. To maintain strong links between membership and the Council of Governors. To strive to ensure that membership matches the diversity of the populations we serve. To maintain membership at a size sufficient to deliver credible elections to the Council of Governors To take action to ensure the active engagement of current members and the recruitment of new members To maintain an accurate membership data base. To improve data quality with regards to the protected characteristics in the Equality Act 2010.
Appendix: Our membership base
Public Membership Targets (actual numbers in brackets)
April April April April April April April April 2008 2009 2010 2011 2012 2013 2014 2015 Public 1200 2160 3120 5770 5600 5900 6200 6500 (2975) (4506) (5282) (5353) (5300) (5430) Service User 1600 2865 4135 3600 3450 3600 3750 3900 (2297) (2935) (3301) (3400) (3481) (3716) Carer 200 375 545 830 850 900 950 1000 (582) (730) (801) (812) (813) (826) Total 3000 5400 7800 10200 9900 10400 10900 11400 (5854) (8171) (9384) (9565) (9594) (9972)
Analysis of Current Membership as of 1ST April 2014
Public Service Users Carers Staff Total Brighton & Hove 1644 824 136 ‐ 2604 East Sussex 1559 1113 274 ‐ 2946 West Sussex 2135 1611 387 ‐ 4133 Out of Area 92 168 29 ‐ 289 Staff ‐ ‐ ‐ 3703 3703 TOTAL 5430 3716 826 3703 13675
Analysis of Current Membership as at 1st April 2014
Catchment Baseline Membership Segmentation Base % of Area Total % of Membership Age 1,634,304 100.00 13675 100.00 0‐16 305,416 18.69 4 0.02 17‐21 93,908 5.75 354 2.60 22+ 1,234,980 75.57 12204 89.24 Not stated 0 0.00 1113 8.14 Age 22+ 1,234,980 75.57 12204 89.24 22‐29 152,933 9.36 1337 9.77 30‐39 192,301 11.77 1884 13.77 40‐49 237,274 14.52 2957 21.62 50‐59 210,634 12.89 3019 22.10 60‐74 272,914 16.70 2330 17.03 75+ 168,924 10.34 677 4.95 Gender 1,634,305 100.00 13675 100.00 Unspecified 0 0.00 86 0.60 Male 796,299 48.72 4718 34.50 Female 838,006 51.28 8871 64.80 Transgender 14 0.10 Sexual Orientation 13675 100.00 Bisexual 249 1.82 Gay 94 0.70
Heterosexual 2462 18.00 Lesbian 68 0.50 Not Stated 10770 78.75 Undecided 32 0.23 Disability 13675 100.00 Aspergers/Autism 38 0.30 Blind/Partially Sighted 22 0.16 Deaf/Hard of Hearing 59 0.43 Dyslexia 193 1.42 A learning disability 117 0.85 A mental health problem 1292 9.44 I do not have a disability 10093 73.80 Need Personal Care/Support 95 0.70 Any other special need (please list in the 'Notes' section) 47 0.34 Unseen Disability e.g. diabetes, epilepsy, asthma, HIV, cancer. 420 3.07 Wheelchair User / Mobility impairment 183 1.33 Not stated 1116 8.16 Ethnicity 1,606,932 100.00 13675 100.00 White ‐ English, Welsh, Scottish, Northern Irish, British 1,420,338 88.39 10926 79.90 White ‐ Irish 13,717 0.85 187 1.40 White ‐ Gypsy or Irish Traveller 2,086 0.13 1 0.00 White ‐ Other 69,292 4.31 470 3.40 Mixed ‐ White and Black Caribbean 7,015 0.44 41 0.30 Mixed ‐ White and Black African 5,103 0.32 41 0.30 Mixed ‐ White and Asian 10,204 0.63 83 0.60 Mixed ‐ Other Mixed 7,714 0.48 62 0.50 Asian or Asian British ‐ Indian 14,908 0.93 143 1.04 Asian or Asian British ‐ Pakistani 6,202 0.39 35 0.25 Asian or Asian British ‐ Bangladeshi 4,755 0.30 9 0.06 Asian or Asian British ‐ Chinese 7,890 0.49 41 0.30 Asian or Asian British ‐ Other Asian 15,000 0.93 123 0.90 Black or Black British ‐ African 9,262 0.58 216 1.57 Black or Black British ‐ Caribbean 2,989 0.19 40 0.30 Black or Black British ‐ Other Black 1,995 0.12 43 0.31 Other Ethnic Group ‐ Arab 3,903 0.24 1 0.00 Other Ethnic Group ‐ Any Other Ethnic Group 0 0.00 147 1.07 Not stated 0 0.00 1066 7.80
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG29.6/14 Attachment: M Sussex Partnership NHS Trust Charity – Fundraising Review & Strategy Author Rachael Duke, Head of Fundraising Section Performance Presented by Rachael Duke, Head of Fundraising
Paper Summary This paper provides an evaluation of Sussex Partnership NHS Trust Charity’s activities over the last 5 years to determine its readiness for fundraising. Following this review the paper recommends a strategic approach to position the charity for fundraising and a subsequent fundraising strategy.
The paper was reviewed and all recommendations approved by the Charitable Funds Committee on 14 April 2014.
The attached paper contains a detailed review and strategy, recommendations for action and a cost benefit analysis for Fundraising expenditure.
The Charitable Funds Committee were asked to review the strategy and implement its main recommendations to enable the charity to raise £625,000 over the next three years. These recommendations include:
Develop a vision and mission for the charity, working in partnership with service users. Renaming the Sussex Partnership NHS Trust Charity to Without Stigma Creating a brand identity for the renamed charity Investing in fundraising materials including website, literature, community fundraising materials etc. Developing a shared social media strategy between the Charity and Trust Purchasing a Charity fundraising database Implementing a relationship management protocol for thanking donors Recruiting a Fundraising Officer and additional finance resource (likely to be a 0.5 FTE Finance Officer) to support the Head of Fundraising and these activities.
Specific points for Governors to note
Points for discussion Repositioning of Sussex Partnership Trust Charity and how best the Council of at meeting Governors could support the charity and fundraising activity.
Recommendation(s) Paper is for information.
Sussex Partnership NHS Foundation Trust Council of Governors: 16 June 2014 – Public Agenda Item: CG29.6/14 Attachment: M For: Information By: Rachael Duke, Head of Fundraising
Sussex Partnership NHS Trust Charity 1051736 (Charitable Funds) Fundraising Review and Strategy
SECTION 1: FUNDRAISING REVIEW
1.0 Introduction
1.1 Sussex Partnership NHS Trust Charity is a registered charity, established in 1996 as an NHS charity using the ‘Corporate Trustee’ model. It is a grant making charity that uses its funds to support “any charitable purpose or purposes relating to the National Health Service and specifically the Mental Health Sector that would not normally be covered by main NHS funds.” In practice, the Charity funds activities delivered by staff of Sussex Partnership NHS Foundation Trust that directly benefit the Trust’s patients or staff, including clinical research.
1.2 To date the Charity’s income has been derived from historical donations, predominantly legacies, which have been invested, ad-hoc donations received from time to time and smaller more recent legacies. The Charity has never fundraised strategically before although some individual Trust services fundraise themselves (e.g. Mill View hospital applying to the Friends of Brighton & Hove Hospitals, the Aldrington Centre applying to the Rockinghorse Appeal and Chalkhill applying to the Arts Council). This fundraising however is not consistent across the organisation and there are several services who have very limited experience in this area.
1.3 In May 2013 the Trust commissioned Think Consulting Solutions to assess the potential for fundraising for the Charity. The key recommendation of Think’s report was to appoint a professional fundraiser to develop and implement a fundraising programme and build voluntary income for the Charity which was endorsed by the Charitable Funds Committee and the Trust Board updated on 26 February 2014.
1.4 The Charity’s appointment of a Head of Fundraising in January 2014 represents a shift in direction for the charity, keen to expand its fundraising reach and capitalise on some of the funding opportunities available to NHS charities.
2.0 Context of fundraising income for Sussex Partnership NHS Trust Charity
2.1 Although the Charity is keen to expand its fundraising activities, it is important to note that at present there is not an accompanying NEED for this increased income that would compel donors to act. The Charity currently undertakes fairly limited grant making, spending in the region of £65,000 each year, and has no large projects identified which would bring with them associated fundraising targets. This lack of need must be addressed if fundraising is to be successful as despite the Charity’s desire to replace depleting funds this alone will not inspire donors to give
2.2 As the Charity has not previously undertaken any fundraising activities, its audience has historically been an internal one focused on encouraging staff to apply for funding. However, despite this internal focus there is fairly low awareness amongst staff of the charity’s existence with some services applying to the funds far more frequently than others.
Page 1 of 13 2.3 At present the Charity does not undertake any fundraising activity to increase income each year, therefore voluntary income is currently exceeded by investment income, although both sources remain low. Our 2012/13 accounts show: Voluntary Income £14,286 Investment Income £19,049 Therefore all fundraising activity is starting from scratch with no established campaigns or donors from which to build.
2.4 For the purposes of this review voluntary/fundraised income is taken to include charitable trusts & foundations, corporate donations and sponsorship, individual giving, community fundraising and legacies.
2.5 At present, an immediate barrier to interpreting the financial data available for donors and fundraising is the lack of a single fundraising record. To date, income has been recorded by the finance department but this is limited purely to the amount received and the service to which it is restricted, any correspondence and donor data available is filed in archive boxes but these are patchy and there are no electronic records.
2.6 In order to commence fundraising the Charity needs to prepare a case for support, develop a clear identity and strong message around what difference donations make to patients.
3.0 Analysis of voluntary income streams 2008-2013
3.1 Sussex Partnership NHS Trust Charity have never proactively fundraised as a charity before, although some services have fundraised themselves for specific activities. Therefore the majority of donations have been unsolicited legacies or ad-hoc donations, primarily from service users or their family and friends. In 2012/13 and 2011/12 our income from investments has actually exceeded our voluntary income.
3.2 Average Annual Voluntary Income The Charity’s average annual voluntary income over the last five years, including legacies, is £32,501 broken down as follows:
Year End Income £’s Legacies £’s Donations £’s Investment Income 2012-13 33,335 0 14,286 19,049 2011-12 18,317 0 7,000 11,000 2010-11 73,435 37,164 31,873 4,398 2009-10 67,354 45,000 18,268 4,086 2008-09 34,978 0 8,915 26,063
Of these donations, the majority have been from individuals predominantly wishing to thank wards/services for care they or their loved ones have received.
3.3 Wards/Services own fundraising Various Trust wards/services have had success in securing funding for additional projects from external funding bodies. In these instances the applications have been generated by staff on the wards/services rather than by central Trust staff. Funders from whom we have received grants include: Friends of Brighton & Hove Hospitals Friends of Worthing Hospitals Rockinghorse Arts Council In addition to these applications, the Trust’s wards and services often receive donations from service users and their families and friends in appreciation of the care people receive. Unfortunately, the lack of a central fundraising function has meant that these donors (whether external funding bodies or individual donors) have not consistently been managed and
Page 2 of 13 supported to develop a closer relationship with the Trust and Charity resulting in repeat donations.
4.0 Case for Support
4.1 The Think Report and the new Head of Fundraising both identified the lack of a case for support as an obstruction to successful fundraising. The report Why We Give published in March 2014 by the Charities Aid Foundation found that eight out of ten major donors would give more if charities showed more hard evidence of the effects of their work. A strong case for support clearly demonstrates to potential donors the work of the charity and the positive impact this has on its beneficiaries which in the case of Sussex Partnership NHS Trust Charity are people with mental health problems, learning disabilities or facing the challenges of substance misuse. Only if this positive impact is communicated clearly will donors feel compelled to act. 75% of major donors consulted reported that they give because of a particular belief in a specific cause. Therefore a clear cause and need, communicated simply and compellingly is essential to developing fundraising for Sussex Partnership NHS Trust Charity.
4.2 In order to develop a case for support, the following work needs to be undertaken: The Charity must determine the impact it aspires to have on service users and identify the impact it is actually having on service users. The aspirational impact becomes the core purpose, or vision, of the Charity. To achieve this vision, a grant making strategy must be developed that becomes the mission for the Charity. (See 4.3 for further detail) Strong case studies must be identified and developed that demonstrate the positive difference Charitable Funds initiatives have made to service users. A compelling NEED for future funding must be identified that will prompt donors to act. This must include a statement on how the existing monies within Charitable Funds will be utilised and where future donations would be used.
4.3 The above mentioned grant making strategy must provide the mechanism for the Charity to achieve its vision and should be based on patient need to ensure maximum impact and provide maximum attraction for donors. To achieve this it is recommended that up to four key funding priorities are identified, in consultation with service users and using equality monitoring data, particularly on patient experience, that will have the most significant positive impact on patients’ lives and that these become the Charity’s grant making areas. This work will include consideration of the protected characteristics and whether these affect patients’ experience of charitable funds. In addition, it is recommended that some larger items or projects are identified for which specific fundraising campaigns could be developed that would enable the profile of charitable funds to be raised and also draw in potential major donors.
5.0 Charity Name, Brand Identity & Website
5.1 Fundamental to successful fundraising is a clear brand identity that gets people engaged and involved in what the charity does. The Charity’s current name; Sussex Partnership NHS Trust Charity is problematic from a fundraising perspective for several reasons. Firstly, the work of the charity does not only take place in Sussex, secondly there is also a perception that people have already paid for the NHS so to include that in the name may reduce their willingness to donate, thirdly the name has no strategic alignment with what we do and finally it is simply a very long name for a charity.
5.2 Ideally, the Charity needs a name that is compelling, attractive to donors and linked to the work of the Charity and Trust. Therefore it is recommended that the Charity is renamed to “Without Stigma”, following testing with service users and potential donors. This clearly conveys our strategic work around reducing the stigma associated with mental health, is
Page 3 of 13 embracing of difference and would also be compelling to donors as it conveys something of what the charity is trying to achieve. “Without Stigma” is already used as the Twitter handle for the Trust and the Director of Communications is in agreement to use this for the Charity name. More detail on this is included in 10.1.
5.3 In addition to a compelling name, the Charity is also lacking a brand identity that is independent of the Trust. In today’s competitive fundraising marketplace a clear brand identity is essential to successful awareness raising and subsequent fundraising. It is therefore recommended that a specialist charity brand agency is engaged to develop a brand identity for the Charity, based on the name “Without Stigma”. It is expected that this would cost a maximum of £12,500 to develop a logo, templates including letter heads, business cards, web templates and fundraising materials etc.
5.4 The Charity’s only online presence is currently a page on the Trust’s main website which unfortunately is aimed at staff wishing to apply for funds rather than the public who may wish to fundraise for us. The Head of Fundraising has revised this page as a stop-gap whilst the visual identity and branding work is undertaken.
5.5 The majority of NHS Charities have separate websites to their Trust sites which enable them to offer their supporters information on how to fundraise, publicise events and take donations. It is important that the Charity is seen to be separate but linked to the Trust and an interesting and engaging website is essential to raising the profile of its work and encouraging donations. Following completion of the visual identity for the Charity it is recommended that an external web agency is commissioned to develop a Charity website for Without Stigma. It is expected that this will cost up to £12,500 and consideration will also be given to translating the website into Easy Read/large font and top community languages.
6.0 Communications & Social Media Strategy
6.1 The Charity’s communications needs are currently met by the Trust’s Communications team, although to date the charity has drawn minimally on their expertise with only the Spring Cycling Challenge really needing marketing support. In the future this will change as the Charity launches its fundraising strategy and garners increased interest in the Charity and Trust itself.
6.2 Although the messaging for the Charity and Trust will differ, with a more corporate and commercially focused presence for the Trust, it is important that the links between the two organisations are exploited to ensure maximum interest in the Charity and increase donations. In addition, both the Charity and Trust stand to benefit from a shared focus on patient experience that generates content to be used by both. It is proposed therefore by the Head of Fundraising and the Director of Communications that a shared Social Media Strategy is developed whereby one Twitter feed (@withoutstigma) and one Facebook page are developed that are used by both the Charity and Trust.
6.3 This approach will involve work from both departments to develop a single social media voice but the most successful NHS Charities have found that this approach garners the most followers and interest. (For example Birmingham Children’s Hospital who now have over 20,000 Facebook followers). In addition, this approach has also resulted in fundraising donations through social media when done well.
7.0 Fundraising records & databases
7.1 At present the Charity has no donor database or consistent records of supporters year on year. There are no computerised donor records.
Page 4 of 13 7.2 Although the Finance Department record individual donations to Charitable Funds, it is not possible to pull off the history of support from a single donor.
7.3 Donor records are a fundamental element of good fundraising practice. It is this which will enable us to build lasting relationships with our funders irrespective of staff or organisational changes. The Charity is lagging behind in this area even when compared with much smaller charities. For example, we have an extensive Membership database of people who are interested in Sussex Partnership. However, we currently have no access to this database in fundraising; therefore, we have no means of cross referencing this list with donor lists to establish who makes cash donations the Charity in addition to supporting the Trust as a member.
7.4 If the Charity wishes to significantly increase its voluntary income and develop lasting relationships with funders that lead to repeat donations it needs to invest in a fit for purpose fundraising database. Such databases enable orgnisations to manage whole relationships with funders, tracking every contact with them, events they participate in, outcomes of applications and crucially managing ongoing contact, whilst at the same time taking little time or effort to do so.
7.5 The expected cost of purchasing a fit for purpose fundraising database is a maximum of £12,000 for purchase (to be depreciated over 5 years) and in the region of £3,000 per annum support costs. Alternatively, it is possible to subscribe to cloud-based fundraising databases from around £100 per month which may be a sensible first step given the very low number of donor records the Charity currently has. Further work needs to be done by the Head of Fundraising in this area to identify a suitable database system that can meet the Charity’s current needs whilst also future proof for current needs to some extent. However, it is imperative that an appropriate system is identified and purchased swiftly in order to begin effectively managing our donors. This is being supported by Theresa James in the Information Technology department and in the first instance it is likely that a cloud based system will be used.
8.0 Financial Records of Income
8.1 In the past voluntary income has been recorded by the Finance Department with individual contact with donors held within the wards/services where donations were received. Moving forwards, it is important that a central fundraising record is maintained that fully tracks a donor’s interactions with the charity. The Head of Fundraising & Finance Analyst for Charitable Funds must work together in order to ensure that consistent records are kept, that these can be accessed easily by both departments and that it fulfills the requirements of both teams with consistency of coding and categorisation year on year. This is particularly important for tracking online donations.
9.0 Thanking our funders
9.1 At present, the Charity has no consistent protocols for thanking our funders. If we wish to attract further support, and particularly corporate support, we need to develop these and demonstrate that by working in partnership with Sussex Partnership NHS Trust Charity we can generate positive PR and offer cause related marketing to truly benefit businesses.
9.2 More and more trusts and foundations expect their support to be prominently featured by the projects they are funding. We will need to introduce a proper ‘thank you’ page on our Charity website, sponsors & supporters boards in our venues where appropriate and better utilise our annual report.
10.0 Internal structure and resources for Charitable Funds and fundraising
10.1 Charitable Funds is currently directed by a Charitable Funds Committee comprising three Executive Directors, one Non-Executive Director, two Governors and the Trust’s Head of
Page 5 of 13 Corporate Finance. The Funds are managed and administered on a day-to-day basis by the Finance Department. Since February 2014 Finance Analyst Carly Brown has been tasked with the management of the funds.
10.2 The application process for staff to apply to the Charity is relatively ‘light-touch’ with a short application form to be completed. However, there have been various inconsistencies identified with the process both during the application stages and following approval and a thorough review has not been undertaken for some time. Therefore a process review is scheduled for May 2014 to develop a clearer application and approval process and guidelines for the subsequent management of Charitable Funds’ grants. The Head of Fundraising has worked previously as a Lottery grant maker and is experienced in reviewing and developing grant making systems and procedures.
10.3 As Charitable Funds have historically had a low profile within the Trust, the number of applications received has remained low. However, with the appointment of a Head of Fundraising the Finance Department have noticed a significant increase in the number of applications received as the profile of the funds is raised internally. This is likely to continue to increase over time and highlights the need for adequate resourcing within the Finance Department to cope with the increased workload.
10.4 The lack of proactive fundraising has also meant that the number of donations received by the Charity each year is low, with minimal input required from the Finance Department to manage income. The prioritisation of fundraising and the appointment of a Head of Fundraising will change this and increased donations and Gift Aid claims will also increase the workload of the Finance Department.
10.5 It is likely that the increase in both donations to the Charity and applications to charitable funds will require an increase in staff resource within the finance department to potentially a full time post supported by cashiers. The Head of Corporate Finance is currently reviewing this and will propose a restructure of the finance resource for charitable funds following the process review of charitable funds referred to in 10.2.
10.6 The new Head of Fundraising was appointed in January 2014 on a part-time 0.8 basis, therefore saving in the region of £8,000 per year against the full time budgeted expenditure in the Think Report. In her first 8 weeks in post whilst evaluating the Charity’s readiness for fundraising she has identified several key barriers to fundraising including the lack of case for support, clear identity for the Charity or strong message on the difference Charitable Funds make to patients. It should be noted that alongside this strategic development work there are various fundraising activities already in place including Walk for Wards in June 2014 which needs managing and administering.
10.7 The Charity’s focus on its development as an effective entity making a real difference to patients will draw heavily on the newly appointed Head of Fundraising to both bring strategic focus and purpose to Charitable Funds and generate income for the benefit of patients. This work will not only increase income for the Charity but also significantly raise its profile and was targeted in the Think Report to raise £75,000 in its first year. However, given the highly time consuming nature of community and event fundraising, the emphasis the committee wishes to place on this type of fundraising and the amount of preparatory strategic work that is needed, it is unlikely that we will achieve these aims with the current level of staffing we have in place.
10.8 It is therefore recommended that the Charity expand the Fundraising department by recruiting a Fundraising Officer to work alongside the Head of Fundraising with a particular focus on community and event fundraising. This will ensure that the strategic focus of the Head of Fundraising is not compromised whilst also enabling the community fundraising work to proceed more swiftly and would increase forecast income in Year 1 to £125,000. To appoint at a consistent level to other charities in the area, it is recommended that the post is
Page 6 of 13 recruited at a Band 5 as a Spot Salary post on Point 20 which is £24,799. A full cost benefit analysis is included in Appendix A.
11.0 Fundraising Review - Key Findings & Recommendations of the Head of Fundraising
11.1 Finding: The lack of a case for support is hampering our ability to effectively commence fundraising. Recommendation: develop a vision and mission for the charity that effectively becomes our case for support.
11.2 Finding: The lack of a compelling name for the Charity will restrict our ability to stand out in a competitive fundraising market place. Recommendation: Rename the Charity as Without Stigma.
12.0 Finding: The Charity has no visual identity or brand. Recommendation: Commission an external agency to develop a visual identity and brand.
13.0 Finding: The Charity has a very limited online presence, restricted to a page of the Trust’s main site. Recommendation: Commission an external web agency to develop a website for the Without Stigma charity.
13.1 Finding: The Charity has no social media strategy in place to manage digital messaging. Recommendation: Develop a shared social media strategy between the Charity and the Trust in partnership with the Director of Communications.
13.2 Finding: The lack of a fit for purpose fundraising database is hampering our ability to develop lasting relationships with our donors that can be developed into repeat funders. Recommendation: Invest in a professional fundraising database following further investigation by the Head of Fundraising into which system is most appropriate.
13.3 Finding: We lack robust relationship management procedures for thanking and cultivating our donors. Recommendation: Head of Fundraising to develop and implement relationship management protocol for department.
13.4 Finding: We have insufficient Fundraising staff resources in house to effectively deliver an extensive community and event fundraising programme alongside the strategic development of the charity in its first year. Recommendation: Recruit a Fundraising Officer at Band 5 with a specialism in Community and Event Fundraising to work alongside the Head of Fundraising.
Page 7 of 13
SECTION 2: FUNDRAISING STRATEGY (2014-2017)
1.0 2014 – 2017 Strategy
1.1 Until a vision and mission for the Charity and case for support have been developed it is not possible to draw up a detailed fundraising strategy for 2014 onwards as it is not yet clear where funds are most needed and therefore which funding streams are most appropriate. However, to give an indication of the level of fundraising work to be undertaken a Legacy Fundraising strategy is attached for the Charity in Appendix B as legacy income is not dependent on specific projects agreed now. Other, more immediate, income streams depend on the projects identified for fundraising now and the strength of our case for support.
1.2 It is recognised that:
If the recommendations of this paper are agreed, in 2014 the fundraising target for the charity will be £125,000 although this is not linked to any particular items or projects. This is forecast to increase to £200,000 in year two and £300,000 in year three. To achieve these fundraising targets a funding mix of community, event, individual and trust fundraising is recommended. Although for any significant gifts to be achieved it is likely that specific, tangible projects will need to be identified. It is likely that community fundraising will be very important to the work of the charity as our local communities who have direct contact with our services are most likely to wish to support us. In addition, this work is essential in raising the profile of the charity. However, it should be noted that community fundraising has one of the lowest returns on investment of 1.75 : 1. To develop and implement a fundraising strategy, the naming, branding and marketing work recommended in the Fundraising Review needs to be implemented first.
1.3 Upon completion of the vision and mission for the Charity and during the development of the case for support the Head of Fundraising will develop and deliver a detailed fundraising strategy that identifies funding streams for each planned activity and a mechanism for accessing these monies to ensure annual targets are achieved.
Page 8 of 13
APPENDIX A
Resource Requirements
Fundraising Resource Requirements
In summary the initial fundraising resource requirements are as follows:
Head of Fundraising Fundraising Officer Visual identity & branding Website Fundraising database, assumed as a cloud based service with monthly charges Fundraising event expenditure to support activities such as Walk for Wards Materials to include purchase of collection tins, t-shirts, literature etc.
The return on investment is shown in the table below.
Year 1 Year 2 Year 3 Income 125,000 200,000 300,000 Expenditure Head of Fundraising 40,000 40,000 40,000 salary & on costs Fundraising Officer 16,232 32,465 32,465 Band 5 Spot Salary Point 20 £24,799 & on costs (assume 6 months of employment in 2014/15) Branding identity 12,500 0 0 Website 12,500 0 0 Materials 5,000 5,000 5,000 Database 1,500 1,500 1,500 Fundraising event 10,000 10,000 10,000 expenditure Travel & Expenses 2,400 2,400 2,400 Mobile Phone 480 480 480 Laptop 1,000 1,000 1,000 Total Expenditure 101,612 92,845 92,845 Net Income 23,388 107,155 207,155
Charitable Funds Finance Department Resource Requirements
In addition, to support the increased activity within charitable funds of both numbers of applications and donations, an increase in the resources provided by the Trust Finance Department is required as follows:
Year 1 Year 2 Year 3 Additional 0.5FTE 16,232 16,232 16,232 Finance Officer @ Band 5 salary & on costs
Page 9 of 13 TOTAL Fundraising & Charitable Funds Resource Requirements
Year 1 Year 2 Year 3 TOTAL Fundraising 101,612 92,845 92,845 287,302 Resources Additional 16,232 16,232 16,232 48,696 Finance Resources TOTAL 117,844 109,077 109,077 335,998 Resource Requirements
It is important to note that the additional finance resources required are primarily to support the efficient processing of applications to charitable funds, which have seen a significant increase since the Head of Fundraising joined the trust and has been actively promoting the funds to staff.
If the Charity is committed to its growth and development, not just in fundraising but in its overall strategic reach, then it is inevitable that additional investment will need to be made in its infrastructure and administrative resourcing.
Page 10 of 13 APPENDIX 1
Sussex Partnership Trust NHS Charity Legacy Fundraising Strategy 2014/17
Introduction
The overarching aim is to establish a consistent income source from legacies for Sussex Partnership NHS Trust Charity and the information included in this strategy outlines the objectives and planned activities in order to support this.
It is usually around 4 years between a person making their last will and death. Therefore this strategy should start to benefit Sussex Partnership NHS Trust Charity from 2018 onwards. It cannot be assumed that any legacy income will be received in time to support specific projects between now and then.
The UK legacy picture
Total UK population is 61,794,000 and will rise in the next 25 years to 74 million. Number of deaths each year is 547,240 and this is continuing to decrease as we live for longer until around 2015 when the baby boomer generation reach old age. By 2040 we will be living 13 years longer than we do now. Total value of legacies in the UK is around £1.9 billion which is the highest level of legacies in the world, greater even that the US. It represents 16% of individual giving. All voluntary income streams for charities dropped as a result of the recession in 2009-10 with the sole exception of legacies. Average UK legacy is £19,900 Average UK cash legacy is £3,500 Average UK residuary legacy is £40,000 Pledging is a popular method for charities to recruit potential legacy givers. However, it should be noted that up to 90% of pledgers lie when stating they are leaving a charity a legacy.
(NOTE – the averages received by large national charities are considerably higher than the above.)
70% of legacies are left by women. Biggest growth areas for legacies are men and millionaires. Men leave 109,000 legacies a year. The recession has meant that larger charities have seen a drop in their legacy income whereas smaller charities have seen an increase. However, although numbers of legacies are increasing their value is lower.
Current legacy position at Sussex Partnership NHS Trust Charity
Our average annual legacy income between 2008-2013 is £16,432 legacies. However, there is considerable variation between years:
2012/13 £0 2011/12 £0 2010/11 £37,164 2009/10 £45,000 2008/09 £0
This is achieved with no input from Sussex Partnership NHS Trust Charity to promote legacy giving.
Page 11 of 13 Legacy Strategy from 2014 onwards
Aim
To establish a consistent income source from legacies for Sussex Partnership NHS Trust Charity by developing and implementing a well researched, ethical and sensitive campaign to promote the use of legacies as a means of supporting Sussex Partnership NHS Trust Charity. Campaign to follow the Fundraising Standards Code of Practice for legacies.
Objectives for 2014/15
Form a legacy working group
To establish ‘buy in’ from the Trust and Charity for a legacy campaign, a working group should be established to develop approach, legacy vision, support campaign and promote legacies. Membership should include:
Head of Fundraising (chair) 1 Executive Director 1 Non-Executive Director 1 Governor 2 Volunteers 3 front line service delivery staff Head of Corporate Finance Director of Communications
Undertake research to understand the motivations behind legacies for Sussex Partnership NHS Trust Charity.
Head of Fundraising to contact the next of kin for all legacies left to Sussex Partnership NHS Trust Charity within the last 5 years to understand their motivation for leaving us a legacy. Head of Fundraising to utilise feedback from staff, service users and volunteers on Sussex Partnership NHS Trust Charity vision and values, specifically what makes Sussex Partnership NHS Trust Charity special and unique to feed into legacy vision.
Creation of a legacy vision
Using the research from above, priority will be given to the creation of a legacy vision, which will then be used in future communication. The vision will have to encapsulate the importance of legacies to the charity and inspire those reading it to remember Sussex Partnership NHS Trust Charity in their Will. The vision must be: fundable, unique, credible, inspirational and tangible. NOTE this vision is not the organisational vision – it must be specific to legacies and designed to make the reader act immediately.
Re-establish contact with existing supporters to build relationships
At present, we are not in regular contact with our existing supporters so have no warm prospects from our previous donors. Relationships need to be built by:
Head of Fundraising to write (or contact otherwise/translate materials where donors have alternative communication requirements) to all regular donors for whom we have contact details to introduce herself – small biog, why working for Sussex Partnership NHS Trust Charity, happy to meet and hear their views. Establishing regular contact through a newsletter or alternative publication (available in alternative formats and community languages upon request).
Page 12 of 13 Sending out annual review if reviewed to become more charity friendly – our current version is very corporate. Christmas event.
Aim for quarterly contact to start with which can be built up.
Methods for recruiting new legacy supporters
Sussex Partnership NHS Trust Charity have never actively promoted legacies or any other kind of fundraising and given the potential returns on legacy funding of 28:1 per £ invested it could be our most lucrative funding stream if handled correctly. In addition, we have a key target group as a significant proportion of our work is with older people.
Research shows that people do not mind being asked to give a gift in their will as long as they feel able to say no and the ‘ask’ is not intrusive. Therefore it is recommended that our campaign is focused on raising awareness that:
Legacies are an important source of income for Sussex Partnership NHS Trust Charity; That all legacies, big or small, make a difference; Anyone can make a gift in their will and Legacies are a way of supporting Sussex Partnership NHS Trust Charity that does not cost anything now.
Tools of recruitment include:
Promotion on back cover of annual review or charity accounts. Inclusion of a legacy PS in all thank you letters to individuals. Other charities have used the simple message below - it not only highlights the need for legacies it but raises awareness in a non-offensive way. In addition it is a no cost option in promoting legacy giving. PS – If the time is ever right for you to remember Sussex Partnership NHS Trust Charity in your Will that would be fantastic. In the future, once relationships are established, trial a short tailored letter to donors who have supported Sussex Partnership NHS Trust Charity for over 5 years enclosing the tools to act e.g. a codicil form. Create a legacies section within Without Stigma’s website utilising new legacy vision and providing tools to act. Q&A around wills in Sussex Partnership NHS Trust Charity newsletters. Produce a piece of legacy literature appropriate for display in our services that promotes legacies sensitively. Hold a will week in October 2014 around World Mental Health Day, working with local solicitors across the trust, where solicitors write wills for free in exchange for people making a donation of around £100 - £150 to Sussex Partnership NHS Trust Charity. Solicitors benefit by increasing their client base therefore making their businesses more valuable and Sussex Partnership NHS Trust Charity receive donations from individuals that can then be encouraged to become regular supporters and potential legators. Promotion of legacies at all talks given by the Head of Fundraising.
The above strategy is designed to take into account existing staffing levels within the fundraising department alongside the need to generate funds from legacies and should be achievable following the appointment of a Fundraising Officer to work alongside the Head of Fundraising.
Page 13 of 13
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG29.7/14 Attachment: N The Sussex MSK Partnership Presentation Author Sam Allen, Commercial Director Section Strategy Presented by Sam Allen, Commercial Director
Paper Summary The Sussex MSK Partnership aims to transform care for patients suffering with joint, bone and muscle pain across Brighton and Hove, Crawley, Horsham and Mid Sussex by tailoring care to the needs of the individual patient ensuring mental health and wellbeing is fully integrated with physical health services.
The partnership has been named the “Sussex MSK Partnership” and comprises of BICS, Horder Healthcare Partnership, Sussex Community NHS Trust and Sussex Partnership NHS Foundation Trust. Each organisation in the partnership recognises the different expertise that each brings and the advantages of working more collaboratively together in order to achieve the commissioners’ vision for an integrated MSK patient pathway.
The presentation will explain the service in greater detail and set out the aim of supporting Sussex Partnership to move into a new market segment of integrated care.
There will be an opportunity for discussion after the presentation.
Specific points for The specific detail of the how the partnership will work is in the process of Governors to note being agreed with the partner agencies, prior to being presented to the relevant boards for approval. Our board will receive the proposal for decision when it meets on 25 June.
Recommendation(s) The Council is asked to note the presentation and ask any questions of the Commercial Director.
COUNCIL OF GOVERNORS
Meeting Date 16 June 2013 Agenda Item & Title CG30.1/13 Attachment: O Foundation Trust Governors Association Annual Subscription Author Natalie Hennings, Corporate Governance Business Manager Section Governance Presented by Peter Lee, Head of Corporate Governance
Paper Summary The trust subscribes to the Foundation Trust Governors Association (FTGA) at a cost of £3960 per annum (including VAT). Our membership is reviewed annually in September. The cost for 2014/15 is not yet known.
The FTGA arrange a series of meetings and seminars for governors throughout the year, in various venues, and also an annual development day in conjunction with the Foundation Trust Network (FTN).
Information received from the FTGA this year includes information on events, board meetings and elections. The FTGA also provides various publications.
Attendance by Governors at FTGA events has been much greater than previous years, and feedback from Development Days are shared with members at Governor Training days.
Specific points for Members are asked to consider the benefits of the FTGA and, in the first Governors to note instance, to agree unanimously whether to renew this membership.
Points for Governors are invited to consider whether to continue membership of discussion at the FTGA and to set out their reason(s). meeting
Recommendation(s) Governors are recommended to discuss this informally prior to the formal meeting.
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG30.3/14 Attachment: P An Update from Task Force 1 Author Martin Jeremiah, Lead Governor Section Governance Presented by Martin Jeremiah, Lead Governor
Paper Summary In order to facilitate compliance with the 2012 Health & Social Care Act in terms of Governance, Governors formed a Task & Finish Group covering ‘What is Governance?’ and ‘What does holding Non-Executive Directors to account mean in practice?’ (Task Force 1). A meeting was of Task Force 1 was held on 16 January 2014 in Seminar Room 1 at the Sussex Education Centre, Nevill Avenue, Hove
Composition: John Bacon, Trust Chair, Martin Jeremiah, Lead Governor Cliff Buckland, Carer Governor Phyllida de Salis, Public Governor Sue Taylor, Public Governor Jane Tatum, Service User Governor
In attendance: Diana Marsland, Non Executive Director Tim Masters, Non Executive Director Natalie Hennings, Corporate Governance Business Manager
It was agreed:
To introduce a new model to the Council of Governors meetings whereby a different Non Executive Director presents an in-depth report on the activities of the Board Sub-committee they Chair on a rotational basis. This would enable Governors to develop their understanding on the work of Non Executive Directors and their Chairmanship responsibilities for Board Committees.
The Governors should form a greater understanding of internal audit through education by Non-Executive Director, Tim Masters.
The Lead Governor would raise awareness of the identities and roles of NEDs through his monthly report.
NEDs objectives would be circulated on which to base Governors NED appraisal input.
There would be a new appraisal process to be agreed and recommended by the Governors Nomination & Remuneration Committee.
The Lead Governor would raise awareness of Board Committees by circulating their Terms of Reference in his monthly report.
Subject to Board approval and a Code of Conduct covering confidentiality of sensitive information, Governors would appoint representatives to observe Board Committees and the private session of the Board. These representatives would feedback NED performance to the Nomination & Remuneration Committee members through the Lead Governor for input into the appraisal process. Rodney Ash would pilot the process with attendance at the Boards Quality Committee.
Governors ‘Sources of Assurance’ were noted to be both internal and external
Internal ‘Sources of Assurance’
The Audit Committee instructs auditors to undertake specific work to ensure Sussex Partnership’s processes are robust and compliant with the law. Internal audits are signed off by the Internal Auditors and an Executive Lead will be designated to address any specific concerns and to implement any necessary changes. The Executive Lead then reports on the programme of work to the Audit Committee. The three Non Executive Director representatives on the Committee are charged by the Board to ensure all actions are addressed, if not they are reported to the Board for further scrutiny.
Dashboard indicators are set and regularly reported. Some of these indicators are required to be set by Monitor and others are desired by the Trust. The indicators are covered by the Boards Finance and Investment Committee. The Trust currently has three different types of indicators on the dashboard (which includes the National Indicators, set by Monitor with direct sanctions). There are also contractual indicators set by commissioners, as well as the self- imposed indicators set by Sussex Partnership. The Executive Team take a view on the colour of the self-imposed targets and these are then scrutinised by the Board and subsequently by the Council on a quarterly basis.
In addition to these, Governors had also asked Non Executive Directors to produce Key Performance Indicators for their individual Board Committees. Richard Bayley had duly reported KPIs for Finance and Investment Committee to October 2013 Council.
External ‘Sources of Assurance’
Our external audit is currently carried out by Price Waterhouse Coopers and reports annually to Council.
The NHS Annual Staff Survey is produced annually.
In addition Sussex Partnership is regularly monitored and reported upon by a range of external agencies, particularly the Foundation Trust regulator, ‘Monitor’ and the ‘Care Quality Commission’. The latter produces the annual ‘Mental Health Act report’ and the annual ‘National Patient Survey’ which are reported to Council. All of these provide general assurance as to the activity of the Trust across the whole of the organisational business.
Specific points for Board Committee Governor observers are now in place: Governors to note Finance & Investment Committee – Christopher Masters People Committee – Elizabeth Hall Quality Committee – Rodney Ash Mental Health Act Committee – Cliff Buckland/Steve Trask Audit Committee – Tony Moore
The new appraisal process was agreed by Council and successfully piloted for both the Chair and NED’s 2013/14 appraisals against their objectives. The final appraisals were unanimously agreed by the Governors Nomination & Remuneration Committee and will be reported to the June Council private session.
Reports to Council by NEDs so far: Richard Bayley, Diana Marsland, Melloney Poole.
Tim Masters (Audit) attending June Council
Points for discussion None. at meeting
Recommendation(s) That Council gratefully approves the work of Task Force 1 and disband this Task & Finish Group.
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & Title CG30.4/14 Attachment: Q Report Back from Task Force 2 on ‘Governor Training & Development Author Martin Jeremiah, Lead Governor Section Governance Presented by Elizabeth Hall, Service User Governor and Group Lead
Paper Summary In order to ensure compliance with the provisions of the Health & Social Care Act 2012 on Governors ‘Training & Development’ Governors had formed a Task & Finish Group. The Group has had two meetings, held in February and April 2014.
Composition:
Elizabeth Hall (Group Lead) Cliff Buckland (Carer Governor) Martin Jeremiah (Lead Governor) Howard Pearce (Public Governor) Nic Allen (Service User Governor)
In attendance: Peter Lee (Head of Corporate Governance)
A new format for Governor training was approved. Previously there had been monthly 2-hour seminars which were poorly attended and often cancelled for lack of take-up. Some Governors found it difficult to justify travelling for short sessions and wanted more time to discuss issues rather than relying totally on presentations.
The first task was to establish a skills audit of individual Governors and identify the training that Governors would find beneficial. This survey was successfully conducted by the Group Lead via Natalie Hennings at the Governance Office and discussed at the first meeting. Results from the survey were used to prioritise the ‘presentation’ style training sessions that Governors would like to see.
The format for new Governor Training Days was agreed as: Governors only seminar session on selected subjects Update and Question & Answer session with the Chairman An 'external source of assurance' piece of training e.g. a speaker from the Care Quality Commission on the new inspection regime An 'internal source of assurance’ piece of training' e.g. on or Serious Incidents data
It was agreed that the draft Governor Training Day agendas would be set by the Group in advance and that any issues arose would be picked up and resolved by the Lead Governor. The Governance Support Office would provide administrative support.
This format was successfully piloted at the first March 2014 Governor Training Day at Langley Green and adopted at the second Governor training day in May. The group was also tasked with producing a new Governor ‘Code of Conduct’. The draft was produced by the Lead Governor, amended with the help and advice of the Head of Corporate Governance, approved and recommended by the Group. The Code of Conduct was subsequently approved by Council in April 2014.
It was agreed that, rather than individual Governors sending around large attachments of suggested reading that links could be provided to the Governance Support Office for putting on the Governors area of the website.
Finally, the Group was tasked with updating the Governors Induction Manual. This has been progressed by the Group Lead and the Governance Office.
Specific points for Draft agendas still need to be set on an ongoing basis for Governors Governors to note Training Days. The skills audit and training requirements survey will need to be re-run to take account of new Governors this August. It is desired to develop and host an induction training day for new Governors; to take place soon after the elections. The Governor Code of Conduct will need reviewing. The induction manual will need regular updating.
Points for discussion None at meeting
Recommendation(s) Council is asked to approve making Task Force 2 on ‘Governor Training & Development’ a permanent Governors Committee according to the appended Terms of Reference
Sussex Partnership NHS Foundation Trust Council of Governors: 16 June 2014 –Public Agenda Item: CG30.4/14 Attachment: Q By: Martin Jeremiah, Lead Governor
TRAINING AND DEVELOPMENT COMMITTEE TERMS OF REFERENCE
1.0 Constitution
1.1 The Training and Development Committee is a Committee appointed by the Council of Governors subject to Standing Order 5.1.
1.2 The Committee is responsible for
1.2.1 Regularly Identifying Governor training needs
1.2.2 Setting the agendas for the Quarterly Governor Training Days
1.2.3 Maintaining the Governors Induction Manual in conjuction with the Governance Support Office
1.2.4 Regularly reviewing the Governor Code of Conduct
2.0 Membership
1 Governor from the service user constituency 1 Governor from the carer constituency 1 Governor from the Public constituency 1 Governor from the Staff constituency 1 Non designated
2.1 All appointments to the Committee will be approved by the Council of Governors and will be reviewed at least once every two years.
2.2 The Chair of the committee will be agreed by its members.
2.3 Only members of the Committee have the right to attend meetings and make decisions of the Committee, but others may be invited to attend by the majority of members
2.4 The Committee may ask any member of staff to be in attendance for all or part of a meeting to advise the Committee.
2.5 The Head of Corporate Governance or their nominee will be in attendance to provide an essential link to the Governance support office, help minute the meetings etc.
Page 1 of 3 3.0 Quorum
3.1 The Chair (or agreed Chair in their absence) plus two members.
4.0 Frequency of Meetings
4.1 Meetings will take place as required, but as a minimum twice a year.
4.2 All meetings are in accessible venues, taking into account the needs of all attendees.
5.0 Calling Meetings
5.1 Meetings will be called at the request of the Chair.
5.2 Notice of each meeting, including an agenda and supporting papers will be sent to the members of the Committee 5 clear days before the date of the meeting.
6.0 Authority
6.1 The Committee is authorised by the Council of Governors to carry out any activity within its Terms of Reference.
7.0 Duties
7.1 Contribute to Governor elections campaigns and related publicity.
7.2 Assist with Governor induction meetings.
7.3 Contribute to and maintain the content of the Governor Induction Manual.
7.4 Annually review and recommend any necessary revisions to the Code of Conduct.
7.5 Organise the agendas of Governor Training Days.
7.6 Oversee and organize other Governor training initiatives as necessary
7.7 Identify Governors training needs via regular issues of the survey, particularly after an influx of new Governors following elections
7.8 Contribute to and maintain the training needs survey
7.9 To evaluate its own membership and performance on a regular basis.
7.10 To ensure that the Committee membership is refreshed and that undue reliance is not placed on particular individuals when undertaking the responsibilities of the Committee
Page 2 of 3 7.11 To review and update annually these Terms of Reference, recommending any changes to the Council of Governors.
8. Reporting
8.1 The Committee reports to the Council of Governors and will present an update to the next meeting of the Council of Governors that follows its own meeting.
8.2 A statement regarding the Committee’s activities will be included in the Annual Report.
9. Communication
9.1 The Committee will agree key messages for communication to the Council of Governors at the end of each meeting.
9.2 All papers, minutes and documents are available in alternative formats, if requested.
10. Confidentiality
10.1 All members of the Committee are required to observe the strictest confidence regarding any confidential information presented to the Committee and must not disclose any confidential information either during or after their term of membership. Failure to comply with these requirements could result in the termination of membership of the Committee and/or could be deemed a breach of the Governor Code of Conduct
11. Review
11.1 These terms of reference will be reviewed at the first meeting of this Committee in 2015.
11.2 These terms of reference can be made available in alternative formats if required.
Date agreed by Council of Governors
…………………………………………………
Page 3 of 3
COUNCIL OF GOVERNORS
Meeting Date 16 June 2014 Agenda Item & CG31.1/14 Title Attachment: R Governors Activities – April to June 2014 Author Natalie Hennings, Corporate Governance Business Manager Section Report back from Sub Committees Presented by Martin Jeremiah, Lead Governor
Paper Summary Elizabeth Hall and the Lead Governor attended a Care Programme Approach policy review workshop at Mill View Hospital.
Karen Braysher, Elizabeth Hall and the Lead Governor attended a packed Public/Members Meeting at Bluebell House discussing care and treatment for people with learning disabilities.
The second Governors Training Day was held on 15 May 2014 at Langley Green Hospital. In the morning session the Governors discussed recruitment issues with Sue Esser, People Director, had a report back from Elizabeth Hall on the FTGA National Development and a seminar led by the Lead Governor on the Care Quality Commission report on Langley Green followed by a question and answer session with the Chair. In the afternoon the Commercial Director gave a presentation on strategic, contractual relationships and the Inspection Manager from the Care Quality Commission gave a detailed explanation on their assessment and inspection regimes.
Elizabeth Hall, lead for the Training and Education Task Group met with Peter Lee, Head of Corporate Governance and Natalie Hennings, Corporate Governance Business Manager to discuss ideas and improvements to the current Governors Induction Manual.
Governor representatives observed the Finance and Investment Committee (Christopher masters) and People Committee (Elizabeth Halll) to build on governors’ responsibility of holding Non Executive Directors to account. The Governors Nomination & Remuneration Committee also met to finalise the Chair and Non-Executive Director appraisals for 2013/2014.
Elizabeth Hall and Cliff Buckland supported prospective Governor workshops in May as well as observing Board meetings on behalf of Governors.
Rodney Ash, Jane Tatum and Elizabeth Hall attended the Public/Members Meeting held with Health in Mind at the Underground Theatre, Eastbourne. It was a lively and engaging meeting about the benefits of talking therapies and the Lead Governor also gave a short talk on foundation trusts, membership and the role of Governors.
Karen Braysher visited Mayfield Court in Eastbourne with Lorriane Reid, Managing Director of Specialist Services and had some good discussions with the team about their vision and current projects. Karen will be writing an article for Membership Matters following this visit.
The Lead Governor gave a talk to Horsham & Crawley Carers Support Group and attended an update meeting on Triangle of Care.
Governors have also been participating in a number of 15 step challenges that will continue over the next few months .
Specific points for None Governors to note
Points for None discussion at meeting
Recommendation The Council of Governors is asked to:
note the report and ask any questions of the Lead Governor