Dorset Healthcare University NHS Foundation Trust Board Meeting

Dorset HealthCare University NHS Foundation Trust

Board Meeting

A meeting will be held on 27 January 2016 at Sentinel House, 4-6 Nuffield Road, Poole, Dorset, BH17 0RB commencing at 1:00pm

If you are unable to attend please notify Keith Eales on 01202 277008.

Yours Sincerely,

Ann Abraham Chair

PART 1 Initials Paper Time

Welcome, Apologies and Previous Meetings 1:00

1 Apologies AA Verbal

2 Patient Story JMcB App A

3 Declarations of interests in relation to agenda AA Verbal items

4 Minutes - to approve AA App B

 the minutes of the meeting held on 25 November 2015

 Notes of the Workshop held on 2 December 2015

 Notes of the Workshop held on 16 December 2015

 Notes of the Workshop held on 6 January 2016

5 Matters Arising - to consider progress AA App C

6 Chair’s Report - to receive the update of the AA Verbal Chair

7 Chief Executive’s Report - to consider a report RS App D from the Chief Executive

Strategy Development: Policy Formulation and Decision Making

8 Estates Strategy SH App E 1.30

To approve the estates strategy for the Trust

9 Draft Annual Plan 2016/17 SH App F 2.00 [To follow] To approve the draft submission to Monitor

Break 2.30

Strategy Implementation: Operational Performance

10 Integrated Corporate Dashboard for December NK App G 2:45 2015

To consider the monthly dashboard

11 Finance Report JC App H 3:00

To consider the report for December

12 People Management CLH App I 3:15

To consider the monthly update

Regulatory and Compliance Matters

13 CQC Items

(a) Quality Improvement Plan-to approve FH App J 3.25 the plan

(b) Updates- to receive updates on FH Verbal

(i) The End of Life Thematic Review

(ii) The Safeguarding Children and Looked After Children Report

14 Well-Led Review Action Plan KE App K 3:45

To note progress and approve the plan

15 Quarterly Review of the Board Assurance KE App L 3:55 Framework

To note the outcome of the quarterly review

16 Quarter 3 Return to Monitor JC App M 4.10

To approve the return to Monitor

17 Reappointment of Mental Health Act Panel SM App N 4:20 Members

To reappoint two Panel Members

18 Board Cycle of Business KE App O 4:25

To receive the annual cycle of business 181 Other Matters

19 Any Other Business AA Verbal -

20 Questions From Governors AA Verbal 4.30

21 Next Meetings AA Verbal -

Board Workshop - Wednesday 3 February 2016 commencing at 9:30am

Public Board Meeting - Wednesday 24

February 2016 commencing at 1pm

[At Sentinel House (Training Rooms 1&2), 4-6 Nuffield Road, Poole, Dorset, BH17 0RB]

Exclusion of the Public AA Verbal 4:40 To resolve 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 of which

would be prejudicial to the public interest.

Break

PART 2: BOARD MEMBERS ONLY

22 To approve the Part 2 minutes of the meeting held AA App P 5:00 on 25 November 2015

[Exemption under Section 43 of the FoI Act-release of information is likely to be prejudicial to the commercial interests of the Trust]

23 Matters Arising – no matters arising AA Verbal -

24 St. Ann’s/PICU Business Case SH App Q 5:05

To approve the business case

[Exemption under Section 43 of the FoI Act-release of information is likely to be prejudicial to the commercial interests of the Trust]

25 Quarterly Whistleblowing Report CLH App R 5:40

To note the report

[Exemption under Section 40 of the FoI Act- personal information]

26 Matters of concern to report 5:50

[Exemption under Section 40 of the FoI Act- personal information]

(a) Formal Notice of Serious Incident FH App S Investigation

To note the planned investigation

(b) Mortality Governance Review NK Verbal To note the review being undertaken

Agenda Item 2

Patient Story

Part 1 Board Meeting 27 January 2016

Mrs Lynne Middleton assisted by Donna Steer (Patient Author Experience Facilitator) Sponsoring Board Member Fiona Haughey, Director of Nursing and Quality Purpose of Report To consider the user’s experiences. Recommendation The Board is asked to discuss and consider the narrative Engagement and Involvement N/A Previous Committee/s Dates N/A

Monitoring and Assurance Summary

This report links to . To provide high quality care; first time, every time; the Strategic Goals . To be a valued partner and expert in partnership working with Patients, Communities and organisations; . To be a learning organisation, maximising our partnership with Bournemouth University and promoting innovation, research and evidence based practice; . To have a skilled, diverse and caring workforce who are proud to work for Dorset HealthCare; . To be a national leader in the delivery of integrated care; . To ensure that all of the Trust’s resources are used in an efficient and sustainable way; . To raise awareness within the Trust and externally of the impact that our work has on people and our environment, and take steps to reduce any negative effects. I confirm that I have considered each of the Any action required? implications of this report, on each of the Yes Yes No matters below, as indicated: Detail in report All three Domains of Quality   Board Assurance Framework   Risk Register   Legal / Regulatory   People / Staff   Financial / Value for Money / Sustainability   Information Management &Technology   Equality Impact Assessment   Freedom of Information  

BACKGROUND

PHYSIOTHERAPY SERVICE AT ST. LEONARD’S COMMUNITY HOSPITAL

Patients are referred to the Physiotherapy Service at St Leonard’s Community Hospital by their GP or Consultant.

Treatment is provided by Chartered Physiotherapists registered with the Health Professions Council. The experienced Physiotherapists all have specialist skills in the assessment and treatment of injuries and conditions that affect muscles, joints and soft tissues.

Physiotherapists use physical approaches. They promote, maintain and restore physical, social and psychological well-being. They are committed to using scientific evidence to support their treatments.

Treatment may involve manual therapy (hands on treatment such as mobilisation /manipulation), electrotherapy (such as ultrasound), therapeutic exercise, rehabilitation advice and education to address back pain, whiplash/neck pain, ankle sprain, bone fracture, neck pain, tendon problems, joint replacements and shoulder problems. There are also Specialist Physiotherapists that can assess and treat some gynaecological conditions.

Patients who are unable to attend the department may be referred to the local Community Rehabilitation Team for assessment in their own environment.

Physiotherapy for chest or neurological conditions may be referred to Specialist Physiotherapist in the patient’s local Community Rehabilitation Team. The patient’s GP, Consultant or Healthcare professional can refer them to the department that is most accessible to them.

The treatment clinics are held in the outpatient department at St Leonard’s Community Hospital Monday to Friday, both morning and afternoon. The department can be contacted on 01202 584213.

Narrative discussed with Lynn Middleton

Assisted by Donna Steer

(Patient Experience Facilitator)

Mrs. Lynn Middleton wishes to share the experience she has received during her treatment from the Physiotherapy Service at St Leonard’s Community Hospital.

Lynn was born with a congenital hip displacement which was only diagnosed when she was three years old. As a result, Lynn has suffered many difficulties with her right hip joint and wore support to her hip until she was nineteen years old.

Up to the age of twelve, Lynn underwent twelve operations related to her hip. This resulted in scarring in the hip area for which she had plastic surgery. Further complications arose because Lynn was allergic to catgut. In addition, she has one leg longer than the other and had to wear a built up shoe until she was thirteen years old.

Despite these challenges Lynn still managed to participate in many sports, including tennis and swimming, and lived life to the full.

One year ago Lynn began to suffer severe pain in her right hip. Her GP diagnosed a bursar and prescribed a steroid injection. An X-Ray showed a small amount of wear and tear to the joint.

Very quickly Lynn became unable to do much physically and although she carried on working, it became increasingly difficult to climb the stairs. She had to stop all sporting activities. The pain extended to her right knee and she began to feel very despondent.

The GP referred Lynn to an Orthopaedic specialist, who to Lynn’s disappointment did not appear to have any empathy towards her and in fact was quite dismissive, but did offer her Physiotherapy treatment.

It was at this point that Lynn met Physiotherapist Suzanna at St Leonards Hospital. Lynn found it reassuring, at a time when she was in pain and feeling low, to meet someone who was willing to listen and appreciate her complicated medical history. Suzanna worked with Lynn to plan what she was to achieve by the end of the treatment.

Suzanna has also arranged for her to attend Aqua-therapy exercise classes at the local leisure centre three times a week and has recommended exercises that are non-weight bearing, such as cycling.

Suzanna has explained to her that although she will probably continue to suffer pain, she has taught her to recognise her limitations, how to get back into a positive frame of mind and how to manage her pain.

Lynn has completed her physiotherapy treatment and is pleased with the care provided to her. She is planning to return to work in the near future. Suzanna has given Lynn her telephone number so that she can contact her if she needs support in the future. Agenda Item 5

Part 1 Matters Arising

Board Meeting 27 January 2016

Matters Arising from Board Meeting 25 November 2015

Minute Topic Action Lead Deadline Response 447/15 Patient Story The experience of a patient SO’D February Scheduled for supported by the integrated care 2016 February 2016 team in Bridport and Weymouth Board meeting would be reported to the Board

450/15 Matters Further assurance would be JC January Update to be Arising required, at the time of reviewing 2016 provided (Savings the Annual Plan for 2016/17, that identified) the IM&T savings identified would not undermine the improvements planned for the service.

453/15 Integrated A report would be submitted on CLH January Included in the Corporate what was externally imposed 2016 Integrated Corporate Dashboard mandatory training, that which the Dashboard Trust considered to be mandatory and the reasons for the training not being completed.

453/15 Integrated The Executive was asked to NK TBC Update to be Corporate review what action could be taken provided Dashboard re those areas that were static below the set performance threshold.

453/15 Integrated The Medical Director and the NK/ TBC A paper is being Corporate Director of Nursing and Quality FH drafted to outline Dashboard undertook to give consideration to proposals for the future development of the amendments in the Dashboard. current dashboard to enable greater clarity and assurance through triangulation using qualitative and quantitative data. 1 Agenda Item 5

454/15 Finance The Finance Report should reflect JC January Update to be Report the action necessary to achieve a 2016 provided most likely year end position of a £2.2m deficit, or better.

455/15 People Details of Prevent training to be CLH ASAP Completed Management distributed to Board members.

457/15 Equality and Equality and diversity objectives CLH January Included in the Diversity would be submitted to the next 2016 People Management meeting report

466/15 PICU A further report on the SH January Item on the agenda development of the PICU would 2016 be submitted to the January 2016 meeting.

Keith Eales January 2016

Agenda Item 7

Chief Executive’s Report

Part 1 Board Meeting 27 January 2016

Author Ron Shields Sponsoring Board Ron Shields Member Purpose of Report To give an overview of the current priorities and key work areas of the Chief Executive and other significant issues in the Trust.

Recommendation The Board is asked to note the report

Engagement and - Involvement Previous Monthly report to the Board Board/Committee Dates Monitoring and Assurance Summary

This report links to the . To provide high quality care; first time, every time; Strategic Goals . To be a valued partner and expert in partnership working with Patients, Communities and organisations; . To be a learning organisation, maximising our partnership with Bournemouth University and promoting innovation, research and evidence based practice; . To have a skilled, diverse and caring workforce who are proud to work for Dorset HealthCare; . To be a national leader in the delivery of integrated care; . To ensure that all of the Trust’s resources are used in an efficient and sustainable way; . To raise awareness within the Trust and externally of the impact that our work has on people and our environment, and take steps to reduce any negative effects.

I confirm that I have considered each of Any action required? the implications of this report, on each Yes of the matters below, as indicated: Yes No Detail in report All three Domains of Quality   Board Assurance Framework   Risk Register   Legal / Regulatory   People / Staff   Financial / Value for Money / Sustainability   Information Management &Technology   Equality Impact Assessment   Freedom of Information     1. Introduction

1.1 My monthly report to the Board highlights

• National developments in the NHS

• External developments to bring to the attention of the Board

• Consultations or other documents that will form future reports to the Board.

2. National News

Annual Planning

2.1 Recent weeks have seen the publication of a number of documents to set the parameters of and to guide the development of annual plans by Trusts.

2.2 A number of guidance documents have been produced to develop the draft 2016/17 annual plan for the Trust. The plan, a draft of which is included elsewhere on the agenda, will be refined following discussion at the meeting and submitted to the Board Workshop on 3 February. The views of the Council of Governors will be sought on the draft plan at its meeting on 10 February. There will be an opportunity to reflect the views of the Council in the final version of the report to be submitted to the Board. The final version of the plan must be submitted in April.

2.3 In the last week NHS Improvement has set a control total for 2016/17 for each Trust. In our case this is breakeven. Trusts must consider and agree to the control total, by 8 February, to obtain funding from the national sustainability and transformation fund.

Publication of Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust

2.4 NHS England South has published the report it commissioned from Mazars into the deaths of all patients of Southern Health who had been in receipt of mental health or learning disability services between April 2011 and March 2015.

2.5 The full report can be accessed on the NHS England South website

www.england.nhs.uk/south/our-work/ind-invest-reports/#mazars

2.6 A review is being undertaken of the mortality governance arrangements in the Trust in the light of the findings at Southern Health. A report will be submitted to the Executive Quality and Clinical Risk Group on 2 February 2015.

Self-Assessment on Avoidable Mortality and Mortality Governance

2.7 NHS England has advised that work has commenced on developing a standardised methodology for reviewing deaths in hospitals with the aim of identifying themes for improvement both nationally and within organisations. The NHS Mandate includes an intention to publish avoidable mortality by Trust ‘to encourage all Trust boards to focus on this difficult issue’.

2.8 To support the process NHS England has asked Trusts to conduct a self-assessment of their avoidable mortality using a simple tool. The self-assessment has to be returned to NHS England by 31 January 2016. 2

2.9 NHS England has also distributed to Trusts a Mortality Governance Guide developed by Monitor and the Trust Development Authority to help support Trust Boards to take a common and systematic approach to the issue of potentially avoidable mortality and to link this to quality improvement work.

2.10 The letter and Guide has been sent to all Board members. The results of the self- assessment and our position in respect of the guide will be reported to the EQCR Group on 2 February and to the Board later in the month.

NHS Sugar Tax

2.11 The Chief Executive of NHS England has said that hospitals across England will start charging more for high-sugar drinks and snacks sold in their cafes and vending machines in an effort to discourage staff, patients and visitors from buying them. He has said that a sugar tax will be introduced in acute, mental health and community services hospitals by 2020. The expected proceeds of £20m-£40m a year will be used to improve the health of the NHS workforce.

3 Trust and Local News

3.1 There are a number of matters that I would like to update the Board on this month:-

Industrial Action by Junior Doctors

3.2 The 24-hour industrial action by junior doctors on 12/13 January 2016 caused minimal disruption to Trust services. The Trust employs 18 junior doctors, all in Mental Health services. Nine participated in the action.

Talks between the Department of Health, NHS Employers and the BMA recommenced on Thursday 14 January. On the basis of the early progress made with these talks, it was announced on 18 January that, the 48-hour industrial action planned for 26-28 January had been suspended.

The final planned date for national action is 10 February, involving the full withdrawal of labour between 8am and 5pm.

Clinical Services Review

3.3 Work has continued on the development of the out of hospital model. A presentation on progress with the development of the model was made to a meeting of Chief Executives on 7 January. The model will be presented to the Board Workshop in March.

3.4 Discussions are continuing with regard to the configuration of the current acute hospitals in the County and the out of hospital model. It is planned that the current discussions will, over the course of the next few months, resolve the issues which will form the basis of the consultation document to be published later this year.

Emergency Preparedness, Resilience and Response (EPRR)

3.5 The Trust has received feedback from Dorset CCG on compliance with the EPRR core standards.

3.6 The Trust has been assessed as being substantially compliant with the 2015 core standards. In assessing this level of compliance, the CCG made positive reference to 3

• The appointment of a new EPRR lead early in 2015, which is dedicated to the EPRR function; the further development of EPRR plans and policies ; the commencement of a review of Business Continuity Management (BCM) arrangements from service level upwards.

• Liaison between the Trust EPRR lead and local authorities in Dorset.

3.7 Five standards were identified on which the Trust is required to undertake further work. This will be completed by October.

Quality Matters Conference and Quality Matters Awards

3.8 The Quality Matters Conference will be held on 26 January at the Hamworthy Club in Canford Magna. The Quality Matters Awards will be presented during the Conference. A verbal report on the Conference and Awards will be made at the Board meeting.

NHS Thames Valley and Wessex Leadership Recognition Awards

3.9 The awards ceremony for these awards was held in November last year. The Pan Dorset Pathfinder Service was a finalist in the NHS Outstanding Collaborative Leader of the Year category.

4 Recommendation

4.1 The Board is asked to note my report.

Ron Shields Chief Executive January 2016

Agenda Item 8

Dorset HealthCare Estates Strategy

Part 1 Board Meeting 27 January 2016

Author Associate Director Estates Sponsoring Board Director of Strategy and Business Development Member Purpose of Report Dorset HealthCare last published an Estates Strategy in 2009. A draft Estates Strategy was taken to the Trust’s Finance, Investment and Performance (FIP) Committee in September 2014 and subsequent versions have been discussed by the Trust Board during 2015. This document sets strategic estates priorities for the coming three to five years. It reflects the earlier Board discussions as well as meetings with a number of Locality Teams and is expected to evolve in line with Trust business and service development Recommendation

The Board is asked to approve the Estates Strategy.

Engagement and Discussions with Locality Team meetings. Involvement Trust Board workshops. Individual discussions with Locality Service Managers

Previous Board Workshop 16 December 2015 Board/Committee Dates

Monitoring and Assurance Summary

Page 1 of 2

Agenda Item 8

the implications of this report, on each Yes No of the matters below, as indicated: Detail in report All three Domains of Quality   Board Assurance Framework   Risk Register   Legal / Regulatory   People / Staff   Financial / Value for Money / Sustainability   Information Management &Technology   Equality Impact Assessment   Freedom of Information  

Page 2 of 2

ESTATES STRATEGY 2016

1. PURPOSE 1.1 Dorset HealthCare last published an Estates Strategy in 2009. A draft Estates Strategy was taken to the Trust’s Finance, Investment and Performance (FIP) Committee in September 2014 and subsequent versions have been discussed by the Trust Board during 2015. 1.2 This document sets strategic estates priorities for the coming three to five years. It reflects the earlier Board discussions as well as meetings with a number of Locality Teams and is expected to evolve in line with Trust business and service development. 2. ESTATES STRATEGY OBJECTIVES 2.1 Our overarching objectives are to: • Ensure we have the best facilities for care, for our staff, within localities and with our partners • Maximise the efficiency and use of our estate • Reduce the costs of our estate by 30% to £15.3m by 2021 (a 6% year on year reduction). 3. DORSET HEALTHCARE EXISTING ESTATE 3.1 The Trust operates from 351 premises: 38 properties are owned by the Trust, 35 have formal leases and the remainder (more than 200) have no formal leases or licences to occupy in place. 3.2 The Trust owns 13 hospital sites and 25 other properties. The freehold properties transferred to the Trust under the Transforming Community Services (TCS) programme require permission from the Department of Health (DoH) for any property related changes, including disposal and lease amendments. 4. FINANCIAL IMPACT OF ESTATE 4.1 The Trust’s total property spend 2015/16 is £21.9m. 4.2 This spend comprises: • £11.9m on Estates and Facilities Management Teams • £2m annual spend on Utilities • £2.3m on Rent - leasing space from third parties • £1.1m on Rates • £4.6m on Capital Charges

4.3 Of the buildings where the Trust has the responsibility for maintenance, a 6-Facet Survey was delivered in 2014 and assessed the current backlog maintenance bill as £8.27M.

4.4 The expenditure on infrastructure backlog maintenance has been: • 2012/13 £2.287M • 2013/14 £2.492M • 2014/15 £1.068M • 2015/16 £1.808M (Estimate)

5. LOCAL SYSTEM ESTATES PLANNING 5.1 Dorset Clinical Commissioning Group (CCG) has an overarching Health Strategy, 2014- 2019, which identifies 3 key ambitions: • Integrated health and social care services designed around the individual • Financially and clinically sustainable services delivered in an innovative way • Focus on services not institutions

5.2 The CCG is also leading the Clinical Services Review (CSR), which is due to publish its plans in the first half of 2016 and an integrated system estates strategy will form a core part of this. The Trust is an active partner in shaping this future vision. 5.3 The key themes emerging from the review are: • Out of Hospital Services A hub and spoke model of service delivery. Seven day access for patients. Services closer to home. Reduction in unnecessary and unplanned acute admissions. Closer working with social services. Greater efficiencies achieved by sharing facilities and support services.

• Acute Hospital Services High quality care, delivered by specialists, available at all times. Improved treatment, recovery and survival. Improved access to specialist care. Services meeting all national quality standards.

6. ASSESSMENT OF BACKLOG MAINTENANCE 6.1 It is essential that the physical condition of our estate is accurately assessed and maintained to ensure it is fit for purpose and safe for patients and staff. 6.2 Where the Trust is a Tenant it is normally the Landlord’s liability to address backlog maintenance non-compliance. For NHS Property Services properties in Dorset, the Trust’s Estates Team is withdrawing from the contract to provide the landlords building maintenance services from 31 March 2016. 6.3 The Trust has adopted a risk-based methodology (6-Facet appraisal process) recommended by the Department of Health to assess and manage the backlog of work required to bring the estate to a satisfactory standard (Condition B). 6.4 Table 1 below sets out the assessed backlog maintenance requirements over a 5-year period.

6.5 Table 1: Total backlog maintenance liability for the current and subsequent 5 year period

FACETS Low Moderat Significan High Totals (£000) e (£000) t (£000) (£000) (£000)

F1 Physical 11,045 10,426 4,311 5 25,787

F2 Statutory 601 1,401 1,155 539 3,696 Health

F3 Equality - - - - - (DDA)

F4 Fire 146 293 477 146 1,062

Totals (£000) 11,792 12,120 5,943 690 30,545

7. KEY ISSUES TO ADDRESS THROUGH STRATEGY • Lack of provision of female PICU facilities for women

• Older people’s organic inpatient mental health wards are not fit for purpose

• The acute mental health inpatient unit in the West of the county (Linden Unit) is not fit for purpose

• The acute treatment ward for women at St Ann’s does not have single rooms

• A sustainable future for the Trust’s community hospitals

• Centralisation of services in localities where appropriate

• Incorporating the outcomes of the Dorset CSR in to our estates planning

• Rationalisation and disposal of estate surplus to requirements, including exiting the most expensive of rented properties

• A sustainable solution for Boscombe, including the Shelley Road and Kings Park sites

8. THE PRIORITY SCHEMES 1. The lack of PICU facilities for women will be resolved by a capital project in 2016/17. It is intended to locate the PICU for women on the St Ann’s Hospital site in conjunction with the current PICU for men.

2. .During 2016 a detailed piece of work will be undertaken to develop a sustainable solution for the Trust’s older people’s services. This work will develop solutions for the Chalbury Unit at Weymouth, as well looking at the possible capital project to upgrade the Older People’s Alumhurst ward at St Ann’s Hospital site. 3. Addressing acute mental health inpatient services in the West of the County to be clear on the future of Linden Unit in Weymouth, investigating plans for possible expansion of acute beds and addressing the issue of shared bedrooms for women at St. Ann’s hospital. 4. Developing community services’ hubs in Weymouth and in Purbeck, addressing the difficulties of operating small clinical units. 5. Incorporating the emerging plans from the Clinical Services Review. 6. Investing to address backlog maintenance.

9. FUTURE FUNDING 9.1 In 2015/16 the Trust invested £10m in the Capital Programme, £6.5m of which was in the estate. 9.2 The Annual Plan for 2016/17 is being prepared. It is expected that the Plan will allow for a similar level of investment as that committed in 2015/16. 9.3 The scale of investment required for the priority schemes above will be the first call on the Trust cash balances. Schemes 1, 2 and 3 are unavoidable commitments to address patient environments that are not fit for purpose.

Agenda Item 10

Trust Board Integrated Corporate Dashboard December 2015 Part 1 Board Meeting 27th January 2016

Fiona Haughey, Director of Nursing and Quality; Jackie Chai, Author Director of Finance; and Colin Hague, Director of Human Resources

Sponsoring Board Dr Nick Kosky, Medical Director / Member Fiona Haughey, Director of Nursing and Quality Purpose of Report To provide the Board with insight and foresight of Trust performance and support effective decision making, highlighting areas of exception and good practice. The Trust performance reported here is underpinned by ward/team level information and aims to provide Board line of sight to performance within wards and teams. This integrated corporate report brings together the Trust’s performance on quality, workforce and finance against the Trust’s plans and targets. Recommendation The Board is asked to note the report and actions planned.

Engagement and All directors, localities – performance business partners, finance, Involvement human resources and quality teams. There has been wide-scale engagement with the new quality metrics with clinical staff from across the organisation.

Previous Executive Performance and Corporate Risk Group Board/Committee Dates

Monitoring and Assurance Summary

I confirm that I have considered each of Any action required? the implications of this report, on each of Yes the matters below, as indicated: Yes No Detail in report All three Domains of Quality   Board Assurance Framework   Risk Register   Legal / Regulatory   People / Staff   Financial / Value for Money / Sustainability   Information Management & Technology   Equality Impact Assessment   Freedom of Information  

Board of Directors January 2016

Trust Board Integrated Corporate Dashboard

Month 9 – December 2015 Contents

1.0 Executive Summary & Performance Synopsis Pages 3-4

2.0 Board Dashboard – Quality Metrics Page 5

2.1 Exception Reports - Are we Safe? Pages 6-10

2.2 Exception Reports - Are we Effective? Pages 11-16

2.3 Exception Reports - Are we Caring? -

2.4 Exception Reports - Are we Well Led? Pages 17-18

2.5 Exception Reports - Are we Responsive? Pages 19-20

3.0 Areas of concern or risk Pages 21-23

4.0 Areas of good practice -

5.0 National Reporting Frameworks

5.1 Board Dashboard – Monitor Indicators Page 24

5.2 CQUINS (Quarterly) Pages 25-26

5.3 External Benchmarking (as appropriate) Pages 27-29

5.4 Nationally reportable concerns (CQC) -

5.5 Research and Development Metrics (Quarterly) Page 30

5.6 Mental Health Act Metrics (Quarterly) Pages 31-32

5.7 Inpatient Nursing Staffing Page 33

6.0 Annual Plan Progress Pages 34-37

7.0 Indicator Overviews

7.1 Indicator Overview – Quality Metrics Pages 38-39

7.2 Indicator Overview – Monitor RAF Page 40

8.0 Data Quality Assurance Activity Summary Page 41-47

2 1.0 Executive Exception Summary

• The number of patients reporting that they did not feel safe has decreased compared to last month • For the latest six-months the percentage of patient safety incidents resulting in moderate to catastrophic harm remains slightly over the threshold • The number of patient falls resulting in injury in inpatient areas is higher than last month, with a higher number of falls overall occurring in hospitals Are we Safe? • The percentage of staff being up to date with their mandatory training remains almost static. Further details of what constitutes mandatory training is included in the report. • The average cumulative sickness absence the last 12 months for the remains slightly above the threshold at almost the same rate as the previous month

• Delayed transfers of care for mental health has risen to above the threshold for December, however the quarterly rate reported to Monitor is in the ‘green’ threshold. • Delayed transfers of care for physical health units has dropped slightly compared to last month, although over the past year there is an upward trend • We continue to fall below the performance threshold for patients with up to date care Are we plans Effective? • Risk assessment data has continued to remain below the performance threshold • Venous thromboembolism (VTE) risk assessments falls below the threshold for the fifth month in a row • Workforce effectiveness thresholds for completed appraisals and clinical supervision show a slight rise, whilst remaining below the threshold.

Are we • No exceptions to report Caring? • The financial performance, including CIP, is still showing as a concern • The main areas to date showing adverse performance continue to be prisons; Are we Well mental health inpatient wards due to high agency spend; and out of area placements Led? • There continues to be concern about mental health medical staffing pay budget, however the year end forecast has improved this month

• Compliance continues to be under the required threshold for community mental health team waiting times. Are we • The waiting times for Steps to Wellbeing (IAPT) remains below the threshold. Responsive? • The Trust action plan to improve CAMHS waiting times continues to be a top priority area for improvement

• All but one indicator were ‘green’ for December, however the indicators are reported Monitor quarterly to Monitor and the Trust has met the threshold all metrics in the quarter. Indicators

• A quarterly progress summary against all Trust Commissioning for Quality and Innovation (CQUIN) schemes is included in the report. There are now five areas which are RAG-rated Red. Recovery plans are in place for two of these, and further CQUINS communication with commissioners is taking place about two other CQUINs. One Quarterly CQUIN payment related to Cardio Metabolic Assessment and Treatment for update Patients with Psychoses is not recoverable. £81.43k will be withheld as the Trust did not achieve 90% compliance in completing assessment and treatment in eight key areas during Q3 for inpatients.

• The summary of the latest results from the national Community Mental Health External Survey shows similar results to last year for the Trust benchmarking

3 • A separate CQC Quality Improvement Action Plan is on the agenda for the Board CQC meeting

Research and • The dashboard for Research and Development shows all metrics are green for Development Quarter 3 and gives a summary of current research involvement Metrics Mental Health • The Mental Health Act dashboard shows three metrics as green and nine as red Act Metrics and action taken to address any concerns

Inpatient • The national return on inpatient staffing fill rates is included in the report Nursing Staffing • In summary, the RAG statuses are as follows: o Green = 15 o Amber/Green = 23 Amber = 11 Annual Plan o o Red = 4 o Completed = 5 • Eight improved month-on-month, forty five remained static and no deliverables have been downgraded. Data Quality • An update on data quality assurance activities for Quarter 3. A progress report on Assurance data quality assurance will be also provided to the Audit Committee 25 January Activity 2016. Summary

Summary Recommendations/comments The Board is asked to: • Note the contents of this report and actions planned

4 2.0 Board Dashboard – Quality Metrics Month 9 - December 2015 Are We Safe? Are We Effective? Are We Well Led?

Trend over Trend over Trend over Thres- Current Forecast Data In Thres- Current Forecast Data Thres- Current Forecast Data Metric In Month YTD last 6 Metric YTD last 6 Metric In Month YTD last 6 hold Status next month Quality Month hold Status next month Quality hold Status next month Quality mnths mnths mnths

Patient experience Patient Experience Organisational Development Q2 Patients not feeling safe in our 11 M Readmission within 28 days to Community (Staff Friends & Family Test) place of L - - - 11.5% 14% - - - M (946) - >=66% G - - inpatient wards (220) Hospitals treatment Quarterly (total responses) 77% (Staff Friends & Family Test) place of Q2 Readmission within 28 days to Mental L 7.8% 13% <9% G G H work Quarterly (946) - >=55% G - - Incidents (number of) Health Wards (total responses) 63% Patient Safety Incidents resulting % of Bed days with delayed transfer from Staff engagement in actual harm of moderate to 9.33% - <8.08% R R M 9.7% - <7.5% R G M mental health unit (coming soon) catastrophic

Violent incidents - Patient on % patients with delayed transfer from 24 151 <30 G G M 16.7% - <3.5% R R M Patient Physical health unit Operational Efficiency £000 £000 £000

Cash Balance 18,562 - - - - H Violent Incidents - Patient on Staff 28 277 <45 G G M Assessments Capital Expenditure 1,646 7,286 7,995 G G H

Up to date care plans are in place for all R A H Falls resulting in injury on CIP Performance 157 3,928 4,449 50 347 <=30 R R M patients on CPA 80.7% - >=95% R R L inpatient wards (mental health) YTD (Surplus)/Deficit 174 3,061 1,620 R R H

G Risk Assessments updated in previous 12 Monitor Financial Sustainability Risk Number of Patients Absconding 5 46 <=6 G M 83.7% - >=95% R R L 4 - 3 G G H months (mental health) Rating −

G H G H Prone Restraint 9 70 TBA - - M CPA 7 Day Follow Up 97.9% 97% >=95% G Monitor Governance Rating Green - Green G −

Seclusion 2 27 <=3 G G M Falls Assessment within 24 hours 97.5% 96% >=95% G G M

Healthcare associated infections – <=1 per Venous Thromboembolism (VTE) risk 0 12 G G H 90.3% 94% >=95% R G C.diff month assessment M Are We Responsive? Pressure ulcer risk assessments G G Healthcare associated infections – 0 per 96.8% 96% >=95% M 0 0 G G H Braden (Walsall coming soon) MRSA bacteraemia month

Avoidable pressure ulcers Trend over Workforce Thres- Current Forecast Data acquired in care (Grade 3 and 4 23 <=6 G G M Metric In Month YTD last 6 hold Status next month Quality above) mnths Completed Appraisals last year 88.65% - >=95% R R M

Workforce Patient access Clinical supervision occurring according to R R R 80.51% - >95% Mandatory training completed 90.56% - >95% R H Trust standard Patients have appointments & treatments within agreed limits - 87.5% 84% >=98% R R M Vacancy numbers 7.53% - 0-10% G G L CMHTs

R R M Patients have appointments & Sickness rates - 4.61% <4.5% 90.3% 90% >=95% R R H Are We Caring? treatments within agreed limits - IAPT

Patients have appointments within 65.0% - - - - M agreed limits CAMHS Tier 3

Patients have appointments within 83.0% - - - - M Trend over agreed limits CAMHS Tier 2 In Thres- Current Forecast Data Legend / Key Metric YTD last 6 Month hold Status next month Quality mnths Patients have appointments within Current status 89.4% 78% >=75% G G M agreed limits MAS (4 weeks)

G Patients have appointments within M Achieving against Trustwide threshold this month 98.0% 80% >=95% G G agreed limits MAS (6 weeks)

R Underachieving against Trustwide threshold this month / expect to underachieve against Trustwide threshold next month Patient Satisfaction Friends & Family Test - Response Rate A Attention required 4% 5% - - - L Patient experience (hospitals)

Friends & Family Test - % Recommended G G M Data Quality 96% 97% >=95% M Number of complaints 39 319 - - - (total responses)

H High. Data is captured electronically within an auditable system. Indicator has a full audit trail and both internal and G Patients involved in their care? 96% 96% >=95% G M Number of compliments 532 5501 - M external audits can assure the data or identify any potential issues. - -

M Moderate. Potential issues that could affect assurance of figures Rating of handling of complaint. Q2 M Reported quarterly (6) 61% >73% - - - L Low. Data is reported with no easily discernible audit trail available or has data issues identified, data quality is (total responses) 50% unknown or individual numbers are small.

Duty of Candour 3 32 - - - M 5 2.1.1 Exception Report - Are We Safe?

6 month Current Forecast next Patient Safety Incidents (PSIs) resulting in actual harm of moderate to catastrophic YTD 2015/16 Threshold Trend Data Quality average status month

Percentage of patient safety incidents (PSIs) resulting in moderate to catastrophic harm 9.33% - <8.08%

What is causing the underperformance? What actions have been taken to improve performance?

Over last 6 months the largest increases were in October and December and were pressure ulcer incidents. 1. Pressure ulcers are all reviewed using a RCA approach and findings linked into the Pressure Ulcer Sign up to Safety Pressure Ulcers are the main type of incident of moderate or above harm. They account for 64.75 % of all work stream. A quarterly report on those assessed as being avoidable including trends of care and service delivery moderate and above harm incidents reported. The teams with the highest number of moderate harm pressure issues identified and action being taken is reported to the Quality Governance Committee. ulcers reported in the period were District nursing teams - East Dorset (29), Christchurch (21) and Weymouth and Portland (19). 2. Deaths are reviewed via the mortality reviews, serious incident panel or drug related death processes. The reporting over the 6 months has remained relatively constant. Second highest area reported is death of patient accounting for 20 % of incidents in the 6 month period. The team with the most deaths reported in the period was HMP Exter with 6. Four of these were expected deaths.

Trend Analysis Forecast

Percentage of PSIs Resulting in moderate to catastrophic harm (6 month 6 month Performance Expected date to be within threshold 31/03/2016 moving average) moving 12% average Jul14-Dec14 7.01% 10% Aug14-Jan15 6.76% Revised date to be within threshold Sep14-Feb15 6.86% Oct14-Mar15 6.66% 8% Nov14-Apr15 6.74% Dec14-May15 7.11% 6% Jan15-Jun15 6.91% Review Feb15-Jul15 6.94% 4% Mar15-Aug15 7.25% Lead Director SO/EY/LB Apr15-Sep15 8.12% 2% May15-Oct15 8.99% Jun-15-Nov-15 8.90% 0% Jul-15-Dec15 9.33%

6 2.1.2 Exception Report - Are We Safe?

Current Forecast next Falls resulting in injury on inpatient wards In month YTD 2015/16 Threshold Trend Data Quality status month

Number of falls resulting in injury on inpatient wards 50 347 <=30 per month

What is causing the underperformance? What actions have been taken to improve performance?

The total number of patient falls in hospital reported in December was 130, with 50 (38.5%) resulting in 1. Learning from root cause analysis reviews (RCAs) is shared across the Trust in various ways every month. In addition to the injury. usual methods, the Falls Lead gave a presentation on learning from RCAs of falls incidents at the Trust Learning Event on 4th December 2015.

2. The Falls Lead recently met with Dorset Fire Brigade and the Manager of Safe and Independent Living to look at ways of collaborative working. As a result of this meeting Dorset Fire Brigade and Safe and Independent Living have been invited to join the Falls Lead as part of Dorset Clinical Commissioning Group Falls Strategy Task and Finish Group.

3. A patient representative has agreed to sit on the Falls Steering Group. This person will attend the Falls Steering Group meeting on 13th January 2016. This will help to ensure that patient views are an integral component of the falls work stream in the Sign Up to Safety campaign.

4. A meeting was held at Westhaven Hospital to finalise the project plan for the Westhaven Medication Optimisation pilot study. This is a pharmacy-led project with involvement from the Falls Lead that aims to reduce, where possible, the number of different medications taken by patients. It is hoped that by reducing polypharmacy, in particular use of sedative medication, there will be health benefits including a reduction in falls. The patients who sustained fractures were on Canford, Fayrewood and Radipole wards. Root cause 5. The Falls Lead facilitated an RCA at Yeatman Hospital and important learning was identified. This included assessment of analysis reviews (RCAs) have been completed for the Canford and Fayrewood patients. The learning lying/standing blood pressure and the need to regularly review the efficacy of sedative medication prescribed 'as required'. The from theses RCAs related to the need to perform and record lying and standing blood pressures for all ward will be implementing various actions including formalised discussion during ward rounds of medication prescribed 'as patients with a history of falls and the need to consider risk factors associated with osteoporosis when required' and documentation of decisions in the clinical record; discuss with other Trust staff about strategies successfully assessing patients. The RCA related to the patient on Radipole is underway, supported by the Associate implemented to manage patients at night who are at high risk of falls; and to implement assessment of lying/standing blood Director of Nursing and Quality. pressure as a standard procedure on the ward for any patients with a history of falls in the previous 12 months.

6. The updated lying/standing blood pressure guideline was published on the Trust intranet in December and is available to all staff.

Trend Analysis Forecast

Month Performance Number of Falls Resulting in Injury on Inpatient Wards Dec 14- Dec 15 Expected date to be within threshold 31/03/2016 fractures* Dec 13- Dec 14 70 Dec-14 34 1 (1%) Jan-15 50 1 (1%) Revised date to be within threshold 60 Feb-15 52 0 Mar-15 35 0 50 Apr-15 32 2 (2%) May-15 0 40 33 Jun-15 39 1 (1%) Review 30 Jul-15 36 2 (2%) Aug-15 54 3 (2%) Lead Director FH 20 Sep-15 31 4 (3%) Oct-15 40 1 (1%) 10 Nov-15 32 2 (2%) Dec-15 3 (2%) Data from 2014 were used to set the threshold, therefore not RAG rated 0 50 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 *% given as a percentage of all inpatient falls

7 2.1.3 Exception Report - Are We Safe?

Current Forecast next Data Mandatory Training Completed In month YTD 2015/16 Threshold Trend status month Quality

Mandatory Training Completed 90.56% 89.6% >95%

What is causing the underperformance? What actions have been taken to improve performance?

The indicator shows the aggregated percentage of staff who have completed all core mandatory training Actions being taken are listed on the following page. subjects relevant to their role and within the Trust stated frequency of update. Further details of the subjects covered are included on the next page. The percentage has increased slightly to 90.56% in the last month.

The teams with the lowest levels of mandatory training completion are as follows (excluding teams with less than 20 staff).

WTE = Whole time equivalent

Forecast

Mandatory Training Month Performance Expected date to be within threshold 31/03/2016 Dec-14 88.61% 100% Jan-15 87.91% Revised date to be within threshold 90% Feb-15 88.64% 80% Mar-15 91.19% 70% Apr-15 89.54% 60% May-15 89.06% 50% Jun-15 89.17% Review 40% Jul-15 89.27% 89.66% 30% Aug-15 Lead Director CH Sep-15 89.28% 20% Oct-15 90.87% 10% Nov-15 89.65% 0% 90.56% Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Dec-15

8 2.1.3 Exception Report - Are We Safe?

Mandatory Training Completed

What Constitutes Mandatory Training? Action Taken

The Trust’s mandatory training % completion rate is made up of the training subjects as defined in the UK •Ongoing monitoring of compliance by locality/teams and the arranging of additional capacity for face to Core Skills Mandatory Training Framework as follows: face sessions where required.

•Conflict Resolution / Breakaway or Prevention & Management of Violence & Aggression (PMVA) •Proactive contacting of teams with low completion rates to identify what advice, guidance and support • Equality & Diversity can be given to staff to complete their mandatory training. •Fire Awareness •Infection Prevention & Control •Flexible range of learning options including: eAssessments/ eLearning, videos, reader documents, face •Information Governance to face sessions, bespoke training sessions by team. •Moving & Handling (includes Health & Safety and Slips, Trips and Falls); •Resuscitation •Procurement of a new elearning platform to consolidate several elearning platforms into one with a •Safeguarding Children and Adults planned launch by end March 2016.

The UK Core Skills Mandatory Training Framework was developed by Skills for Health and is endorsed by •Telephone or onsite support for individuals to access elearning , including using a Sentinel hot desk for Health Education England through the Learning and Development Agreement that the Trust has signed with community staff in the area requiring access to elearning Health Education Wessex. •Moving & Handling Link staff trained in each inpatient team to undertake assessments within the The Chief Executive and Associate Director – Learning and Development have had preliminary meetings to workplace review what constitutes mandatory training. Consideration relates to both the detail around this and what should be included in the Trust’s overarching mandatory training % completion rate. •Staff outstanding Safeguarding Children/Adults Level 2 Update have been emailed their login details again to advise them on how to complete their update. Reasons for Non-Completions There are various reasons why some staff have not completed their mandatory training in a timely manner. •An alternative web page has been setup to enable staff working in GP practices/ non Trust sites to be The below references feedback from staff: able to complete eAssessments.

Too short staffed, Work pressures, Don’t see the importance, Don’t know how to access the training, no •Additional capacity for the face to face mandatory training topics has been commissioned, e.g. face to face sessions available in my immediate area when I need it, eLearning platforms are confusing / Immediate Life Support and Safeguarding Children/Adults unreliable / difficult to access, Smart Cards not always working when staff want them to, IT not working in GP practices or on non-Trust Sites, •Daily rather than fortnightly exception reports have been available to managers / staff from September 2015 to provide more accurate and up to date information. There has also been some occasions where there is no immediate capacity for face to face sessions in a specific area. The L&D Service plans the capacity a year in advance across Trust sites and factors in a Do •National Conditions and a locally agreed framework do allow withholding of increments where mandatory Not Attend (DNA) rate. However, the average DNA rate for period April – November 2015 was 13.89% training and appraisal are not up to date and an appraisal is due. The Executive Team have considered which is exceptionally high. This impacts on other staff not being able to book training and the L&D Service this but take the view that withholding increments would be detrimental to the culture of the organisation. needing to arrange additional sessions as the year progresses at short notice. With over 600 face to face sessions per year, an average of 20 staff per session and a DNA rate of 13.9%, this equates to 1668 lost places that other staff could have booked on to attend.

9 2.1.4 Exception Report - Are We Safe?

Current Forecast next Data Sickness rates In month YTD 2015/16 Threshold Trend status month Quality

Sickness rates - 4.61% <4.5%

What is causing the underperformance? What actions have been taken to improve performance?

Absence rates remain fairly static at present with the figure for the 12 months to December 2015 being 1. HR Coordinators (HRCs) continue to support, coach and advise line managers in respect of absence 4.61%. Excluding teams with less than 20 staff, the teams with the highest sickness absence levels are management and application of the Health, Wellbeing and Attendance policy and guidelines. shown below 2. Absence Management training took place during December with a total of 16 delegates attending.

3. The services highlighted continue to have ongoing cases of long term sickness which contribute in the main to the high cumulative absence rates. HRCs maintain close contact with line managers in the identified services to support with case management.

4. Anxiety / Stress / Depression are identified as continuing to be the most significant reason for absence across the Trust. As a Mental Health Trust it may be beneficial for the Trust to consider the During December the highest number of calendar days lost to sickness were due to the following reasons NHS Employers guidance "Rapid access to treatment and rehabilitation for NHS staff". in descending order:

Trend Analysis Forecast

Expected date to be within threshold 30/06/2016 Sickness Rate Month Rolling 12 months 5.0% Dec-14 4.77% Revised date to be within threshold 31/01/2016 Jan-15 4.77% 4.5% Feb-15 4.76% Mar-15 4.75% 4.0% Apr-15 4.73% May-15 4.72% 3.5% Jun-15 4.64% Review Jul-15 4.66% 3.0% Aug-15 4.72% Lead Director CH Sep-15 4.66% 2.5% Oct-15 4.69% Nov-15 4.62% 2.0% Dec-15 4.61% Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

10 2.2.1 Exception Report - Are We Effective?

Current Forecast next Delayed Transfer from physical health unit In month YTD 2015/16 Threshold Trend Data Quality status month

Percentage of patients whose transfer of care from community hospitals is delayed 16.7% - <3.5%

What is causing the underperformance? What actions have been taken to improve performance?

Delayed transfers of care from Community Hospital wards has remained a significant challenge since Winter 1. The plans for reducing overall length of stay in Community Hospitals are being amalgamated by the newly 2014. The number of delayed patients on the snapshot day of 31st December was 49, a decrease of 4 formed clinically-led working group which met for the first time on 7th January. Reduction in delayed transfers compared to the last Thursday of November. This figure still requires formal validation with Social Care of care is a very important component of those plans. The working group is meeting every three weeks, with providers prior to reporting to Unify but is unlikely to change significantly. The percentage of delayed patients agreed activities taking place between meetings with precise outputs. Agreed actions include: against the number of Community Hospital beds calculates at 16.7% against a target of 3.5% - development of use of the Rockwood Frailty Score to provide realistic expectations of the length of stay of patients on admission to Community Hospitals. This will enable prioritisation of discharge planning for patients Subject to formal validation, the main reasons for the delayed discharges remain: with the shortest expected length of stay - finalisation of length of stay timelines with agreed milestones to measure the patient's progress from patients were awaiting packages of care in their own homes admission to discharge - to be agreed with all relevant Social Care Teams patients were awaiting nursing home placement - development of SystmOne templates and reportable fields to enable accurate and timely monitoring of patients were awaiting residential home placement discharge planning from admission to discharge

The snapshot date was in the middle of the Christmas and New Year holiday period when it is especially 2. Meetings have also been undertaken with key Social Care and Continuing Healthcare (CHC) managers at difficult to arrange discharges to residential and nursing homes and commencement of new packages of many levels to ensure a consistent and complementary approach to managing discharges from Community domiciliary care. However, the trend throughout December and early January is for 45-55 patients to be Hospitals. The agreement of the length of stay timelines will be supported by clear interfaces between medically fit in our Community Hospitals and awaiting discharge so the timing of the snapshot date has not Community Hospital, CHC and Social Care staff that will be more formal than some of the current interfaces, materially affected the number of patients showing as delayed discharges. It should also be noted that all with agreed expectations as to documentation requirements and timescales for actions that support the three acute hospitals have experienced delayed discharges for the same reasons during December and early discharge process. January. 3. Although there is considerable very good activity being undertaken, discussions with Local Authority Analysis has shown that 42 of the 53 patient shown on the November snapshot (72%) are not showing on the managers have highlighted the serious difficulties providing packages of care and nursing or residential home December snapshot. This indicates that patients are being successfully discharged but are then replaced by placements in some areas in Dorset. Thus the problem of arranging safe discharge of patients from hospital other patients becoming medically fit during the month, with about a dozen patients having a delayed settings in Dorset remains extremely difficult and is unlikely to ease in the short-term. discharge of over a month.

Trend Analysis Forecast

Percentage of patients whose transfer of care from community Month Performance Expected date to be within threshold 31/03/2016 20% hospitals is delayed Dec-14 10.1% Aim for end March, however this is dependent on whole systems 18% Jan-15 15.2% 16% Feb-15 9.2% Revised date to be within threshold 14% Mar-15 9.5% 12% Apr-15 10.2% 10% May-15 7.1% 8% Jun-15 6.4% Review 6% Jul-15 8.1% 4% Aug-15 9.8% Lead Director SO 2% Sep-15 9.8% 0% Oct-15 17.2% Nov-15 17.9% Dec-15 16.7%

11 2.2.2 Exception Report - Are We Effective?

Current Forecast next Data Up to date care plans are in place for all patients on CPA In month YTD 2015/16 Threshold Trend status month Quality

Percentage of patients on CPA with up to date care plans (mental health) 80.7% - >95%

What is causing the underperformance? What actions have been taken to improve performance?

This relates to 2371 specific problems or issues which haven't been updated within a care plan in the 1. A task and finish group has been established to review care planning, documentation and clinical record (care plans can consist of several problems/issues). This equates to 607 individual training to address the chronic underperformance with this indicator patients (604 in December). There has been very little movement since December. 2. Trajectories have been set by team to ensure an improvement in performance is driven forward, To update a care plan, every care plan issue needs to be opened and edited. If there is no change which will be rated as red, amber or green and monitored on a weekly basis. to a care plan issue clinicians do not go into the care plan to update it to reflect "no change". 3. A revised process is being explored to monitor compliance with updating care plans which links Exceptions relate to the following areas: to the 12 month CPA Review process.

Bournemouth & Christchurch 1096 Dorset 804 Poole & East Dorset 471 Blank 26 Grand Total 2371

Trend Analysis Forecast

Up to Date Care Plans in Place for all Patients on CPA Month Performance Expected date to be within threshold 31/03/2016 Dec-14 100% Jan-15 Revised date to be within threshold 95% Feb-15 83.3% Mar-15 90% 82.4% Apr-15 81.4% 85% May-15 77.5% 80% Jun-15 81.3% Review 75% Jul-15 80.6% 70% Aug-15 80.4% Lead Director EY/LB/SO 65% Sep-15 80.4% 60% Oct-15 80.3% 55% Nov-15 80.7% Dec-15 80.7% 50% Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

12 2.2.3 Exception Report - Are We Effective?

Current Forecast next Data Risk Assessments updated in previous 12 months In month YTD 2015/16 Threshold Trend status month Quality

Percentage of risk summaries updated in previous 12 months (mental health) 83.7% - >95% L

What is causing the underperformance? What actions have been taken to improve performance?

This indicator is on an improving trajectory. It indicates 2178 individual patients risk assessments 1. Exceptions continue to be sent to all teams to address. have not been updated within the past 12 months from over circa. 9000 people with an open referral. 2. Reports have been updated to include the person who completed the Risk Assessment as well These are split across localities as follows: as the persons Care-coordinator who is responsible for their ongoing care.

- Bournemouth & Christchurch 825 3. A review of the indicator is being completed to determine the appropriate parameters as there is - Dorset 623 under reporting of what is happening in clinical practice. - Poole & East Dorset 704 Grand Total 2178 4. A report in Business Objects has been reviewed and noted to be corrupt which provided incorrect exception data to teams. This has been withdrawn and replaced by exception reporting for each Risk Assessments cannot be closed in RiO, therefore when a patient is re-referred the risk team. assessment becomes "live" and will automatically be out of date until the person has been assessed and the Risk Assessment updated).

Of the 2178 people a large majority are not on CPA. People who are not on CPA should have a review at least every 12 months. Risk information is recorded in letter format which is uploaded to RiO. Compliance cannot be calculated based on these reviews as they are not recorded in the field in RiO used to calculate this.

Trend Analysis Forecast

Risk Assessments Updated in previous 12 months Month Performance Expected date to be within threshold 31/03/2016 Dec-14 100% Jan-15 Revised date to be within threshold 95% Feb-15 56.0% 90% Mar-15 54.0% 85% Apr-15 75.0% 80% May-15 77.5% Jun-15 Review 75% 83.0% Jul-15 82.6% 70% Aug-15 83.4% Lead Director NK 65% Sep-15 83.1% 60% Oct-15 83.0% 55% Nov-15 83.2% 50% Dec-15 83.7% Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

13 2.2.4 Exception Report - Are We Effective?

Current Forecast next Data Venous Thromboembolism (VTE) risk assessment In month YTD 2015/16 Threshold Trend status month Quality

Percentage of VTE risk assessments completed 90.3% 94.0% >=95%

What is causing the underperformance? What actions have been taken to improve performance?

Performance for Community Hospitals was 91.9% with 25 exceptions from 310 admissions. 1. Lack of medical cover at Wareham Community Hospital was caused by short notice non- availability of medical staff. This has been addressed by the Locality Manager with cover secured Performance for Mental Health inpatients was 89.5% with 2 exceptions from 19 admissions of from early January. individuals aged 65 years and over, both exceptions were at Herm Ward. 2. The issue of weekend admissions into Community Hospitals is the subject of discussion Of the Community Hospital exceptions the wards with the most exceptions were Wareham and between the Quality Team and operational clinical managers with a view to agreeing a way forward Portland with 5 exceptions each, and Shaftesbury with 4. At Wareham there were still difficulties with on VTE risk assessments at weekends. medical cover, which have now been resolved, and at Portland there is agreement to accept VTE assessments from Dorset County Hospital for step-down patients, but these still show as exceptions. 3. A monthly dashboard with performance by Community Hospital Ward and exception reporting At Shaftesbury all four patients were already prescribed preventative anticoagulant medication. has been devised and is circulated to all Community Hospital Matrons, Locality Managers and Locality Directors for review and action. The remaining 11 exceptions were spread around the remaining Community Hospitals, except Alderney, Swanage and Wimborne which had no exceptions. Most exceptions were weekend 4. Staff at Herm Ward have been reminded of the need to undertake VTE assessments for eligible admissions where the assessment was undertaken on the next day that medical cover was patients on admission. available, while some were not assessed as they were already prescribed anti-coagulant medication.

Trend Analysis Forecast

VTE risk assessments completed Month Performance Expected date to be within threshold 29/02/2016 Dec-14 97.6% 100% Jan-15 97.7% Revised date to be within threshold 95% Feb-15 98.1% 90% Mar-15 96.8% 85% Apr-15 95.5% 80% May-15 94.6% 75% Jun-15 96.2% Review 70% Jul-15 95.4% Aug-15 94.2% Lead Director LB/SO/EY 65% Sep-15 94.6% 60% Oct-15 93.4% 55% Nov-15 91.7% 50% Dec-15 90.3% Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

14 2.2.5 Exception Report - Are We Effective?

Current Forecast next Completed appraisals last year In month YTD 2015/16 Threshold Trend Data Quality status month

Percentage of completed appraisals 88.7% 91% >=95%

What is causing the underperformance? What actions have been taken to improve performance?

Compliance for December 2015 was 88.65%. Excluding teams with less than 20 staff, the areas with the 1. The Learning & Development Service continues to contact teams with low appraisal compliance on a continuous lowest compliance for appraisals are: basis to identify what support, advice, guidance or training can be provided to support teams with increasing the number of staff who receive an annual Appraisal.

2. There is ongoing work; engaging with Clinicians and gaining feedback on how to improve the overall process. L&D have organised Appraisal Focus Groups through January 2016 to gain further staff feedback and engagement, as well as making small changes to the Appraisal Module on Ulysses to make the system more user friendly based on feedback from staff.

3. The Appraiser and Appraisee training being offered by L&D have received very positive experiences, with staff saying they have a greater understanding of the Appraisal process and recording tool.

4. On site support from the L&D Service was provided to the Crisis team at St Ann's Hospital on 23/12/2015. Support has also been offered to Inpatient Service Manager for Mental Health with no reply as yet but to be followed up in January.

5. L&D has developed and communicated 'useful tips' for staff, together with 'dispelling appraisal myths' to help appraisers and appraisees with the three elements for the appraisal: Plan-Talk-Record. together with a concise preparation pack with guidance and recommended time allocations.

6. There are currently behaviour and appraisal objective workshops being delivered across the county to capture ideas around objective setting, provide examples for different roles, and educating staff on the need to be aligning their objectives with the Trust priorities. The outcomes of these workshops will enable specific examples of objectives to be written for a range of roles to enable staff to read as part of their appraisal preparation.

7. On site support from the L&D Service was provided to Bridport Hospital on the 15/12/2015.

Trend Analysis Forecast

Completed Appraisals Month Performance Expected date to be within threshold 31/12/2015 Dec-14 72.4% 100% Jan-15 76.0% Revised date to be within threshold 31/03/2016 95% Feb-15 85.4% 90% Mar-15 93.0% 85% Apr-15 95.0% 80% May-15 94.5% 75% Jun-15 94.1% Review 70% Jul-15 93.1% Aug-15 91.2% Lead Director CH 65% Sep-15 90.9% 60% Oct-15 87.0% 55% Nov-15 87.9% 50% Dec-15 88.7% Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

15 2.2.6 Exception Report - Are We Effective?

Current Forecast next Clinical supervision occurring according to Trust standard In month YTD 2015/16 Threshold Trend Data Quality status month

Clinical supervision occurring to Trust Standard 80.5% 79.6% >95%

What is causing the underperformance? What actions have been taken to improve performance?

Compliance as at end of December was 80.51%. The teams showing lowest compliance (excluding teams 1. The Learning & Development Service continues to contact teams with low clinical supervision completion rates where the target for clinical supervision is lower than 10) are: on a continuous basis to identify what support, advice, guidance or training can be provided to support teams with increasing the number of staff who receive clinical supervision.

2. On site support from the L&D Service was provided to the Crisis team at St Ann's hospital on 23/12/2015. Support has also been offered to Inpatient Service Manager for Mental Health with no reply as yet but to be followed up in January.

3. Monthly Clinical Supervision for Supervisors training is now currently being delivered in Exeter once monthly for Devon Prisons.

4. On site support from the L&D Service was provided to Bridport Hospital on the 15/12/2015.

5. Regarding the confusion between Management and Clinical Supervision, these differences are being addressed through the training once staff have attended and the feedback being received is very positive. This confusion will be non-existent once the updated Clinical Supervision Policy becomes live and Management Supervision is no longer required. The Policy is currently being finalised.

6. There is ongoing work; engaging with Clinicians and gaining feedback on how to improve the overall process and improve the Supervision module on Ulysses. The L&D Service has been working with Ulysses to develop a group supervision option within the Clinical Supervision module of the Ulysses system. This has now been tried and tested with Clinicians and the feedback we have received has been very positive. There are a few minor tweaks needed but this will be going live towards the end of January for staff to use.

Trend Analysis Forecast

Clinical Supervision According to Trust Standard Month Performance Expected date to be within threshold 30/11/2015 Dec-14 64.0% 100% Jan-15 65.0% Revised date to be within threshold 31/03/2016 95% Feb-15 73.0% 90% Mar-15 79.1% 85% Apr-15 81.0% May-15 80.9% 80% Jun-15 80.1% Review 75% Jul-15 78.6% 70% Aug-15 78.1% Lead Director FH 65% Sep-15 78.9% 60% Oct-15 79.4% 55% Nov-15 79.1% Dec-15 80.5% 50% Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

16 2.4.1 Exception Report - Are We Well Led?

In Current Data Cost Improvement Programme (CIP) YTD YTD Threshold Trend Forecast next month month status Quality

Performance against the CIP plan 157 3,928 4,449 A

What is causing the concern? What actions have been taken to improve performance? Savings of £157k were banked in month resulting in a total of £3,928k to date. 1. Fortnightly Workforce, Recruitment and Retention meetings chaired by the Chief Executive and Year-to-date is now behind plan by £521k. This is anticipated. incorporating the Agency CIP workstream.

A small additional rates savings is recognised this month from negotiations started in 2. Mobilisation of Workforce and Agency Project chaired by Director, Linda Boland,with a team 2014/15. Overall the forecast is an under achievement of £879k. incorporating expertise from Quality, HR, Finance and Projects.

The most significant area of under achievement is the reduction in agency expenditure 3. This is a large programme of work and besides initiatives on recruitment and retention, also which was planned to deliver £1,450k. This was due to the Trust's very high agency includes areas such as rostering management, control on use of temporary staff, and staff bank spend in operational areas resulting in non-delivery of any savings this year. development. The under achievement has been alleviated by over achievement on the pay realignment, tax efficiencies, energy efficiency and other 2015/16 schemes. 4. Tight control of Medical Agency spend through Medical Director oversight with initiatives to move agency workers to substantive posts together with increased recruitment activity. The Key operational overspend areas driven by high agency expenditure are: appointment to two further substantive posts this month has reduced the forecast overspend by - Prisons £42.3k. - Mental Health wards - Medical staffing 5. Whilst there are anticipated shortfalls against specific CIP schemes, the Trust has worked to implement plans of £2.4m to recover the overall Trust financial position. These plans are reported within the Finance Report and not listed as CIP schemes. If these schemes were included as CIP, the Trust would exceed its overall target of £6.1m.

Year to Date Trend Analysis Forecast

Month Performance Expected date to be within threshold Not achieved CIP performance against the plan 1200 £000 Apr-15 127 1000 May-15 818 800 Jun-15 1,030 Jul-15 229 600 Aug-15 956 Review 400 Sep-15 363 200 Oct-15 85 Lead Director JC/LB Nov-15 163 0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Dec-15 157

17 2.4.2 Exception Report - Are We Well Led?

In month YTD Current Forecast Income and Expenditure Performance YTD Threshold £000 Trend Data Quality £000 £000 status next month

Overspend against budget (EXCLUDING PLANNED DEFICIT) (6) 1441 1620 H

What is causing the underperformance? What actions have been taken to improve performance?

There has been an in month deficit against the Trust's financial budget in December of £174k, 1. ERoster in all prisons from 11 January 2016. Four more staff starting in January. Dorset has 3 increasing the YTD deficit to £3,061k. However, £1,620k of this relates to the planned deficit YTD agency GP locums (one maternity cover, one expected to be filled in February, further candidate (£180k current month). The key unplanned operational adverse variances contributing to the being interviewed). Discussions with NHSE regarding financial support for bed watch and escorts remaining £1,441k are listed below. These are offset by underspends elsewhere, mainly within underway. New Offender Health Specialist Services Manager started 4 January 2016. Staff have other pay areas: been advised of retention premium arrangements.

1. Prison Services Pay - £1,606k 2. There continues to be a focus on roster management with the necessary oversight and review by There are still 43 nursing vacancies across Dorset and Devon, an improvement of 9 since Month 8. the Acute Inpatient Services Manager and Head of Mental Health. The use of agency is closely Ongoing agency costs covering nursing vacancies, plus 3 wte GP vacancies and one Consultant monitored and planned reductions of agency usage are being phased in across a number of wards. Psychiatrist post, resulting in YTD agency spend of £2,841k (of which £672k medical, £1,912k The adverse forecast position has remained consistent over the last 3 months, demonstrating the nursing), representing 43% of the pay budget. GP medical cover, The Verne IRC, HMP Exeter, and impact of these actions to mitigate any further increase in the adverse position. the high cost of bed watch and escorts, being the areas of greatest challenge, plus time lag in prison clearance for agencies within the cap. 3. Weekly review and repatriation planning of all out of area patients by Director and Lead Consultant. Home treatment assessment and discharge facilitation for out of area patients to allow 2. Mental Health Inpatient Wards Pay - £596k for timely repatriation to local area. A new PICU unit for women is scheduled for completion in the There has been high bank and agency usage on mental health wards. There has been above autumn of 2016. average sickness in some areas, of up to 8.9%, and extra shifts rostered for high patient acuity.

3. Out of Area Placements - £886k Acute Mental Health Inpatient Services has seen a high number of patients who require an inpatient admission and an increase in patients being admitted under sections of the Mental Health Act who cannot be accommodated within the Trust's available bed capacity, resulting in out of area placements.

The graph below reflects the unplanned adverse variance position, net of the planned deficit.

Trend Analysis Forecast

Overspend against budget (excluding planned deficit) Month Performance Expected date to be within threshold 31/03/2016 600 Apr-15 357 May-15 172 Revised date to be within threshold 400 Jun-15 469 Jul-15 166 200 Aug-15 (387) Sep-15 (32) 0 Oct-15 389 Review Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Nov-15 313 Dec-15 Lead Director JC/EY/SO -200 (6) Jan-16 £000's Adverse/(Favourable)£000's Feb-16 -400 Mar-16

18 2.5.1 Exception Report - Are We Responsive?

Current Forecast next Data Patients have appointments & treatments within agreed time limits- CMHTs In month YTD 2015/16 Threshold Trend status month Quality

Patients with appointments & treatments within agreed time limits- CMHTs 87.5% >=98%

What is causing the underperformance? What actions have been taken to improve performance?

Within adult and older people's CMHTs there were 719 individuals due to be seen within 28 days of 1. Exception reporting continues to be provided to Locality Managers for remedial action. referral. 2. Teams have commenced migration to the new RiO waiting list module to improve the waiting There were 90 breaches, of which 21 have now had a recorded 1st appointment. The longest wait list management and validation process. was 44 days and shortest 28 days. 3. All automated reports are being reviewed to ensure consistency and transparency of reporting. The following teams were below the 95% target threshold: 4. This indicator has been aligned to indicator reporting within the CCG Contract. It doesn't include OPMH Sherborne Team 93.33% CAMHS or other specialist services as these indicators are reported seperately and covers AMH Dorchester Sector Team 92.59% differnet reporting thresholds. AMH Blandford Sector 91.30% OPMH Bridport Team 90.00% AMH Weymouth South Sector Team 89.29% OPMH Bournemouth West Team 88.89% OPMH Blandford Team 87.50% AMH Weymouth North Sector Team 86.11% AMH Sherborne Sector 84.62% AMH Turbary Park Sector Team 82.35% AMH Bridport Sector Team 78.95% AMH Shaftesbury Sector 77.78% OPMH Bournemouth North Team 76.92% AMH Boscombe Sector Team 76.56% OPMH Bournemouth East Team 70.83% AMH Hahnemann Sector Team 70.45% AMH Christchurch & Southbourne Team 62.50%

Trend Analysis Forecast

Patients receiving appointments and treatments within agreed Month Performance Expected date to be within threshold 31/08/2015 Dec-14 85.8% 100% time limits- CMHTs Jan-15 82.6% Revised date to be within threshold 30/04/2016 90% Feb-15 86.2% 80% Mar-15 82.5% 70% Apr-15 76.8% 60% May-15 84.8% Review 50% Jun-15 85.8% Jul-15 Lead Director EY/SO/LB 40% 86.8% Aug-15 77.2% 30% Sep-15 88.6% 20% Oct-15 85.4% 10% Nov-15 85.9% 0% Dec-15 87.5%

19 2.5 Exception Report - Are we Responsive?

Patients have appointments & treatments within agreed time limits In Current Forecast next Data YTD 2015/16 Threshold Trend Steps to Wellbeing month status month Quality

Patients with appointments & treatments within agreed time limits- IAPT 90.3% 89.9% >=95% R R H

What is causing the underperformance? What actions have been taken to improve performance? The Steps to Wellbeing Service is a high volume service with challenging access time frames. 1. Referral rates during January are being monitored on a weekly basis to understand if the peak in During last autumn the service received an unprecedented number of referrals with September, referrals during Autumn 2015 is temporary or whether it is reflective of a general increase in numbers of October and November being the highest the services have ever seen and significantly above patients requiring the service. This information is being regularly shared with the management team and that required to achieve contractual targets. the Dorset Clinical Commissioning Group commissioners.

Whilst the referral rate fell in December, this month typically has a low referral rate and therefore 2. The services are actively recruiting to the vacancies. Bank staff and overtime has been utilised to it remains to be seen whether the referral rate overall has stabilised. So far in 2015-16 the support the teams until these posts are filled. Discussions are taking place with the Locality Director service has received 1266 more referrals than the same time last year (a 9.5% increase). regarding the use of agency to support achievement of targets.

The difficulty was further compounded by reduction in service capacity due to high levels of 3. The team leads are regularly reviewing waiting lists and ensuring that those service users who have attrition in the Psychological Wellbeing Practitioner (PWP) team. In total the service has/will lose the longest waits are being prioritised. 6.7whole time equivalent (WTE) PWPs. This is due to PWPs moving into High Intensity and Clinical Psychology Training Programmes and subsequent challenges recruiting qualified PWPs 4. Internal discussions and discussions with commissioners are being had regarding the skill mix of the (this is a national problem). The service currently has 3.8wte PWP vacancies despite two service and whether this can be altered to address this recurrent issue. recruitment rounds. Furthermore, with a high proportion of trainee PWPs in the service this also impacts on capacity.

Year to Date Trend Analysis Forecast

Patients receiving appointments and treatment within Month Performance Expected date to be within threshold 31/01/2016 agreed time limits IAPT Jan-15 98.7% 100% Feb-15 95.5% Revised date to be within threshold 29/02/2016 90% Mar-15 84.8% 80% Apr-15 75.4% 70% May-15 85.6% 60% Jun-15 83.2% 50% Jul-15 95.7% 40% Aug-15 99.5% Review 30% Sep-15 99.4% 20% Oct-15 89.7% Lead Director LB 10% Nov-15 89.2% 0% Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Dec-15 90.3%

20 3.1 Area of Concern - Are we Safe?

Current Forecast next Data Do you feel safe question (inpatients) In month YTD 2015/16 Threshold Trend status month Quality

11 123 Number of patients responding 'no' to the 'Do you feel safe?' question (number of respondents) - - (220) (2059)

What is causing the underperformance? What actions have been taken to improve performance?

The number of people responding 'no' to the do you feel safe question is shown and includes 1. An issue has been identified in the alert process from the handheld devices and gathering patients from both mental health wards and community hospital wards. additional information on why patients don't feel safe. This has been raised with the manufacturer and resolved for future months' reporting. In community hospitals patients are asked as part of a discharge survey. In December one of nine patients on Tarrant Ward responded no. 2. Ward managers are asked what action they take when a patient responds that they do not feel safe. In mental health this question is asked at two different times. This question is asked of every patient on a mental health ward on a snapshot day in the month. This captures people at different stages of 3. Data on any trends in why patients respond that they do not feel safe will be collected so that their admission. 89 patients responded in December. 85 patients responded yes and 4 patients action can be focussed as necessary. responded no.

Patients answering no were from Nightingale Court (1), Kimmeridge Court (1); and Waterston AAU (2). As this question is asked verbally on the day of the Patient Safety Thermometer snapshot, there is an opportunity for staff to discuss any concerns raised by a patient at the time.

This is also asked as part of the discharge survey. In December 6 people answered no from Dudsbury Ward (2); Melstock House (1); and Waterston Ward (3).

It is noted that the same patient might have answered the question both as part of the mental health safety thermometer and the discharge survey in the month.

21 3.3 Area of Concern - Are we Well led?

In Current YTD Trend Forecast next month Data Quality month status

81 473

What is causing the concern? What actions have been taken to improve performance? During the month, the Adult & Older Peoples Mental Health medical staffing pay budget over spent by £81k, 1. The Medical Director now has budgetary responsibility for the Mental Health budgets and meets with Medical which has resulted in a year to date over spend of £473k. This is a significant reduction on last months over HR and Finance to discuss the financial position as well as all medical vacancies, recruitment and locums across spend of £127k. the Trust.

The year-end forecast has improved by £73k to an over spend of £722k. Agency costs have reduced with just 2. No recruitment will take place without finance approval to ensure costs stay within budgets. two trainee posts being covered on the February rotation. 3. Every locum has, and is being, reviewed to see if locum cover is necessary; if the post can be covered at a Please note that the above figures only relate to the centralised Adult & Older Peoples Mental Health medical different grade or by a non medic; and, if the locum can be split across two posts. staffing budgets, however, many of the issues affecting Mental Health also apply to other medical staffing budgets. The issues are as follows: 4. The intention is to fill some vacancies with Nurse Practitioners or GP sessions which are less expensive options. Lack of a formal budget structure The budgets were split and devolved to individual services so there was no central oversight of the whole 5. Recruitment of trainees from abroad is being explored and initial steps to progress this are underway. medical staffing budgetary performance. 6. The Consultant recruitment process has been streamlined so that no Royal College approval is required Consultant over establishment before the post goes to the interview panel. There has been a historical failure to match recruitment with budget. 7. Salaries are being offered higher up the scale to secure appointments. High locum spend whilst locums have been necessary to cover sickness, the majority are used to cover the significant number of 8. Job descriptions have been improved so they are accurate and the recruitment process has been made more vacancies at Consultant and Trainee level. user friendly. These vacancies have arisen for a number of reasons: 9. A culture is being developed so that all medical staff are aware of the financial position. - There is a national shortage of psychiatric trainees 10. The aforementioned run parallel with the nursing staff developments. - Our banding supplement paid to trainees for the rota intensity is low at 20%; pay is important to trainees rather than the number of hours they work 11. A recruitment stand at the Royal College of Psychiatrists (Forensics) conference in March.

- Our geography makes recruitment difficult.

Year to Date Trend Analysis

Overspend against budget Month Performance Not achieved 250000 Dec-14 117,066 Jan-15 103,857 200000 Feb-15 74,222

150000 Mar-15 94,078 Apr-15 -2,947 100000 May-15 -8,966 Jun-15 40,163 NK 50000 Jul-15 26,983 Aug-15 13,967 0 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Sep-15 192,748

-50000 Oct-15 2,450 Nov-15 127,346 Dec-15 80,805

22 3.4 Area of Concern - Are We Responsive?

In YTD 2015/16 Threshold Current status Trend Forecast next month Data Quality month

CAMHS Tier 3 Assessment Waiting Time (% within 4 week target) 65.0% - TBC TBC TBC M

CAMHS Tier 2 Assessment Waiting Time (% within 8 week target) 83.0% - TBC TBC TBC M

What is causing the underperformance? What actions have been taken to improve performance? These figures are reported to the commissioners on a monthly basis as part of the contract performance report and relate 1. RiO WAITING LISTS: 7 teams in DHUFT are now live with RiO waiting lists, including one CAMHS team. This pilot is due for to the Child and Adolescent Mental Health Services (CAMHS) waiting times for Tier 3 (specialist) and Tier 2 (early review in January 2016 when CAMHS will consider extending RiO waiting lists to all CAMHS teams. intervention) targets 2. WAITING LIST AUDIT: Focus currently is on weekly review of all clients who have been waiting longer than the target time for The target is for tier 3 assessments to be completed within 4 weeks and tier 2 assessments within 8 weeks. assessment or treatment. Since September the number of clients has reduced from 667 to 532. The Tier 2 average wait time of those still awaiting assessment has dropped from 10.6 weeks to 7.6 weeks over the last 5 months. There are 6 teams in CAMHS; Bournemouth & Christchurch, North Dorset, West Dorset, East Dorset, Poole, and Weymouth & Portland. 3. NEW INVESTMENT £250k AND £63k; • New investment in two full time band 7 Nurse Prescribers to work alongside medical consultants working with ADHD and ASD A breakdown of this month’s breaches is shown below: • A dedicated hospital liaison worker based at Poole Hospital offering rapid Deliberate Self Harm (DSH) Assessment and Training and support to paediatric ward staff and over lapping with out of hours services; Tier 3 • One full time OT and 0.8wte behaviour nurse supporting developmental work in the west of the county to free other workers to There were a total of 30 breaches and 56 non breaches, total of 87 appointments. undertake DSH assessments;(Recruited) The longest wait was for 13 weeks which is in the Weymouth and Portland team. • Two band 5 ASD case co-ordinators to work with the Schools, Hospital based paediatric staff and CAMHS services supporting The following team had the most breaches: children, young people and families along the ASD pathway. Bournemouth & Christchurch: 21 4. CCG/LOCAL AUTHORITY/TRUST – LOCAL TRANSFORMATION PLANS The Trust is working towards the implementation of “Future in Mind” with Partners in the CCG and Local Authority to develop a Pan Tier 2 Dorset Local Transformation Plan for Children and Young People. Outline plans submitted to NHS England in September 2015 There were a total of 21 breaches and 102 non breaches, total of 124 appointments. targeting national investment of £1.5 million have received a favourable response. Further work is being undertaken to finalise The longest wait was 30 weeks in the Bournemouth & Christchurch team. plans. The CCG have confirmed new investment of £325,000 recurrent from April 2016 to develop Young Person Eating Disorder The following team had the most breaches: Services. Non Recurrent funding from January 2016 has also been secured to commence rollout of 7 day services for Eating Bournemouth & Christchurch: 16 Disorder. All the priorities in the Transformational Plan are subject to further discussion.

Trend Analysis Forecast

CAMHS Tier 3 Assessment Waiting Time (% within 4 week Month Tier 3 Tier 2 Expected date to be within threshold TBC Dec-14 79.3% 95.2% Jan-15 79.4% 82.9% Revised date to be within threshold TBC 100% target) 90% Feb-15 89.5% 74.3% 80% Mar-15 73.9% 72.9% 70% Apr-15 75.3% 64.3% 60% 76.2% 56.6% Tier 3 May-15 50% Jun-15 71.2% 68.7% Review Tier 2 40% Jul-15 63.6% 43.1% 30% 59.0% 70.8% 20% Aug-15 Lead Director LB, SD & EY 10% Sep-15 57.3% 61.9% 0% Oct-15 71.0% 76.0% Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Nov-15 75.0% 89.0% Dec-15 65.0% 83.0%

23 5.1 Jun-15 Board Dashboard Monitor Indicators

Month 9 - December 2015

Current reporting Latest Quarter TRUST POSITION month October - Weighting Target Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 December Indicator Name 2015 Clostridium Difficile - meeting the Clostridium Difficile objective 1.0 0 (above contract) 0 1 0 0 1 1 3 3 1 2 1 0 0 0

Referral to treatment waiting times within 18 weeks - Incomplete Pathway 1.0 > 92% 98.86% 98.14% 98.12% 98.03% 98.13% 99.63% 97.59% 97.66% 97.61% 97.53% 96.31% 95.47% 93.65% 95.10%

A&E - % of patients waiting less than 4 hours 1.0 > 95% 99.93% 99.94% 100.00% 100.00% 100.00% 99.92% 99.98% 98.98% 99.95% 99.97% 100.00% 100.00% 99.97% 99.99%

Individuals on enhanced CPA receiving follow up within 7 days > 95% 98.95% 95.65% 98.06% 97.25% 95.58% 96.23% 95.82% 96.76% 96.60% 95.54% 96.97% 97.14% 97.85% 97.32% 1.0 Individuals on enhanced CPA having formal review within 12 months > 95% 95.9% 95.7% 97.3% 97.3% 97.9% 95.2% 95.7% 95.1% 95.5% 95.80% 96.10% 95.80% 95.20% 95.00%

Delayed discharges per annum 1.0 < 7.5% 9.22% 9.26% 8.86% 8.17% 5.01% 5.55% 5.23% 5.24% 5.44% 5.77% 5.20% 6.51% 9.65% 7.4%

Inpatient access to crisis resolution home treatment services 1.0 > 95% 96.39% 98.67% 98.73% 100.00% 96.15% 97.26% 97.18% 97.37% 98.75% 95.83% 98.67% 94.44% 95.95% 96.4%

New psychosis cases seen (taken on) by early intervention teams 1.0 > 95% 102.63% 105.00% 96.77% 103.00% 275.00% 136.36% 100.00% 81.8% 85.0% 102.2% 103.6% 108.7% 114.47% 114.5%

Data completeness: identifiers 1.0 > 97% 99.6% 99.6% 99.6% 99.7% 99.7% 99.7% 99.7% 99.7% 99.6% 99.68% 99.70% 99.67% 99.70% 99.70% Compliance Access to healthcare for people with a learning disability 1.0 6 6 6 6 6 6 6 6 6 0 6 6 6 6 against 6 criteria Data completeness: outcomes 1.0 > 50% 52.3% 54.3% 53.9% 54.8% 54.0% 54.1% 54.8% 54.3% 55.3% 54.90% 55.40% 54.70% 54.90% 55.00%

Data completeness: Community Services - RTT Information 91.80% 91.58% 92.10% 92.19% 92.78% 92.31% 92.04% 90.92% 92.60% 93.62% 93.76% 92.15% 92.02% 92.02%

Data completeness: Community Services - Referral Information 1.0 > 50% 92.03% 95.89% 94.38% 93.97% 94.69% 96.06% 94.56% 97.28% 98.05% 97.48% 98.63% 98.65% 98.48% 98.48%

Data completeness: Community Services - Treatment Activity Information 85.63% 89.10% 86.05% 86.35% 85.47% 89.85% 87.29% 91.58% 91.93% 90.11% 92.66% 92.63% 91.20% 91.20%

Early intervention in Psychosis - care package within two weeks of referral 1.0 > 50% 88.88% 86.67% 83.47% 84.44% 86.36% 87.43% 85.78%

IAPT - common mental health problems treated within 6 weeks of referral 1.0 >75% 91.64% 89.41% 89.28% 90.70% 88.87% 91.43% 90.77% 90.75% 93.74% IAPT - common mental health problems treated within 18 weeks of referral 1.0 >95% 99.59% 99.19% 98.97% 99.75% 99.60% 99.36% 99.58% 100.00% 99.71%

* Please note that the data reflects reports provided by our Patient Management System supplier (Mayden) based on guidance from HSCIC. Mayden are testing replica reports from HSCIC to allow up to date reporting to be completed by the service

24 5.2 CQUINS

On track G Work in progress - expected to deliver A/G Reduced confidence in delivery A Off track R

£4,643.50 k Maximum total to be earned

Value Deliverable Lead Director RAG £k 3a Dementia and Delirium - Find, Assess, Investigate, Refer and Inform (FAIRI)

Carry out case finding question for patients over 75 years of age admitted or accepted for emergency unplanned care to community hospital or community services, with length of stay >72 hours,90% or A/G more of patients asked Dementia finding question from the start of Q3 Collect the number of above patients with a clinical diagnosis of dementia and a new assessment is 271.50 S'OD indicated or who have answered positively on the dementia case finding question90% or more of A/G patients referred for diagnostic assessment from the start of Q3 Share the diagnostic assessment and plan of care on discharge with GPs for above patients.90% or G more of patients have plan of care on discharge for the whole of Q4

3b Dementia and Delirium – Staff Training 90% of staff have received training by March 2016 45.00 FH R

3c Dementia and Delirium - Supporting carers

Carry out survey of carers of people with dementia and delirium and report to Board bi-annually 136.00 FH G

4a Cardio Metabolic Assessment and Treatment for Patients with Psychoses

90% (inpatients) and 80% (EIS) compliance in national audit of schizophrenia in Q2/Q3 362.00 EY R NB Relates to CQUIN M11

4b Communication with General Practitioners

90% compliance in audit in Q2 91.00 EY G

8b Reduction in A&E MH re-attendances Number of times a re-attendance occurred within 7 days following attendance with diagnosis of 453.00 EY G mental health. Baseline to be agreed

9a Cardio metabolic assessment - patients on CPA with a diagnosis of schizophrenia or psychotic disorder including Bi-Polar or identified within the psychotic super cluster

Number of cohort who have received cardiometabolic assessment and pulse check. Number who are 451.00 EY G identified at risk who have received life-style advice.

9b Learning Disability and Autism reasonable adjustments

Assessment of patients with LD and/or autism and where necessary care plan within 24hrs of 453.00 EY G admission to mental health inpatient ward (48hrs if out of hrs admission)

10 Admission avoidance - early diagnosis and intervention in people with atrial fibrillation

Set up systems to report on patients 65 years and over who have a pulse check and if required ECG. 453.00 S'OD/LB G

11a Reduction in the number of late discharges and transfers

Reduction in the number of late discharges and transfers 302.00 SO'D/LB/EY G

11b Increase Weekend discharges Physical Health services to review discharges with packages of care to determine if facilitated support 302.00 SO'D/LB G would increase weekend discharges

11c Improve the timeliness of discharge summaries quarter on quarter

25 On track G Work in progress - expected to deliver A/G Reduced confidence in delivery A Off track R

£4,643.50 k Maximum total to be earned

Value Deliverable Lead Director RAG £k

Number of all discharge summaries sent within 24 hours 0.00 SO'D/LB/EY R

11d Improve the quality of discharge summaries

Quarterly audit 50 discharge summaries and action plan 302.00 EY/S'OD/LB R

13a Acute Kidney Injury Improve diagnosis and treatment of people with AKI 453.00 S'OD/LB/EY G

14a Reducing the proportion of avoidable emergency admissions to hospital Reduce the number of patients with ambulatory care conditions being admitted to hospital through 453.00 EY/S'OD/LB G provision of urgent care services outside hospital.

MH1 Secure Service Users Active Engagement Programme EY G

MH2 Supporting Service Users in Secure Services to Stop Smoking EY G

MH6 Perinatal Specific Involvement and Support for partners EY G

MH8 Mental Health Carer Involvement Strategies EY G

MH9 Assuring the Appropriateness of unplanned CAMHS admissions

60% improvement in number of reviews held within 5 working days of unplanned admission EY G

MH10 Adult Eating Disorders Outcome Measures year 2 90% inpatients have outcome measures completed LB G

MH11 Improving Physical Healthcare to Reduce Premature Mortality in People with MH

90% (inpatients) EY G NB Relates to CQUIN 4a

PH1 Child Health Information Service - Interoperability 2.5% of the total contract value, including all Public Health Services within the contract JC R

PH2 Health Visiting Health, wellbeing and development of the Two year old review (integrated review) and support to be ‘ready for school’ 116.00 LB A/G CQUIN payments will be made in =12ths with 50% payable on a monthly basis with the remaining 50% payable following quarterly reconciliation once quarterly

PH3 Local Dental network N/A

26 5.3 Community Mental Health Survey Results Summary (December 2015)

This report presents the latest CQC Mental Health survey results. The survey looks at the experiences of people receiving Community Mental Health services from a sample of patient who had received care in 2014.

Introduction:

This survey is completed by people who have received care or treatment for a mental health condition. The eligible sample for this survey excludes the following: - Individuals who were only seen once for an assessment, - Current inpatients, - And anyone primarily receiving treatment in specific areas such as drug and alcohol abuse, learning disability services and specialist forensic services.

Nationally the number of completed surveys has decreased this year however it should be noted as an organisation our number of completed surveys has increased from 253 in 2014 to 265 this year.

Findings:

Overall there have been insignificant changes but below are the main areas which have seen either an increase or decrease in results.

Changes In Who You See (18/19/20):

Although the number of people who have experienced changes in individuals involved with their care has increased, this has had a positive reflection on their care that they have received; 37% of individuals rated their care had got better (21% in 2014.)

In the last 12 months, have the people you see for your care or services changed? 60% 50% 40% Sum of My 30% Org 20142 20% Sum of My 10% Org 20152 0% Don’t know / not My care has No Yes Yes, but this was sure started but not because I moved changed home

What impact has this had on the care you receive? 60% 50% 40% Sum of My Org 20142 30% Sum of My 20% Org 20152 10% 0% It got better It got worse It stayed the same Not sure

27 Crisis Care (21, 22, 23):

The percentage of people who answered No to the question “Do you know who to contact Out of Office Hours if you have a Crisis” has increased from 21% in 2014 to 25% this year.

Do you know who to contact out of office hours if you have a crisis? 100%

80% Sum of My Org 60% 20142 Sum of My Org 40% 20152 20% 0% No Not sure Yes

Although the percentage of people who answered No to the question above has increased, the results from the question “When you tried to contact them, did you get the help you needed” has risen 12% from last year.

When you tried to contact them, did you get the help you needed? 40

30 Sum of My Org 2014 20 Sum of My Org 10 2015

0 I could not contact No Yes, definitely Yes, to some extent them

28 Treatments (24-31):

Under this section the results for this year show very similar to last year. The only question which has changed significantly is the question “In the last 12 months, have you been prescribed any new medicines for your mental health needs?” where people who answered Yes has risen from 47% to 53%.

In the last 12 months, have you been prescribed any new medicines for your mental health needs? 55%

50%

45%

40% No Yes

Sum of My Org 20142 Sum of My Org 20152

29 5.5 Research and Development Metrics Quarter 3

The following provides details of the Quality Metrics for the Trust’s Research and Development (R&D) activities.

Metric In Quarter Current Additional details Status Time taken to issue NHS permissions All studies received permission within 15 day timescale. 100% Recruitment to target Ahead of Recruitment is ahead of target in Q3. target Recruitment of first participant to the This is within target. study Green

Number of incidents (target < 2) 0 There were no incidents in Q3. Number of studies in progress - 21 open to recruitment (some of these studies are national studies). 38 17 closed to recruitment and in follow up. (Full list available on request from R&D team) Number of studies in set-up 4 - 4 studies currently in set up.

Summary of research involvement The following areas/specialities are involved in research R&D Metrics Status per • Speech & Language • Eating Disorder • Prisons Healthcare • Perinatal • Physiotherapy • Autism Quarter • Dementia Psychosis pathway • Stroke 4 • Chronic Fatigue • Pain • Cancer 3 • Podiatry 2 Red 1 Green Review of capacity to participate in commercial studies: A 0.2 whole time equivalent clinical trials pharmacist is in post on a bank basis funded by 0 National Institute for Health Research – Wessex, who is developing the processes for the Q1 Q2 Q3 Q4 Trust to participate in commercial studies. A paper outlining the case for this participation is due at the Executive and Clinical Risk Group in January 2016 for consideration and recommendations for next steps.

30 5.6 Mental Health Dashboard Quarter 3

In Current Trend over Metric Threshold Additional details Quarter Status 6 months Lapsed Sections Reasons given for the lapsed sections were: • Oversight by RC. Reminder not provided by MHL Office as patient end of section date not recorded on task bar. • MHA assessment requested 16/11 for patient whose detention under s2 expired on 18/11, AMHP did not attend to complete application for s3 until 19/11. • RC aware section was ending and made decision not to renew it. 5 0 • Crisis consultant made aware of section expiry, MHL Office that patient was now being picked up by Community Consultant, but information not received until section had lapsed. • Patient required urgent medical treatment in general hospital and s5(2) lapsed when the patient left the ward. Action: An incident form (Ulysses) was completed in each case and issue escalated to Lead Consultant for Mental Health and Medical Director to raise with the consultant concerned. Unlawful Detentions Circumstances triggering the unlawful detentions were as follows; • The AMHP completed an application for s2 rather than s3 1 0 • Action: An incident form (Ulysses) was completed in each case and issue escalated to the relevant managers of those professionals involved for follow up / action. Deaths of detained There were no reported deaths of detained patients for the quarter. patients 0 0

Admissions of under 18’s There were no admissions of a minor (under 18) to an Adult ward during the quarter. to Adult wards 0 0

Compliance with Code of Current Trend over Period Threshold Practice Status 6 months Consent to Treatment Oct-15 The audit undertaken in October 2015 returned a 84% compliance rate. This is a fall from 93% from the Capacity to consent to last audit which took place in June 2015. treatment at first Action: The Medical Director and Lead Consultant for Mental Health are notified of any incidences of administration of 84% 100% non-compliance of those doctors failing to record an entry in the progress notes at first administration of medication recorded by medication for follow up / action. RC within patient’s notes.

RC recorded feeding back The audit undertaken in October 2015 returned an 93% compliance rate. This is an increase from 86% in of SOAD decision to the audit undertaken in June 2015. Of the 14 eligible patients, the RC provided feedback to the patient, patient following discussion with the SOAD in 13 cases and also ensured this was recorded within the progress notes. 93% 100% Action: The Medical Director and Lead Consultant for Mental Health are notified of any incidences of non-compliance for follow up / action

1 31 Section 5(2) Nov-15 Ward recorded the request The audit undertaken in Nov 2015 returned a 50% compliance rate. This is a fall from 70% in the audit for a MHA assessment has undertaken in May 2015. been rung through to the Action: The Acute Services Manager is notified of any incidences of non-compliance of those wards 50% 100% relevant Local Authority failing to record a need for a MHA assessment within the patient’s notes. This information is then taken to the ward managers meeting for follow up / action.

Outcome of the section The audit undertaken in November 2015 returned an 100 % compliance rate. This is an increase from 5(2) has been recorded in 80% in the audit undertaken in May 2015. the patient’s notes. Action: The Acute Services Manager is notified of any incidences of non-compliance of those wards 100% 100% failing to record the outcome of section 5(2) within the patient’s notes. This information is then taken to the ward managers meeting for follow up / action.

Section 132 Rights Aug-15 Attempts made to give The audit undertaken in August 2015 returned an 83% compliance rate. This has remained static from the information relating to audit undertaken in April 2015. Of the 30 patients audited in August 2015, 5 had received no attempts at their 132 rights to patients information being given to them in relation to 132 rights. before discharge. Action: The Acute Services Manager is notified of any incidences of non-compliance of those wards 83% 100% failing to attempt to read patient’s information relating to their 132 rights before discharge. This information is taken to the ward managers meeting for follow up / action and recorded as an incident (Ulysses).

Attempts made to give The audit undertaken in August 2015 returned a 53% compliance rate. This is a fall from 57% in the audit information relating to 132 undertaken in April 2015. 16 of the 30 patients audited for the period of August 2015 had attempts made rights to patients within 24 to read them information relating to their 132 rights within the first 24 hours following admission. hours. 53% 100% Action: The Acute Services Manager is notified of any incidences of non-compliance of those wards failing to attempt to read patient’s information relating to their 132 rights within the first 24 hours following discharge. This information is taken to the ward managers meeting for follow up / action.

RC Responsible Clinician SOAD Second opinion appointed doctors

2 32 5.7 Inpatient Nursing Staffing – National Return for December

Day Night Day Night Registered Registered Average Average Hospital Site Details Main Specialties on each ward Care Staff Care Staff midwives/nurses midwives/nurses fill rate - Average fill rate - Average Total Total Total Total Total Total Total Total registered fill rate - registered fill rate - Ward name Site monthly monthly monthly monthly monthly monthly monthly monthly nurse s/ care staff nurse s/ care staff Hospital Site name Specialty 1 Code planned actual staff planned actual staff planned actual staff planned actual staff midwives (%) midwives (%) staff hours hours staff hours hours staff hours hours staff hours hours (%) (%) RDY22 ALDERNEY HOSPITAL Guernsey Ward 314 - REHABILITATION 1378 1119.75 1384.5 1478 651 610 325.5 682.5 81.3% 106.8% 93.7% 209.7% RDY22 ALDERNEY HOSPITAL Jersey Ward 314 - REHABILITATION 1360.75 1161.5 1384.5 1328.25 525 619.5 325.5 652.75 85.4% 95.9% 118.0% 200.5% RDY22 ALDERNEY HOSPITAL Herm Ward 715 - OLD AGE PSYCHIATRY 897.17 905.67 2363.75 2498.42 340 330 1173.5 1189.5 100.9% 105.7% 97.1% 101.4% RDY22 ALDERNEY HOSPITAL St Brelades Ward 715 - OLD AGE PSYCHIATRY 1211 1186.08 2519.5 2617.42 470 378 1179 1230.5 97.9% 103.9% 80.4% 104.4% RDYER BLANDFORD COMMUNITY HOSPITAL Tarrant Ward 314 - REHABILITATION 922.75 963.02 1998.5 1957.42 651.25 653.83 315 640.25 104.4% 97.9% 100.4% 203.3% RDYEJ BRIDPORT COMMUNITY HOSPITAL Langdon Ward 314 - REHABILITATION 1384.5 908.26 1368.5 1575.5 651 504.58 325.25 523.5 65.6% 115.1% 77.5% 161.0% RDYEJ BRIDPORT COMMUNITY HOSPITAL Ryeberry Ward 314 - REHABILITATION 900 832.25 675 1212.5 315 325.5 630 630 92.5% 179.6% 103.3% 100.0% RDYEW FORSTON CLINIC Melstock House 710 - ADULT MENTAL ILLNESS 1043.73 1251.25 842.5 990.98 330.77 344.03 661.58 663.98 119.9% 117.6% 104.0% 100.4% RDYEW FORSTON CLINIC Waterston AAU 710 - ADULT MENTAL ILLNESS 922.5 1067.25 1382.7 1558.45 629.25 513 659.98 798.7 115.7% 112.7% 81.5% 121.0% RDYFX NIGHTINGALE HOUSE Florence House 710 - ADULT MENTAL ILLNESS 357.24 386.59 307.92 325.99 317.24 330.07 317.24 226.6 108.2% 105.9% 104.0% 71.4% RDYFX NIGHTINGALE HOUSE Nightingale Court 710 - ADULT MENTAL ILLNESS 564.08 692.71 449 851.14 333.25 334.25 333.25 363.75 122.8% 189.6% 100.3% 109.2% RDYFX NIGHTINGALE HOUSE Nightingale House 710 - ADULT MENTAL ILLNESS 862 821.75 1446.25 1196 332.75 333.75 655.75 656.5 95.3% 82.7% 100.3% 100.1% RDY32 KIMMERIDGE COURT Kimmeridge Court 710 - ADULT MENTAL ILLNESS 480.5 474.9 659.75 673.5 330.27 320.1 330.77 321.59 98.8% 102.1% 96.9% 97.2% RDYFT MAIDEN CASTLE HOUSE Glendinning Unit 710 - ADULT MENTAL ILLNESS 461.5 546.5 462 582.5 333.25 356.25 333.25 387.25 118.4% 126.1% 106.9% 116.2% RDYCV OAKCROFT Oakcroft 700- LEARNING DISABILITY 127.5 135 127.5 120 - - 114 114 105.9% 94.1% - 100.0% RDYMR PEBBLE LODGE Pebble Lodge 711- CHILD and ADOLESCENT PSYCHIATRY 925.5 1173 1364.25 958 355.67 497.17 1357 1301 126.7% 70.2% 139.8% 95.9% RDYEH PORTLAND HOSPITAL Castletown Ward 314 - REHABILITATION 923 871.75 1150.5 1116.25 651 619.5 325.5 357 94.4% 97.0% 95.2% 109.7% RDY10 ST ANN'S HOSPITAL Alumhurst Ward 710 - ADULT MENTAL ILLNESS 900 1129.2 1350 2201.39 305.1 341.6 610.2 1039.84 125.5% 163.1% 112.0% 170.4% RDY10 ST ANN'S HOSPITAL Dudsbury Ward 710 - ADULT MENTAL ILLNESS 923.75 909.76 2237.98 2502.8 330.77 330.77 992 1088.35 98.5% 111.8% 100.0% 109.7% RDY10 ST ANN'S HOSPITAL Harbour Ward 710 - ADULT MENTAL ILLNESS 927.75 864.89 1335 1514.86 320.1 330.77 661.23 757.26 93.2% 113.5% 103.3% 114.5% RDY10 ST ANN'S HOSPITAL Seaview AAU 710 - ADULT MENTAL ILLNESS 1446.75 1190.79 1079.25 1621.29 394.73 339.25 650.57 953.66 82.3% 150.2% 85.9% 146.6% RDY10 ST ANN'S HOSPITAL Twynham Ward 712 - FORENSIC PSYCHIATRY 843.75 832.04 2151.75 2370.08 309.6 319.93 990.5 1055.1 98.6% 110.1% 103.3% 106.5% RDYFG ST LEONARDS COMMUNITY HOSPITAL Canford Ward 314 - REHABILITATION 924 815.5 1154.5 1064.5 651 630 325.5 336 88.3% 92.2% 96.8% 103.2% RDYFG ST LEONARDS COMMUNITY HOSPITAL Fayrewood Ward 314 - REHABILITATION 925 923.5 1812.5 1756.75 651 651 325.5 336 99.8% 96.9% 100.0% 103.2% RDYFF SWANAGE COMMUNTIY HOSPITAL Stanley Purser Ward 314 - REHABILITATION 999.75 907.68 1142 1299 651 474.75 325.25 757.5 90.8% 113.7% 72.9% 232.9% RDYFE VICTORIA HOSPITAL W'BORNE Hanham Ward 314 - REHABILITATION 906 867.5 1518 1507.5 651 651 325.5 346.5 95.8% 99.3% 100.0% 106.5% RDYFD WAREHAM COMMUNITY HOSPITAL Saxon Ward 314 - REHABILITATION 888 790 1156.5 1118.5 651 604.25 325.25 369.25 89.0% 96.7% 92.8% 113.5% RDYEG WESTHAVEN HOSPITAL Linden Unit 710 - ADULT MENTAL ILLNESS 994 1091.75 915.25 905 661.23 645.41 661.23 671.9 109.8% 98.9% 97.6% 101.6% RDYEG WESTHAVEN HOSPITAL Radipole Ward 314 - REHABILITATION 1914.5 1888.83 2254 2331 966 792.25 651 946.5 98.7% 103.4% 82.0% 145.4% RDYEY WESTMINSTER MEMORIAL HOSPITAL Ashmore/Shaston Ward 314 - REHABILITATION 919.5 812.25 1144 1103.5 650.5 603.5 325.5 379 88.3% 96.5% 92.8% 116.4% RDYEF WEYMOUTH COMMUNITY HOSPITAL Chalbury Unit 715 - OLD AGE PSYCHIATRY 887.75 715.5 2246.25 1605.17 661.23 469.36 981.33 863.96 80.6% 71.5% 71.0% 88.0% RDYFC YEATMAN HOSPITAL The Willows 314 - REHABILITATION 1842.5 1655 2209.5 1992.5 976.5 966 651 661.5 89.8% 90.2% 98.9% 101.6% RDY10 ST ANN'S HOSPITAL Haven Ward 996 - PSYCHIATRIC INTENSIVE CARE UNIT 1518 1440 1159 1289 330.77 320.1 992 991.5 94.9% 111.2% 96.8% 99.9%

33 6.0 Annual Plan Progress

RAG Status Movement Count Count PMO Appendix 1 On track G 15 ↑ 8 Work in progress - expected to deliver A/G 23 ↔ 45 Reduced confidence in delivery A 11 ↓ 0 ANNUAL PLAN 2015/16 - as at the end of December 2015 Off track R 4 10 Complete C 5

Movement Actual / PMO Ref Deliverable Lead Director RAG* on Month Forecast Date 15-APL-1.0 Key Delivery Theme One : Quality Strategy - Delivery of Quality Priorities 15-APL-1.1 Experience - lessons learned from the findings from local investigations and reviews will be shared beyond FH G 31/03/2016 the team involved to improve the experience of our patients ↔ 15-APL-1.2 Safety - to promote safe and therapeutic staffing levels within community mental health teams (including FH A/G 31/03/2016 home treatment) and district nursing teams ↔ 15-APL-1.3 Clinical effectiveness - support staff to implement the NICE quality standards through policy and guideline FH A/G 31/03/2016 update, local clinical audit and action plan delivery ↔ 15-APL-1.4 Delivery of 2015/16 Actions: FH - Approval of Quality Strategy 2015-18, including Quality Objectives A/G ↔ 31/03/2016 - Actions arising from quarterly reviews 15-APL-1.5 Delivery of 2015/16 CQUINS SO'D/EY/LB/ A 31/03/2016 (FH) ↔

15-APL-2.0 Key Delivery Theme Two : Integration 15-APL-2.1 Explore Mental Health payment systems with commissioners that will support service integration EY C 15/01/2016 NB This is reliant on CCG 15-APL-2.2 Complete review of adult community mental health services to ensure that they are managed effectively EY G 31/03/2016 within integrated teams within localities ↔ 15-APL-2.3 Scope work programme to progress integrated working with GPs across Dorset SH A/G ↔ 31/03/2016 15-APL-2.4 Implement work programme for progressing integrated working with GPs across Dorset - ongoing SH A/G 31/03/2016 programme ↔ 15-APL-2.5 Deliver 2015/16 Better Together Work Programme SO'D Better Together Workstreams: - Integrated Locality Teams - Information Sharing G ↔ 31/03/2016 - Dorset Care Record - Workforce and Organisational Development - Carers Services 15-APL-3.0 Key Delivery Theme Three: Mental Health 15-APL-3.1 Reduce the number of patients who have to be placed out of area EY/NK A 31/03/2016 - out of area target of less than 7 ↔

Annual Plan Live 34 Movement Actual / PMO Ref Deliverable Lead Director RAG* on Month Forecast Date 15-APL-3.2 Review impact of Action Plan to improve service quality of the crisis response service and develop further EY A 31/03/2016 actions ↔ 15-APL-3.3 Delivery of Action Plan to improve service quality - services provided within Dudsbury Ward EY A ↔ 31/12/2015 15-APL-3.4 Q4 Action Plan to implement recommendations of review of adult community mental health services EY A/G 31/03/2016 (Acute Care Pathway) ↔ 15-APL-3.5 Review Mental Health Acute Care Pathway with Dorset CCG and implement changes EY C 15/01/2016 15-APL-3.6 Complete review of Children’s Emotional Health and Wellbeing across Bournemouth, Poole and Dorset, LB and implement resulting service improvement transformation programme, comprises: - Implementing findings of Pan-Dorset CAMHS Review - Developing service improvement plan across all localities by end September 2016 A/G 31/03/2016 - Finalising with commissioners priority schemes for £250k investment in financial year 2015/16 ↔ - Completing CAMHS future-in-mind self assessment tool to inform local transformation plans -Working with commissioners to submit local transformation plans for further investment by October 2015

15-APL-3.7 Delivery of Action Plan for delivery of local psychiatric intensive care services for women EY/SH G ↑ 31/01/2016

15-APL-4.0 Key Delivery Theme Four: Community Services 15-APL-4.1.1 Continue the transformation of health visiting workforce across Bournemouth, Poole and Dorset LB - Rolling recruitment campaign to increase the number of Health Visitors to reach the trajectory of 180.6 WTE. - To deliver the change in delivery of services from a GP registered population to a resident population in A/G ↔ 31/03/2016 Health Visiting Services. With all families handed over, where appropriate by 31.03.2016.

15-APL-4.1.2 Continue the transformation of school nursing workforce across Bournemouth, Poole and Dorset LB - Develop and implement a pan Dorset approach to delivery of school nursing, joint with Public Health Dorset (as per SDIP for School Nursing) - Ensure the whole school nursing workforces are trained to meet the needs of the local population and all A ↔ 31/03/2016 elements of current specification. (as per SDIP for School Nursing) - Ensure allocation of school nursing time to Special Schools and Pupil Referral Units (PRUs) (or equivalent) to deliver the healthy child programme (as per SDIP for School Nursing) 15-APL-4.2 Deliver the recommendations from the productivity and efficiency reviews in Intermediate Care services SO'D A/G 31/03/2016 aligned to individual action plans, re-profiling as necessary ↔ 15-APL-4.3 Develop Action Plan to exploit the excellent work being done to address the health needs of people within SO'D A/G 31/03/2016 the criminal justice system ↔

15-APL-5.0 Key Delivery Theme Five: Workforce and workforce development

15-APL-5.1 Develop Recruitment and Retention Strategy as part of HR Strategy CH C 30/11/2015 15-APL-5.2 Develop and deliver an Action Plan for Attraction, Recruitment and Retention CH A ↔ 31/03/2016 15-APL-5.3 Improvement in options and availability of a range of temporary staff CH A ↔ 31/03/2016

Annual Plan Live 35 Movement Actual / PMO Ref Deliverable Lead Director RAG* on Month Forecast Date 15-APL-5.4 Develop and deliver goals to improve the Trust's Equality performance and outcomes and implementation CH G 31/03/2016 of BME Workforce Equality Standard ↔ 15-APL-5.5 Development of new pathways/programmes with educational partners to address gaps identified as a CH G 31/03/2016 result of new models of working ↔ 15-APL-5.6 Further embed coaching and broaden provision CH G ↔ 31/03/2016 15-APL-5.7 Redesign of the corporate induction, workplace induction and preceptorship to embed the Trust's new CH/NP A 31/03/2016 Vision and Values and review against Behaviour framework once approved ↔ 15-APL-5.8 Develop and embed a diverse portfolio of flexible learning opportunities to enhance knowledge, skills, CH A/G 31/03/2016 behaviours and confidence to deliver Better Every Day ↔ 15-APL-5.9 Continuation and further development of Board and leadership development programmes to meet CH G 31/03/2016 evolving needs and support culture change ↔

15-APL-6.0 Key Delivery Theme Six: Bournemouth University 15-APL-6.1 Develop a think tank with Bournemouth University which meets at least quarterly where proposals and SH projects can be presented regarding how the two organisations can share expertise and work more closely G ↔ 31/03/2016 together

15-APL-7.0 Key Delivery Theme Seven: Organisational Development 15-APL-7.1 Launch and embed staff recognition scheme and annual awards NP G ↔ 30/09/2015 [Proposing closure as delivered] 15-APL-7.2 Develop, deliver and embed the Behaviours Framework NP G ↔ 31/03/2016 15-APL-7.3 Deliver Vision and Values Development Plan to include: NP A 31/03/2016 publication and delivery of external engagement programme ↔ 15-APL-7.4 Develop a cultural barometer and report within the Corporate Dashboard NP A/G ↑ 31/03/2016 15-APL-7.5 Delivery of external website with a 50% improvement against current baseline for the following measures NP R 31/03/2016 of success: customer experience benchmarking data based on survey results ↔ Under review 15-APL-7.6 Redevelopment of Trust intranet into an internal website with a 50% improvement against current NP baseline for the following measures of success: A 31/03/2016 ↑ Under review - user experience benchmarking data based on survey results 15-APL-7.7 Development and launch of a participation toolkit, with case studies, best practice and guidance NP A/G 31/03/2016 documents ↔ Under review 15-APL-7.8 Develop and launch a Carer's Strategy to include carers' passports NP A/G 31/03/2016 ↔ Under review

15-APL-8.0 Key Delivery Theme Eight: Information Management &Technology 15-APL-8.1 Implement IMT Work Programme as detailed within IMT Strategy JC A/G ↔ 31/03/2016

15-APL-9.0 Key Delivery Theme Nine : Estates 15-APL-9.1 Project Work undertaken Results presented to the Board:

Annual Plan Live 36 Movement Actual / PMO Ref Deliverable Lead Director RAG* on Month Forecast Date 15-APL-9.1.1 - 13 Locality Estates Plans SH A ↔ 31/01/2016 15-APL-9.1.2 - PICU OBC SH G ↑ 31/01/2016 15-APL-9.1.3 - Chalbury OBC SH A/G ↔ 30/07/2015 15-APL-9.1.4 - St Ann`s FBC SH A/G ↔ 31/01/2016 15-APL-9.1.5 - Forston Clinic SH A/G ↑ 31/01/2016 15-APL-9.1.6 - Shelley Road/Kings Park Hospital SH A/G ↑ 31/01/2016 15-APL-9.2 Enhance the care environment for Mental Health service users SH G ↔ 18/01/2016

15-APL-10.0 Key Delivery Theme Ten: Financial Plans 2016/17 15-APL-10.1 Deliver Financial Plan 2015/16 15-APL-10.1.1 - Delivery £6.1m CIP Programme JC R ↔ 31/03/2016 15-APL-10.1.2 - Delivery £4.5m of investments JC R ↔ 31/03/2016 15-APL-10.1.3 - Final position £2.2m deficit JC R ↔ 31/03/2016 15-APL-10.2 Delivery of Capital Programme JC/SH G ↑ 31/03/2016

15-APL-11.0 Clinical Services Review 15-APL-11.1 Respond to the public consultation on the recommendations of the Clinical Services Review SH/SO'D/ A/G 31/03/2016 NP ↔ 15-APL-11.2 Define the function and purpose of each community hospital in relation to Acute services and in their SH/SO'D/LB localities, consistent with the Clinical Services Review A/G ↔ 31/03/2016 [Requesting closure as incorporated within 15-APL-2.3]

15-APL-12.0 Capacity and Resilience 15-APL-12.1 Development of 7-day working proposals: SO'D/EY/LB - SDIP: Exploration into the extension of the role of home treatment and/or CMHT to enable 7-day working for patients with mental health needs G ↑ 31/03/2016 [Requesting closure as delivered] 15-APL-12.2 Develop capability to flex services at short notice, and / or with longer-range warning, with the production SO'D A/G 28/02/2016 of refreshed Business Continuity template, and delivery of training ↔ 15-APL-12.3 Produce productivity report for intermediate care services to gain a better understanding of the capacity SO'D C 30/11/2015 of this provision across the teams in Dorset HealthCare 15-APL-12.4 Ensure Winter Plan and bank holiday preparation reflects lessons identified from pressures during Winter SO'D C 13/10/2015 2014/15 and Easter 2015 15-APL-12.5 Participate in the CCG task and finish group planning for expected pressures, working to improve the use SO'D A/G 31/03/2016 of MIUs instead of A&E where possible ↔

Annual Plan Live 37 7.1 Indicator Overview- Quality Metrics

KLoE Indicator Why we are using this metric Description Threshold Whether patients do not feel safe in Feeling safe is essential for recovery and therapeutic The number of patients responding 'no' to the 'Do our hospitals interventions. you feel safe?' in community and mental health hospitals. This includes responses in the mental no threshold health patient safety thermometer and discharge survey (handhelds and paper surveys) Patient Safety Incidents A good safety culture is shown by high reporting of Percentage of all patient safety incidents which patient safety incidents with low or avoided harm and a have actual impact moderate, major or catastrophic. low reporting of moderate impact or above incidents. Threshold based on being in the top half of trusts < 8.08% green providing mental health services from a six-monthly >=8.08% red average of NRLS data (Sep 14) Reported as a six-monthly moving average Violent incidents patient on patient Patients expect to be treated in a safe and therapeutic Number of violent incidents (patient on patient) environment. Violent incidents are no more acceptable reported on Ulysses for inpatient areas of physical on inpatient units than in the community. assault between patients in the month. Threshold <30 green based on a 20% reduction on 2013/14 incidents as >=30 red used in the Quality Priority indicators for 2014/15.

Violent incidents patient on staff Staff expect to work in a safe and therapeutic Number of incidents reported on Ulysses for environment. Violent incidents are no more acceptable inpatient areas of physical assault from patients to <45 green in inpatient units than in the community. staff in the month. Threshold based on a 20% >=45 red reduction on 2013/14 incidents as used in the Quality Priority indicators for 2014/15. Falls on inpatient wards All falls put patients at risk of more serious injury e.g. Number of incidents of falls resulting in injury fracture. The focus on falls resulting in injury is to help reported on Ulysses in the month in hospitals. <=30 green understand the number of falls that result in harm, Threshold based on 20% reduction on 2014 >30 red including minor harm. incidents. Number of Patients Absconding Many patients brought into hospital are at risk of Number of absconding incidents in the month of harming themselves or others. Patients who abscond inpatients sectioned under the Mental Health Act. It <=6 green may harm themselves or others. excludes failure to return incidents. Threshold >6 red based on a 20% reduction on 2014 incidents.

Prone Restraint People must not be deliberately restrained in a way that Number of prone restraint incidents. Threshold to be impacts on their airway, breathing or circulation such as agreed. TBA prone restraint (Department of Health April 2014).

Seclusion Seclusion should not be included in a care plan and Number of seclusion incidents. The threshold is <=3 green only used as a last resort. based on a 20% reduction on 2014 incidents. >3 red Are We Safe?Are We Healthcare Acquired Infections: C. diff C.diff can be life threatening in the elderly or otherwise Number of Clostridium difficile cases identified on a nb. This is also a Monitor Risk vulnerable patients. Good infection control measures hospital ward in the month. This includes those <=1 green Assessment Framework indicator on inpatient units should prevent/limit the numbers of which are found not to be due to a lapse in care. >1 red patients infected. The threshold is based on an annual maximum of 12 as set by Dorset CCG for 2015/16. Healthcare Acquired Infections: MRSA MRSA bacteraemia can be life threatening in the Number of MRSA bacteraemia cases identified on a bacteraemia elderly or in otherwise vulnerable patients. Good hospital ward in the month. This includes those 0 = green infection control measures on inpatient units should which are found not to be due to a lapse in care. >=1 red prevent/limit the numbers of patients infected. The threshold is based on a national zero tolerance.

Avoidable pressure ulcers acquired in Good nursing care should prevent pressure ulcers from Number of avoidable grade 3 and above (including care (Grade 3 and above) being acquired in care. unstageable) pressure ulcers acquired in care provided by the Trust reported to commissioners is the month. This is identified after a root cause <=6 = green analysis review which will be completed up to 45 >6 = red days after the event. Threshold based on a 20% reduction on 2014 incidents.

Mandatory training completed Staff must have had mandatory training for their own Percentage of staff at month end having completed safety and the provision of safe care for patients. the required core mandatory training as per Trust >95% green stated update frequencies. Threshold has been <=95% red locally set. Vacancies The number of vacancies has a direct link to the ability The full time equivalent active vacancies at month to staff wards and teams. end from the Electronic Staff Record (ESR) and <=10% green expressing them as a percentage of budgeted >10% or <0% red establishment. Threshold has been locally set.

Sickness rates There is a recognised link between sickness rates, Full Time Equivalent hours expressed as a particularly short-term sickness rates and staff morale. percentage of Available Full Time Equivalent hours. <4% green Good HR measures to support staff are also Threshold has been locally set. >=4% red recognised to reduce sickness rates. Re-admission within 28 days to Early readmission may be an indicator that discharge Of those patients admitted as an emergency to a Community Hospitals planning was inappropriate. community hospital, how many had been previously TBA discharged from a Trust community hospital within 28 days. Re-admission within 28 days to Mental Early readmission may be an indicator that discharge Of those patients admitted as an emergency how Health Wards planning was inappropriate. many had been previously discharged within 28 9% days. National benchmarking threshold.

% of Bed days with delayed transfer Delayed discharges are a significant factor with Of those occupied bed days in mental health units, from mental health unit negative consequences for the effectiveness and how many were delayed. Monitor target. < 7.5% green nb. This is also a Monitor Risk quality of care received and also contribute to >= 7.5% red Assessment Framework indicator significant additional costs. % of Bed days with delayed transfer Delayed discharges are a significant factor with Percentage of patients delayed on an agreed from physical health unit negative consequences for the effectiveness and snapshot day in the month, calculated using the < 3.5% green quality of care received and also contribute to number of community hospital beds. Contractual >=3.5% red significant additional costs. target. Up to date care plans are in place for A care plan is an essential component for the delivery Up to date care plans are in place for all patients on >= 95% green all patients of evidence based patient centred care. the care programme approach. Threshold has been <95% red locally set. Risk Assessments updated in An up to date risk assessment is required to ensure Percentage of clients with an open referral and a previous 12 months that the care plan includes measures to reduce risks if Risk Summary completed on RiO (clinical records) >= 95% green possible. Also the risk assessment will be used by where it has been updated in the previous 12 <95% red clinicians in an emergency to review an up to date months. Threshold has been locally set. summary of risk concerns CPA 7 Day Follow Up Evidence shows that mental health patients are at The number of people under adult mental illness nb. This is also a Monitor Risk highest risk of suicide in the first two weeks after specialties who were followed up either face to face >= 95% green Assessment Framework indicator leaving hospital. or by phone with 7 days of discharge from <95% red psychiatric inpatient care. Monitor target.

Falls assessments within 24 hours Falls assessments should be carried out in order for Percentage of applicable patients who receive a interventions to be implemented to avoid falls. falls risk assessment within 24hours of admission to Are we Effective? we Are hospital. Contractual target changed from within 48 >= 95% green to 24 hours from Oct15). Community hospital <95% red patients and mental health patients >=65 years old. Contractual target. Venous Thromboembolism (VTE) risk Venous thromboembolism (VTE) is a life threatening Percentage of applicable patients who receive a assessment condition causing thousands of preventable hospital venous thromboembolism risk assessment within >= 95% green deaths each year. 24hours of admission to hospital. Community <95% red hospital patients and mental health patients >=65 years old. Contractual target. Pressure ulcer risk assessments Pressure ulcer risk assessments should be carried out Percentage of applicable patients who receive a (Braden) in order for interventions to be implemented to avoid pressure ulcer risk assessment within 4hours of >= 95% green pressure ulcers developing. admission to hospital. Community hospital patients <95% red and mental health patients >=65 years old. Contractual target. Walsall TBA TBA TBA 38 7.1 Indicator Overview- Quality Metrics

KLoE Indicator Why we are using this metric Description Threshold Completed Appraisals in the last year Appraisal is an important opportunity for staff to discuss Percentage of staff having an appraisal within a with their manager concerns about performance, rolling 12 month period. Threshold has been locally practice and working environment. Objectives to be set set. >= 95% green which both improve individual practice and the care <95% red provided to patients. Clinical supervision occurring Clinical supervision should be in place to ensure that Percentage of registered staff (excluding medical according to Trust standard registered staff are supported in meeting the Trust and staff) receiving a minimum of quarterly clinical >95% green professional requirements for delivering safe, high supervision. Threshold has been locally set. <=95% red quality care. Are we Effective? we Are Patient Friends & Family Test - The family and friends test is a nationally used Family and Friends Tests completed by patients on Response Rate measure to record the satisfaction of patients. The the handheld devices and paper surveys in hospital TBA more people we ask, the more meaningful the results. as a percentage of discharges in the month.

Patient Friends & Family Test - % We want local people to use our services. It helps to Those responding 'extremely likely' plus those Recommended identify where we are getting care right and when we responding 'likely' as a percentage of all responses 95% might need to take action to improve patient in the month. Threshold has been locally set. experience. Patients involved in their care It is important that patients are involved in planning and Percentage of respondents answering 'yes making decisions about their care and treatment. definitely' and 'yes to some extent' to whether they were involved in their care. This is taken from Are We Caring?Are We questionnaires on the Trust’s handheld device. The 95% threshold is based on a 10% improvement on the 2013/14 position as included in the 2014/15 Quality Priorities. Whether staff would recommend This is a nationally reported measure and allows for Percentage of staff responding 'extremely likely' or teams in which they work to family and Trust benchmarking. It is a proxy indicator as to staff 'likely' to the question "How likely are you to friends (Staff Friends & Family Test) - engagement and morale. recommend Dorset HealthCare to friends and family place of work is they needed care or treatment?" The survey is carried out three times in the year and all staff have >=55% at least one opportunity to respond. Threshold based on 10% improvement for the Trust based on the comparable question in the 2014 annual staff survey. (Mean for all trusts was 54% in 2014)

Whether staff would recommend This is a nationally reported measure and allows for Percentage of staff responding 'extremely likely' or teams in which they work to family and Trust benchmarking. 'likely' to the question "How likely are you to friends (Staff Friends & Family Test) - recommend Dorset HealthCare to friends and family place of treatment as a place to work? The survey is carried out three times in the year and all staff have at least one >=66% opportunity to respond. Threshold based on 10% improvement for the Trust based on the comparable question in the 2014 annual staff survey. (Mean for all trusts was 59% in 2014) New measure of staff engagement TBA TBA TBA Cash balance Figure taken from the accounts ledger. no threshold Capital Expenditure Figure taken from the accounts ledger. Within 15% of planned green Are We Well Led? Well Are We All these metrics contribute to demonstrating that the >15% or < 15% Trust is managing its business well. That finances are red CIP Performance being used to deliver its services and strategy in order Figure taken from the accounts ledger, with input Within planned to provide high quality services. from the PMO office. amount green < plan red YTD Surplus / Deficit Figure taken from the accounts ledger. Surplus green Deficit red Financial Sustainability Risk Rating This provides and indication of any financial risks which The rating for the Trust is based on quarterly returns could jeopardise the Trust's financial standing and so to Monitor. Possible ratings from 1 (lowest) to 4 3 threaten the continuity of key services or indicates a (highest) financial governance concern. Monitor Governance Rating This provides an indication of how well the Trust is The rating for the Trust is based on quarterly returns being run. to Monitor which is either red, under review, or green Green

Patients have routine appointments Patients have the right to timely assessment and Percentage of clients being seen within 4 weeks of for first assessment within agreed treatment. referral to a CMHT. This excludes emergency and 98% limits - CMHT (4 weeks) urgent referrals which have a shorter access time. Contractual target. Patients have appointments and Patients have the right to timely assessment and Percentage of clients being seen in 4 weeks of treatments within agreed limits treatment. referral to assessment within Steps to Wellbeing - IAPT services. Contractual target is 100%, however in >=95% line with our agreement with Dorset CCG 95% to 100% is rated green. Patients have appointments within Patients have the right to timely assessment and Percentage of patients seen within four weeks of agreed limits CAMHS Tier 3 treatment. referral to assessment to Tier 3 Child and no threshold Adolescent Mental Health Services (CAMHS). Contractual target. Patients have appointments within Patients have the right to timely assessment and Percentage of patients seen within eight weeks of agreed limits CAMHS Tier 2 treatment. referral to assessment to Tier 2 Child and no threshold Adolescent Mental Health Services (CAMHS). Contractual target. Patients have appointments within Patients have the right to timely assessment and Percentage of patients seen within four weeks of agreed limits MAS (4 weeks) treatment. referral to assessment in the Memory Assessment >=75% Service (MAS). Contractual target. Patients have appointments within Patients have the right to timely assessment and Percentage of patients seen within six weeks of agreed limits MAS (6 weeks) treatment. referral to assessment in the Memory Assessment >=95% Service (MAS). Contractual target. Complaints Patients' experience of not being satisfied with their Number of complaints received, both written and care and treatment provides an opportunity for learning. verbal. no threshold Are We Responsive?Are We Compliments Patients' experience of being satisfied with their care Number of compliments received. and treatment provides an opportunity for learning. no threshold

Complainants rating of the handling of How people's concerns or complaints are listened to Percentage of complainants who rated the handling their complaints and responded to is an indicator of the quality of their of their complaints as 'very good', 'good' or care. 'satisfactory' in the quarterly complainant >73% green satisfaction survey. The threshold is based on <=73% red improving on the 2013/14 position as included in the 2014/15 Quality Priorities. Duty of Candour Ensuring openness and transparency with patients and Number of times duty of candour disclosure was their representatives in relation to care and treatment. identified as appropriate following incidents resulting Duty of candour includes informing people about in moderate, major or catastrophic harm. no threshold incidents, providing reasonable support, providing truthful information and an apology when things go wrong.

Any amendments from the previous month / updates are shown in blue

39 7.2 Indicator Overview- Monitor Risk Assessment Framework

Monitoring Area Name Description / Notes Target period Performance is measured on an aggregate (rather than Referral to treatment waiting times within 18 specialty) basis and NHS foundation trusts are required to > 92% Quarterly weeks - incomplete pathways meet the threshold on a monthly basis. Waiting time is assessed on a provider basis, aggregated across all sites: no activity from off-site partner organisations A&E - % of patients waiting less than 4 hours should be included. The 4-hour waiting time indicator will > 95% Quarterly apply to minor injury units/walk in centres.

Individuals on enhanced Care Programme All patients discharged to their place of residence, care > 95% Quarterly Approach receiving follow up within 7 days home, residential accommodation, or to non-psychiatric care must be followed up within seven days of discharge. Failure Individuals on enhanced Care Programme against either threshold represents a failure against the > 95% Quarterly Approach having formal review within 12 months overall target. This indicator applies only to admissions to the foundation trust’s mental health psychiatric inpatient care. The indicator Access applies to users of working age (16-65) only, unless otherwise contracted. This includes CAMHS clients only Inpatient access to crisis resolution home where they have been admitted to adult wards. An > 95% Quarterly treatment services admission has been gate-kept by a crisis resolution team if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted in admission.

Quarterly performance against commissioner contract. New psychosis cases seen (taken on) by early Threshold represents a minimum level of performance > 95% Quarterly intervention teams against contract performance, rounded down.

Delayed transfers of care attributable to social care services Delayed discharges per annum < 7.5% Quarterly are included. de minimus: limit currently set at 12. Will apply to any inpatient facility with a centrally set C. (Monitor may difficile objective. Monitor will assess trusts for breaches of Meeting the Clostridium. difficile objective consider scoring Quarterly the C.diff objective at each quarter using a cumulative YTD cases of <12 if trajectory PHE indicates multiple outbreaks) Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Compliance Healthcare for All (DH, 2008). NHS foundation trust boards against 6 criteria Access to health for people with a learning are required to certify that their trusts meets these set out in Quarterly disability requirements above at the annual plan stage and in each Healthcare for All quarter. Failure to do so will result in the application of the (DH, 2008) service performance score for this indicator. Outcomes Patient identity data completeness metrics (from MHMDS) : Data completeness - identifiers NHS number / DOB / Postcode / Current gender / GP > 97% Quarterly organisation code / commissioner organisation code Completeness of outcomes (from MHMDS): employment Data completeness - outcomes for patients on status / accommodation status / HoNOS assessment in last > 50% Quarterly CPA 12 months Data completeness: Community Services - RTT Data completeness levels for trusts commissioned to information provide community services, using Community Information Data completeness: Community Services - Data Set (CIDS) definitions. While failure against any > 50% Quarterly Referral information threshold will score 1.0, the overall impact will be capped at Data completeness: Community Services - 1.0. Failure of the same measure for three quarters will Treatment Activity Information result in a red-rating. People experiencing a first episode of psychosis treated with a NICE approved care package within two weeks of referral. This waiting time measure does not consider DNAs & Cancellations as re-starting the clock. The measure also Early intervention in Psychosis (EIP) - to requires any assessment to be in concordance with NICE > 50% Quarterly commence reporting in Quarter 4 of 2015/16 guidelines. This can only be assured retrospectively by clinical audit and therefore, is currently not a part of the methodology. There are known issues with late recording for

New the service involved and the use of 'urgent' referrals. People with common mental health conditions referred to the IAPT programme will be treated within 6 weeks of > 75% Quarterly Improving access to psychological therapies referral (IAPT) - to commence reporting in Quarter 3 of People with common mental health conditions referred to 2015/16 the IAPT programme will be treated within 18 weeks of > 95% Quarterly referral

8.0 Briefing Note: Data Quality Assurance Activity Summary

7 January 2016 1.0 Introduction and Purpose

The purpose of this report is to update the Trust Board for the period October 2015 to December 2015 on data quality assurance activities. A progress report on data quality assurance will be also provided to the Audit Committee on 25 January 2016.

2.0 Priority Plan

The Data Quality Steering Group met for the first time in December. They reviewed the DQAF Priority Plan and agreed to add four metrics. The priority plan identifies particular metrics for targeted review, and improvement where this is required. Audits and quality assurance tests are built into processes on a case by case basis.

The confidence rating for Monitor RAF: Access to health for people with a learning disability has increased from low to moderate. The data journey has been reviewed and an evidence file for each quarterly return to the CCG has been introduced and, subject to a cohort of service users being identified, staff compliance and the data quality will be assured through a clinical audit as part of the Annual Clinical Audit Plan 2016-17.

The Quality Metrics will be reviewed led by the Medical Director and the Director of Nursing and Quality. A review of the Indicator Owners will take place at the same time to ensure the most appropriate person is identified to sign off the quality of the data capture processes and compliance.

41 3.0 DQAF Priority Plan (subject to Quality Metrics review)

Ref Indicator Confidence Main issues Actions completed Actions outstanding Rating

1 Risk Assessments Low Report not accurate Reporting process has been reviewed and The DQSG to make a decision on how to updated in previous fine-tuned. standardise clinical processes to enable OR 12 months in mental improved performance monitoring and Confirmed that the Board Report and the health (RiO) No clinical reporting needs. online Quality Metrics use the same source requirement to enter data. data in one agreed place in the health record. The information is recorded in different places in the health record. There is no high level mandate that data has to be entered in one place. Performance exception reports can be ignored by clinical staff because the Health Record has the information, just not where B&P team expect to extract it.

2 Up to date care plans Low Same as above Reporting process and metric build has The DQSG to make a decision on how to are in place for all been reviewed and changed. standardise clinical processes to enable

patients in mental improved performance monitoring and health care (RiO) reporting needs.

42 Ref Indicator Confidence Main issues Actions completed Actions outstanding Rating

3 Clinical Supervision Low Data capture tool was DQIP is in place. Clinical Supervision policy to be finalised. occurring according not fit for purpose. It goes to the policy group this month. Written procedure is available to support to Trust standard Staff are adjusting to good data entry (along with the policy when To review the metric construction and (Ulysses) entering data in a that is in place). reporting to reflect the new policy. As part different place. of this, to check if the data journey could New data capture tool has been developed be more automated than it is currently A process is required in Ulysses and launched to staff. and to ensure clear ownership of non- to count and monitor Communications roadshow undertaken to compliance monitoring. non-compliance. promote clinical supervision to staff and To fully implement the Group Supervision explain the new recording method. functionality. New ‘Group Supervision’ functionality is New data collection method to potentially being piloted. This will streamline recording. start Q1 2016.

4 Friends and Family Low Staff do not always ask Approximately 90% of improvement is Final 10% of process improvement: Test – response rate patients to complete complete. To develop a compliance test, to check (Elephant Kiosk) the Patient Experience Improved process and procedure for data whether staff are asking the question and discharge survey. collection. It is documented and available to monitor this and if it starts to dip to Elephant handheld e- on the intranet. take action. (The test cannot be done for devices are not community care as there is no known Service managers can see FFT performance popular with staff. target figure.) via a link to online reports. Unable to monitor To review the confidence rating once the The Patient Experience & Complaints staff compliance. compliance test results are in. manager has trained the new reporting analyst and is confident data-out processes are robust. A new question has been added to the survey, ‘patient declined question’ to allow the Patient Experience team to monitor

43 Ref Indicator Confidence Main issues Actions completed Actions outstanding Rating staff compliance.

5 Vacancy Numbers Low No nationally agreed As no national definition exists, the The Workforce Management Agency (ESR, Efin, eRoster, method for measuring reporting method is a Trust methodology Project group is looking to refine / payroll) vacancy numbers. This and this is still being refined. Current redefine the metric. Once the metric metric counts the definition: definition and build is agreed, a robust variance. data collection and reporting system will Numerator: difference between budgeted need to be devised. fte and actual fte excluding account codes within cost centres with vacant fte of 0.2 Map the complete data journey and and less identify procedures and quality check points. Denominator: budgeted fte HR to document the reporting procedure The Data Quality Lead has looked at the for business continuity and transparency. data journey. The data journey is complex, with input from multiple support services, involving multiple systems and manual reporting and in this respect is exposed to risk of data quality error. The complexity of the data journey and lack of a single over-arching owner for the end to end process means this metric will be restricted to a ‘low’ confidence rating. A robust quality assurance test is built into the Management Account process whereby budget managers sign off their funded establishment figures as correct before these are uploaded. A decision was made not to report this in the staff accessible online Quality Metrics tool until metric construction is confirmed.

44 Ref Indicator Confidence Main issues Actions completed Actions outstanding Rating

6 Staff FFT – place of Low Board Report uses Board Report has consistently reported this Confirm that online Quality Metrics uses treatment consistent method but using same data source since April 2015. the same data source. need to check if the Staff FFT – place of Data capture and reporting to be same method is used work documented for transparency and for the staff accessible business continuity. (in-house system, online Quality Metrics. purpose built for this)

7 Patients have Moderate Newly added to this Indicator Owner tbc as part of the Quality appointments within Priority Plan. To be Metrics review the agreed limits reviewed. IAPT (IAPTUS) Monitor RAF: People with common mental health conditions referred to the IAPT programme will be treated within 6 weeks of referral

People with common mental health conditions referred to the IAPT programme will be treated within 18 weeks of referral

45 Ref Indicator Confidence Main issues Actions completed Actions outstanding Rating

8 Duty of Candour Moderate Newly added to this Indicator Owner tbc as part of the Quality (Ulysses) Priority Plan. To be Metrics review reviewed.

9 Staff Engagement Low Newly added to this Indicator Owner tbc as part of the Quality Priority Plan. To be Metrics review reviewed.

10 Monitor RAF: Access Moderate Stronger process and This has been reviewed by the Head of Plan and deliver audit. to health for people evidence was needed Regulation & Compliance and the Data A High confidence rating is possible. It with a learning to support the Quality Lead. (Was Low relies on the clinical audit next year disability (Word reported now Based on the review and the new processes demonstrating patients experience the document) Moderate) performance. in place, this metric can change (from Low) claims made by the Trust. A review was needed. to Moderate confidence rating. DQIP is in place. A clinical audit for the framework has been added to the Annual Clinical Audit Plan for 2016/17. An evidence file for each quarterly return will be maintained by the Head of Regulation & Compliance.

46 3.0 Technical Governance Group

The Business & Performance team have set up a Technical Governance group for Lead Analysts and the Developers to progress technical aspects of the performance information agenda. The group does not have a data quality remit but will aid good communications and through this help to standardise analysts’ reporting practice which contributes to data quality.

4.0 Internal Audit of data that comes within FOMI scope (False or Misleading Information Offence February 2015)

TIAA have completed an internal audit of the Commissioning Data Set data relevant to the new FOMI guidance and to check compliance. The report is due at the end of January 2016.

5.0 Field trip to Southern Health NHS Foundation Trust

In November the Associate Director of Business & Performance and the Corporate Performance Business Partner met with the Head of Information at Southern Health, who presented the transformation work that has taken place over a two year period to improve the processes and the change of culture that underpins data quality. It was an opportunity to ask questions and to see an approach to Trust-wide change. The visit was very useful and inspirational. Key points from the day:

 Managers and team leaders are able to manage performance information and staff compliance with health record keeping standards, because they are equipped with a real time view of their service’s performance for ward to Board metrics. This ‘view’ of service performance includes two RAG quality markers, one to show performance and one to show compliance to help leaders and managers own problems.  Analysts are field-based and assigned a group of services to support, this support is expected to be as much about change of culture as provision of technical / analyst support.  A Data Quality Integrity Group meets to ensure organisational changes at team level are agreed and that systems accurately reflect the agreed team structures. This prevents reports showing old teams.  Southern Health Information Team do not manually validate data the way DHC Business & Performance team do. This is possible because three things are in place: 1) Southern Health has a data warehouse and single source of data; 2) services can see problems early on and take action; 3) the Board is clear that those entering data are accountable for data quality; 4) a standard operating procedure is in place for each team and metric.

[The reports in the press relate to work and processes from four or five years ago. Southern Health has put this new data quality process in place recently.]

47 Agenda Item

Trust Finance Report for Month 9, December 2015 Part 1 Board Meeting 27 January 2016

Author Head of Management Accounts, Director of Finance Sponsoring Board Member Director of Finance Purpose of Report To advise the Board of the financial position at Month 9, December 2015.

Recommendation The Board is asked to note the report.

Engagement and Involvement . Directors and budget managers are involved in providing updates and information affecting the financial position. . Notable feedback and actions from Directorate teams with regard to their reported financial position are included within the report. Previous Board/Committee Executive Performance and Corporate Risk Group Dates 19 January 2016. Monitoring and Assurance Summary This report links to the . To ensure that all of the Trust’s resources are used in an Strategic Goals efficient and sustainable way;

I confirm that I have considered each of Any action required? the implications of this report, on each of Yes the matters below, as indicated: Yes No Detail in report All three Domains of Quality   Board Assurance Framework   Risk Register   Legal / Regulatory   People / Staff   Financial / Value for Money / Sustainability   Information Management &Technology   Equality Impact Assessment   Freedom of Information  

FINANCE REPORT FOR MONTH 9, DECEMBER 2015

Metric YTD Summary Position  = Improved Performance Budgetary 1. OVERALL POSITION Performance ↑

The Financial Plan is for a £2.2m deficit to reflect the importance the Trust places on investment.

The Month 9 net position is a cumulative deficit of £3.1m (1.7%) which is £1.4m worse than Plan (Month 8 £1.4m). Further detail is in Appendix 1 (Income & Expenditure Summary) and in the sections below.

The overspend position is mainly driven by agency expenditure and workforce issues. Reducing agency expenditure and improving workforce management remains the key focus to improving the Trust’s financial performance. Actions include ceasing use of expensive agencies, determining exit strategies for others and maximising use of the in-house Bank. We are seeing positive results from these actions.

The most significant pay overspends, are within Prisons. A range of actions have been put in place to mitigate this cost pressure; such as the newly appointed Offender Health Specialist Services Manager having a more focussed

portfolio than his predecessor, the implementation of E-Roster, instigating a review of management processes and the introduction of retention premiums for key roles.

Other key issues include Medical Staffing, MH Inpatient wards, Out of Area placements and CIP underachievement. Further detail for all key issues is in sections 3 and 4.

The overspend areas above are largely counter balanced by net pay underspends across all directorates and projected to underspend by £4.7m.

The overall year-end forecast has broadly remained the same as last month. The most likely scenario remains at

£2.5m deficit as reported at M8. The revised forecast range is: most favourable £1.9m, most likely £2.5m, least favourable £3.9m. Further detail is in Appendix 2 (Forecast Outturn / Bridge and Range) including movements since

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We remain absolutely committed to delivering our £2.2m deficit plan. The remaining forecast gap is anticipated to be closed through workforce management, recruitment and retention actions and sustained reductions in agency staff usage. The contingency will be required.

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2. INCOME

 Plan to date: £189.0m.  Actual to date: £189.0m  Matching Plan YTD  Year-end forecast: £0.2m adverse variance

The main drivers of the year-end forecast are the loss of income relating to the Flaghead Detox Unit (£0.6m), offset by over performance in other areas for example cost per case activity.

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3. MAIN DETERMINANTS OF ADVERSE EXPENDITURE POSITION

 Plan to date: £185.8m  Actual to date: £188.8m  Variance to date: £3.0m  Year-end forecast: £4.1m adverse variance

Four of the major contributors to the adverse financial position, as previously reported to the Trust Board, represent a combined forecast overspend of £5.3m (see sections 3.1-3.4 below).

The major determinant of the adverse expenditure position is agency spend. Actions taken are yielding results, with reduced costs over the last 3 months (see section 3.6).

3.1 Out of Area Placements

Overview:  Actual to date: £2.3m  Overspend to date: £0.9m  A deterioration of £0.1m against last month  Year-end forecast remains at £1.1m overspend.

There are currently 8 placements out of county all of whom are women in PICU units. This is a net reduction of 6 against November.

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The new PICU unit for women is scheduled for completion in the Autumn of 2016. Until then, effort continues to minimise out of area placements.

3.2 Mental Health Inpatient Wards – Pay

Overview:

 Actual to date: £8.9m (of which agency is £0.6m)  Overspend to date: £0.6m as reported at Month 8  Year-end forecast: £0.6m, as reported at Month 8

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Actions taken are:  Revised systems of control for approval of agency shifts across all mental health inpatient areas.  Additional eRoster training for all managers to ensure effective staff management to reduce reliance on temporary staffing.  Exception reporting with senior manager oversight for all additional staffing above ward establishment  Review of all staffing establishments across the wards in line with acuity and occupancy levels with any suggestions to vary skill mix to reduce bank / agency usage submitted to the Director of Nursing for approval.

3.3 Prison Services

Overview:  Actual to date: £11.5m  Overspend to date: £2.0m  Deterioration of £0.3m against last month: o Pay: £214k o Non-pay: £67k  Main driver for this position is: o Pay: agency spend on medical and nursing staff which is only partially offset by pay underspends from vacancies o Non-pay: unavoidable Bedwatch and Escort costs for hospital treatment  Year-end forecast: £2.5m, a deterioration of £0.3m on Month 8

Actions taken include:  The appointment of a new Offender Health Specialist Services Manager, 4 new nurses commencing in January and 2 GP posts being offered.  The Trust Bank taking on booking of prison agency, ensuring robust controls and E-Roster being fully rolled out across the service.  Recruitment support and focus from Support Services.  Cheaper agency options, such as non-medical prescribing, are being vetted.  Exploring the potential for a DHC Community Oncology Nurse to support chemotherapy on site.  Actions taken to reduce annual pay costs are anticipated to reduce the overspend by £1.0m next year. Page 6 of 15

3.4 Medical Staffing - Pay

Overview:

 Actual to date: £12.0m (of which agency is £2.4m)  Overspend to date: £1.1m as reported at Month 8  Year-end forecast: £1.5m, an improvement of £0.1m on Month 8

Mental Health £0.6m Prisons (reported separately) £0.4m Children £0.3m Other £0.2m £1.5m

Actions taken are:  Minimising cover for trainee posts  Appointing Nurse Practitioners and staff on Trust fixed term contracts to cover trainee posts  Offering acting up opportunities and backfilling less expensive grades with agency  Working with existing staff to cover gaps  Recruitment process streamlined and salaries offered up the scale to secure appointments

3.5 Additional Lines/Service Contributions to Financial Position

 Dorset Locality Community Hospitals pay over spends reduced further in Month 9, resulting in a saving of £84k against budget, reducing the overspend YTD to £75k.

 The Weymouth and Portland MIU remains constant at £106k overspent YTD, mainly driven by high agency usage at the beginning of the year (£90k). Portland remains closed at weekends and this position is expected to be maintained.

 The Pulmonary Rehabilitation service, which is funded on a cost per case basis, continues to promote

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the service and introduce new clinics to improve on income shortfall of £77k (forecast £93k). Dorset CCG has increased the tariff, staff recruitment and an activity plan is in place.

 Swanage Income is based on activity which is presumed to remain high as in the first half of the year with an increase due to the introduction of bowel screening activity (£79k favourable YTD, forecast £106k).

 Non pay expenditure for the Dorset Locality, excluding Prisons, is £264k under spent YTD with the largest contributor being travel costs, currently £119k underspent.

 The Alderney Rehab Unit continues to overspend (£148k YTD, £99k Forecast for the year). The main drivers are medical staffing costs. Plans are in place to address the issues and expected to impact 2016/17. Progress in reducing nursing expenditure continues to be sustained with no agency use in December.

 The Night Nursing service is overspent (£133k YTD), due to continued bank cover for vacancies and long term sickness absence. The forecast overspend of £202k remains unchanged.

 The Audiology service is overspent (£126k YTD), an increase by £7k from last month, due to unexpected demand in walk in repair services for hearing aids. The forecast overspend is £122k, a deterioration of £38k against last month. The cost pressure is due to increased activity, and is being included in contract negotiations with commissioners.

 The Orthotics Service remains overspent (£118k YTD). Actions are still in place to reduce costs resulting in the forecast overspend of £163k (a £3k improvement against M8). The Trust is seeking to negotiate a revised contract with commissioners to address the shortfall in the income.

 Pain Service activity data has been reviewed, which will result in a credit to Dorset CCG, bringing income for the service to the budgeted levels.

 Additional income of £432k has been received from Dorset CCG to target improvements in Eating Disorders and to support general transformation of CAMHS across the Trust.

 Vacancies within Strategy & Business Development, mainly within Estates (£408k), Nursing & Quality

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(£155k), Finance and IM&T (£284k) and HR (£37k), together with HR non pay (£25k), are the significant drivers of the favourable Support Services position. This is offset by overspends on contractors within Estates (£296k), computer expenditure in IM&T (£151k) and lower income in Human Resources from Occupational Health and Counter fraud (£95k) plus other small variances.

 There is income risk on target achievement payments on CQUIN for Cardio Metabolic Assessment and advice for mental health patients (£80k) and Child Health Information Service (£16k). Also, HSCIC minimum data set improvements where impact of improvement changes is not known until 2 quarters later (£108k). Work is progressing to achieve targets.

 The adverse position reported within centrally held funds is being driven by 9/12th of the £2.2m planned annual deficit (£1,620k).

 Net pay underspends across all directorate areas are supporting the overall financial position. A year end underspend of £4.7m is forecast.

3.6 Impact of Agency Spend

To date, total agency spend is £10.3m of which:

Medical agency spend is £2.4m Nursing agency spend is £5.5m Admin and clerical agency spend is £1.6m (A&C group covers clinical and non clinical including estates and ancilliary) Other Professional Groups £0.7m

This compares with full-year spend in 2014/15 of £11.4m, of which:

Medical agency spend was £2.5m Nursing agency spend was £4.8m

December agency expenditure (£985k) has decreased compared to November (£1,027k).

Page 9 of 15

Agency Expenditure Trend by Staff Group 700

600

500 Medical 400 Nursing Qualified £'000 300 Nursing Unqualified Non-Clinical 200 Other Professional Groups 100

0 April May June July Aug Sept Oct Nov Dec

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There is a concerted focus on tackling agency spending led by the Chief Executive and the Locality Director for Poole & East Dorset, with dedicated support to project manage the workforce programme. Focused areas of action continue to be:

 Medical Director oversight of all agency locums and identification of exit strategies, including the transfer of budget responsibility

 Robust roster management

 Improved management processes to approve additional shifts and agency staffing and to fully roster contracted hours

 Cease the use of expensive agencies and reduction of hourly rates paid

 Maximum use of in-house Bank by increasing the number of bank staff and extending the Bank Office working hours

 Reviewing all non-clinical agency assignments and determining exit strategies.

The highest YTD agency expenditure is in the following areas:

£000 2,841 Prisons - both nursing and medical staff 1,739 Medical staff - locums (excluding Prisons) 1,276 Community Hospitals - nursing staff (excludes £515k for the temporarily funded Canford Ward) 854 Mental Health Inpatient wards (Adult & Older People) – nursing staff 863 Community Mental Health Services (mainly nursing staff) 751 Community Services (mainly AHPs) 248 IT (excludes £568k IT investment budgeted)

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CIP 4. COST IMPROVEMENT PROGRAMME ↑ Plan: £6.1m Performance to date: £3.9m delivered Variance to date: £0.5m favourable Year-end forecast: £0.9m adverse, as reported at Month 8

Adverse performance is due to £2.0m shortfall in agency schemes including slippage of £0.5m in the VAT agency supply scheme.

A summary of actual and forecast performance against CIP schemes in 2015/16 is set out at Appendix 3.

Investments 5. INVESTMENTS ↔ In its annual planning process, the Board identified £4.5m for investment in key infrastructure projects and for pump priming integration projects.

To date, £2.7m is spent. Forecast includes recovery plan actions with slippage of £0.6m in IT and £0.2m against pump prime funding.

A further £1.0m spend is anticipated giving a total commitment of £3.7m against the £4.5m plan.

Detail of all investment schemes is in Appendix 4a) with further analysis of pump priming plans at Appendix 4b).

Capital 6. CAPITAL ↓ Forecast expenditure: £9.7m, £0.5m less than plan Total year to date: £7.3m

Capital expenditure reached the Q3 threshold at 90%, within the Monitor +/-15%. Delays in November to consider capital to revenue transfer has contributed to year end forecast underspend. Areas affected were lower priority areas. In addition, there was equipment planned no longer required. Effort continues and options are explored to reduce the capital underspend.

Page 13 of 15

St Ann’s ward refurbishment is estimated at £0.5m over budget, as previously reported. Based on the draft valuation this will result in an impairment of £1.3m.

Plans are still in place to transfer Whitfield Rural Centre to NHS Property Services, resulting in a technical impairment charge of £346k.

Overall, based on the draft Total Valuation received from the District Valuer, the Trust will incur a net impairment cost of £0.9m.

Cash ↓ 7. BALANCE SHEET Cash position: £18.5m, reduction of £3.6m in month.

Sales ledger debtors stand at £3.9m, an increase of £0.6m against last month due to a query on an invoice to Dorset CCG for £793k, this will be resolved in February when we expect to receive payment.

Cash position at the year end will improve as accrued income translates to cash payments. This occurs as in year contract variations are finalised and settled by Commissioner.

A detailed statement of the Trust’s financial position at 31st December 2015 is attached at Appendix 5.

FSRR 8. FINANCIAL SUSTAINABILITY RISK RATING (FSRR) ↑ The Financial Sustainability rating comprises 4 metrics, which are equally weighted. These include the 2 metrics which were previously in place (Capital Service Cover Rating and Liquidity Rating) plus two new metrics (I&E Surplus Margin and I&E Margin Variance). The new metrics measure profitability and achievement of Plan and thresholds are shown below:

FSRR 1 FSRR 2 FSRR 3 FSRR 4

I&E surplus margin <= -1% -1% < > 0 0 =< >= 1% > 1%

I&E Margin Variance <= -2% -2% < > -1% -1% < 0 0 =>

Should one or more of the metrics score a ‘1’, then an override will be triggered, resulting in a maximum overall rating of ‘2’. Page 14 of 15

The risk rating YTD at Month 9 is as follows:

Capital Service Capacity rating 4 Liquidity rating 4 I&E Margin rating 3 I&E Margin Variance rating 4

Financial Sustainability Risk Rating before overrides 4

1 Rating Trigger for FSRR No Trigger Financial Sustainability Risk Rating after 1 rating override 4

Overall Financial Sustainability Risk Rating 4

The threshold triggering between FSRR 3 and FSRR 2 is affected by three key variables: (1) annual revenue, (2) asset disposal income and (3) impairment. Threshold is £3.5m deficit but will change according to the variables.

9. CONCLUSION

The financial forecast at Month 9 broadly stayed the same against Month 8 at £2.5m deficit, being £0.3m worse than plan.

The £1.7m contingency funding is currently uncommitted but will be needed.

THE BOARD IS ASKED TO:  Note the Finance report

Appendices  1. Income/Expenditure Summary  2a. Forecast Outturn / Bridge  2b. Forecast Range  3. Cost Improvement Programme  4a. Investments  4b. £500k Pump Prime Transformation Investment Fund  5. Statement of Financial Position

Page 15 of 15

APPENDIX 1

INCOME & EXPENDITURE SUMMARY Month 9 2015/16 (December)

CURRENT ANNUAL BUDGET YEAR TO DATE FORECAST @ M9 Total Budget Actual Variance Over/(Under) Pay Non-Pay Pay Non-Pay Income Inc & Exp Pay Non-Pay Inc & Exp Pay Non-Pay Inc & Exp Pay Non-Pay Inc & Exp £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 % £000 £000 £000 INCOME

Baseline Income (230,277) (172,637) (172,637) (0) (0%) G 0 Dorset Locality (6,438) (5,039) (4,737) 301 6% R 389 Poole & East Dorset Locality (4,825) (3,700) (3,951) (250) (7%) G (215) Bournemouth & Christchurch Locality (6,717) (5,013) (4,952) 61 1% R 81

Other Income (3,412) (2,596) (2,663) (67) (3%) G (76)

Total Trust Income (251,669) (188,985) (188,940) 45 0% R 179

EXPENDITURE

Dorset Locality 49,889 18,422 68,312 37,274 13,717 50,991 37,593 13,821 51,414 319 104 423 1% R 120 521 Poole & East Dorset Locality 51,381 17,644 69,025 38,596 13,007 51,603 37,788 13,229 51,017 (808) 222 (586) (1%) G (703) 164 Bournemouth & Christchurch Locality 55,936 11,882 67,819 41,730 8,941 50,671 42,547 10,010 52,557 816 1,069 1,886 4% R 892 1,433 Nurse Executive & Quality 4,187 918 5,104 3,128 701 3,829 2,973 716 3,689 (155) 15 (140) (4%) G (244) 38 Finance, IT, Business Performance 9,427 5,058 14,486 6,642 3,760 10,402 6,359 3,891 10,249 (284) 131 (153) (1%) G (833) 89 Human Resources 4,776 1,237 6,012 3,474 703 4,177 3,437 678 4,115 (37) (25) (62) (1%) G (34) (13) Strategy & Estates 6,614 6,608 13,222 4,939 4,930 9,869 4,531 5,306 9,836 (408) 376 (32) (0%) G (395) 796 Corporate Services 2,135 1,034 3,169 1,510 834 2,343 1,535 839 2,374 25 6 31 1% R 1 (62) Central Budgets 0 (74) (74) 0 (1,620) (1,620) 0 71 71 0 1,691 1,691 (104%) R (0) 2,362

Total Trust Expenditure 184,346 62,729 247,074 137,294 44,972 182,266 136,762 48,561 185,323 (532) 3,589 3,057 2% R (1,196) 5,327

NET INCOME & EXPENDITURE (4,595) (6,719) (3,617) (532) 3,589 3,102 (1,196) 5,327 179

Interest Received * (66) (49) (91) 0 0 (41) 84% G (41) Public Dividend Capital Dividend 4,660 4,660 3,495 3,495 3,495 3,495 0 0 0 0% G

RETAINED (SURPLUS)/DEFICIT 0 (3,273) (212) (532) 3,589 3,061 R 4,269 EBITDA 4.7% 3.4%

Memorandum Note Performance v Monitor Plan Segmental Performance Annual Turnover (at Month End) Financed By; £000 Income versus Expenditure YTD Forecast Annual YTD YTD £000 £000 Total Trust Income 251,669 Plan Plan Actual Bournemouth & Christ'ch Locality 2,348 3,830 Total Annual Turnover before Interest received 251,669 £000 £000 £000 Dorset Locality 1,128 1,641 Interest Received * 66 Poole & East Dorset Locality (415) (1,202) 2,160 (441) (212) Total Annual Turnover 251,735 Total 3,061 4,269 APPENDIX 2 a)

Dorset HealthCare University NHS Foundation Trust 2015/16 Forecast Outturn / Bridge

Significant Forecast movements from plan as at December, with comparison to November 2015:

Month 9 Change Month 8 (Under) (Better) (Under) Over Worse Over £000 £000 £000 Planned Outturn 2,160 2,160 Prisons Pay 2,095 262 1,833 Prisons Non-Pay 370 35 335 MH Inpatient Wards Pay 629 8 621 Medical Staffing (excl Prisons) 1,044 (164) 1,208 Other Pay net Vacancies (4,651) 122 (4,773) Investment Slippage (776) (1) (774) CIP Scheme Slippage 879 (65) 944 Out of Area Placements 1,076 (48) 1,123 Property Transfers & Impairments 562 (284) 846 Flaghead Unit Loss 265 (1) 265 NCA Income 191 20 171 Software, Licences & Maint 130 6 124 Orthotics Service 163 (3) 166 Estates contractors (vacancy cover) 466 94 372 Pulmonary Rehab Income 93 2 91 Capitalised Consultancy Fees (123) 0 (123) Health Care Purchase (209) (37) (172) Cost Pressure Funds not required (207) 0 (207) CQUIN & DQIP Under Achievement 204 204 0 Other Miscellaneous (91) (90) (1) Forecast Outturn 4,269 60 4,210 APPENDIX 2 b)

Forecast Outturn Range - Best Case / Likely Case / Worst Case APPENDIX 3 Dorset HealthCare University NHS Foundation Trust

2015/16 Cost Improvement Programme (CIP)

2015/16 CIP 2015/16 CIP 2015/16 CIP Forecast Full Current RAG Status applicable to 2015/16 Plan Year Effect Forecast CIP Ref 2015/16 CIP Scheme Executive Sponsor (recurrent)

£000 £000 £000 /

ent

Risk

ders

Plan

ment

Status

impact

Quality

benefits

ontrack

Manage

Stakehol

engaged engaged

Financial

assessm managed 14.15 Schemes bfwd -

Psychiatric on-call rota 22 31 80

Estates Strategy Project 463 463 0

Prescribing 23 62 57

E-travel 90 90 90

Tax Efficiences 64 220 0

Other 14/15 Schemes 0 150 35

15/16 Schemes -

Other 15/16 schemes 427 435

0.2 In year budget savings 0 40 0

1.1 Vacancy Review and Adjustment Colin Hague 2,000 2,102 2,109

2.1 Workforce Management - Agency Linda Boland 1,450 0 0 Sally O'Donnell,Linda 2.2 Team Productivity - Community Health Services 250 248 167 Boland & Eugine Yafele Sally O'Donnell,Linda 2.3 Team Producivity - CMHT 250 240 177 Boland & Eugine Yafele 2.4 Agency Procurement Project Colun Hague 550 10 0

3.1 Procurement Plan Jackie Chai 300 300 300

4.1(1) Soft FM reorganisation efficiencies Steve Hubbard 500 500 500

4.1 (2) Tenancy Agreement Disposal Steve Hubbard 100 100 100

4.1 (3) Estates Energy Efficiency Steve Hubbard 0 200 0

Total 2015/16 CIP savings to be achieved 6,062 5,183 4,049

Full Year Effect towards 2016/17 Savings Target (1,134) Forecast Outturn Variance: Fav. / (Adv.) (879) APPENDIX 3

Dorset HealthCare University NHS Foundation Trust 2015/16 Cost Improvement Programme (CIP) - Profiling Detail

2015/16 Monthly Profiling

Actual Forecast

Recurrent Forecast ('R), Non CIP Ref 2015/16 CIP Scheme April May June July August September October November December January February March Outturn Recurrent (NR) Total £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Psychiatric on-call rota R 31 ------31 Estates Strategy Project NR - - - - - 463 463 Prescribing R 12 6 10 - 5 5 5 5 4 4 8 62 E-travel R - - - 30 30 30 90 Tax Efficiences NR 19 20 7 18 18 18 19 21 20 20 20 20 220 Other 14/15 Schemes R/NR 77 - - 1 12 61 - - - 150 Other 15/16 schemes R 427 - - - - 427 0.2 In year budget savings NR 40 40 1.1 Vacancy Review and Adjustment R 743 1,017 82 - 260 - - - - 2,102 2.1 Workforce Management - Agency R - - - 2.2 Team Productivity - Community Health Services R - 248 - - 248 2.3 Team Producivity - CMHT R - 80 80 80 240 2.4 Agency Procurement Project R - - 3 3 3 10 3.1 Procurement Plan R - 113 61 31 49 - - 47 300 4.1(1) Soft FM reorganisation efficiencies R 20 55 88 70 15 15 38 - 198 500 Tenancy Agreement Disposal and elimination of rentl 4.1 (2) R 8 31 31 31 100 from GP Practices 4.1(3) Estates Energy Efficiency NR/R - - 39 81 81 200 -

Total CIP savingsachieved/to be achieved: 127 818 1,030 229 956 363 85 163 157 207 249 800 5,183

Actual 2015/16 Cumulative CIP savings profile £'000 127 945 1,976 2,205 3,160 3,524 3,608 3,771 3,928 4,135 4,383 5,183 Planned 2015/16 Cumulative CIP profile £'000 32 865 1,242 1,568 1,953 2,474 2,870 3,366 4,449 4,945 5,441 6,062 Monthly cumulative CIP variance: Fav / (Adv) £ 95 81 734 637 1,207 1,049 738 405 (521) (811) (1,058) (879) £4.5m Investments 2015/16 - Plan vs Forecast APPENDIX 4 a)

April May June July Aug Sept Oct Nov Dec Jan Feb March Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 CIS Plan 17 17 17 20 20 20 28 28 28 28 28 28 277 Actual / Forecast 45 84 -42 32 27 32 42 32 32 26 26 29 365 RIO 2015 Plan 40 115 115 386 60 60 60 60 60 52 52 52 1109 Actual / Forecast 7 4 237 2 412 3 -24 29 30 33 33 33 797 Wi-Fi Plan 0 0 0 33 33 33 33 33 33 33 21 0 254 Actual / Forecast 0 0 333 0 0 0 0 0 0 0 0 0 333 Dorset Shared Record Plan 0 0 0 24 39 39 39 39 39 39 39 39 339 Actual / Forecast 0 0 0 0 0 0 0 0 0 4 4 4 11 Reporting functionality improvements (managed through Trust PMO) Plan 15 15 15 15 15 15 15 15 15 15 15 15 180 Actual / Forecast 13 21 23 11 4 5 10 8 0 0 0 0 95 Electronic correspondence and information sharing, including test requesting/reporting Plan 0 0 25 12 12 12 23 23 23 23 23 23 201 Actual / Forecast 0 0 0 0 0 0 0 0 0 10 10 10 30 Project staff - proposed in new structure Plan 0 21 22 22 22 22 22 22 22 22 22 22 242 Actual / Forecast 0 0 26 3 11 11 44 61 38 44 44 44 326 Provision for temporary project staff to cover prioritised projects Plan 8 8 8 8 8 8 8 8 8 8 8 8 100 Actual / Forecast 22 50 1 16 19 7 0 0 0 0 0 0 115 COIN Re-Procurement Plan 0 0 0 0 0 0 0 0 0 0 0 78 78 Actual / Forecast 0 0 0 0 0 0 0 0 0 0 0 0 0 Other Minor Schemes Plan 4 4 50 12 29 29 16 16 16 12 12 21 221 Actual / Forecast 9 9 28 25 23 16 52 11 16 77 17 26 310 Total Plan - IT 84 180 252 533 239 239 245 245 245 233 220 287 3002 Total Actual / Forecast - IT 94 169 606 89 497 74 124 140 115 193 133 145 2380 April May June July Aug Sept Oct Nov Dec Jan Feb March Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Business & Strategy Plan 9 9 9 9 9 9 9 9 9 9 9 9 110 Actual / Forecast 0 10 10 10 10 10 10 10 10 10 10 10 110 Communications Plan 0 0 0 0 0 29 29 29 29 29 29 29 200 Actual / Forecast 0 0 0 0 0 0 33 33 33 33 33 33 200 Governance Plan 2 2 2 2 2 2 2 2 2 2 2 2 18 Actual / Forecast 0 2 2 2 2 2 2 2 2 2 2 2 18 Human Resources Initiatives Plan 26 26 26 26 26 26 26 26 26 26 26 26 313 Actual / Forecast 9 17 9 9 38 14 30 38 20 26 29 70 310 E - Roster Phase 2 Plan 30 30 30 30 30 30 30 30 30 30 30 30 359 Actual / Forecast 21 18 44 30 30 61 37 35 -1 34 38 38 386 Total Plan - Investments 67 67 67 67 67 95 95 95 95 95 95 95 1000

Total Actual / Forecast - Investments 30 47 65 50 80 86 112 119 65 105 112 153 1023

April May June July Aug Sept Oct Nov Dec Jan Feb March Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Pump Prime Investment Plan 0 0 0 56 56 56 56 56 56 56 56 56 500 Actual / Forecast 0 0 0 0 26 0 80 9 26 51 61 71 323

Total Investments by Month Plan 151 247 318 655 361 390 396 396 396 384 371 438 4502 Actual / Forecast 124 215 670 139 603 161 316 268 206 349 306 369 3726 Total Investments YTD Plan 151 397 716 1371 1732 2122 2518 2913 3309 3693 4064 4502 Actual / Forecast 124 339 1010 1149 1752 1912 2229 2497 2702 3052 3358 3726 Colour Key: Actual Expenditure Planned expenditure Current Forecast

Note: YTD Expenditure is matched with budget each month, as a result any variance against plan will impact the overall Trust budgetary performance at Month 12 only APPENDIX 4 b)

TRANSFORMATION FUND PROPOSALS Lead NR Recurring Director 15/16 cost FYE 15/16 cost FYE

Service Reviews Capacity modelling for MH & Community Services. The project uses predictive modelling and data analysis to EY £67,000 scope out the appropriate bed numbers as well as size of community teams to manage the demand of the local population. This will help to identify clinical efficiencies that the services can employ to better manage demand and help to inform the acute care pathway of what other similar services have done to manage demand. The project will provide an objective view based on service usage, prevalence of mental illness and depravation indices that can inform service redesign and remodelling decisions.

A workforce wide review across Prisons to deliver recruitment objectives and increase retention of staff and S O'D £25,000 productivity. Improving service delivery and addressing cost pressures.

Service Development Pilots Pilot for 7 day working in 3 Community Hospitals starting from Q3. This is a CCG contract requirement S O'D £50,000 £100,000

Service Integration & Transformation Increase capacity for education for Diabetic Services, resulting in improved service provision S O'D £10,000 TBC Ssubject to Contract variation

Facilitation of cultural change where there is increased clinical engagement in system implementation and NK/JC £37,422 £64,152 development, leading to improved patient care (CCIO). Sharing of physical health records on SystmOne with partner organisations by default JC £18,000 Integration Lead to promote integration between Localities SH £0 £0 £19,216 £76,863

Improvements to Public engagement e.g. website redevelopement, external marketing materials, photography NP £20,000 and filming

Workforce Developments Refresher training for District Nurses to ensure that they are using the patient records system correctly and S O'D / £23,375 recording all of the data that is required to demonstrate good patient care. JC Enabling a GP to become a consultant. Investment to aid service delivery NK £15,000 £15,000 Harmony Project - investment in staffing £10,000

Quality & Governance External Pharmacy review recommendation for Medicines Safety Officer post FH £13,606 £54,423 End of Life Facilitator FH £14,642 £25,100

Total £163,375 £159,885 £335,538 2015/16 Total (R & NR) £323,261

Balance of £500k £176,739 APPENDIX 5

DORSET HEALTHCARE UNIVERSITY NHS FOUNDATION TRUST

Statement of Financial Position as at 31 December 2015

£000's £000's £000's £000's 30th 31st Movement 31st March November December (Month on NON-CURRENT ASSETS 2015 2015 2015 Month)

Intangible assets 107 81 171 90 Property, plant and equipment 151,933 152,506 153,546 1,040

TOTAL NON-CURRENT ASSETS 152,040 152,587 153,717 1,130

CURRENT ASSETS Inventories 755 755 754 (1) Non-current assets for sale 2,334 2,334 2,334 0 NHS receivables 2,783 2,100 2,599 499 Provision for impaired receivables (53) (72) (71) 1 Related Party receivable 0 3 4 2 Other receivables 1,508 2,009 2,133 124 NHS Accrued Income 1,299 9,666 11,157 1,491 Accrued Income 225 369 297 (72) Prepayments 1,608 1,915 2,225 310 PDC dividend receivable 75 0 0 0 Cash and cash equivalents 30,115 22,205 18,562 (3,643)

TOTAL CURRENT ASSETS 40,649 41,284 39,994 (1,291)

CURRENT LIABILITIES

NHS payables (933) (2,109) (1,452) 657 Borrowings (8) (4) (3) 1 Other payables (9,830) (9,724) (9,446) 278 PDC dividend payable 0 (777) (1,165) (388) Trade payables - capital (672) (863) (694) 169 Related Party payable (12) 0 0 0 Accruals (6,967) (6,602) (5,904) 698 Receipts in advance 0 0 (990) (990) Provisions (1,206) (839) (786) 53

TOTAL CURRENT LIABILITIES (19,627) (20,918) (20,440) 478

TOTAL ASSETS LESS CURRENT LIABILITIES 173,062 172,953 173,271 319 NON-CURRENT LIABILITIES Borrowings (1) (1) (0) 1 Provisions (2,494) (2,511) (2,492) 19

TOTAL ASSETS EMPLOYED 170,567 170,440 170,779 339

FINANCED BY (TAXPAYERS' EQUITY)

Public Dividend Capital (31,080) (31,080) (31,080) 0 Income and expenditure reserve * (88,443) (88,316) (88,655) (339) Revaluation reserve (51,044) (51,044) (51,044) 0

TOTAL TAXPAYERS' EQUITY (170,567) (170,440) (170,779) (339)

* This is the equivalent of Retained Earnings for a Limited Company. The working capital is: £19,555 k NOTES APPENDIX 5 000's 000's 000's 000's 30th 31st Movement 31st March November December (Month on 2015 2015 2015 Month)

1. Sales Ledger Aged Debt Analysis Current - £2,338 £989 £1,664 £675 +30 days - £717 £1,496 £425 (£1,071) +60 days - £173 £151 £1,247 £1,096 +90 days - £620 £680 £605 (£76)

Total Trade Debtors £3,849 £3,316 £3,940 £624

2. The interest rate as at 31st December 2015 for our Government Bankings Service Account and our Lloyds TSB Account was 0.25% 3. Not included in the above balance sheet, the Trust has the following amount in NHS bank accounts in respect of patients' investments £16k.

Agenda item 12

People Management Part 1 Board Meeting 27 January 2016

Author Colin Hague Sponsoring Board Member Colin Hague, HR Director Purpose of Report To give an update on people management over the last two months.

Recommendation The Board is asked to note the report

Engagement and Involvement Appropriate Trade Union Partnership Forum, Doctors and Dentists Joint Negotiating Forum, Equality and Diversity Steering Group and Health and Safety Committee engagement and Executive Performance and Corporate Risk Group consideration has taken place on matters raised in this report. Previous Board/Committee This follows a monthly Part 1 Board reporting on People Dates Management in November 2015. Monitoring and Assurance Summary This report links to the . To provide high quality care; first time, every time; Strategic Goals . To be a valued partner and expert in partnership working with Patients, Communities and organisations; . To be a learning organisation, maximising our partnership with Bournemouth University and promoting innovation, research and evidence based practice; . To have a skilled, diverse and caring workforce who are proud to work for Dorset HealthCare; . To be a national leader in the delivery of integrated care; . To ensure that all of the Trust’s resources are used in an efficient and sustainable way; . To raise awareness within the Trust and externally of the impact that our work has on people and our environment, and take steps to reduce any negative effects.

1. Summary

This report updates on a range of HR, Equality, Occupational Health and people management activities since the October People Management Board report and includes the following:

• Industrial action by Junior Doctors

Positive steps have been taken to improve attraction which effects all 3 domains of quality including:

• Recruitment open days in Community Hospitals • Recruitment stands at job fairs

Retentions action include:

• Development of relocation assistance and pastoral care

Active promotion of attraction, recruitment and retention work being undertaken:

• Go live of TRAC system • Process changes for recruitment of medical staff

Data on recruitment set out in section 5 of the report shows areas of improvement.

Information on the implications of the new Living Wage implications for the Trust is set out in section 7.

A range of actions have been taken to support agency staff management, control of costs and development of the Bank.

Local mileage rates are being reviewed by the Executive team.

Some initial feedback on staff survey responses is included within section 9 of the report. There appears to be some overall improvement on question responses compared with responses given in the previous survey although a fuller assessment will follow publication of the 2015 Staff survey results in February.

A report will be submitted in February on actions being taken to meet our Public Sector Equality Duty and Equality targets for 2016/17.

A new e-learning platform is to be introduced in March 2016 and a range of other learning and development areas of activity are set out in section 12 of the report.

Flu programme uptake has improved on last year, although this is still an area we would wish to improve further in 2016/17. Information on Health and Wellbeing actions is also set out at the end of the report.

2. Organisational Change

Intermediate Minor Oral Surgery Service The current contract expired on 31 October 2015 and has not been renewed by the Trust. The consultation process has been concluded and whilst two staff have found other roles in the Trust,

regretfully six staff have been made redundant as the specialist nature of their roles has meant that it was not possible to find suitable alternative positions. Breastfeeding Support Service Consultation commenced on 11 January 2016 with the Bournemouth and Poole Breastfeeding Support Service as the service is being re-commissioned; two models are currently operating in Dorset.

In Bournemouth and Poole there is a specialist breastfeeding support service provided by the Trust with paid counsellors and volunteers. This service has Stage 3 Breast Feeding Initiative accreditation and was highly commended by the Care Quality Commission for its specialist support of mothers at home. In the rest of Dorset there is a peer support service provided by volunteers. Training and supervision to these volunteers is provided by a third sector provider, Real Baby Milk.

The formal specification was received from Public Health on 18 November 2015 and bids had to be submitted by 21 December 2015.

Dorset HealthCare has decided not to submit a bid due to the significant differences in service and budget. A formal announcement as to who the new providers will be is expected on 5 February 2016. The consultation is due to conclude on 19 February 2016 and options for alternative employment are currently being explored.

Secure Counter Fraud Services Consultation is taking place on the transfer of the Secure Counter Fraud service to TIAA with a proposed transfer date involving a last day of service with the Trust of 31 March 2016. This affects up to 7 staff. The Trust will continue providing Security Management services to other Trusts and organisations.

3. Attraction Strategy

Consistent with the HR Strategy and Board Assurance Framework a range of activities continue to take place to support recruitment outcomes and recent/future activities include:

Recruitment Fairs In addition to the recruitment open days held at Blandford and Shaftesbury Hospitals during November and Swanage and Wareham Hospitals in January, the Trust has also had a stand at the following events:

• RCN Conference in Manchester • St Aldhelms Academy Careers Fair • Southampton University Careers Fair • Pop Up Christmas Recruitment in Brewery Square, Dorchester

Forthcoming events include:

• 11/12 February - RCN Jobs Fair, London • 11 February – Bournemouth Echo Careers Fair, Bournemouth • 24 February – Dorset Echo Careers Fair, Weymouth • 9 March - Careers Fair, Parkstone Grammar School • 6 April - Careers Fair, Bournemouth University • 18 June - RCN Congress, Glasgow

Attraction, Recruitment and Retention Strategy Work

• A structured Recruitment/Communications Advertising and Marketing strategy has now been developed in collaboration with the Communications Team, supported by a two-three month project plan. The following key areas are included in the plan: Building an ‘Employer Brand’, becoming an ‘Employer of Choice’, building the ‘Bank Brand’ and targeted recruitment and marketing campaigns. • Developing the plan highlighted the need to consider centralising advertising spend in-order to secure the most cost effective pricing which is now underway. • Linked to the Recruitment/Communications Advertising and Marketing strategy, the Trust’s Twitter account is due to be re-launched as part of the refresh of the Social Media Policy. The new Head of Digital Communication is now in post within the Communications Team and will be leading on this area. The ‘LinkedIn’ company page has been set up and a LinkedIn strategy has been developed. • In partnership with the Learning and Development Team, a structured process and toolkit is being developed to assist managers to support work experience placements and apprenticeships across the Trust. A project plan has now been developed and is being actioned. • Further links with universities further afield are being identified and built to increase our scope to attract and recruit graduates from across the country. • An initial meeting has taken place with the Chief Executive of Poole Housing Partnership and the HR Director to explore scope for developing housing provision for new recruits.

Director consideration has been taking place.

4. Recruitment

Applicant Tracking System An electronic applicant tracking system known as TRAC was implemented on 19 November 2015 and is designed to better record vacancies and applicants. To date, eighteen managers have attended training on the system and a further forty-six are booked to attend sessions during January and February. In addition, the HR Services team have attended or are shortly due to attend 17 team meetings across the Trust during December, January and February onwards, to give an overview of the system.

5. Agency Project Through collective efforts progress is being made on reducing agency expenditure. Year to date agency expenditure is £10,288k. In early November the forecasted position was a potential £14.6m on agency spend in 2015/16 based on year to date expenditure. As a result of actions to date the forecast agency expenditure for the year is £12.4m, a reduction of £2.2m. Nursing expenditure increased slightly in December compared to November. This was expected due to the Christmas period. Qualified Nursing agency expenditure was 8% of total qualified nursing spend for the month of December. This is 1% lower than the 9% predicted to Monitor for December performance. The trajectory is to achieve 6% by end of March, 2016.

Considerable work has been undertaken to re-negotiate rates with all of the agencies that regularly supply workers to the Trust. The procurement team have also been contacting new agencies who are compliant with the national Frameworks and rates to see if they are able to provide workers to the Trust. Those who have confirmed have been added to the list of agencies that Nurse Bank can use. A detailed summary has been produced and bookings are now being done in the most cost effective order. There should now be sufficient agencies such that shifts booked by Nurse Bank Team are compliant except in exceptional circumstances.

Monitor has now responded to the application made for them to consider approving the use of non-framework agencies. The use of two agencies for Band 5 Nurses has been approved until 31st March 2016. A further reduction in rate caps is introduced on the 1st February 2016. Liaison 4

has been undertaken with agencies to ensure that they are working towards complying with the forthcoming caps. One agency has advised that they will be unable to meet the February caps. Nursing Bank capacity is being developed and the Bank is now a Nurse led function.

6. Current Recruitment Position In connection with recruitment: • Data confirms that more staff have been recruited and are in post involving an increase from 4377.3 fte at the end of December 2014 to 4606.3 fte at the end of December 2015. • The increased number of staff in post is supported by data extracted from the general ledger (reflecting the budgeted position) to indicate a reduction in vacancy levels from 8.82% in December 2014 to 7.53% in December 2015. • Budgeted establishment has increased from 4822.17 in December 2014 to 5000.93 in December 2015, an overall increase of 178.76 fte where the Board has sought to increase establishments to support service improvement. • Vacant budgeted fte (without bank and agency cover) on the general ledger involved a decrease from 425.24 to 376.53 overall between December 2014 and December 2015. • There are more Nursing vacancies on the budgeted ledger increasing from 138 in December 2014 to 165 in December 2015 and likewise, the budgeted establishment for nurses has increased by 66 fte from 1638 to 1701. • Budgeted vacancies in other areas have decreased overall from 286 in December 2014 to 210 in December 2015. • Nursing vacancies still remain the most difficult staff group to recruit to with Organic OPMH and Prison Healthcare services being the most difficult areas, with a vacancy factor of 18.84% and 32.3% respectively. • Most of the Community Hospitals have significant RGN vacancies at the moment; however the substantial number of new nursing recruits with agreed start dates, as well as those progressing through pre-employment checks, will have a considerable impact on this position.

The Trust has difficulty recruiting to clinical and non-clinical vacancies across some services. This is a similar position for NHS Trusts across the county and country, leading to a highly competitive market.

The vacancy data above is based on the difference between the general ledger and in post establishment. An exercise has been undertaken to validate vacancy data for services to identify areas where recruitment action is taking place or planned by managers.

The validated position of posts where recruitment is taking place or planned by managers shows that there are 283.04 WTE vacancies across operational services with a vacancy rate of 6.14 % using this method. This data indicates the following vacancies that are being recruited to:

Inpatient Services Vacancies Community Service Vacancies

Locality Registered Unregistered Registered Unregistered Total WTE WTE WTE WTE WTE

Bournemouth and 26.3 22.35 15.36 10.97 74.98 Christchurch

Poole and East Dorset 18.83 11.2 30.35 15.83 76.21

Dorset 41.38 12.94 27.87 11.53 93.72

Medical Staff 7

Support Services 31.2

Total 86.51 46.49 73.58 38.33 283.04

The information gives a clearer position on the level of vacancy activity being recruited to.

7. Introduction of the Living Wage

The national Living Wage for employees aged 25 or over becomes law on 1 April 2016 and replaces the National Minimum Wage. The national Living Wage is different from the Living Wage previously published by the Living Wage Foundation.

At present, no Trust employees are paid less than the introductory rate of the new national Living Wage of £7.20 per hour, with the exception of apprentices. The minimum hourly rate under national conditions of service is currently £7.72 per hour.

The government has given a target (subject to conditions) that the Living Wage will rise to £9.00 per hour by 2020. Assuming an increase at the rate of 0.45p a year, and an annual increase in NHS salaries of 1% a year over the same time period, the NHS lowest paid staff would be expected to fall behind the national Living Wage in April 2018 affecting approximately 440 fte Trust employees, not including Bank workers.

This will be taken into account with future financial planning.

8. Equality, Diversity and Workforce

Equality Developments and planned reports

Work Place Race Equality Standards and Action Plan which are mandatory expectations have been updated and agreed by the Executive Performance and Corporate Risk Group.

Equality Delivery System Objectives for 2016/17 have been reviewed. This follows a November 2015 Board workshop.

The Equality and Diversity Manager has, following a consultation process, proposed equality objectives for 2016/17 which have been considered by the Executive Performance and Corporate Risk Group in December 2015.

At a Board Workshop in December the Board were concerned to raise the profile of equalities work. A report covering equality developments and plans will be submitted to the February Board.

NHS Employers Partners Programme The annual partners’ programme works with people from trusts nationwide to develop their practice of diversity and inclusion. The work programme for 2016 is based on five developmental seminars which will: • provide partners with detailed strategic policy support • support personal development • share good practice • network with fellow colleagues who work in the NHS and experts.

Dorset HealthCare successfully became an NHS Employers Partner in 2011 and this is an opportunity to gain valuable support and recognition for Diversity and Inclusion in Dorset Health Services.

Holocaust Memorial Day Events A series of events will be taking place across Dorset with the largest free event taking place at 6

Poole Lighthouse on Sunday 30 January 2016. Over 500 people are expected to attend.

A presentation and display will be on show in the reception at Sentinel House during the last week of January 2016. Additional supporting information has been sent to all Community Hospitals and events will be promoted through the Weekly Roundup.

• Bournemouth Holocaust Memorial Day, Poole Lighthouse on Sunday 31 January 2016 - http://bphmd.weebly.com/ • Southwest Dorset Multicultural Network, Dorchester Corn Exchange on Friday 29 January 2015 - https://www.dorsetforyou.com/multiculturalnetwork

Equal Pay Audit An equal pay audit has been carried out. This has been considered by the Executive Performance and Corporate Risk Group. A copy of this audit was also provided to Board members as part of documentation provided for a Board Workshop in December 2015. The Equal Pay audit has been considered by the Trade Union Partnership Forum, Doctors and Dentists Negotiating Forum and the Equality and Diversity Steering Group.

The conclusions included this comment. “The information set out in the report does suggest that there are issues of access to more senior roles for women in the Trust. The principle suggestion from this report is for the Trust to explore what are the barriers to women’s career progression within the workforce and what measures can be adopted to remove them.”

Considerations and recommendations of the audit include:

• In respect of Clinical Excellence Awards equal opportunities monitoring should routinely be undertaken and the results reviewed cumulatively – so that patterns can be identified over time. • In respect of pay on appointment for “Agenda for Change Staff” the Trust monitors those decisions where appointments are made at a salary other than the minimum of the scale – particularly when the applicant is from outside the NHS • In respect of Recruitment and Retention Premia, the current review should be based on clear and objective criteria that reflect any evidence about difficulty in recruiting and retaining staff. These criteria should be consistent with the guidance set out in Agenda for Change. • This approach should be the basis of a Trust wide policy which can be applied to future cases for Recruitment and Retention premia as they arise. • Although the Trust does not have a history of varying individual incremental progression it does have the power to do so. It should ensure that it has a policy that monitors such decisions on an Equal Opportunities basis. • The Trust should reinstitute periodic consistency checking of its job evaluations so that it can be reassured that it remains compliant with national standards and also identifies any anomalies that may have been created by the acquisition of staff and functions from other NHS organisations. • Developing a suitable session to support female staff (and staff in general) to achieve their full potential

Recommendations made are being implemented following Executive Performance and Corporate Risk Group consideration and plans are being developed for a focus group to support consideration or review findings to assess what other actions may be taken to support female staff (as well as all other employees) achieving their full potential.

9. ECJ ruling on working time – staff based at home

The European Court of Justice (ECJ) has ruled that where workers have no fixed place of work, 7

the time they spend travelling between home and their first and last customer is working time under the Working Time Directive. For health, social care and social housing employers that employ workers who travel to and from their own home to patients and service users, this decision has the potential to impact on the monitoring of working time and ensuring that workers comply with the 48 hour limit set out in the Working Time Regulations. Whilst the Regulations themselves do not deal with how payment for working time is calculated, the decision may in some cases have an impact on the calculation of pay for travel time and whether national minimum wage requirements are satisfied.

The Trust has reviewed, with managers, the implications of the ruling on current arrangements and is satisfied that we have no workers who are impacted by the new ruling and no action has been necessary.

10. Mileage rates

There are differences in the local mileage rate applying to original Dorset HealthCare staff and new appointments who have a rate that commences at 46.2p per mile and those who transferred to Dorset HealthCare on National terms, who have a mileage rate that commences at 56p per mile. We are not aware of other Trusts in the South West or nationally who are not applying national mileage rates. Nationally the rates of reimbursement are reviewed every May and November, using the latest information on motoring costs, in line with business motoring costs. The rates were due to be checked in May 2015, using information on motoring costs in the twelve months ending March 2015; however the data was not made available and as a result, the Staff Council agreed to await the outcome of the November 2015 review. The rates of reimbursement were subsequently checked in November 2015 using information on fuel prices and motoring costs in the twelve months ending October 2015. Rates change if the impact of price changes on the standard mileage rate is five per cent or greater and it was surprisingly concluded that changes in fuel and car running costs were less than five per cent, which meant that the national rates of reimbursement did not change. (A decrease had been forecast).

As a consequence, the Executive Team have considered options to assess if there is scope to take some steps to move towards more harmonised mileage rates locally though this carries cost implications and therefore opportunities to seek to reduce mileage use are also being considered. Accordingly, the Executive Team has requested further information and an update on the position will be provided in February’s Board report.

11. Medical Staffing

BMA Industrial Action

The 24-hour industrial action by junior doctors ended at 08:00, 13 January 2016. Industrial action by junior doctors at Dorset HealthCare, all of whom are employed within Mental Health, caused minimal disruption to services. The number of doctors taking action was 9. The Trust employs 18 junior doctors. Talks between the Department of Health, NHS Employers and the BMA recommenced on Thursday 14 January in an attempt to avert further industrial action.

The local working arrangements with junior doctors and medical staff involved good relationships and a recognition that this is a national and not a local dispute. The next proposed dates of the planned national action were:

• 26 January 2016 Emergency care only between 8am on Tuesday 26 January and 8am on Thursday 28 January (48 hours) • 10 February 2016 Full withdrawal of labour between 8am and 5pm on Wednesday 10 February. 8

A decision was, however, taken by the BMA to suspend the industrial action scheduled for 26-28 January. As national talks continue it is understood that the dispute particularly involves disagreement between the BMA and Government over weekend pay.

12. Learning and Development

Welcoming the Open University Pre-Registration Nurse Training to Dorset HealthCare Following the allocation of funding from Health Education Wessex to support pre-registration nurse training in 2015/16, the Learning and Development Service has been working in partnership with the Open University to bring the first cohort of seconded Open University nursing students to Dorset HealthCare.

There were more than 30 applications from support workers for this opportunity. Following a values based recruitment process between the Open University and Trust, seven support workers have been successful in securing a place which will commence in February 2016. Of these seven pre-registration students, two will be undertaking the adult nursing programme and five will be undertaking the mental health programme. The students are all experienced healthcare support workers with the Trust and come from a variety of practice settings, including Community Hospitals, Criminal Justice, Community Mental Health, Rehabilitation and Dementia Services.

The Open University works in partnership with healthcare organisations to deliver a part-time, distance learning, pre-registration nursing programme over a four year period. The programme is designed to be practice based. One of the benefits of the Open University pre-registration programme is that the student’s time is split between working in their support worker role and working as a supernumerary student nurse. They will have placements outside of their normal team to ensure they have experienced a range of clinical settings by the end of their programme, in line with Nursing and Midwifery Council requirements.

The open learning approach means that within the parameters of the programme and protected supernumerary learning in practice; students are free to study at a time, place and pace that suits their lifestyle, home and work commitments. The learners will be jointly supported by the Open University and the Trust’s Practice Development Team to ensure that they receive a high quality, positive student experience.

New E-Learning Platform The Trust will be losing access to its two main e-learning platforms by mid-March 2016, as a result a new e-learning platform has been procured. The selection process for the new platform included representatives from clinical services, IT, Communications, Procurement and Learning and Development Services. The successful supplier is Dynamic, a learning solutions company, who has a number of NHS clients including Health Education Wessex. A major benefit of Dynamic is that they are supplying the Trust with its own designed and branded e-learning platform that it will own and on which it can continue to build on, rather than licencing an external platform that will expire after a three year period.

A single e-learning platform will be launched in the Trust by the end of March 2016 to consolidate all its e-learning provision, enabling easy access by staff and providing a user friendly experience. All online content (including e-assessments, videos, podcasts and workbooks) will be hosted on the single system and course completions will be recorded directly onto the Trust’s Learning Management System. The implementation project is underway and representatives from clinical services, subject matter experts and the Learning and Development Service will be involved in reviewing course content and the usability of the e-learning platform, prior to implementation.

Care Certificate Update As reported in the October 2015 Board report, the Care Certificate pilot for Health Care Support 9

Workers (HCSWs) in five sites across the Trust was launched in September 2015. The pilot which comprised of 45 HCSWs is now complete, with an evaluation report to follow.

As knowledge of its value and shared experiences of those who have completed it gathers pace, it is anticipated that the number of support workers completing the Care Certificate will continue to rise. Feedback from participants of the pilot to date includes:

• “It’s made me more mindful”

• “[regarding the self-assessment tool] love it as it allows me to be honest personally and seeing where the gaps are (in my practice)”

• “Not enough time”

• “None of it (learning) is wasted as it brings you back down to basics”

• “Seeing and feeling the experience from the patient’s point of view”

Feedback also continues to raise the importance of securing sufficient time to complete the Care Certificate within practice.

The Care Certificate has been launched in January 2016 for all new HCSWs. This year is an important one in establishing the Care Certificate across clinical services, as part of the Trust’s ambition to ensure that all support staff, irrespective of where they work, deliver high quality care underpinned by the 15 standards embraced in the Care Certificate programme.

From January 2016, the Learning and Development Service has organised an induction programme across the county for new HCSWs, together with support from practice educators, clinical colleagues and those who have completed this dynamic national initiative.

Partnership Working – Revalidation Roadshows In support of partnership working with the GP practices, the Learning and Development Service has opened up its Nurse Revalidation roadshows to GP practice nurses. From discussions with locality managers, it was recognised that some practice nurses are expressing some anxiety around understanding their individual responsibility for adhering to the new Nursing and Midwifery Code (NMC) and the relationship it has to revalidation (fitness to practice).

The Learning and Development Service is providing regular drop-in revalidation roadshows for Trust nurses and now practice nurses, to give them the opportunity to explore revalidation and to support them with tools to ensure their portfolio meets NMC requirements. Feedback received at the end of the sessions has been positive; showing that staff are feeling more prepared and less anxious about the new MNC Code and the relationship it has to revalidation and their fitness to practice.

Leadership Development Update Thames Valley and Wessex Leadership Academy Annual Summit and Recognition Awards

The Associate Director – Learning and Development and Leadership Administrator had an active role in the market place at the Thames Valley and Wessex Leadership Academy Annual Summit and Recognition Awards on 19 November 2015. This provided Dorset HealthCare with the opportunity to showcase its investment in leadership development, outcomes achieved and next steps with colleagues from across the region. The event provided the chance for networking and opportunities to share what Trusts are doing in the field of leadership development. There was a good turn out and lots of interest in the Trust’s comprehensive leadership strategy.

Furthermore, with regards to the leadership awards, Dorset HealthCare did really well and had

three finalists across two categories as follows:

1. NHS Inspirational Leader of the Year:

• Pan Dorset Pathfinder Service – recognised for the work they undertake with adult males with offending histories whom have personality disorders, comorbid mental health difficulties and present high levels of risk to themselves and the public. They rely on collaborative working within the team and multi-agencies to ensure risk management, public protection and enhance service user wellbeing.

2. NHS Outstanding Collaborative Leader of the Year:

• Stan Sadler – Service Manager – Criminal Justice and Liaison and Diversion and Street Triage Service. Stan said he was thrilled to have been nominated and believes that successful collaboration is achieved by developing trust, effective negotiation and having a real commitment to integration.

• Pan Dorset Pathfinder Service – as above. The team said they were especially pleased to be nominated for the award in light of their CQC rating of Outstanding. They use an interdisciplinary approach rather than a multi-disciplinary approach to develop shared goals.

All of the finalists should be very proud of themselves to have been nominated and regionally recognised for their excellent achievements brought about through their leadership.

In-house Leadership Facilitator A new in-house leadership facilitator post is to be created within the Learning and Development Service. This will create capacity within the existing budget to design, develop and deliver on the below new initiatives for 2016/17 and support the HR and OD Strategies: • Induction for New Leaders

• Admin Team Leaders’ Development Pathway

• Career Pathways for Staff

Furthermore, a follow up programme for leaders having completed the Empowering Leaders: Empowering Teams leadership pathway is to be developed for implementation in 2016/17.

The below section provides the quarterly update on key elements of the leadership strategy:

Empowering Leaders: Empowering Teams Since the launch of the pathway in September 2013: 190 leaders have completed the pathway as at end December 2015; a further 41 leaders are currently undertaking the pathway and 61 leaders are scheduled to commence a cohort before end September 2016. A total of 19 cohorts have been delivered over the past two years.

The post pathway evaluation continues to positively demonstrate the benefits of the leadership pathway and its value for leaders. Some participant comments are provided below:

• “A better relationship with my consultant – timely as a new Team Leader.”

• “Ideas on not only how to effect change, but also how to sustain it”

• “The opportunity to develop, enhance or learn new leadership skills is always good but then to have the bonus of getting post-grad accreditation with BU is fantastic. It’s a really good, well thought out programme.”

• “Relevant and, actually, quite inspiring.”

• “Positives - time for reflection on practice and practice issues; networking with colleagues from differing disciplines and areas; excellent presenter; excellent admin support and intranet resources”

• “It will help me to achieve and meet my career aspirations, from the learning but also from the qualifications gained.”

• “Put the importance of leadership and understanding your style of leadership at the fore front of my work.”

Coaching During Quarter Three 2015/16, 12 coaching sessions were delivered to 12 coachees; 3 applications were received from staff wanting to undertake coaching; 34 staff have received coaching since its formal launch in January 2015.

The post coaching evaluation demonstrates positive benefits for staff undertaking coaching. Some staff comments are provided below:

• “having time to formulate a plan with regards to challenges in my role.”

• “Time to discuss issues and find solutions.”

• “It encouraged me to look at issues from different perspectives and pushed me to dealing with things I may not have faced up to before.”

• “Being challenged to explore and determine solutions; recognition of being responsible and able to provide a point of view or challenge the thinking of other colleagues, thereby improving personal effectiveness.”

The main areas in which coaching is supporting staff are listed below:

• Increased knowledge of self/self-awareness

• Increased confidence

• Increased ability to challenge unhelpful behaviours

• Increased sense of direction and focus

• Increased ability to deal with difficult conversations

Furthermore, 100% of coachees fedback that they would recommend coaching to colleagues.

Team Development Opportunities For the period 01 October – 31 December 2015, nine teams have completed a team development programme, 15 teams are booked in for development and a further eight teams have expressed interest in development. 46 teams have undertaken team development since 2014 as at end December 2015.

Line Leader Development For the period 1 October – 31 December 2015, 129 team leaders, irrespective of banding, completed a total of 201 stand-alone leadership or management learning sessions that are available through the Trust’s Line Leader Development Prospectus. During the period 1 April 2015 – 31 December 2015, 385 team leaders, irrespective of banding, have completed a total of 653 stand-alone leadership or management learning sessions. As at Quarter three, this level of attendance is exceptional when compared with the attendance for the 12

whole of 2014/15 when 566 stand-alone leadership or management learning sessions were completed.

The most popular leadership and management learning sessions that team leaders are attending include:

Leadership Modules Management Modules

Leading Effective Meetings Managing Capability (Performance) Courageous Conversations Managing Absence (Managing Health And Wellbeing) Value Led Leadership Recruitment and Selection Assertiveness Skills Managing Disciplinary (Conduct)

The Leadership Development section of the Trust’s intranet site has received 1,149 views during Quarter 3 2015/16. This is an indication of there being significant interest in leadership development opportunities of staff.

Furthermore, the initial findings from the Staff Survey 2015 show a significant improvement in areas of leadership and team development. The below highlights the 2015 % for the most positive areas of improvement of 5% or over (the improvement % compared to 2014 is shown in brackets):

• My immediate manager takes a positive interest in my health and wellbeing – 72% (+13%)

• My immediate manager asks for my opinion before making decisions that affect my work – 63% (+8%)

• My immediate manager encourages those who work for him/her to work as a team – 79% (+6%)

• I am satisfied with the support I get from my immediate manager - 74% (+5%)

13. Staff Survey

The Trust has received from Quality Health, our Staff Survey provider, the detailed, unanalysed data gathered from responses to the 2015 survey. Towards the end of February 2016 the formal report which distils the data into 28 Key Findings will be published by the Department of Health.

For the first time, the majority of eligible staff received their survey questionnaire by email. The change to electronic format has had an impact on the response rate which was 33% in 2015 against 46% in 2014 and indicates that whilst the majority of staff have a Dorset HealthCare network login, there are significant numbers who do not log into email regularly, despite a good communications campaign which included cascading of information through line managers. 65% of respondents in 2015 were clinical staff, compared with 76% in 2014. We will review the response rates by staff group and will be able utilise electronic and paper questionnaires in a more targeted way in 2016.

Initial analysis shows that for those questions with a direct comparator in 2014, there are improved responses across 67.4% of questions, a decline across 20.2% of questions, and 12.4% of responses remained at the same percentage.

Positives include percentage increases of 5% or more in those who:

• Look forward to going to work • Are enthusiastic about their job • Say there are frequent opportunities to show initiative in their role • Say they are able to make improvements happen at work • Say they are satisfied with the support received from their manager, including - help with difficult tasks, being asked for their opinion, managers taking a positive increase in health and wellbeing • Believe that care of patients is the Trust’s top priority • Would recommend the Trust as a place to work • Would be happy with the standard of care provided by the Trust if a friend or relative needed treatment

Percentage increases of 5%, but still low numbers overall include:

• Satisfaction with the extent to which the Trust values their work 41% • Effective communication between senior management and staff 36% • The belief that senior managers try to involve staff in important decisions 31% • Belief that managers act on staff feedback 28%

Areas where staff views had declined included:

• Perception of the Trust acting fairly with regard to career progression/promotion, regardless of ethnic background, gender, religion, sexual orientation, disability or age • An increase in those believing that they had experienced gender discrimination.

14. Occupational Health

Flu Programme The flu programme for staff continued into December with continued support from the communications team. By the end of December there was an overall 5.3% increase in the numbers of staff vaccinated against a national reduction in uptake of around 4%. Reporting on uptake will continue for a further month with final figures being reported to the Department of Health in mid-February.

A flu planning meeting for 2016 will be scheduled for the end of February.

Details of this year’s uptake by 31st December 2015 with comparative figures for the same period in 2014 are detailed in the table below.

December 2015 December 2014 Staff Group Number Staff numbers % vaccinated % vaccinated vaccinated Doctors 62 163 38.0% 27.5% Qualified 523 1882 27.7% 21.3% Nurses Professionally 236 713 33.0% 27.8% Qualified Clinical Staff Support to 420 1633 25.7% 22.6% Clinical Staff Total 1241 4391 28.3% 23%

Non-Clinical 613 1587 38.6 % 32.8% Support Staff (not reported) Total 1855 5978 31% 25.4%

Health and Wellbeing There has been additional development and promotion of topic specific health and wellbeing resources during October, November and December including:

• Stoptober • Oral Health (in conjunction with Dental Services) • World Mental Health Day • NHS Health Checks • Skin Health • Local Mindfulness Events • Domestic Violence awareness week

The trust has signed up to a further two Public Health Responsibility Deal pledges in respect of Alcohol and Domestic Violence and action plans have been submitted to the Responsibility Deal pledge site. Intranet pages for both alcohol awareness and domestic violence have been published and promoted in the ‘Weekly Roundup’ and the Trust is encouraging staff to sign up for Dry January.

Agenda Item: 13

CQC Quality Improvement Action Plan Part 1 Board Meeting 27 January 2016 Fiona Haughey, Director of Nursing and Quality & Hazel Author McAtackney, Head of Regulation and Compliance & Sponsoring Board Fiona Haughey, Director of Nursing and Quality Member Purpose of Report The purpose of this paper is to present the CQC Quality Improvement Action Plan following the publication of the CQC Inspection report in October 2015. This is the first formal report to the Board presenting the core service action plans and progress to date. The action plans have been developed by the designated core service lead manager and lead clinicians, supported by the relevant locality Director, and addresses ‘must do’ and ‘should do’ actions from the CQC report. The Programme Management Office (PMO) will monitor and review achievement of the actions supported by the Nursing and Quality Directorate.

The Trust will be re inspected within six months of the reports being published so this will occur before end of April 2016. The inspection will focus on areas that require improvement to see what progress has been made against the actions from the reports.

Recommendation The Board is asked to approve: • The content of the CQC Quality Improvement Action Plan and note the progress made to date:  8 ‘must do’ actions completed  20 ‘should do’ actions completed  No outstanding actions to report  Ongoing monitoring to ensure the actions are embedded in practice To: • Receive further updates on a monthly basis as part of the integrated quality dashboard: • Discuss and consider whether this report provides sufficient assurance regarding progress of the CQC Quality Improvement Action Plan: • Agree that the plan and ongoing progress reports will be shared with the CQC, commissioners and partners / stakeholders Engagement and

Involvement Previous Board 28 October 2015 and 25 November 2015 Dates Monitoring and Assurance Summary This report links to . To provide high quality care; first time, every time; the Strategic Goals . To be a valued partner and expert in partnership working with

Patients, Communities and organisations; . To have a skilled, diverse and caring workforce who are proud to work for Dorset HealthCare; . To be a national leader in the delivery of integrated care; . To ensure that all of the Trust’s resources are used in an efficient and sustainable way; I confirm that I have considered each of Any action required? the implications of this report, on each of Yes Yes No the matters below, as indicated: Detail in report All three Domains of Quality   Board Assurance Framework   Risk Register   Legal / Regulatory   People / Staff   Financial / Value for Money / Sustainability  Information Management &Technology  Equality Impact Assessment  Freedom of Information 

1. BACKGROUND

1.1 As previously reported to the Board (October and November 2015) in June 2015 the CQC undertook a five-day announced comprehensive on-site inspection of the Trust in order to review whether our services are safe, effective, caring, responsive to people’s needs and well-led.

1.2 The draft reports (17 in total, 16 core service reports and an overall quality report) were shared with the Trust on 16 September 2015 and rated the Trust overall as ‘Requires Improvement’. The final reports were published in October 2015. The CQC reported that:

“It is our view that the provider had made significant progress in developing services and bringing about improvements. We saw that it was well led by its new leadership team and was in the process of deploying effective systems that we were confident would result in the delivery of improved, high quality services for the patients it serves in the near future.”

1.3 The Trust considers this to be a fair reflection, recognising the journey of quality improvement the Trust is on. We were delighted to have achieved two outstanding ratings for the acute wards for adults of working age and psychiatric intensive care units, and the community forensic service. The outstanding rating for the former was the first awarded in England.

1.4 Following publication of the CQC report the Trust is required to develop a Quality Improvement Action Plan (QIP) that sets out how we are addressing the themes and issues identified. On 21 December 2015 The Trust had the first follow-on meeting with the CQC to discuss and review progress and share the draft action plan. It was agreed that the plan would be submitted to the Board in January 2016 and shared formally with the CQC at this time. There are regular meetings scheduled with the CQC every six weeks to review progress against the plan.

1.5 At this meeting we were informed that the Trust would be re inspected within six months of the reports being published so this will occur before end of April. The inspection will focus on areas that require improvement to see what progress has been made against the actions from the reports.

1.5 Key themes and issues arising from the inspection include:

• Significant variance in the quality of care delivered between some teams across the Trust • Inconsistencies in the planning and delivery of a number of services • Areas of non-compliance with CQC regulations.

1.6 The concerns did not result in enforcement action being taken against the Trust. During the Quality Summit meeting there was a clear recognition by partners and commissioners that joint action was required to address some of the key challenges raised by the CQC report. A commitment was made by Dorset CCG, the three local authorities, NHS Dorset and other partners and stakeholders to support the Trust in making these improvements.

1.7 The six main areas of challenge posed by the CQC’s report are:

• Mental Health Services for Children and Young People (CAMHS) o Inconsistencies in quality of care and service provision between teams o Long waiting list and systems required to ensure the safety of the children waiting to be seen o Excess demand is a growing problem that is system-wide and requires multi- agency solutions

• Minor Injury Units (MIU) o The sustainability, function and purpose of the MIUs o The need to deliver consistency in the operating arrangements for all MIUs o The need for a county-wide strategy for urgent and emergency care

• Mental Health Crisis & Home Treatment Services and Health Based Place of Safety o Inconsistencies between teams o Demand and capacity and the commissioned service model requires support and potential investment from the commissioners (Dorset Clinical Commissioning Group)

• Mental Health Services for Older People o The need for a clear Trust strategy for Older People’s Mental Health Services o Inequality in the commissioned services and the need to provide access to services across all of Dorset. This requires consideration within the Clinical Services Review and Better Together Programme

• End of Life Care o The need for a clear plan for End of Life Services provided by the Trust to ensure equity of access for patients o The need for a commissioned pan Dorset integrated model of End of Life Care as there are multiple providers

• Long Stay Rehabilitation Mental Health wards o High levels of detention under the MHA in rehabilitation services o Access to comprehensive rehabilitation programmes in the community o Review of the long stay rehabilitation service model

1.8 The CQC also identified 41 areas of good practice. These are areas where the Inspectors noted practice that was ‘above and beyond’ good care.

Core service non-compliance with the fundamental standards regulations

1.9 Within each core service report there are actions required to improve compliance with CQC fundamental standards. There are two types of action:

• Actions the Trust MUST take against the requirement notice(s) – these actions, if not achieved, have a potential to have a negative effect on the Trust provider licence and the Trust reports progress against these to Monitor as well as the CQC • Actions the Trust SHOULD take to improve as this will have a positive impact on patient care and the support to staff, visitors or carers.

1.10 Across the 16 core service lines the Trust was found to be in breach of 8 (of the 13) Regulations as indicated below:

Regulation Subject Must Do Number actions 10 Dignity and respect 5 11 Need for consent 1 12 Safe care and treatment 19 13 Safeguarding service users from abuse and improper 1 treatment 15 Premises and equipment 3 17 Good governance 19 18 Staffing 11

Regulation Subject Must Do Number actions 20 Duty of Candour 1 Total 60

Must Do Actions 1.11 A total of 60 ‘must do’ actions have been identified through the inspection process. 27 of the must do actions are within the mental health core service areas (45%) with 33 (55%) attributed to the community core service areas.

1.12 The most frequent breaches involve Regulation 12: Safe Care and Treatment (19); Regulation 17: Good Governance (19) and Regulation 18: Staffing (11).

Regulation 12 1.13 The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Actions within this domain include: • Clinical risk assessment and risk management processes • Staff demonstrating the right skills and competences through the appropriate training and education (mandatory training compliance) • Premises and any equipment used is safe and regularly tested and/or monitored • Medicines must be managed safely and administered appropriately • Prevent and control the spread of infection

Regulation 17 1.14 To meet this regulation we must have effective governance, including assurance and auditing systems or processes. These must assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service. Actions within this domain include: • Contemporaneous record keeping • Up-to-date risk assessments • Personalised care plans

Regulation 18 1.15 The Trust must provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times. Staff must receive the support, training, professional development, supervision and appraisals that are necessary for them to carry out their role and responsibilities. Actions within this domain include: • Availability of sufficient numbers of skilled and competent staff – e.g. school nursing service and Night Nursing team, CAMHS, CMHT’s, MIU’s • Access to clinical supervision and appraisal

Should Do Actions 1.16 Across the core service reports there are a total of 89 ‘should do’ actions. 62 of these actions are within the mental health core services (70%) and 27 (30%) within the community core services. This division is to be expected given that the mental health services have 11 (69%) of the core services.

1.17 Collectively there are 149 must / should do actions which translate across the 16 service lines into detailed action plans with a total of 325 actions. How the actions are distributed across the 16 core service areas are shown in the table below:

CORE SERVICE S E C R W-L Regulation breached & number ‘Must Do’ ‘Should Do’ Service of actions Action Actions Line total actions MENTAL HEALTH SERVICES MH Adult/PICU * * 6 6 MH Rehabilitation 10(1): 12(2) 3 15 18 Forensic Inpatient 12(3) 3 6 9 MH Older People In patient 10(3): 12(1): 15(3): 17(1) 8 2 10 CAMHS Inpatient 6 6 MH Crisis/Home Treatment 12(2): 18(2) 4 5 9 MH Adult Community 10(1): 11(1): 12(1): 17(1): 18(1) 5 5 10 MH Older People Community 17(1) 1 5 6 CAMHS Community 12(1): 18(2) 3 6 9 LD /Autism Community 4 4 Forensic Community * * 2 2 Total 27 62 89 COMMUNITY SERVICES Children, Families and YP 12(3): 17(3) 6 3 9 Community Health Adults 17(1): 18(1): 20(1) 3 2 5 Community Health Inpatient 12(4): 15(3): 17(3): 18(2) 9 6 15 Minor Injury Units (MIU) 12(5): 13(1): 17(3): 18(2) 12 11 23 End of Life 17(3) 3 5 8 Total 33 27 60 OVERALL TOTAL 60 89 149

KEY KEY Inadequate S Safe

Requires Improvement E Effective Good C Caring

* Outstanding R Responsive Not rated W-L Well-Led

2. MENTAL HEALTH ACT (MHA) 1983: CODE OF PRACTICE 2015 INSPECTION

2.1 As a community and mental health Trust part of the CQC inspection involves looking at how the Trust implements the MHA: Code of Practice. While this does not impact on the compliance ratings it is important for the Board to see the findings within the comprehensive inspection process. The Code of Practice provides statutory guidance to registered medical practitioners, approved clinicians, managers and staff of providers, and approved mental health professionals on how they should carry out functions under the Mental Health Act (‘the Act’) in practice. It is statutory guidance in relation to the medical treatment of patients suffering from mental disorders. The CQC is required to monitor the use of the Mental Health Act 1983 (MHA) to provide a safeguard for individual patients whose rights are restricted under the Act. They do this by looking across the whole patient pathway experience from admission to discharge regardless of whether patients have their treatment in the community, under a supervised treatment order or are detained in hospital.

2.2 Mental Health Act Commissioners interview detained patients or those who have their rights restricted under the Act and discuss their experience. They also talk to relatives, carers, staff, advocates and managers, and they review records and documents to ensure compliance.

2.3 In addition to the 16 core service reports, the Trust received six Mental Health Act Monitoring reports which also require action. These action plans relate specifically to the following wards: o Nightingale House, MH Rehabilitation o Twynham Ward, Forensic Low Secure o Alumhurst Ward, Older People Mental Health o Pebble Lodge, CAMHS o Dudsbury Ward, Female Treatment Ward o Waterston Acute Assessment Unit 2.4 There are 29 actions arising from breaches of the MHA Code of Practice. The table below gives an overview of each ward, the regulation breached and the number of actions that have been identified as required to meet the regulation (please note for some actions there are multiple components required to work up to achievement of the standard).

WARD CODE OF PRACTICE CHAPTER ACTIONS BREACHED Nightingale House 1, 8, 25 4 Twynham Ward 1, 8, 26, 27 5 Alumhurst Ward 1, 8, 24, 25 6 Pebble Lodge 1, 4, 19, 25, 27 6 Dudsbury Ward 4 1 Waterston AAU 1, 4, 8 7 Total 29

CHAPTER SUBJECT 1 Guiding principles, (e.g. least restrictions, involvement, engagement) 4 Information for Patients, Nearest Relatives, Carers and Others 8 Privacy, Safety and Dignity 19 Children and Young People under the age of 18 24 Capacity and Consent

25 Treatments Subject to Special rules and Procedures 26 Safe and Therapeutic Responses to Behavioural Disturbance 27 Leave of Absence

2.5 There is a very clear process in place to monitor and review the implementation of the MHA action plan via the Mental Health Legislation Assurance Committee and for that reason the full action plans are not included within this report. Going forward any exceptions in meeting the target dates will be included in the overall report to the Board.

2.6 Of the 29 actions and their component parts, eight actions have been completed, 21 are in progress and no actions are past the deadline identified by the service leads. Progress with these action plans by ward is shown below:

WARD Actions Partially Complete Comments complete Nightingale 4 2 2 Actions due completion House January 2016. Twynham 5 3 2 Actions due completion Ward January 2016 Alumhurst 6 5 1 Issues with gender Ward separation on the ward – developing estates strategy and OPMH plan This is being managed as well as possible to ensure patient privacy and dignity. Pebble 6 4 2 Actions not due until end of Lodge March 2016. On progress to meet deadlines. Dudsbury 1 1 Ongoing action - Ward Ward Manager is progressing with additional measures to improve compliance with s132 rights. Existing measures met. Waterston 6 6 1 Remaining actions relate to AAU care plans and S132 rights – these are due end of January 2016 Total 29 21 8 *there are no overdue actions

3. DEVELOPMENT, IMPLEMENTATION AND MONITORING OF THE CQC QUALITY IMPROVEMENT ACTION PLAN AND LEVELS OF ASSURANCE

3.1 The Trust has developed a comprehensive action plan aligned to each core service area and the overarching plan is presented in Appendix 1 for each core service area. Each core service plan has a lead clinician, lead manager and lead Director who is responsible for ensuring the actions are kept on track and the supporting evidence to provide assurance is available. These actions constitute the first line of defence in assuring that the plans are owned and actions are being implemented within the service areas

3.2 Alongside this the corporate services such as Learning and Development, Estates and Human Resources have taken a Trust-wide approach and are supporting the core service actions plans where there are cross cutting improvements required. Examples include:

• Compliance with mandatory training and ensuring sufficient, accessible training programmes to meet the needs of staff groups • Estate improvements • Recruitment and retention plans to support safe staffing across the services.

3.3 The monitoring and tracking of the action plans will be managed by the Programme Management Office (PMO). This process will be overseen by the Nursing and Quality Directorate. Quality assurance visits are undertaken by the Quality Assurance Team to ensure that the evidence is in place once an action has been completed. The internal quality assurance visits constitute the second line of defence.

3.4 The CQC MHA Inspections have continued and the most recent visit took place to St Brelades ward on 11 January 2016 feedback from these inspections will provide the Trust with assurance as to compliance with the Mental Health Act and Code of Practice and any further actions required. External visits and inspections constitute the third line of defence

Other Sources of Assurance

3.4 Dorset Clinical Commissioning Group continues to visit service areas and provide feedback to the Director of Nursing on their findings. Since the CQC Inspection in June visits have taken place to the following areas:

• Swanage Hospital – 13 July 2015 • Chalbury Ward, Weymouth Community Hospital – 19 August 2015 • Yeatman Hospital, Sherborne – 28 September 2015 • Waterston Unit, Forston Clinic – 12 October 2015 • Portland Hospital – 24 November 2015 • Victoria Hospital, Wimborne – 12 January 2016

3.5 These reports have been mostly positive and where actions are required they are put into immediate effect by the Ward Manager/Clinical Lead. These reports are available via the Director of Nursing and Quality.

3.6 The CQC have undertaken two thematic inspections of the Trust during Q3:

• End of Life Care - 19 October 2015 • Safeguarding Children and Looked After Children (Dorset) - 16 November 2015

3.7 The draft Safeguarding Children and Looked After Children inspection report has been shared for factual accuracy and the final report is yet to be published. The Trust is meeting with Dorset CCG on 22 January to review the draft report and to consider the actions required to meet the recommendations emerging.

3.8 The Trust has not yet received the draft End of Life report and has asked CQC when the report is likely to be available.

Reporting against the Quality Improvement Action Plan

3.10 All core service leads are in contact with the PMO and meetings are scheduled, firstly with the CQC priority areas. The PMO will work to a monthly timetable with progress updates required from the core service leads by the 25th of the month and the PMO will review these with the Quality team. Issues will be raised and addressed as they occur with the Quality team and shared with the relevant leads and service Director. The meetings will comprise a review of the planned actions and seek to gain evidence of delivery which will then enable an internal quality inspection to be scheduled.

3.11 Monthly updates will be provided by the PMO report which will include a dashboard summary with a RAG-status against the agreed target dates. This will be discussed and reviewed at the Executive Quality and Clinical Risk Group, highlighting any exceptions. The reports will also be shared with the three Directorate Locality Group meetings. It is proposed that the Board receives a monthly high level report on progress against the must do and should do actions and identify any exceptions with mitigations after they are discussed by Executive Quality and Clinical Risk Group.

3.12 The Director of Nursing and Quality, Locality Directors and Head of Regulation and Compliance will continue to meet six-weekly with the CQC team to share progress and assurance that the action plan is being delivered and that any exceptions, including late and non-delivery of actions are understood, managed and risk mitigated.

4. PROGRESS TO DATE

4.1 The action plan leads were asked to provide an update on their actions by 31 December 2015. These updates were supported by quality assurance visits to a sample of sites and the charts below show the progress to date.

4.2 For the 149 actions identified in the CQC reports, there are 325 component actions being implemented across the services. There has been progress with many of the actions but because some have multiple components, until every component has been achieved the action will remain open.

4.3 At the time of reporting 8 of the 60 must do actions have been completed and 20 of the 89 should do actions. In total 28 actions have been completed (19%) of the 149 actions.

4.4 At this time no actions have been found to be past the target dates identified by the core service leads

4.5 Additionally, internal quality assurance visits are taking place to services rated as ‘requires improvement’. The findings from these visits are reported to the Locality Director and service leads at the time of the visit.

4.6 The table below provides the progress by core service where must do and should do actions have been completed. Nine out of 16 services have completed some actions. The other service areas all have actions in progress as highlighted in Appendix 1.

CORE SERVICE ‘MUST ACTIONS COMPLETE AS AT 31.12.15 ‘SHOULD ACTIONS COMPLETE AS AT 31.12.15 DO’ DO’ ACTION ACTIONS MENTAL HEALTH SERVICES Acute Wards for Adults and 0 6 1) Review description of word seclusion while Psychiatric Intensive Care Unit describing de-escalation on RiO in order that the intervention is accurately recorded. Long Stay Rehabilitation 3 1) Protect patients against the risks 15 1) Ensure that the frequency of audits of Wards associated with the unsafe use controlled drugs is in line with the trust’s and management of medicines policy. on Glendinning ward by ensuring 2) Review the current system of smoking that the record of the breaks in the very small yard in Nightingale administration of medication is House. accurate. 3) Cigarette remains should be cleared 2) Nightingale House 51 ligature promptly to ensure patient safety risks identified – plans in place to mitigate risk however, 3 patients at increased risk of self-harm and upstairs male bathroom was isolated, unobserved, unlockable and had no alarm system Forensic Inpatients 3 1) Provide clear written policies on 6 1) Review its blanket policy of locking all procedural security on the ward, patients’ bedrooms during the day, and which should include perceived lack of choice by patients when management of barred items, attending groups. use of emergency alarms and 2) Ensure that resuscitation equipment is security of keys. routinely checked. 2) Ensure that sharps bins are used 3) Review the seclusion room in accordance appropriately and that lids are with the Mental Health Act Code of secured when in use. Practice. 4) Consider the specific training needs of staff working in a low secure service. 5) Review access to secure services for women and consider, with commissioners whether this service should be offered. 11

Wards for Older People with 8 1) Provide appropriate wheelchair 2 Mental Health Difficulties access to disabled people’s bedrooms in Melstock House. 2) *Provide patients with enough access to outside areas and ensure that staff are competent in fire evacuation procedures. (partial completion of full action) 3) Ensure that privacy and dignity are protected on Alumhurst ward and at Melstock House, with robust systems to check and monitor compliance and to ensure that staff understands their responsibilities. MH Crisis/Home Treatment 4 4 1) *Staff working in the Crisis team have up to and Health Based Place of date mandatory training – additional Safety floating staff added to e-roster to ensure additional staffing is available to support S136 assessments when required (sub action completed) MH Older People Community 1 1) Ensure that care records are 5 accurate, complete and contemporaneous.

CAMHS Community 3 6 1) Ensure that the action plans it produced following the CQC visit to the community child and adolescent mental health service teams are implemented without delay. 2) *Keep staff up to date with their mandatory training – initial summary position (sub action completed) 3) *Provide systems to ensure greater consistency in the standards and working practices across the different community child and adolescent mental health service 12

teams (Partial completion of full action)

Learning Disability/Autism n/a 4 1) Ensure that mental capacity assessments Community are conducted and documented and ensure that consent to treatment is always sought. 2) Ensure that staff pass on information about how to access advocates in an accessible way 3) Ensure timely uploading of care information to the electronic record system Forensic Community n/a 2 1) Review access to secure services for women

Total 7 Fully Completed 14 Fully completed

COMMUNITY SERVICES Community Health Inpatient 9 1) *Ensure that emergency 6 1) Service strategies should be clear and that equipment and suction machines they are communicated effectively. are fit for purpose (partially 2) Encourage and support staff at all levels to completed) raise concerns, promote improvement and 2) *Implement infection prevention contribute to innovation and control policies and 3) *Provide enough adequately experienced procedures (partially completed) and trained staff to meet the assessed 3) *Store medicines in accordance needs of patients (partially completed) with its policies and standard operating procedures (partially completed)

Minor Injury Units (MIU) 12 1) *Implement a formal system that 11 1) Ensure that minor injury units and adjacent ensures all patients attending departments such as x-ray departments MIUs receive a timely clinical are easily accessible assessment (partially complete) 2) Support and encourage all staff to report and learn from incidents and complaints consistently to support continuous improvement in service quality 3) *Ensure that the patient group directions used in MIUs to enable staff to administer prescription only medication are signed by staff (partially complete) 4) *Ensure staff are up to date with safeguarding training (partially complete)

End of Life Care) 3 1) Strengthen strategic leadership 5 and governance arrangements and ensure that there is regular reporting to the trust board on the quality of end of life services.

Total 1 Fully Completed 6 Fully Completed

OVERALL TOTAL 8 Fully Completed 20 Fully Completed

*The update includes significant elements of 5 must do and 5 should do have been achieved to date but not included in the number of fully completed actions.

5. CONCLUSION AND RECOMMENDATION

5.1 Good progress has been made in formulating detailed action plans for each core service area supported by corporate plans for cross cutting actions.

5.2 The Board is asked to note: • The content of the CQC Quality Improvement Action Plan and the progress made to date: o 8 ‘must do’ actions completed o 20 ‘should do’ actions completed o No outstanding actions to report o Ongoing monitoring to ensure the actions are embedded in practice

5.3 It is proposed that the Board receives updates on a monthly basis as part of the integrated quality dashboard.

5.4 To discuss and consider whether this report provides sufficient assurance regarding progress of the CQC Quality Improvement Action Plan.

5.5 Agree that the action plan and ongoing progress reports will be shared with the CQC, commissioners and partners / stakeholders.

Agenda Item 14

Well-Led Governance Review Action plan

Part 1 Board Meeting 27 January 2016

Author Keith Eales Sponsoring Board Ann Abraham Member Purpose of Report This report presents the draft action plan in response to the PM Governance review of the Trust against the Monitor Well-Led Framework.

Recommendation The Board is asked to approve the action plan and note the progress made to date. Engagement and - Involvement Previous Board Meeting October 2015, Council of Governors December Board/Committee Dates 2015 Monitoring and Assurance Summary

1.1 Under the Risk Assessment Framework and in line with the NHS Foundation Trust (FT) Code of Governance, Monitor expects Foundation Trusts to carry out an external review of their governance every three years. To support this process, Monitor has published the Well-Led Framework. The Framework is outcomes-led with four domains, ten high-level questions and 34 subsidiary questions based around good practice outcomes. Trusts and reviewers can use the domains and questions to assess governance.

1.2 The Trust commissioned PM Governance to undertake the review. The on-site field work was undertaken in July and reported to the Board in October.

1.3 The report identified 17 recommendations and a number of areas of good practice that the Trust could consider. No material governance concerns were identified. The report commented that

‘The Trust has built a good governance structure that is conceptually sound, incorporating leading edge practices in risk management and board assurance’.

1.4 Monitor has been advised of the outcome of the review and of the recommendations, as required under the Risk Assessment Framework

2 Action Plan

2.1 A lead Director(s) has been identified for each of the 17 recommendations and the action to be taken identified. This is summarised in the attached schedule.

2.2 In addition, the areas of good practice identified in the review are being taken forward with the relevant Director.

2.3 Progress in implementing the action plan, using a RAG rating, will be reported to each meeting of the Executive Performance and Corporate Risk Group and to the Board quarterly.

3 Recommendation

3.1 The Board is asked to approve the action plan.

Keith Eales

Trust Secretary January 2016

Well-Led Governance Review Action Plan: January 2016

Recommendation Action to be taken Lead Target Progress Update

Strategy and Planning Domain

1 That the Board develop strategic The key action being taken is in respect S O’D March A project team has been meeting to options aligned to a variety of of the development of the “out of 2016 develop the model. The model will possible outcomes from the Hospital model”. This will be used to be submitted to the Board CSR, while at the same time influence and respond to the CSR Workshop in March seeking to shape the CSR.

2 That the Executive sets out more The Stages of Excellence methodology SH Progress The adoption of the model has precisely the measures of will be used to measure delivery of the report to been agreed. An engagement success for each strategic goal, strategic goals. Board in event plan was implemented and outline in more detail February between November and December implementation plans beyond the 2016 2015. The outcome of this will be current year. reported to the Board.

3 That a Clinical Strategy is A strategy will be developed for NK July The approach for developing the developed and agreed in order to submission to the Board 2016 strategy has been agreed provide a clearer steer on future clinical models and strategic 1. Draw together project group decisions concerning the Trust’s when new clinical leads in place future estate requirements. 2. Identify national and local context and priorities which will have bearing on strategy development, including perspective of relevant stakeholders and partners

3. Draw up strategy by service and adjust by needs of particular locality

4. Test strategy at Clinical Executive and Board Workshop

5. Prepare and implement communication plan to broaden awareness within the Trust and with relevant stakeholders and partners.

6. Develop process whereby strategy delivery is tracked

7. Maintain overview so that Strategy remains ‘live’ and updated

8. Maintain communication of progress to the Trust and relevant stakeholders and partners.

4 To enhance further control over Reports to the Board, Audit and Quality KE January Completed risk, the Board should put greater Governance Committees will provide 2016 emphasis on effective risk more emphasis on risk treatment A programme of monthly meetings treatment and move beyond a with each risk lead has been focus on scoring or risk established to review risk definitions. treatment.

The reporting template to the Board and Board Committees now provides for an assessment by each risk lead as to the effectiveness of the risk treatment plans

5 That the Board explore what Develop the CQC Quality Improvement FH January Completed additional assurance it requires Plan (QIP) in response to the recent 2016 in order to declare ongoing published inspection outcome for Board compliance with the CQC’s discussion at the Trust Board minimum standards for registration. The QGC to consider the evidence required to ensure the actions have been met and how assurance is currently 31/12/15 Completed achieved

Map any assurance deficits using the 3 31/12/15 Completed lines of defence model and propose solutions

Ongoing operational monitoring and Ongoing review CQC at the EQCRG

Assurance reports to the QGC Quarterly In place highlighting where there are gaps and potential risks to compliance

6 That the Board develop horizon Horizon scanning and scenario analysis SH/KE Jan/Feb The proposed approach to the scanning and scenario analyses to be undertaken through the Annual 2016 development of the 2016/17 BAF, to evaluate the risks to strategy, plan process (SH) with identified risks to and the identification of strategic applying a greater emphasis on be incorporated into BAF (KE) risks, is to be recommended to the strategic risks in the BAF. January 2016 Board meeting

Capability and Culture Domain

7 That the Remuneration The Appointments & Remuneration CH January Completed Committee sets out clearly for Committee will consider succession 2016 the Board its programme of work planning and Executive Director The Appointments and in relation to succession planning development Remuneration Committee has and Executive development. agreed an annual cycle of business

which includes a review of succession planning and reviewing the outcome of Director appraisals.

8 To inform current practice and To review the dashboard with regard to JC/FH/ March A wider review of the dashboard is variation between Localities, the the possibility of including locality NK 2016 underway, being led by the Director Board incorporate Locality performance. of Nursing & Quality and the performance into the dashboard Medical Director. The inclusion of for comparable indicators of To investigate and propose prior to Locality performance information quality. To enhance implementation, which clinical and clinical benchmarking is being understanding of best practice in benchmarking is appropriate for use. considered as part of this. the sector the Board extend the use of clinical benchmarking, where appropriate.

9 That the Board consider the To agree an appropriate methodology SH/FH March A report on a proposed approach is benefits of adopting a clear 2016 to be considered by the Executive corporate methodology that it can Quality & Clinical Risk Group in use to drive improvement across February and the Board in March the organisation. 2016.

10 That the Executive ensure any Directors to agree recommendations and FH January Directors review process has care management problem identify trends on a monthly basis 2016 commenced identified using root cause . analysis is evaluated and acted Head of Patient Safety and Risk/Medical Quarterly reporting arrangements in upon. Director to review trends quarterly, place for Quality Governance monitor repeat recommendations. Committee Patient Safety team to report on This process has been evidence of change in practice on implemented selection of recommendations that have been reported as completed.

Progress of recommendations to be Completed reported quarterly to the Quality Governance Committee

Processes and Structure Domain

11 That action be taken to improve Meeting planning and arrangements for RS/FH/ January The terms of reference of the the effectiveness of the the two main Executive Groups will be NK/KE 2016 Executive Quality & Clinical Risk Executive Group meetings. Such reviewed. Group have been reviewed and a action may involve clarifying cycle of business established. more directly the information Additional meeting time has been requirements in advance, programmed. standardising the structure of reports, prioritising agendas and The annual cycle of business for major decisions as part of the the Executive Performance & annual cycle of business, and Corporate Risk Group has been giving each agenda item an reviewed and arrangements agreed appropriate amount of for the distribution of items outside time, rather than a standard ten meetings to streamline agendas. minute allocation, in order to get through the required business. The arrangements will be reviewed in August 2016.

12 That the Non-Executive Directors A review will be undertaken and a report Chairs January This was discussed at the meeting consider whether the outputs of submitted to the Chairs Meeting Meeting 2016 of the Non-Executive Directors the clinical audit programme and Chairs on 21 January and assume sufficient prominence in a report will be submitted to the the assurance framework or Audit Committee. sufficient scrutiny by the assurance committees.

13 In the event that a whistleblowing The Speaking up and Whistleblowing CH January Completed concern is raised which relates to Policy will be amended to reflect this. 2016 an Executive Director, an The revised policy, agreed by the exception be considered to allow Board in November, included the a Non-Executive Director to lead following the investigation, which might complement the existing role of “Concerns relating to the Chief

the Senior Independent Director. Executive or a Director can be raised with the Senior Independent Director (details for content are in 5.6 above) and/or with the Chair of the Trust”.

Measurement Domain

14 That the Board explore and To understand how the thresholds have FH October Completed debate its tolerance for serious been set and the rationale that underpins 2015 incidents and review the this The threshold for the PSI moderate threshold accordingly. and above is set at 8.08%. This was determined from reviewing the available data nationally on PSI’s at this level. Nationally over a 6 month period (NRLS data) the average for moderate and above harms was 8.08%. We are currently measuring our performance monthly so is subject to in-month variation that may be higher or lower than the 6 month average and hence misleading.

The data is six months behind so should be reviewed every six months to understand the national position from which to base our own threshold.

Consider whether the threshold needs to FH October Completed be changed in the light of the review. 2015 Measure has been adjusted on the Trust Integrated Corporate Dashboard to reflect the finding

from the review of the indicator.

15 That the Audit Committee satisfy The Audit Committee to review JC October Completed, existing reporting itself that the frequency of frequency of assurance reporting 2015 considered appropriate reviewing assurance on data quality is proportionate to the level of concern within the Trust.

16 The Audit Committee obtains FH and lead clinicians to join the Data NK/FH January The Director of Nursing and Quality assurance and is satisfied that Quality Steering group to work with the 2016 has joined this Group. Appropriate there is sufficient clarity informatics team on dashboard data clinical representation is being regarding the numerator and quality. identified. denominator for all indicators expressed as a percentage in the dashboard. The Data Quality Steering Group to provide assurance reports to the Audit As Completed Committee from the clinical perspective required regarding the data quality and that it is understood in practice regarding the collection and recording of the data.

The Data Quality Steering group to As Completed highlight any quality issues regarding the required data to the Audit Committee as required.

17 The Trust reviews the The Audit Committee will review this. JC October Completed mechanism for making 2015 judgements on data quality confidence ratings and explores how this could be automated or at least become less dependent upon the judgement of one individual.

Agenda Item 15

Quarterly Review of the Board Assurance Framework January 2016

Part 1 Board Meeting 27 January 2016

Author Keith Eales, Trust Secretary Sponsoring Board Member Ron Shields, Chief Executive Purpose of Report To advise the Board of the outcome of the review of the Board Assurance Framework (BAF).

Recommendation/Action for The Board is asked to Committee (a) note the outcome of the quarterly review of the BAF

(b) review, in conjunction with the lead Director(s), progress in respect of the treatment of BAF risks

Engagement and Involvement Consultation with lead Directors for BAF risks Report to Quality Governance Committee 21 January 2016 and Audit Committee 25 January 2016 Previous Committee/s Dates None

Monitoring and Assurance Summary

This report links to the . To provide high quality care; first time, every time; following Strategic . To be a learning organisation, maximising our Objective(s) partnership with Bournemouth University and promoting innovation, research and evidence based practice; . To ensure that all of the Trust’s resources are used in an efficient and sustainable way; I confirm that I have considered each of the Any action required? implications of this report, on each of the Yes Yes No matters below, as indicated: Detail in report All three Domains of Quality   Board Assurance Framework   Risk Register   Legal / Regulatory   People / Staff   Financial / Value for Money / Sustainability   Information Management &Technology   Equality Impact Assessment   Freedom of Information  

Agenda Item 15

1. Introduction

1.1 The Board agreed the BAF for 2015/16 at its March 2015 meeting. An update is provided to each meeting of the Executive Performance & Corporate Risk Group. The Board and Board Committees review the BAF on a quarterly basis. This quarterly review of the BAF will be considered by the Quality Governance Committee on 21 January and the Audit Committee on 25 January 2016.

1.2 The focus in this report has, in line with the recommendation in the external governance review, moved to reviewing the treatment and management of BAF risks. The external governance review also suggested that accountability would be enhanced if, at Executive and Board/Board Committee meetings, the relevant Executive Director reported on progress in the management of BAF risks. To address this, the report sets out

• previously agreed actions that have been completed

• additional sources of assurance now included

• new actions identified, rather than commenting on movement in risk scores

• a commentary from the lead Director for each risk on the effectiveness of its treatment

1.3 It is suggested that the commentary from the lead Director (section 4 of the report) is the focus for debate at the Board.

2. Strategic Goals and Significant Risks

2.1 The seven strategic goals for 2015/16 and the six current significant risks of failure to achieve them are shown in the table below. For the Trust’s purposes, ‘significant risks’ are those scoring 15-25 in the Trust’s risk register.

Strategic goal for 2015/16 Significant risk Risk Risk Owner scoring 15+ as at Score March 15 1 To provide high quality care; first time, Failures in care. 20 SO'D/LB/EY every time. Lead Director: EY Inadequate 16 SO'D/LB/EY staffing levels. Lead Director: S O’D 2 To be a valued partner and expert in - - partnership working with patients, communities and organisations. 3 To be a learning organisation, maximising - - - our partnership with Bournemouth University and promoting innovation, research and evidence based practice. 4 To have a skilled, diverse and caring Ineffective clinical 16 NK/FH/CH workforce who are proud to work for leadership across Dorset HealthCare. some services. Lead Director: NK

5 To be a national leader in the delivery of Locality 16 SO'D/LB/EY 2

Agenda Item 15 integrated care. governance. Lead Director: LB 6 To ensure that all of the Trust’s resources Financial 16 JC are used in an efficient and sustainable challenge. way. Lack of resilience. 16 SH 7 To raise awareness within the Trust and - - - externally of the impact that our work has on people and our environment, and take steps to reduce any negative effects.

3. January Update of the Board Assurance Framework

3.1 A number of changes have been made to the BAF in the last month to reflect developments in the treatment and management of risks

(a) Failures in care, inadequate staffing levels, ineffective clinical leadership and locality governance; an additional control has been included in respect of the CQC action plan. This has been added to the risks in respect of failures in care, inadequate staffing levels, ineffective clinical leadership and locality governance. The gap in control reflects the fact that the action plan has not yet been agreed by the Board.

(b) Failures in Care; the CQC conclusions in respect of the Crisis Service, the MIU’s and CAMHS have been included as a gap in control in the failures in care risk.

Additional sources of assurance have been recognised in respect of

• Review of incidents and RCA’s (first line of defence)

• The escalation process for staffing issues in and out of hours (second line of defence)

• Falls and pressure ulcer panels (second line of defence)

• CCG announced inspections (third line of defence)

• Independent reviews of serious untoward incidents through Serious Case Reviews (third line of defence)

A key action completed in the last month was in respect of agreeing the role and composition of the newly established Clinical Executive.

Additional sources of assurance have been identified

• Psychiatric medical staff meetings reconfigured to promote clinical engagement

• CCIOs appointed to promote clinical engagement in issues around IT and Information Management (first line of defence source of assurance)

• The Department of Community Medicine has been established to promote engagement of other medical staff (first line of defence source of assurance) 3

Agenda Item 15

(d) Locality Governance; this risk has been updated with the following

A key action completed in the last month was in respect of agreeing the role and composition of the newly established Clinical Executive.

Additional sources of assurance added;

• Reference to the developing role of Directorate Management Groups and super- locality meetings as a second line of defence source of assurance

• The development of service specific dashboards, for example for CAMHS, as a second line of defence source of assurance

• The role of quality and performance meetings with Locality Managers as a second line of defence source of assurance

Additional actions for completion added;

• Recruitment process to the Clinical Executive (completed in December)

• Consideration being given to extending the use of service specific dashboards (Locality Directors)

• Review of the operation of the locality structure one year on (Chief Executive and Locality Directors in January 2016)

(e) The Financial Challenge; the risk has been updated with the following

A key action completed was the internal audit review of the cost improvement programme. Other key changes are

• An additional source of assurance following the commencement of the monthly reporting on individual CQUIN schemes has been added (first line of defence)

• A gap in assurance has been included following the internal audit of the cost improvement programme in December 2015

• An additional action to develop a plan following the internal audit report referred to above has been included

• Reference to the development of the sustainability and transformation plan and the out of hospital model.

(f) Lack of Resilience; the risk has been updated to reflect

• The commencement of work on the Annual plan for 2016/17 (with an action for the draft to be submitted to the Board in January 2016)

• The requirement to produce a sustainability and transformation plan

Agenda Item 15 4. Commentary on the Effectiveness of Risk Treatment

4.1 The Lead Director for each risk has assessed the current position in respect of the action being taken to manage the risk for which they are responsible

Failures in Care (EY)

There is some improvement in adherence to risk assessment and care planning guidelines, however, in some areas of the Trust, this guidance is not consistently applied and improvement has plateaued. Robust Management of poor performance and better access to training and development have been implemented to ensure consistent application of guidelines and policy. Clinical standards have generally improved and overall there has been a reduction in the use of restrictive interventions. The CQC action plans have been agreed for all Trust services and progress is being made to complete outstanding actions. Learning from incidents is now shared widely through quality matters, directorate meetings and dedicated learning events across the Trust. The CAS alert system database has been refreshed and there is assurance that alerts are being seen and responded to by the most appropriate individuals. This BAF risk remains a focus for the Trust.

Whilst the impact of the risk materialising may remain the same, the likelihood is considered to have reduced.

Inadequate staffing levels (S O’D)

A variety of initiatives have been introduced to support the better utilisation of the existing workforce. The effective use of the e-rostering system, the enhanced Trust bank, the reduction of agency staff and the employment of permanent employees have all contributed to the more effective deployment of Trust staff. However, challenges remain in recruiting staff in some geographical and functional areas and there remains scope to enhance the retention of staff. The further progression of recruitment and retention initiatives will be key to the continued effective management of this risk. As such, the risk score remains unchanged.

Ineffective clinical leadership across some services (NK)

The key development in respect of the management of this risk has been the commencement of meetings of the new Clinical Executive. The first meeting was held in January 2016. There has been a significant level of clinical engagement in the development of the new group.

This, alongside the embedding of the locality governance structures, suggest that considerable progress has been made in mitigating this risk whaich may not be reflected in the current scoring.

Whilst the impact of the risk materialising may remain the same, the likelihood is considered to have reduced.

Locality Governance (LB)

Considerable progress has been made in implementing the locality structure within the Trust. The new structure has supported positive engagement with stakeholders and has contributed to the achievement of the Trust objective in respect of the delivery of integrated care.

However, it is acknowledged that the new structure has brought with it a number of challenges at an operational level. This was reinforced by the findings of the CQC inspection published in October 2015. Action is being taken to address these through the CQC action plans. This includes strengthening systems to address variations in practice pan-Dorset. Additionally, a ‘one year on’ review is being undertaken by the Chief Executive and Locality Directors. No reduction in the risk score is suggested prior to this.

Agenda Item 15

Financial Challenge (JC)

The actions taken in recent months are beginning to have a positive impact on the financial position of the Trust. At the end of November 2015 the Trust was forecast to be £250,000 adrift from the forecast deficit for the year. Action to be taken over the remainder of the year will further reduce the gap between the planned and forecast year end position.

On this basis, the risk that the Trust will be in excess of £1m off the planned position is unlikely to materialise and should be reflected in the risk score.

With regard to the longer-term financial viability of the Trust, the requirement to produce a sustainability and transformation plan, and the likely Trust objective to produce a medium-term financial plan will be additional sources of assurance.

Whilst the impact of the risk materialising may remain the same, the likelihood is considered to have reduced.

Lack of Resilience (SH)

The Trust has continued to manage this risk through full engagement in the health economy planning processes, particularly in respect of Better Together and the CSR. The same approach will be adopted for the development of a sustainability and transformation plan for the health economy.

More specifically, the Board will be aware that work has commenced on the development of the Annual plan for 2016/17.

It is considered that the completion of these two documents over the coming months, and the agreement on the out-of hospital model of care will make a significant contribution to the effective mitigation of this risk. Pending this, the risk remains unchanged.

5. Development of the BAF for 2016/17

5.1 Typically, the BAF for a year is developed in conjunction with Board members.

5.2 For the 2016/17 BAF it is suggested that the identification of the key risks to the strategic objectives is undertaken, in the first instance, by a small group of Board Directors. The group would draw on the draft Annual Plan for 2016/17 as the basis for identifying the risks. The BAF would then be developed and submitted for approval by the Board in March 2016.

6. Recommendations

6.1 The Board is asked to note the outcome of the quarterly review of the BAF and to review, in conjunction with the lead Director(s), progress in respect of the treatment of BAF risks.

Keith Eales, Trust Secretary

January 2016

The Trust's goals for 2015-16 (approved January 2015 Board).

1 To provide high quality care; first time, every time.

3 To be a learning organisation, maximising our partnership with Bournemouth University and promoting innovation, research and evidence based practice; 4 To have a skilled, diverse and caring workforce who are proud to work for Dorset HealthCare;

5 To be a national leader in the delivery of integrated care;

6 To ensure that all of the Trust’s resources are used in an efficient and sustainable way;

7 To raise awareness within the Trust and externally of the impact that our work has on people and our environment, and take steps to reduce any negative effects. SIGNIFICANT RISK REGISTER 2015/16

# Goal we could fail Risk of failure to achieve objective that we face now Exec Lead Impact x Acceptable Our Target to achieve likelihood score assurance date (max 5 x 5) oversight today

1 To provide high quality care; Failures in care. SO'D; LB; EY 4 x 4 = 16 4 x 2 = 8 Quality 31.3.16 first time, every time Caused by gaps in adherence to assessment care planning policy / guidelines; poor use of risk Governance (Goal 1). assessments or other lapses in protocol. Committee May result in inadequate patient experience; failure to protect patients and staff from harm ; adverse (+MHLAC) publicity; disruption to one or more locality; loss of stakeholder confidence, failure to comply with clinical standards and regulatory action.

2 To provide high quality care; Inadequate staffing levels. SO'D; LB; EY 4 x 4 = 16 2 x 3 = 6 Quality 31.3.16 first time, every time Caused by high rates of staff churn; unplanned absences; skill mix; inadequate workforce planning; Governance (Goal 1). insufficient workforce availability; failure to motivate, engage, retain talent. Committee May result in inadequate patient experience; failure to protect patients and staff from harm ; adverse publicity; disruption to one or more locality; loss of stakeholder confidence, failure to comply with clinical standards with adverse regulatory action.

3 To have a skilled, diverse Ineffective clinical leadership across some services. NK; FH; CH 4 x 4 = 16 2 x 3 = 6 Quality 31.3.16 and caring workforce who Caused by change programmes; uncertainty; failure to recruit, retain and develop clinical leaders. Governance are proud to work for May result in a lack of clinical leadership; harm to patients or staff, disruption to one or more Committee Dorset healthcare Localities, extended service closure. (Goal 4).

4 To be a national leader in Locality governance SO'D; LB; EY 4 x 4 = 16 2 x 4 = 8 Quality 31.3.16 the delivery of integrated Caused by failures to agree, communicate and work according to an effective system of locality Governance care governance or failures to identify and report on relevant smart performance data. Committee (Goal 5). May result in harm ; adverse publicity; disruption to one or more localities or extended service closure.

5 To ensure that the Trust's The financial challenge. JC 4 x 4 = 16 2 x 4 = 8 Audit 31.3.16 resources are used in an Caused by lack of budgetary control, lack of resilience on CIP programme development; Committee efficient and sustainable failure to capitalise on commissioners' discretionary payment schemes and uncertainty over way the longer-term financial sustainability of the Trust. (Goal 6). May result in variances from plan in excess of £1M; adverse publicity and regulatory action and future restructuring of the Trust to ensure the continued viability of services.. 6 To ensure that the Trust's Lack of resilience. SH 4 x 4 = 16 3 x 3 = 9 Audit 31.3.16 resources are used in an Caused by a failure to integrate services with Local Authority social care and other partners and to Committee efficient and sustainable influence the outcomes of Better Together, Dorset CCG Review in the interests of the Trust's patients. way May result in disruption to one or more localities or service loss / closure. (Goal 6). Board Assurance Framework 2015-16 Date on which data valid: 15-Dec-15

Corporate objective no. 1 To provide high quality care; first time, every time. Risk description: Failures in care. Caused by gaps in adherence to assessment care planning policy / guidelines; poor use of risk assessments or other lapses in protocol. May result in inadequate patient experience; failure to protect patients and staff from harm ; adverse publicity; disruption to one or more locality; loss of stakeholder confidence, failure to comply with clinical standards and regulatory action.

Range of outcomes Outlying clinical outcomes Worse than peer clinical In line with peer Better than peer clinical Exemplar clinical outcomes Outcome trajectory RAG rating today's Assurance oversight BAF risk and harm outcomes & harm outcomes and harm and harm assurance position Ulysses No: Scores Initial Today Acceptable no 1

S x L 4 x 4 = 16 4 x 4 = 16 4 x 2 = 8 Risk Quality Governance SO'D; LB; EY Current position ↔ A owner • Committee (+MHLAC)

Main Control description Gaps in control Assurance from first line of defence Assurance from second line of defence Assurance from third line of defence Gaps in assurance position Further action or assurance required by committee / controls 1- (front line evidence) (management evidence) (independent evidence) Board, with dates 6 1 Our staff have been trained to deliver Not all patients have a care plan or adequate Integrated corporate dashboard. Care Certificate programme for healthcare CQC unannounced inspections. CQC inspection report may identify specific gaps Peer review of mental health legislation safe and compassionate care. care plan. Early warning trigger tool data. support workers and adult social care workers CQC inspection in June . in assurance. Mandatory compliance to be considered (FH). Non-compliance with mandatory training . Quality Effectiveness & Safety Trigger Tool. Bands 1-4 . CCG announced inspections training compliance. Delivery of the New arrangements to support operation of Weaknesses in evidencing safe care in some Staff Friends and Family test data (STT). Incident reporting and risk management Well-led governance review July 2015. Audit DTOC target on a sustained basis MHLAC introduced October 2015 (FH). teams. Team level dashboards. systems. findings homicide action plan Director of Nursing to report to Quality Weaknesses in organisational learning from Mental health legislation training. Mortality and morbidity reviews. Governance Committee on effectiveness of incidents Ulysses incident reports. Safety thermometer. shared learning events (January 2015) Sign up to safety campaign. Monthly staffing report. CQC action plan October 2015 (FH) Escalation process for staffing issues in hours and out of hours Clinical audit programme. SUI Panels. Sign up to safety workstreams. Care planning and pressure ulcer dashboards

2 Our clinical standards, processes, Staff may deviate from these standards, Local induction. Policy Group . CQC inspection in June 2015. Timely review and sign off of policiesincluding 1) Implement action plans following internal guidelines and policies are available, processes, guidelines when planning or Supervision. Violence & Aggression Management Group Internal audit of policy process June 2015 audit arrangements audit (KE) October 2015. communicated, well designed and delivering care. Review of incidents and RCA's Security Management Group Independent reviews of serious untoward 2) Review arrangements for management of operate effectively. Inconsistent care pathways in mental health. Clinical Audit plan 2015/16. Integrated incidents through Serious Case Reviews or DHR policy database (KE) October 2015 Our DOLS practice may be non-compliant with corporate dashboard. Locaity and investigations Cheshire West judgement (#849). dashboards. Practice in providing s132 rights under the ClinicalPolicy Approval Group. Mental Health Act Code of Practice. Falls and PU RCA Panels and Serious Incident Weaknesses in safeguarding controls. Panel Delayed transfers of care numbers. Demands on the CAMHS service with capacity and leadership constraints.

3 Our CQC action plan has been Action plan not yet agreed. Specific CQC Monitoring implementation of local action Monthly reports to the Executive Quality and Six-weekly progress meetings with CQC Locality monitoring of progress against agreed Action plan to Board in November (FH). developed to address areas identified concerns re the Crisis Service, the MIU’s and plans Clinical Risk Group. Quarterly reports to the CQC action plan Commemcement of agreed reporting for improvement CAMHS Board. arrangements thereafter (FH)

4 Our quality governance arrangements Evidence of Trust learning from incidents could Regular communications with staff on the Nursing and Quality Directorate initiatives such CQC readiness assessment April 2015. Evidence that learning from incidents has Report to the Quality Governance Committee support the identification of learning be improved. quality priorities and progress against them as: safe & therapeutic staffing levels; integrated CQC inspection June 2015. improved following initiatives introduced in on action taken and impact of action taken to opportunities and track progress in including learning from incidents. personal care; improving responsiveness to Well Led Review July 2015 2015 improve learning from incidents. improvements. Positive incident reporting culture in the Trust patient and carer feedback; pressure ulcer Develop E-roster framework. Improved training incidence; care planning; use of restrictive for EPR systems. Establish interventions. Risk management standards of data quality and input and incident reporting systems are in place Develop user guide for use of EPR systems

5 Talented, motivated management Reporting processes for OD Strategy; Comms Integrated performance report. Exec Performance & Corporate Risk Group and Staff survey results March 15. Assurance over the extent to which internal Development and delivery of staff engagement teams effectively lead well engaged Strategy; HR Strategy to be embedded Leadership programmes. the Exec Quality & Clinical Risk Group . CQC inspection June 15. communications channels meet staff needs. plan in 2016/17 (NP) staff, wards and services to account Recruitment and Retention Group PMO reports on delivery of Annual Plan (SH) for performance.

6 Our medical devices and equipment Slow response to CAS alerts. Database for Verbal feedback from staff during walkarounds Monitoring reports on the effectiveness of the Internal Audit review of governance of medical Embedding of new approach to tracking CAS Monthly reports to the Executive Quality and (and mandatory training in how to use tracking training and maintence may not be up by Execs and NEDs. Medical Devices policy IN-132. devices & equipment. alerts. Clinical Risk Group on the new arrangements them) are registered, tracked, to date in each service Working Group review of CAS alerts system in for monitoring CAS alerts (FH). maintained and replaced in line with the Trust. Trust and manufacturers guidelines. Board Assurance Framework 2015-16 Date on which data valid: 15-Dec-15

Corporate objective no. 1 To provide high quality care; first time, every time. Risk description: Inadequate staffing levels. Caused by high rates of staff churn; unplanned absences; skill mix; inadequate workforce planning; insufficient workforce availability; failure to motivate, engage, retain talent. May result in inadequate patient experience; failure to protect patients and staff from harm ; adverse publicity; disruption to one or more locality; loss of stakeholder confidence, failure to comply with clinical standards with adverse regulatory action.

Range of outcomes Regulatory intervention to Trends in harm connected to Many services dependence Programmed use only of Over-recruiting talent Outcome trajectory RAG rating today's assurance Assurance oversight protect service users. unplanned clinical on irregular clinical staffing. locums, agency or bank. mitigates staff churn. Full position BAF risk no 2 Ulysses No: Scores Initial Today Acceptable workforce. establishment.

S x L 4 x 4 = 16 4 x 4 = 16 2 x 3 = 6 Quality Governance Risk owner SO'D; LB; EY Current position ↔ A • Committee

1 We collect and report staffing Recruitment challenges in some areas. Robustness Staffing of shifts monitored daily by shift leaders Nurse revalidation (April 2016). CQC inspection June 15 . Impact of recruitment and retention initiaitives. Monthly report to Board on recruitment and data daily to highlight of monitoring and reporting systems Monthly integrated performance reports . CQC unannounced inspections. CQC report has identfied issues in some services retention initiaives(CH). outstanding shifts requiring Daily report on e-rostering staff exceptions. CCG announced inspections at the time of their visit in June 2015. Capacity review of community teams cover and six monthly to Response to escalation alerts via Ulysses. Monthly Geographical and functional gaps in staffing CQC Quality Improvement Plan to the Committee support evidence based staffing staffing report to Executive Quality & Clinical Risk and Board on progress against recommendations decisions. group and six monthly to Board. Senior manasgers (FH, quarterly commencing January 2016) ward visits

2 We recruit proactively and Recrutiment and retention in some areas remains Recruitment response times. Recruitment and retention group. Board report on CQC inspection June 2015. Impact of the work of the recruitment and Continuation of monthly report to the Board on innovatively; we have retention a challenge. Leadership and other training programme recruitment and retention initiatives Staff Survey retention group. recruitment and retention initiatives (CH) Focused strategies to raise the calibre of Reliance on agency staff in a number of areas. attendance. Staff friends and family test Staff continue to be difficult to recruit to in some recruitment marketing campaign in first quarter of our staff and reduce churn and Over-recruitment in some areas. areas. 2016 (CH) vacancy rates. Enhanced Bank support to Trust. Introduction of retention premia in Prisons

3 We engage with our staff and Embedding of Reporting mechanism for OD Multiple channels of communication; Weekly Staff engagement events CQC inspection June 15 . Staff survey results. Quarterly progress reporting on the communicate via channels and Strategy; Comms Strategy; HR Strategy Comms Round Up. Staff Survey Information on the effectiveness of Communications, Organisational Development media which suits their Communication channels in the process of being '@DorsetHealth' Twitter communication channels. and Participation strategies (NP). Development of preferences. updated https://www.facebook.com/pages/Dorset- Regular reporting on levels of staff engagement effective reporting on staff engagement and HealthCare/270334029735263. organisational culture in 2016/17 (NP) The CEO communicates with staff regularly on a predictable time and platform. Leadrship development. Training in communication skills Team meetings, CEO briefings,drop ins; Exec 4 Our CQC action plan has been Action plan not yet agreed Monitoringlk b implementation f of local hl action plans Monthly reports to the Executive Quality and Six-weekly progress meetings with CQC Locality monitoring of progress against agreed Action plan to Board in November (FH). developed to address areas Clinical Risk Group. Quarterly reports to the CQC action plan Commemcement of agreed reporting identified for improvement Board. arrangements thereafter (FH) Board Assurance Framework 2015-16 Date on which data valid: 15-Dec-15

Corporate objective no. 4 To have a skilled, diverse and caring workforce who are proud to work for Dorset Healthcare. Ineffective clinical leadership across some services. BAF risk no Ulysses No: Caused by change programmes; uncertainty; failure to recruit, retain and develop clinical leaders. 2 May result in a lack of clinical leadership; harm to patients or staff, disruption to one or more Localities, extended service closure.

Range of outcomes Unsustainable services Deflection of activity to Emergence of hard to Declining trend in clinical Full clinical Outcome trajectory RAG rating today's Assurance oversight BAF risk no 5 Scores Initial Today Acceptable neighbours recruit to clinical vacancy rates establishment assurance position 5 positions S x L 4 x 3 = 12 4 x 4 = 16 2 x 3 = 6 Quality Governance Risk owner NK; FH; CH Current position • ↔ A Committee

1 Trust clinical leadership Model of clinical leadership not yet Locality management structure in place. Leadership programmes. MoU with Bournemouth University re Review of locality structure Embedding of clinical leadership structure structure. agreed. Model of clinical leadership agreed. Quality assurance visits. Mental Health and Health Visitor implementation. (NK). Portfolio management arrangements not Incident reporting trends Nursing Strategy. programme. fully embedded. monitored/reported. Triangulation of performance data. CQC inspection June 2015 Ineffective service delivery in some HR framework in place. Integrated corporate dashboard. Well Led review July 2015 areas. CCIOs appointed to promote clinical Clinical strategy . Coroners' Reports. Development and implementation of engagement in issues around IT and Trust Clinical Executive. Serious Case Reviews. Trust Clinical Executive Information Management. Psychiatric Medical Staff Meetings. Department of community medicine set up Clinical Executive meetings commenced January 2016

2 Quarterly Leadership Forum Medical representation on the Forum is Upto 70 leaders attend. Forum meets quarterly to discuss CQC routine inspection reports. Improved Medical engagement in the Medical Director and Director of OD to low. Feedback from attendees about usefulness strategically important initiatives-outcome CQC inspection June 2015. Forum required. review scope to encourage further clinical of the Forum of these events Well Led review July 2015. engagement (January 2016) (NK/NP).

3 Multi-disciplinary team and Teams are at different stages of MDT meeting minutes. Access to peer, regional and national CQC unnanounced inspection reports. Planned programme to develop MDT None partnership working development in their approach to MDT Development of new models of working in development programmes eg Thames Stakeholder feedback. working effectiveness. arrangements working. Bridport, Weymouth and Portland Valley & Wessex Leadership Academy Safeguarding Board reports, Health & Planned developments to improve Professional conversation. prrogrammes. Wellbeing Board reports. parttnership working. Quality metrics. Coaching network CCG contractual arrangements. Progress in developing integrated teams. Ofsted reports. New service developments and Serious case reviews. innovations. Independent Homicide Reviews. 4 Our CQC action plan has been Action plan not yet agreed Monitoring implementation of local action Monthly reports to the Executive Quality Six-weekly progress meetings with CQC Locality monitoring of progress against Action plan to Board in January 2016(FH). developed to address areas plans and Clinical Risk Group. Quarterly reports agreed CQC action plan Commemcement of agreed reporting identified for improvement to the Board. arrangements thereafter (FH) Board Assurance Framework 2015-16 Date on which data valid: 15-Dec-15

Corporate objective no. 5 To be a national leader in the delivery of integrated care. Risk description: Locality governance Caused by failures to agree, communicate and work according to an effective system of locality governance or failures to identify and report on relevant smart performance data. May result in harm ; adverse publicity; disruption to one or more localities or extended service closure.

Range of outcomes Universally weak Little evidence of any Mixed strength and Some evidence of Exemplar integrated Outcome trajectory RAG rating today's Assurance oversight BAF risk no Ulysses No: Scores Initial Today Acceptable Locality exemplar services. weaknesses within exemplar services. services across all assurance position 4 performance. Localities. Localities. S x L 4 x 4 = 16 4 x 4 = 16 2 x 4 = 8 Quality Governance Risk owner SO'D; LB; EY Current position • ↔ A Committee

1 Mental Health and community Transitional period where senior Effective locality governance Service dashboards eg CAMHS. CQC inspection in June 2015. CQC action plan, to be prepared Internal audit review of locality services are arranged and managed managers aleading across new evidenced in improvements in care; DMG's. Well-Led assessment July 2015. following publication of the governance 2016 (JC). through integrated structures. service areas, where their knowledge improved outcomes; improved Monthly quality/performance inspection report, will identify areas Quarterly reporting to the Board on is shallower; they may be less well clinical effectiveness and patient meetings with Locality Managers to be addressed. CQC action plan implementation (FH). able to identify risk and signs of experience identifiable in the Clinical leadership structure to be Consider scope for extending failure. Gaps in integrated performance report. embedded. dashboards for services split into the leadership structure Training to ensure locality managers Further assurance is required that the locality structure (LB). Specifically, loss of experienced Team have a common understanding of leadership and management capacity Review of locality structure one year leader capacity and capability in the service requirements and that the Trust has in place for the on (RS/Locality Directors) (January CAMHS service may impact on the expectations. locality model is sufficient to deliver 2016). Well-Led recommendation to ability to deliver the transformation Appointment of a strategic CAMHS the Trust's agenda. be taken forward-the Board programme. advisor to take forward the incorporate Locality performance into transformation programme. the dashboard for comparable Internal communications and indicators of quality; extend use of engagement processes (see clinical benchmarking, where elsewhere on BAF) appropriate (JC)

2 Our CQC action plan has been Action plan to be agreed Monitoring implementation of local Monthly reports to the Executive Six-weekly progress meetings with Arrangements for Locality monitoring Action plan to Board in January 2016 developed to address areas identified action plans Quality and Clinical Risk Group. CQC of progress against agreed CQC action (FH). Commemcement of agreed for improvement Quarterly reports to the Board. plan reporting arrangements thereafter (FH)

3 Incident reporting, risk management There is less evidence of learning There is a positive incident reporting Risk management policy approved CQC inspection June 2015. Implementation and effectivenessof Review of the operation of the two practice, escalation frameworks and across the organisation from and raising concern culture . with a 12 month programme of Well Led Review July 2015. risk training programme. Extent to Executive groups following the Well- performance management. incidents. Incident management and support has been developed for 15- which the risk management process Led review (RS/FH/NK/KE). Review of investigation is udertaken effectively 16; Executive group review of risks is understood and implemented at all locality structure one year on scoring 10+ . Roadshow and levels across the system. (RS/Locality Directors) (January 2016) enagement events to broaden understanding from incidents.

4 Trust clinical leadership structure. There are gaps in management Locality management structure is Engagement of clinicians in Executive CQC inspection June 2015. There may be knowledge gaps in First meeting of Clinical Executive to structure and leadership now in place. groups and the Clinical Executive Well Led Review July 2015. locality management structure as be held (January 2016) (RS). development needs resulting in Trends in incident reporting are managers now manage portfolios and Appointment & Remuneration leadership weaknesses. triangulated with Localities. are less likely to be subject matter Committee consideration of There may be insufficient leaders in experts. succession planning (January 2016). some specialisms. Succession planning arreangements. Review of locality structure one year Clinical leadership structure not yet on (RS/Locality Directors) (January embedded 2016) Board Assurance Framework 2015-16 Date on which data valid: 14-Dec-15

Corporate objective no. 6 To ensure that all of the Trust’s resources are used in an efficient and sustainable way. Risk description: The financial challenge. Caused by lack of budgetary control, lack of resilience on CIP programme development; failure to capitalise on commissioners' discretionary payment schemes and uncertainty over the longer-term financial sustainability of the Trust. May result in variances from plan in excess of £1M; adverse publicity and regulatory action and future restructuring of the Trust to ensure the continued viability of services..

Range of outcomes Special Administration In turnaround >1% variance to <1% variance to <0.3% variance to Outcome trajectory RAG rating today's Assurance oversight BAF risk no planned outturn & CIP planned outturn & CIP planned outturn; CIP assurance position Ulysses No: Scores Initial Today Acceptable 3 target missed target achieved met; surplus materially materially generated.

S x L 4 x 4 = 16 4 x 4 = 16 2 x 4 = 8 Risk owner JC Current position • ↔ R Audit Committee

1 Budgetary control and Financial performance is off plan. Key Monthly finance, workforce and Monthly reports to the Executive Internal and external audit review Year end forecast at November Monthly reporting to Board (JC). reporting areas are: Prisons, MH inpatient pay, agency performance reports at Performance and Corporate Risk financial systems annually. 2015 off plan. Remedial actions Continued implementation of Medical Staffing and Out of Area. cost centre level and to localities. Group and to the Board. Monthly reporting to Monitor, agreed but further action required plans for recruitment, workforce Key drivers are: difficulty in recruitment, Board has agreed structure for quarterly feedback. to close the gap to plan. management and reduction in use sickness absence and high use of

agency/locum. monitoring financial performance of agency/locum (CLH/Locality under five headings Directors).

2 Cost improvement programme Forecast under-delivery of 2015/16 Monthly reporting of individual PMO oversight and monthly Well-Led review July 2015. Internal Plan to deliver £6.1m 2015/16 Report to Board on action to governance via the PMO CIP programme. project progress reporting to the Executive audit review of 2015/16 CIP in programme. deliver 2016/17 CIP target (JC). Annual programme developed at Perfomance and Corporate Risk December 2015 Robustness of planning for 2016/17 Develop plan to address internal too late a stage each year Group plan audit recommendations (JC) 3 Nursing and Quality Regular CQUIN performance Monthly reporting of individual PMO oversight and monthly report None Embedding of monthly CQUIN Quarterly update in Finance and Directorate oversight of CQUIN reporting only recently CQUIN scheme. to Executive Performance and reporting process. dashboard reports to the Board scheme commenced Corporate Risk Group (JC)

4 Capital planning and allocation. Robustness of process to ensure no Individual project reporting Monthly meetings of the Capital None Capital planning, control and Internal audit of capital 2015/16. underspends Investment Group reporting audit not undertaken in Major capital investment strategy previous year. to Board in January 2016 (SH). Absence of a major capital investment strategy. 5 Effective planning to mitigate Medium to long term financial Monitoring of in-year financial Reports to Board on financial Monitor review of Trust Annual Financial viability of the Trust Annual strategy and financial the financial challenge in future viability of Trust. performance and forecasting. Long- performance and forecasting. Plan. towards the end of the five year budgeting cycle with reporting to years Robustness of annual financial term CIP and investment planning. Annual financial planning cycle Sustainability and Transformation planning cycle and impact of CSR the Board to support effective planning process Development of the out-of-hospital Plan forecasting, strategy development Impact of Clinical services Review model and planning (SH). Board Assurance Framework 2015-16 Date on which data valid: 15-Dec-15

Corporate objective no. To be a valued partner and expert in partnership working with patients, communities and organisations. Risk description: Lack of resilience. Caused by a failure to integrate services with Local Authority social care and other partners and to influence the outcomes of Better Together, Dorset CCG Review in the interests of the Trust's patients. May result in disruption to one or more localities or service loss / closure.

Range of Universally weak Little evidence of Inability to Some evidence of Universally strong Outcome trajectory RAG rating Assurance BAF risk outcomes integration and any exemplar recover quickly exemplar integration and today's assurance oversight Ulysses No: Scores Initial Today Acceptable no 6 competitive services. from shocks. services. competitive advantage. position disadvantage. Risk S x L 3 x 4 = 12 4 x 4 = 16 3 x 3 = 9 Audit Committee SH Current position • ↔ A owner

Main Control description Gaps in control Assurance from first line of defence Assurance from second line of Assurance from third line of defence Gaps in assurance position Further action or assurance required controls 1- (front line evidence) defence (independent evidence) by committee / Board, with dates 6 (management evidence)

1 A formal process of Metrics to measure the Vision and purpose Monthly reporting to Board Monitor assessment of the Complete implementation of the Report to Board early 2016 strategic planning, which delivery of the plan agreed cascaded to all staff. on Annual Plan Annual Plan 2016. Stages of Excellence Model. on Stages of Excellence builds on Monitor's September 2015 but now Ongoing staff engagement deliverables. Stage of CQC inspection June 2015. Annual Plan 2016/17 to be agreed implementation (SH). Draft guidance, has been used to need to be implemented. programme re vision and Execellence model being Well Led Review July 2015. Annual Plan to vbe develop a strategic vision, values. implemented submitted to january purpose, goals and metrics. Strategic goals agreed. 2016/17 Board (SH) Strategic goals agreed. Programme developed for 2016/17 annual plan 2 Activity which optimises CCG's are tendering Working in partnership with Key stakeholders were CQC inspection June 2015. Business intelligence function to be Establishment of the our relationships with services the Trust provides GP's at locality level. identified in the Blueprint. Well-Led review July 2015. established. business intelligence external stakeholders inc which could result in the Engagement with GP's Quarterly reporting to Investment in communications function (SH). commissioners and other loss of services despite the during the establishment of Board on engagement team to be completed. Development and GPs relationships that have Federations strategy investment in the been established. communications and engagement team (NP).

3 The Trust's approach to / Ambition of acute trusts to Full involvement of Trust Reports to Board on CSR. Out of hospital model Agreement on Trust model of out of Out of hospital model to be engagement in Better deliver out of hospital care. staff in GP workstreams. Board approval of out of agreed for inclusion in CSR. hospital care. approved by the Board (S Together , Dorset CCG Timing of CSR unclear. Trust taking lead in hospital model Trust contribution to Completion of sustainability and O'D). Continuation of Clinical Services Review, Out of hospital model of development of out of sustainability and tranformation plan engagement with GP's and sustainability and care to be agreed hospital model of care transformation plan agreed GP Federation (Executive) transformation plan and GP commissioning of services is to be open, transparent and patient focussed. Agenda Item

Monitor Quarterly Return for Month 9, December 2015 Part 1 Board Meeting 27 January 2016

Author Associate Director of Finance and Director of Nursing & Quality Sponsoring Board Member Director of Finance Purpose of Report The Trust’s Quarter 3 submission and associated declarations are due to be submitted to Monitor on Friday 29th January.

The proposed Q3 narrative includes exception reporting in respect of financial elements, compliance, Governors, Board changes and any other items which Monitor should be advised of.

Also included are:  Appendix A – Summary Financials  Appendix B – Targets and Indicators  Appendix C – Governance Statements  Appendix D - Workforce

Although based on the same source of data as the monthly Finance Report to the Trust Board, the outputs reported in the Monitor monthly and quarterly returns differ to the outputs reported in the Board report. The reasons for difference are summarised in the table below.

The Trust received a letter on 15 January setting out action to be taken in respect of 2015/16. This is referred to in paragraph 1.8.

Regarding our internal reporting process, and assurance of the data quality for these two different financial requests, it should be noted that:  Both the Monitor performance position and the Trust reported position can be found in Appendix 1 of the Finance Report.  Accuracy of the Monitor returns is tested via the regular Financial Accounting audit carried out by our Internal Auditors.

Monitor Return Board Report Plan Fixed per early Apr Live and moving, to aid submission management control of budgets

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Profiling Reflective of prior Budgets are specific and year profile at the detailed to each service highest level – and cost centre reflecting Income received the year in question as evenly and new items arise expenditure rising through the year Reported Trust wide By service / locality Categories expenditure by category e.g. Pay, Drugs, Clinical Supplies, agency

Recommendation Governance Statements (Appendix C) The Board is required to submit an in Year Governance declaration which requires a response of ‘confirm’ or ‘not confirm’ to the following statements. The recommended responses are:

For Finance that: The Board anticipates that the Trust will continue to maintain a financial sustainability risk rating of at least 3 over the next 12 months – Not Confirmed (see section 3.17)

The Board anticipates that the Trust’s capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return - Confirmed

For Governance, that: The Board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards – Confirmed

Otherwise: The Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework Table 3) which have not already been reported – Confirmed

 The Board is asked to consider and agree the proposed Quarter 3 submission.

Engagement and Involvement . The Contents of the report are collated from a number of sources including the Finance Directorate, the Nursing and Quality Directorate and the Corporate Directorate. Previous Board/Committee Executive Performance and Corporate Risk Group Dates 19 January 2016.

Board of Directors March 2015 2 | P a g e

Agenda Item

Monitoring and Assurance Summary

This report links to the . To provide high quality care; first time, every time; Strategic Goals . To be a valued partner and expert in partnership working with Patients, Communities and organisations; . To ensure that all of the Trust’s resources are used in an efficient and sustainable way; . To raise awareness within the Trust and externally of the impact that our work has on people and our environment, and take steps to reduce any negative effects. I confirm that I have considered each of Any action required? the implications of this report, on each of Yes the matters below, as indicated: Yes No Detail in report All three Domains of Quality   Board Assurance Framework   Risk Register   Legal / Regulatory   People / Staff   Financial / Value for Money / Sustainability   Information Management &Technology   Equality Impact Assessment   Freedom of Information  

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Monitor Financial Monitoring Narrative Quarter 3 2015/16

1.0 Income & Expenditure (I&E) Position

1.1 The Quarter 3 Income & Expenditure position is a £212k surplus which is a variance of £229k from our Q3 planned surplus of £441k. The Board continues to be committed to achieving the financial plan for the year. The mitigating actions the Executive is taking are yielding results.

1.2 ‘NHS Clinical Income’ is ahead of plan for the Quarter by £1,133k. The main variations are:  £400k additional income for opening of winter pressure ward  £906k other contract variations  (£218k) income behind plan regarding Flaghead inpatient Detox Service where the unit has closed after becoming financially unsustainable following a change in commissioning arrangements

1.3 ‘Employee Expenses’ are lower than plan for Quarter 3 by £412k, most significantly for the following reasons:  £3,888k general operational pay underspends being driven by vacancies, offset by:  (£1,577k) agency costs above that planned  (£1,150k) increased costs associated with new contract variations (section 1.2 refers)  (£670k) pay CIP behind plan  (£271k) continued use of Canford ward, temporarily opened to address winter pressures – the cost is offset by additional income received from commissioners (section 1.2 refers).

1.4 ‘Clinical Supplies and Services Expenses’ are lower than plan for Quarter 3 by £381k. This is mainly due to the phasing effect of costs being incurred earlier in the year (and now reducing) in respect of Medical & Surgical equipment & supplies and wheelchair costs.

1.5 ‘Other Operating Expenses within EBITDA’ are lower than plan for Quarter 3 by £793k most significantly for the following reasons:

 £515k non-pay CIP savings higher than plan  £837k telephone and travel costs being lower than plan for the quarter, offsetting the previous quarters reported overspends in these areas (net variance YTD minimal and resulting from phasing within the Plan assuming that all non-pay spend is lower at the beginning of the year and increasing in the later part of the year)  £124k investments behind planned profile, offset by:  (£312k) of costs associated with purchasing healthcare including placing Mental Health patients out of the area  (£287k) increased costs associated with new contract variations (section 1.2 refers)  (£117k) continued use of Canford ward temporarily opened to address winter pressures – this cost is offset by additional income from commissioners (section 1.2 refers)

1.6 CIP of £330k has been achieved in Quarter 3. YTD the CIP is £155k behind plan. The CIP is forecast to underachieve by £879k.

1.7 The Trust’s forecast outturn at Month 9 is £2.5m deficit, which is £0.3m behind plan. The forecast outturn includes unallocated £1.2m contingency funding and £0.5m severance funding. The Executive are continuing with actions to deliver the plan and identify further areas for recovery.

1.8 Following the letter from NHS Improvement dated 15 January 2016, the suggested opportunities to be considered as part of 2015/16 recovery and the outcome of our review are set out below. NHS Improvement is seeking from Trusts the value of action taken in respect of each of these. The items referred to are part of the normal Trust budget process and it is not possible, in most cases, to attribute a value to the action.

Item Assessment Local Capital to Revenue The overall level of capital expenditure, and the Transfers programme agreed for the year, was set to address identified areas for improvement in facilities for patients and staff. The Board considered that any deferral of projects would, therefore, at best delay the improvements anticipated from the investment. The Board concluded that, in the light of this and the forecast level of expenditure, it would not participate in the capital to revenue transfer scheme Accurate monthly capital Our capital programme progress and forecast outturn forecasting is reviewed monthly. £0.5m underspend is currently forecast for the year end. Other priority schemes, which could not be met from within the capital resources available for the year, are now under review for completion in 2015/16. Accurate provision reporting Provisions are reviewed regularly. Impacts to the I&E are already included in our forecast outturn. Workforce – no non-medical We do not provide cover for short term sickness as a agency cover for short term matter of routine. Patient acuity and numbers are sickness considered. Staff work flexibly and there is clear process before engagement of agency staff. Agency staffing – Full The Trust is engaged in a considerable work compliance programme to reduce agency expenditure. This includes focus on reducing the number of shifts above rate cap and bringing our nursing agency spend down in line with our trajectory to meet the nursing agency ceiling, alongside strengthening our internal bank and recruitment and retention initiatives. Reductions in costs to date have been reflected in our forecast outturn. We are hopeful that we will see further financial improvement in this area in the last Quarter. Reviewing in-year priorities We have addressed cost control, efficiencies and reviewed & ceased appropriate investments in order to recover our forecast outturn down to the current position. Balance sheet review: We have reviewed our accruals and deferred income prudence and believe that they are appropriate. We review our accruals monthly. Bad debt provisions Bad debt provisions are reviewed monthly to ensure

they are appropriate VAT changes VAT reclaims are regularly reviewed by appointed VAT advisors. The latest review has identified a VAT rebate of c£80k which will improve our forecast position. Annual Leave – manage the Trust policy is that all annual leave should be used by carry forward and ensure the end of the financial year, with only a maximum of 5 data used for calculations is days remaining as unbooked at 31st December. Up to robust 5 days can be carried over in exceptional circumstances. Calculations for the value of annual leave carried over is based on data collected from each budget manager at the year end. Asset valuations – revalue at Our assets are currently valued at modern equivalent modern equivalent asset asset value. We have had a full revaluation in value using alternative site preparation for the year end. Alternative sites have method where appropriate been considered for each site as part of the valuation. Asset lives review Asset lives are reviewed by the District Valuer as part of their inspection of individual sites.

2.0 Statement of Financial Position (Balance Sheet)

2.1 The forecast cash balance was £24.6m for the end of December. The actual cash balance was £18.6m, £6m below plan. The main reasons are set out below.

£’m

Forecast cash 24.6

The expected surplus is above plan 0.1

NHS trade receivables including NHS accrued income are (5.4) above plan. Payments are expected in Q4 as in year contract variations are signed off and invoices settled. Capital movements are below plan 0.3

Proceeds on disposals are below plan (2.6)

Other receivables are above plan (0.9)

Provisions are above plan (0.4)

NHS trade payables are above plan 0.5

Other payables are above plan 2.4

1 December 2015 actual cash 18.6

3.0 Monitor Governance Compliance

3.1 This section of the report will address reports and outcomes for the period October - December 2015 (Q3) in five areas namely CQC compliance, including unannounced CQC Mental Health Act Inspections; Independent Inquiries; Coroner’s Regulation 28 Reports; Internal Audit Reports and reporting against Monitor targets.

Care Quality Commission Enforcement Action

3.2 As reported in Q2 the Trust has no enforcement actions outstanding.

Care Quality Commission Compliance Inspections (covers the period Q3 into Q4)

3.3 The CQC have undertaken two thematic inspections of the Trust during Q3:

 End of Life Care - 19 October 2015  Safeguarding Children and Looked After Children (Dorset) - 16 November 2015

3.4 The draft Safeguarding Children and Looked After Children inspection report has been shared for factual accuracy and the final report is yet to be published. The Trust is meeting with Dorset CCG on 22 January to review the draft report and to consider the actions required to meet the recommendations emerging.

3.5 The Trust has not yet received the draft End of Life report and has asked CQC when the report is likely to be available.

3.6 The Targets and Indicators sheet within the Financial Template has been completed as follows based on the items listed in the Rationale column.

INDICATOR RESPONSE RATIONALE Risk of, or actual, failure to No No change in risk factors deliver mandatory services CQC Compliance action Yes The 17 reports resulting from the outstanding (as at time of comprehensive inspection undertaken in submission) June were published on 16 October 2015. The Trust has developed action plans to address the findings of this inspection. CQC enforcement action within No last 12 months (as at time of submission) CQC enforcement action No (including notices) currently in effect (as at time of submission) Moderate CQC concerns or Yes The suite of reports identify 58 ‘must do’ impacts regarding safety of actions – these have been developed healthcare provision (as at into a formal action plan and shared with time of submission) CQC.

Major CQC Concerns or No There are currently no outstanding major impacts regarding the safety of impact findings. healthcare provision (as at The CQC have not taken any time of submission) enforcement action against the Trust.

Trust unable to declare Yes The reports have identified breaches in

INDICATOR RESPONSE RATIONALE ongoing compliance with regulations however these have not minimum standards of CQC resulted in any enforcement action being registration taken against the Trust.

CQC Mental Health Act Inspections

3.7 On 6 November the Trust received 6 Mental Health Act Monitoring Visit reports for sites that were inspected as part of the comprehensive inspection undertaken in June 2015. The provider action statements were submitted by the deadline of 26 November 2015.

3.8 The reports were received for the following sites;

 Alumhurst Ward, St Ann’s Hospital  Dudsbury Ward, St Ann’s Hospital  Nightingale House, Alumhurst Road  Pebble Lodge, Alumhurst Road  Twynham Ward, St Ann’s Hospital  Waterston Ward, Forston Clinic

3.9 The reports noted where actions previously identified had been addressed and the improvements with care plans and electronic records. Other improvements noted were;  the IMHA being involved with patients and  a weekly ‘drop in surgery’;  leave of absence was well recorded on the electronic patient records with evidence of risk assessment before leave was granted and patient signatures, indicating they had been offered copies.

3.10 Patients spoken with reported that they felt nursing staff were kind and caring towards them. They were positive about the treatment they were receiving and that they had their s132 rights explained to them.

3.11 The young people at Pebble Lodge spoke positively about the Quay School which was rated by OFSTED as outstanding, and said that they enjoyed the range of subjects on offer.

3.12 The recommendations included providing lockable space in patients’ rooms, a review of the smoking breaks to ensure these did not constitute a blanket restriction, ensuring that patient’s own views and words can be incorporated more fully into care planning records

Independent Inquiries

3.13 As previously reported, the Trust received the draft report from HASCAS during Quarter 2 and has fed back on factual accuracy. A workshop was facilitated by HASCAS on 12 August 2015 to review the lessons for learning and consider appropriate recommendations arising from the report findings

3.14 The Trust will be attending a HASCAS Pre Publication Meeting with the CCG scheduled for 1st February 2016.

Coroner’s Regulation 28 Reports

3.15 No Coroner’s Regulation 28 reports have been received during Quarter 3.

Internal Audit Reports and Progress

3.16 In Quarter 3 the Trust has received one internal audit report with findings of limited assurance for the Cost Improvement Programme. One action implemented has been to amend the finance report to include a traffic light assessment of stage of projects and recurrent/non-recurrent impact. The report will also highlight exceptions in the executive summary.

Monitor Targets

3.17 With regard to the compliance statement "The board anticipates that the Trust will continue to maintain a financial sustainability risk rating of at least 3 over the next 12 months” declaration, whilst our risk rating is expected to be at least 3 for the remainder of this year, the current uncertainty of what level of income for 2016/17 is available to the Trust means we are unable to confirm that a FSRR 3 would be maintained.

Delayed Transfers

3.18 Although the Trust has sustained compliance with this indicator for Quarter 3 (7.4% against a target of 7.5%), this has increased since the Quarter 2 outturn position of 5.8%. As noted in the Quarter 2 narrative, it was anticipated that there would be an increase in the percentage of delayed days due to Winter pressures. The actual December position is in excess of target at 9.65%. Winter pressures have impacted most significantly during the month of December, due to staffing shortages in local brokerage services and care homes during the holiday period. Homes have been reluctant to assess clients on the wards or accept new admissions during this period, especially over the Christmas and New Year weeks. There will be close monitoring during January in order to aim to recover the position back within target. 3.19 Local Authorities have received some additional funding support to manage Winter Pressures and the Trust has been working closely with Local Authorities as to how these funds can be used. In some instances this has included being able to place clients in homes beyond usual funding limits to try and maintain discharge rates from hospital during winter months and free up bed capacity. 3.20 The Quarter 2 narrative also reported concerns that one of the key nursing home providers catering for clients with complex and challenging behaviours in dementia had a safeguarding block meaning they could accept no new admissions. There has been some progress with the home meeting quality standards set by the Local Authority Safeguarding Teams and CQC, however the home continues to have restrictions placed upon it. This includes only being able to accept three new clients per month. In addition it is anticipated based on the findings of the safeguarding investigations that the home will no longer market itself as a specialist home in meeting the needs of more challenging clients who often make up the patient group within the Trust’s inpatient dementia services. This further limits the number of locally available homes that the Trust is able to discharge clients to and concerns therefore remain about

availability of specialist residential and nursing home placements, in particular those that can offer safer arm holds. This remains one of the key barriers to timely discharges for the Trust.

Clostridium Difficile

3.21 In Quarter 3 there was 1 case of clostridium difficile identified within our services, bringing a total of 12 cases. There was found to be no lapse in care in this case. The Trust C Diff action plan has been shared and discussed with Monitor during a teleconference on 15 December. There have been no further cases since October.

4.0 Trust Membership

4.1 As at the end of the Quarter 3 2015/16 the total membership stands at 11,067.

Staff 6,553 Public 4,514 Total Members 11,067

5.0 Governors and Board Changes

Board

5.1 There have been no changes to Board membership in the last quarter.

5.2 The Board membership at the end of Quarter 3 was:

Non – Executive Directors Ann Abraham – Chair Lynne Hunt – Deputy Chair David Brook – NED Dr. John Hughes – NED John McBride – NED Sarah Murray – NED Peter Rawlinson - NED Nick Yeo – NED Executive Directors Ron Shields – Chief Executive Jackie Chai – Director of Finance Colin Hague – Director of Human Resources Fiona Haughey – Director of Nursing and Quality Dr. Nick Kosky– Medical Director Associate Directors Linda Boland – Director Poole / East Dorset Locality Steve Hubbard – Director of Strategy and Business Development Sally O’Donnell – Director Dorset Locality Nicola Plumb – Director for Organisational Development, Participation and Corporate Affairs Eugine Yafele – Director Bournemouth / Christchurch Locality

Governors

5.3 There were no Governor resignations during Quarter 3.

5.4 Elections were held in the Bournemouth constituency (where no candidates came forward) and in the Dorset / Rest of England Constituency during November. Two Governors were elected

Name Constituency Effective Date Jan Turnbull Public Governor, 9 December 2015 Dorset/Rest of England & Wales Constituency Justine McGuinness Public Governor, 9 December 2015 Dorset/Rest of England & Wales Constituency

5.5 There are two vacancies for Public Governors on the Council (both in the Bournemouth Constituency). The electoral process will commence shortly to fill these vacancies. The nomination of the local government Partner Governor for Bournemouth Borough Council is awaited.

5.6 Chris Balfe, Lead Governor can be contacted through the Trust Chair Personal Assistant, [email protected]

5.7 The composite list of Governors at the end of Quarter 3 is as follows:

Public Governor Poole Constituency Sue Evans-Thomas Public Governor Poole Constituency Patricia Scott Public Governor Poole Constituency Anna Webb Public Governor Bournemouth Constituency John Bruce Public Governor Bournemouth Constituency Vacant Public Governor Bournemouth Constituency Vacant Public Governor Dorset/Rest of England & Chris Balfe (Lead Wales Constituency Governor) Public Governor Dorset/Rest of England & Scottie Gregory Wales Constituency Public Governor Dorset/Rest of England & Sue Howshall Wales Constituency Public Governor Dorset/Rest of England & Justine McGuinness Wales Constituency Public Governor Dorset/Rest of England & Jan Owens Wales Constituency Public Governor Dorset/Rest of England & Guy Patterson Wales Constituency Public Governor Dorset/Rest of England & Angela Reed Wales Constituency Public Governor Dorset/Rest of England & Jan Turnbull Wales Constituency Staff Governor Angela Bartlett Staff Governor Steve Clark Staff Governor Pat Cooper Staff Governor Peter Kelsall Staff Governor Teresa North Local Government Dorset District Councils Bill Batty Smith Local Government Dorset County Council Michael Bevan Local Government Bournemouth Borough Vacant Council Local Government Poole Borough Council Vishal Gupta

Partnership Governor Bournemouth University Karen Parker Partnership Governor Dorset Police and The Simon Thorneycroft Prison Service Partnership Governor Third sector organisations Vacant Partnership Governor Service user, voluntary and Becky Aldridge carer groups

Click to go to index Summary of Financial Statements for Dorset Healthcare University NHS Foundation Trust

Adjusted Forecast Audited For Plan For Actual For Variance For Plan For Actual For Variance For Plan For Simple Forecast Forecast Variance units sense PrevYE ending Month ending Month ending Month ending YTD ending YTD ending YTD ending Year ending Year ending Year ending Year ending 31-Mar-15 31-Dec-15 31-Dec-15 31-Dec-15 31-Dec-15 31-Dec-15 31-Dec-15 31-Mar-16 31-Mar-16 31-Mar-16 31-Mar-16

Summary Income and Expenditure Account

Operating income (inc in EBITDA) NHS Clinical income £m (+ve) 231.059 19.533 20.282 0.749 175.778 178.995 3.216 234.371 237.587 238.364 3.993 Non-NHS Clinical income £m (+ve) 4.519 0.246 0.325 0.078 2.771 3.506 0.735 3.706 4.442 4.663 0.957 Non-Clinical income £m (+ve) 9.406 0.605 0.669 0.064 6.550 5.958 (0.593) 8.200 7.607 8.023 (0.177) Total £m 244.985 20.384 21.275 0.891 185.100 188.459 3.359 246.277 249.636 251.050 4.773

Operating expenses (inc in EBITDA) Employee expense £m (-ve) (176.023) (15.374) (15.270) 0.104 (135.051) (136.764) (1.712) (180.719) (182.432) (183.900) (3.181) Non-Pay expense £m (-ve) (59.232) (5.450) (4.785) 0.664 (40.848) (42.947) (2.099) (55.269) (57.368) (57.292) (2.023) PFI / LIFT expense £m (-ve) ------Total £m (235.256) (20.824) (20.055) 0.768 (175.900) (179.711) (3.811) (235.989) (239.800) (241.193) (5.204)

EBITDA £m 9.729 (0.440) 1.220 1.659 9.200 8.748 (0.452) 10.288 9.836 9.857 (0.431) EBITDA Margin % % 3.97% (2.16%) 5.73% 7.89% 4.97% 4.64% (0.33%) 4.18% 3.94% 3.93% (0.30%)

Operating income (exc from EBITDA) Donations and Grants for PPE and intangible assets £m (+ve) 0.624 - 0.043 0.043 - 0.317 0.317 - 0.317 0.463 0.463

Operating expenses (exc from EBITDA) Depreciation & Amortisation £m (-ve) (6.868) (0.641) (0.640) 0.001 (5.769) (5.565) 0.204 (7.692) (7.488) (7.524) 0.168 Impairment (Losses) / Reversals £m (+/-ve) (0.955) ------(0.615) (0.615) (1.277) (0.662) Restructuring costs £m (-ve) ------Total £m (7.823) (0.641) (0.640) 0.001 (5.769) (5.565) 0.204 (8.307) (8.103) (8.801) (0.494)

Non-operating income Finance income £m (+ve) 0.133 0.006 0.007 0.001 0.049 0.091 0.041 0.066 0.107 0.107 0.041 Gain / (Losses) on asset disposals £m (+/-ve) 0.116 0.463 0.000 (0.463) 0.463 0.035 (0.428) 0.463 0.035 0.465 0.002 Gain on transfers by absorption £m (+ve) - - 0.099 0.099 - 0.099 0.099 - 0.099 0.099 0.099 Other non - operating income £m (+ve) ------Total £m 0.249 0.469 0.107 (0.362) 0.512 0.225 (0.288) 0.529 0.241 0.671 0.143

Non-operating expenses Interest expense (non-PFI / LIFT) £m (-ve) (0.034) (0.001) 0.000 0.001 (0.003) (0.000) 0.003 (0.005) (0.002) (0.000) 0.004 Interest expense (PFI / LIFT) £m (-ve) ------PDC expense £m (-ve) (4.282) (0.389) (0.388) 0.001 (3.495) (3.495) 0.000 (4.660) (4.660) (4.660) - Other finance costs £m (-ve) (0.010) (0.001) (0.002) (0.001) (0.004) (0.017) (0.013) (0.006) (0.019) (0.022) (0.017) Non-operating PFI costs (e.g. contingent rent) £m (-ve) ------Losses on transfers by absorption £m (-ve) ------Other non-operating expenses (including tax) £m (-ve) ------Total £m (4.326) (0.392) (0.391) 0.001 (3.503) (3.513) (0.010) (4.671) (4.681) (4.683) (0.013)

Surplus / (Deficit) after tax £m (1.547) (1.003) 0.339 1.342 0.441 0.212 (0.229) (2.160) (2.389) (2.493) (0.332)

Profit/(loss) from discontinued Operations, Net of Tax £m (+/-ve) ------

Surplus / (Deficit) after tax from Continuing Operations £m (1.547) (1.003) 0.339 1.342 0.441 0.212 (0.229) (2.160) (2.389) (2.493) (0.332)

Memorandum Lines:

Surplus / (Deficit) before impairments and transfers £m (0.592) (1.003) 0.239 1.242 0.441 0.112 (0.328) (1.545) (1.874) (1.316) 0.230

One off income/costs £m (0.839) 0.463 0.100 (0.363) 0.463 0.134 (0.329) (0.152) (0.481) (0.713) (0.561) Normalised Surplus / (Deficit) £m (0.708) (1.466) 0.239 1.705 (0.022) 0.078 0.100 (2.008) (1.908) (1.780) 0.228 Normalised Surplus / Deficit Margin % % (0.29%) (7.19%) 1.12% 8.31% (0.01%) 0.04% 0.05% (0.82%) (0.76%) (0.71%) 0.10%

Summary Statement of Financial Position

Non-current Assets Intangible assets £m (+ve) 0.107 0.081 0.171 0.090 0.081 0.171 0.090 0.072 0.162 0.072 - Property, Plant & Equipment £m (+ve) 151.933 154.250 153.546 (0.704) 154.250 153.546 (0.704) 153.824 153.120 153.423 (0.401) On-balance sheet PFI £m (+ve) ------Other £m (+ve) ------Total £m 152.040 154.331 153.717 (0.614) 154.331 153.717 (0.614) 153.896 153.282 153.495 (0.401)

Current Assets Cash and cash equivalents £m (+ve) 30.115 24.608 18.562 (6.046) 24.608 18.562 (6.046) 27.070 21.024 27.138 0.068 Other current assets £m (+ve) 10.534 12.726 21.432 8.706 12.726 21.432 8.706 8.404 17.110 8.404 - Total £m 40.649 37.334 39.994 2.660 37.334 39.994 2.660 35.474 38.134 35.542 0.068

Current Liabilities Overdrafts and drawdowns in committed facilities £m (-ve) ------PFI / LIFT leases £m (-ve) ------Other borrowings £m (-ve) (0.008) (0.003) (0.003) - (0.003) (0.003) - (0.001) (0.001) (0.001) - Other current liabilities £m (-ve) (19.619) (18.176) (20.427) (2.251) (18.176) (20.427) (2.251) (18.490) (20.741) (18.490) - Total £m (19.627) (18.179) (20.430) (2.251) (18.179) (20.430) (2.251) (18.491) (20.742) (18.491) 0.000

Non-current Liabilities PFI / LIFT leases £m (-ve) ------Other borrowings £m (-ve) (0.001) ------Other non-current liabilities £m (-ve) (2.494) (2.478) (2.502) (0.024) (2.478) (2.502) (0.024) (2.472) (2.496) (2.472) - Total £m (2.495) (2.478) (2.502) (0.024) (2.478) (2.502) (0.024) (2.472) (2.496) (2.472) 0.000

Reserves £m (+ve) 170.567 171.008 170.779 (0.229) 171.008 170.779 (0.229) 168.407 168.178 168.075 (0.332)

Summary Statement of Cash Flows

Surplus (Deficit) from Operations £m 2.530 (1.081) 0.622 1.703 3.431 3.500 0.069 1.981 2.050 1.519 (0.462)

Operating activities Non-operating and non-cash items in operating surplus/(deficit) £m (+/-ve) 7.834 0.641 0.639 (0.002) 5.774 5.531 (0.243) 8.309 8.066 8.310 0.001 Operating Cash flows before movements in working capital £m 10.364 (0.440) 1.261 1.701 9.205 9.031 (0.174) 10.290 10.116 9.829 (0.462)

Movements in working capital £m (+/-ve) (1.352) (0.476) (3.059) (2.583) (7.366) (11.345) (3.979) (1.084) (5.063) (1.084) - Increase/(Decrease) in non-current provisions £m (+/-ve) 1.585 (0.001) (0.009) (0.008) (0.016) 0.008 0.024 (0.022) 0.002 (0.022) - Net cash inflow/(outflow) from operating activities £m 10.597 (0.917) (1.807) (0.890) 1.823 (2.306) (4.129) 9.184 5.055 8.723 (0.462)

Investing activities Capital Expenditure (Accruals basis) £m (-ve) i (10.002) (1.393) (1.672) (0.280) (8.061) (7.288) 0.773 (10.163) (9.390) (9.663) 0.500 Increase/(decrease) in Capital Creditors £m (+/-ve) (0.257) - (0.169) (0.169) 0.228 0.022 (0.206) (0.251) (0.457) (0.251) - Proceeds on disposal of PPE, intangible assets and investment property £m (+ve) 0.867 2.797 - (2.797) 2.797 0.204 (2.593) 2.797 0.204 2.799 0.002 Other cash flows from investing activities £m (+/-ve) 0.133 - - - - 0.053 0.053 - 0.053 0.041 0.041 Net cash inflow/(outflow) from investing activities £m (9.259) 1.405 (1.841) (3.246) (5.036) (7.009) (1.973) (7.617) (9.590) (7.074) 0.543

Financing activities Public Dividend Capital repaid £m (-ve) ------Repayment of borrowings £m (-ve) i (1.443) - (0.001) (0.001) - (0.001) (0.001) - (0.001) - - Capital element of finance lease rental payments £m (-ve) i (0.010) - - - (0.006) (0.003) 0.003 (0.008) (0.005) (0.008) - Interest element of finance lease rental payments £m (-ve) i (0.002) (0.001) - 0.001 (0.003) - 0.003 (0.005) (0.001) (0.001) 0.003 Interest paid on borrowings £m (-ve) (0.032) ------Other cash flows from financing activities £m (+/-ve) (4.332) 0.005 0.005 (0.000) (2.285) (2.234) 0.051 (4.600) (4.549) (4.617) (0.017) Net cash inflow/(outflow) from financing activities £m (5.819) 0.004 0.004 0.000 (2.295) (2.238) 0.056 (4.613) (4.557) (4.627) (0.014)

Opening cash and cash equivalents less bank overdraft £m (+/-ve) 34.597 24.116 22.205 (1.911) 30.115 30.115 - 30.115 30.115 30.115 - Net cash increase / (decrease) £m (4.482) 0.492 (3.644) (4.136) (5.507) (11.554) (6.046) (3.045) (9.092) (2.978) 0.068 Changes due to transfers by absorption £m (+/-ve) ------Closing cash and cash equivalents less bank overdraft £m 30.115 24.608 18.561 (6.046) 24.608 18.561 (6.046) 27.070 21.023 27.137 0.068

Financial Sustainability Risk Rating

Capital Service Cover Revenue Available for Capital Service £m 9.862 9.250 8.839 (0.411) 10.354 9.943 9.965 (0.390) Capital Service £m (5.779) (3.509) (3.517) (0.008) (4.679) (4.687) (4.691) (0.013) Capital Service Cover metric 0.0x 1.71 2.64 2.51 (0.12) 2.21 2.12 2.12 (0.09) Capital Service Cover rating Score 2 4 4 3 3 3

Liquidity Working Capital for FSRR £m (+/-ve) 17.933 18.315 16.476 (1.839) 16.138 14.299 16.206 0.068 Operating Expenses within EBITDA, Total £m (235.256) (175.900) (179.711) (3.811) (235.989) (239.800) (241.193) (5.204) Liquidity metric Days 27.442 28.113 24.754 (3.359) 24.618 21.466 24.189 (0.430) Liquidity rating Score 4 4 4 4 4 4

I&E Margin Normalised Surplus/(Deficit) £m (+/-ve) (0.708) (0.022) 0.078 0.100 (2.008) (1.908) (1.780) 0.228 Adjusted Total Income for FSRR £m (+ve) 245.741 185.149 188.866 3.717 246.343 250.060 251.620 5.277 I&E Margin % (0.29%) (0.01%) 0.04% 0.05% (0.82%) (0.76%) (0.71%) 0.10% I&E Margin rating Score 2 2 3 2 2 2

I&E Margin Variance I&E Margin % (0.01%) 0.04% 0.05% (0.82%) (0.76%) (0.71%) 0.10% I&E Margin Variance From Plan % 1.87% 1.87% 0.05% 1.87% 0.05% 0.11% I&E Margin Variance From Plan rating Score 4 4 4 4 4

Overall Financial Sustainability Risk Rating Score 4 4 3 3 3

Continuity of Service Risk Rating Score 3

CIPs

CIPs as a percentage of opex within EBITDA less PFI expenses % 2.75% 2.81% 0.65% (2.15%) 2.14% 2.01% (0.13%) 2.24% 2.14% 1.84% -0.40% CIPs £m (+ve) 6.641 0.601 0.132 (0.469) 3.846 3.691 (0.155) 5.400 5.245 4.521 (0.879) Click to go to index Declaration of risks against healthcare targets and indicators for 201516 by Dorset Healthcare University NHS Foundation Trust Annual Plan Quarter 1 Quarter 2 Quarter 3

Scoring Per Scoring Per Scoring Per Scoring Per Scoring Per Targets and indicators as set out in the Risk Assessment Framework (RAF) - definitions per RAF Appendix A Threshold Risk Risk Risk Risk Risk Risk NOTE: If a particular indicator does not apply to your FT then please enter "Not relevant" for those lines. or target Performance Declaration Comments / explanations Performance Declaration Comments / explanations Performance Declaration Comments / explanations Assessment declared Assessment Assessment Assessment Assessment YTD Framework Framework Framework Framework Framework

Key: must complete may need to complete

Target or Indicator (per Risk Assessment Framework) Referral to treatment time, 18 weeks in aggregate, incomplete pathways i 92% 1.0 No 0 98.5% Achieved 0 97.5% Achieved 0 95.1% Achieved 0

A&E Clinical Quality - Total Time in A&E under 4 hours i 95% 1.0 No 0 100.0% Achieved 0 100.0% Achieved 0 100.0% Achieved 0

Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation i 85% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 0 0 Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - post local breach re-allocation i 90% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 Cancer 62 Day Waits for first treatment (from urgent GP referral) - pre local breach re-allocation i 0.0% 0.0% 0.0%

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - pre local breach re-allocation i 0.0% 0.0% 0.0%

Cancer 31 day wait for second or subsequent treatment - surgery i 94% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant

Cancer 31 day wait for second or subsequent treatment - drug treatments i 98% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0

Cancer 31 day wait for second or subsequent treatment - radiotherapy i 94% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 Cancer 31 day wait from diagnosis to first treatment i 96% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0

Cancer 2 week (all cancers) i 93% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 0 0 Cancer 2 week (breast symptoms) i 93% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 Care Programme Approach (CPA) follow up within 7 days of discharge i 95% 1.0 No 95.8% Achieved 95.5% Achieved 97.3% Achieved 0 0 0 Care Programme Approach (CPA) formal review within 12 months i 95% 1.0 No 95.7% Achieved 95.8% Achieved 95.0% Achieved 0 Admissions had access to crisis resolution / home treatment teams i 95% 1.0 No 0 96.9% Achieved 0 95.8% Achieved 96.4% Achieved 0 0 Meeting commitment to serve new psychosis cases by early intervention teams OLD measure - use until Q1 2016/17 i 95% 1.0 No 0 100.0% Achieved 0 102.2% Achieved 114.5% Achieved 0 0 Ambulance Category A 8 Minute Response Time - Red 1 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 Ambulance Category A 8 Minute Response Time - Red 2 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 Ambulance Category A 19 Minute Transportation Time i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 C.Diff due to lapses in care (YTD) i 1.0 No 0 0 Achieved 0 5 Achieved 6 Achieved 0 0 Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) i 5 11 12

C.Diff cases under review i 4 4 3

Minimising MH delayed transfers of care i <=7.5% 1.0 Yes 1 5.3% Achieved 0 5.8% Achieved 7.4% Achieved 0 0 Meeting commitment to serve new psychosis cases by early intervention teams NEW measure (scored from Q4 2015/16) i 50% 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant

Improving Access to Psychological Therapies - Patients referred within 6 weeks NEW measure (scored from Q3 2015/16) i 75% 0.0% Not relevant 0.0% Not relevant 93.7% Achieved

Improving Access to Psychological Therapies - Patients referred within 18 weeks NEW measure (scored from Q3 2015/16) i 95% 0.0% Not relevant 0.0% Not relevant 99.7% Achieved

Data completeness, MH: identifiers i 97% 1.0 No 0 99.7% Achieved 0 99.7% Achieved 99.7% Achieved 0 0 Data completeness, MH: outcomes i 50% 1.0 No 0 54.3% Achieved 0 54.9% Achieved 55.0% Achieved 0 0 Compliance with requirements regarding access to healthcare for people with a learning disability i N/A 1.0 No 0 N/A Achieved 0 N/A Achieved N/A Achieved 0 0 Community care - referral to treatment information completeness i 50% 1.0 No 92.0% Achieved 93.6% Achieved 92.0% Achieved

Community care - referral information completeness i 50% 1.0 No 0 94.6% Achieved 0 97.5% Achieved 98.5% Achieved 0

Community care - activity information completeness i 50% 1.0 No 87.3% Achieved 90.1% Achieved 91.2% Achieved 0

Risk of, or actual, failure to deliver Commissioner Requested Services N/A No No No No

Date of last CQC inspection i N/A N/A 22/06/2015 22/06/2015 22/06/2015

CQC compliance action outstanding (as at time of submission) N/A Yes Yes See Q1 Commentary Yes See Q2 Commentary Yes see Q3 commentary

CQC enforcement action within last 12 months (as at time of submission) N/A No No No No

CQC enforcement action (including notices) currently in effect (as at time of submission) N/A No No No No Report by Moderate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) i N/A Yes Yes See Q1 Commentary Yes See Q2 Commentary Yes see Q3 commentary Exception Major CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) i N/A No No No No

Overall rating from CQC inspection (as at time of submission) i N/A N/A N/A Requires improvement Requires improvement

CQC recommendation to place trust into Special Measures (as at time of submission) N/A N/A No No No

Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A Yes Yes See Q1 Commentary Yes See Q2 Commentary Yes see Q3 commentary

Trust has not complied with the high secure services Directorate (High Secure MH trusts only) N/A N/A N/A N/A N/A

0 i 0 0 0 Results left to complete: 0 i Checks Count: 0 i OK Checks left to clear: i 1 0 0 0 Service Performance Score Click to go to index In Year Governance Statement from the Board of Dorset Healthcare University NHS Foundation Trust

The board are required to respond "Confirmed" or "Not confirmed" to the following statements (see notes below) Board Response

For finance, that: The board anticipates that the trust will continue to maintain a financial sustainability risk rating of at least 3 over the next 12 months. Not Confirmed

The Board anticipates that the trust's capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return. Confirmed

For governance, that:

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set Confirmed out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.

Otherwise: The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework, Confirmed Table 3) which have not already been reported.

Consolidated subsidiaries:

Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds. 0

Signed on behalf of the board of directors

Signature Signature

Name Name

Capacity [job title here] Capacity [job title here]

Date Date

Responses still to complete: 0

Notes: Monitor will accept either 1) electronic signatures pasted into this worksheet or 2) hand written signatures on a paper printout of this declaration posted to Monitor to arrive by the submission deadline. In the event than an NHS foundation trust is unable to confirm these statements it should NOT select 'Confirmed’ in the relevant box. It must provide a response (using the section below) explaining the reasons for the absence of a full certification and the action it proposes to take to address it. This may include any significant prospective risks and concerns the foundation trust has in respect of delivering quality services and effective quality governance. Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the NHS foundation trust.

The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:

A Whilst our risk rating is expected to be at least 3 for the remainder of this year, the current uncertainty of what level of income for 2016/17 is available to the Trust means we are unable to confirm that a FSRR 3 would be maintained.

C Click to go to index Workforce for Dorset Healthcare University NHS Foundation Trust

Plan For Actual For Variance For Plan For Actual For Plan For Actual For Plan For Actual For Plan For Plan For Actual For Variance For Plan For units Month ending Month ending Month ending Quarter ending Quarter ending Quarter ending Quarter ending Quarter ending Quarter ending Quarter ending YTD ending YTD ending YTD ending Year ending 31-Dec-15 31-Dec-15 31-Dec-15 30-Jun-15 30-Jun-15 30-Sep-15 30-Sep-15 31-Dec-15 31-Dec-15 31-Mar-16 31-Dec-15 31-Dec-15 31-Dec-15 31-Mar-16

Analysis of Pay Costs

Medical and Dental staff Consultants (substantive) £m (0.708) (0.726) (0.018) (2.124) (2.285) (2.124) (2.454) (2.124) (2.345) (2.124) (6.373) (7.084) (0.710) (8.498) Consultants (locum) £m (0.035) (0.089) (0.055) (0.103) (0.785) (0.103) (0.494) (0.103) (0.268) (0.103) (0.308) (1.548) (1.240) (0.411) Trainee grades (substantive) £m (0.121) (0.088) 0.033 (0.361) (0.242) (0.361) (0.281) (0.361) (0.261) (0.361) (1.082) (0.784) 0.298 (1.442) Trainee grades (locum) £m ------Career/staff grade (substantive) £m (0.112) (0.203) (0.091) (0.334) (0.474) (0.334) (0.470) (0.334) (0.532) (0.334) (1.002) (1.476) (0.474) (1.336) Career/staff grade (locum/fixed term appointments) £m (0.076) (0.130) (0.054) (0.226) (0.270) (0.226) (0.433) (0.226) (0.392) (0.226) (0.677) (1.095) (0.418) (0.903) Any other substantive staff at any level £m (0.090) (0.004) 0.085 (0.268) (0.012) (0.268) (0.014) (0.268) (0.013) (0.268) (0.803) (0.039) 0.764 (1.070) Any other non-substantive staff at any level £m (0.032) (0.001) 0.032 (0.094) - (0.094) - (0.094) (0.001) (0.094) (0.283) (0.001) 0.282 (0.377) Medical and Dental staff, total £m (1.173) (1.242) (0.068) (3.509) (4.068) (3.509) (4.146) (3.509) (3.811) (3.509) (10.528) (12.025) (1.498) (14.037)

Registered nurses, midwives and health visiting staff Registered nurses (substantive) £m (5.056) (4.268) 0.788 (13.718) (12.431) (13.722) (12.363) (15.170) (12.583) (14.889) (42.610) (37.376) 5.234 (57.499) Registered nurses (bank and overtime) £m (0.144) (0.246) (0.102) (0.433) (0.747) (0.433) (0.716) (0.432) (0.739) (0.433) (1.299) (2.202) (0.903) (1.732) Registered nurses (agency) £m (0.184) (0.492) (0.308) (0.552) (1.335) (0.552) (1.726) (0.552) (1.470) (0.552) (1.656) (4.531) (2.875) (2.208) Registered midwives (substantive) £m ------Registered midwives (bank and overtime) £m ------Registered midwives (agency) £m ------Registered health visitors, district nurses and school nurses (substantive) £m (1.002) (0.815) 0.187 (2.862) (2.417) (2.914) (2.391) (3.004) (2.452) (2.927) (8.780) (7.260) 1.520 (11.707) Registered health visitors, district nurses and school nurses (bank and overtime) £m (0.029) (0.009) 0.020 (0.088) (0.020) (0.088) (0.026) (0.089) (0.028) (0.088) (0.264) (0.075) 0.189 (0.352) Registered health visitors, district nurses and school nurses (agency) £m - (0.000) (0.000) - (0.027) - (0.016) - (0.001) - - (0.044) (0.044) - Registered nurses, midwives and health visiting staff, total £m (6.415) (5.830) 0.585 (17.653) (16.977) (17.709) (17.240) (19.247) (17.272) (18.889) (54.609) (51.489) 3.121 (73.498)

Qualified scientific, therapeutic and technical staff Allied health professionals (substantive) £m (1.253) (1.224) 0.029 (3.761) (3.582) (3.761) (3.629) (3.761) (3.664) (3.738) (11.284) (10.875) 0.409 (15.022) Allied health professionals (bank and overtime) £m (0.012) (0.022) (0.010) (0.038) (0.090) (0.038) (0.076) (0.038) (0.074) (0.038) (0.113) (0.241) (0.128) (0.150) Allied health professionals (agency) £m (0.028) (0.029) (0.002) (0.086) (0.120) (0.086) (0.124) (0.086) (0.143) (0.086) (0.257) (0.387) (0.130) (0.343) Healthcare science staff (substantive) £m (0.053) (0.046) 0.007 (0.161) (0.129) (0.161) (0.139) (0.161) (0.139) (0.161) (0.484) (0.408) 0.076 (0.646) Healthcare science staff (bank and overtime) £m - (0.002) (0.002) - (0.002) - (0.002) - (0.005) - - (0.009) (0.009) - Healthcare science staff (agency) £m - (0.001) (0.001) - (0.042) - (0.009) - (0.005) - - (0.057) (0.057) - Other scientific, therapeutic and technical staff (substantive) £m (0.843) (0.863) (0.021) (2.531) (2.504) (2.531) (2.536) (2.531) (2.552) (2.526) (7.592) (7.593) (0.000) (10.118) Other scientific, therapeutic and technical staff (bank and overtime) £m - (0.019) (0.019) - (0.072) - (0.064) - (0.062) - - (0.199) (0.199) - Other scientific, therapeutic and technical staff (agency) £m (0.054) (0.037) 0.017 (0.162) (0.058) (0.162) (0.088) (0.162) (0.086) (0.162) (0.485) (0.232) 0.254 (0.647) Qualified scientific, therapeutic and technical staff, total £m (2.242) (2.244) (0.001) (6.738) (6.602) (6.738) (6.667) (6.738) (6.731) (6.711) (20.215) (19.999) 0.216 (26.926)

Qualified ambulance service staff Qualified ambulance paramedics (substantive) £m (0.009) (0.006) 0.003 (0.025) (0.025) (0.025) (0.025) (0.025) (0.022) (0.025) (0.075) (0.072) 0.003 (0.100) Qualified ambulance paramedics (bank and overtime) £m ------Qualified ambulance paramedics (agency) £m ------Qualified ambulance technicians and other qualified ambulance staff (substantive) £m ------Qualified ambulance technicians and other qualified ambulance staff (bank and overtime)£m ------Qualified ambulance technicians and other qualified ambulance staff (agency) £m ------Ambulance service staff, total £m (0.009) (0.006) 0.003 (0.025) (0.025) (0.025) (0.025) (0.025) (0.022) (0.025) (0.075) (0.072) 0.003 (0.100)

Support to clinical staff Support to doctors/dentists & nursing staff (substantive) £m (1.771) (1.881) (0.110) (5.313) (5.504) (5.313) (5.438) (5.313) (5.683) (5.293) (15.940) (16.626) (0.686) (21.233) Support to scientific, therapeutic & technical staff (substantive) £m (0.362) (0.349) 0.013 (1.088) (1.016) (1.088) (1.059) (1.088) (1.075) (1.084) (3.265) (3.150) 0.115 (4.349) Support to ambulance staff (substantive) £m ------Other clinical support staff (substantive) £m (1.212) (1.106) 0.107 (3.519) (3.287) (3.644) (2.867) (3.636) (3.228) (3.611) (10.799) (9.382) 1.417 (14.410) Support to clinical staff (bank and overtime) £m (0.029) (0.299) (0.270) (0.085) (1.020) (0.085) (1.004) (0.085) (0.939) (0.085) (0.255) (2.962) (2.707) (0.340) Support to clinical staff (agency) £m (0.093) (0.104) (0.010) (0.277) (0.262) (0.277) (0.429) (0.277) (0.293) (0.277) (0.832) (0.984) (0.152) (1.109) Support to clinical staff, total £m (3.468) (3.739) (0.271) (10.283) (11.089) (10.408) (10.797) (10.400) (11.218) (10.350) (31.091) (33.104) (2.013) (41.442)

Managers and infrastructure Support Managers and infrastructure support (substantive) £m (1.716) (1.928) (0.212) (5.080) (5.332) (5.154) (5.827) (5.150) (5.728) (5.134) (15.384) (16.887) (1.504) (20.518) Managers and infrastructure support (bank and overtime) £m (0.350) (0.147) 0.203 (1.050) (0.513) (1.050) (0.537) (1.050) (0.493) (1.050) (3.150) (1.542) 1.608 (4.200) Managers & infrastructure support (agency) £m - (0.132) (0.132) - (0.591) - (0.624) - (0.429) - - (1.644) (1.644) - Managers and Infrastructure Support, total £m (2.066) (2.206) (0.141) (6.130) (6.436) (6.204) (6.988) (6.200) (6.650) (6.184) (18.534) (20.073) (1.540) (24.718)

Total Planned Staff Costs (excluding contingency) £m (15.374) (15.267) 0.107 (44.338) (45.196) (44.594) (45.863) (46.120) (45.704) (45.668) (135.052) (136.763) (1.711) (180.720)

Contingency Substantive, bank and overtime staff £m ------Locum and Agency staff £m ------Contingency, total £m 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000

Analysis of staff costs Substantive, bank and overtime staff £m (14.872) (14.252) 0.621 (42.839) (41.705) (43.094) (41.920) (44.620) (42.617) (44.169) (130.554) (126.241) 4.313 (174.722) Locum and agency staff £m (0.501) (1.015) (0.514) (1.499) (3.491) (1.499) (3.943) (1.499) (3.088) (1.499) (4.498) (10.522) (6.023) (5.998) Total Planned Staff Costs £m (15.374) (15.267) 0.107 (44.338) (45.196) (44.594) (45.863) (46.120) (45.704) (45.668) (135.052) (136.763) (1.711) (180.720)

Check to SoCI Substantive, bank and overtime Staff £m (14.874) (14.267) 0.607 (42.838) (41.705) (43.094) (41.920) (44.620) (42.632) (44.169) (130.553) (126.256) 4.297 (174.721) Variance Check OK OK OK OK OK OK OK OK OK OK OK OK OK OK

Locum and agency staff £m (0.499) (1.003) (0.504) (1.499) (3.491) (1.499) (3.940) (1.499) (3.076) (1.499) (4.498) (10.507) (6.009) (5.998) Variance Check OK OK OK OK OK OK OK OK OK OK OK OK OK OK

Analysis of Workforce Numbers

Medical and Dental staff Consultants (substantive) WTE 62.2 59.3 (2.9) 61.0 56.8 62.2 59.1 62.2 59.4 62.2 61.8 58.4 (3.4) 62.2 Consultants (locum) WTE 4.1 2.4 (1.7) 5.0 10.0 4.1 8.4 4.1 3.1 4.1 4.4 7.2 2.8 4.1 Trainee grades (substantive) WTE 22.3 18.9 (3.4) 21.5 19.1 22.3 19.6 22.3 19.3 22.3 22.0 19.3 (2.7) 22.3 Trainee grades (locum) WTE ------Career/staff grade (substantive) WTE 20.1 9.1 (11.0) 19.4 19.0 20.1 17.2 20.1 9.1 20.1 19.8 15.1 (4.7) 20.1 Career/staff grade (locum/fixed term appointments) WTE 3.0 21.3 18.3 4.0 5.5 3.0 9.1 3.0 20.0 3.0 3.3 11.5 8.2 3.0 Any other substantive staff at any level WTE 16.0 12.6 (3.4) 16.0 14.1 16.0 13.5 16.0 12.3 16.0 16.0 13.3 (2.7) 16.0 Any other non-substantive staff at any level WTE 1.2 - (1.2) 1.5 - 1.2 - 1.2 - 1.2 1.3 - (1.3) 1.2 Medical and Dental staff, total demand WTE 128.9 123.6 (5.3) 128.4 124.5 128.9 127.0 128.9 123.2 128.9 128.7 124.9 (3.8) 128.9

Registered Nurses, midwives and health visiting staff Registered nurses (substantive) WTE 1,329.8 1,280.7 (49.1) 1,306.7 1,251.4 1,314.8 1,242.3 1,329.5 1,272.5 1,327.9 1,317.0 1,255.4 (61.6) 1,326.9 Registered nurses (bank and overtime) WTE 54.3 84.3 30.0 54.3 65.1 54.3 80.0 54.3 82.5 54.3 54.3 75.9 21.5 54.3 Registered nurses (agency) WTE 29.7 104.5 74.7 32.2 45.5 29.7 108.3 29.7 81.5 29.7 30.6 78.4 47.9 29.7 Registered midwives (substantive) WTE ------Registered midwives (bank and overtime) WTE ------Registered midwives (agency) WTE ------Registered health visitors, district nurses and school nurses (substantive) WTE 272.3 232.0 (40.4) 256.1 233.0 268.3 231.1 271.0 238.6 271.8 265.1 234.2 (30.9) 271.5 Registered health visitors, district nurses and school nurses (bank and overtime) WTE 11.0 3.5 (7.5) 11.0 5.1 11.0 2.3 11.0 3.1 11.0 11.0 3.5 (7.5) 11.0 Registered health visitors, district nurses and school nurses (agency) WTE - - - - 1.0 - - - 0.3 - - 0.4 0.4 - Registered Nurses, midwives and health visiting staff, total demand WTE 1,697.2 1,705.0 7.8 1,660.4 1,601.1 1,678.2 1,664.0 1,695.5 1,678.5 1,694.7 1,678.0 1,647.9 (30.2) 1,693.5

Qualified Scientific, Therapeutic and Technical Staff Allied health professionals (substantive) WTE 380.8 386.5 5.7 380.6 384.5 380.8 383.8 380.8 391.9 381.8 380.8 386.7 6.0 382.3 Allied health professionals (bank and overtime) WTE 5.2 7.0 1.8 5.6 7.0 5.2 8.0 5.2 7.8 5.2 5.3 7.6 2.3 5.2 Allied health professionals (agency) WTE 5.0 3.3 (1.7) 5.5 11.3 5.0 5.8 5.0 8.4 5.0 5.2 8.5 3.3 5.0 Healthcare science staff (substantive) WTE 17.6 19.6 2.0 17.1 14.8 17.6 17.4 17.6 19.8 17.6 17.4 17.3 (0.1) 17.6 Healthcare science staff (bank and overtime) WTE 0.1 0.6 0.6 0.1 0.3 0.1 0.5 0.1 0.4 0.1 0.1 0.4 0.3 0.1 Healthcare science staff (agency) WTE - - - - 0.2 - 0.8 - 0.1 - - 0.4 0.4 - Other scientific, therapeutic and technical staff (substantive) WTE 249.9 261.0 11.1 251.0 188.0 249.7 250.4 249.9 259.1 253.6 250.2 232.5 (17.7) 255.4 Other scientific, therapeutic and technical staff (bank and overtime) WTE - 6.9 6.9 1.6 5.7 - 7.5 - 7.1 - 0.5 6.8 6.3 - Other scientific, therapeutic and technical staff (agency) WTE 6.9 4.4 (2.5) 7.4 5.6 6.9 2.0 6.9 2.4 6.9 7.1 3.3 (3.8) 6.9 Qualified Scientific, Therapeutic and Technical Staff, total demand WTE 665.5 689.3 23.8 668.8 617.4 665.3 676.1 665.5 697.0 670.1 666.5 663.5 (3.0) 672.5

Qualified Ambulance service staff Qualified ambulance paramedics (substantive) WTE 2.8 3.2 0.4 2.8 2.8 2.8 2.8 2.8 2.9 2.8 2.8 2.8 0.0 2.8 Qualified ambulance paramedics (bank and overtime) WTE - 0.0 0.0 - - - 0.1 - 0.0 - - 0.0 0.0 - Qualified ambulance paramedics (agency) WTE ------Qualified ambulance technicians and other qualified ambulance staff (substantive) WTE ------Qualified ambulance technicians and other qualified ambulance staff (bank and overtime)WTE ------Qualified ambulance technicians and other qualified ambulance staff (agency) WTE ------Qualified Ambulance service staff, total demand WTE 2.8 3.2 0.4 2.8 2.8 2.8 2.9 2.8 2.9 2.8 2.8 2.9 0.1 2.8

Support to clinical staff Support to doctors/dentists & nursing staff (substantive) WTE 888.3 927.1 38.8 886.6 892.2 888.0 911.8 888.2 928.7 888.6 887.6 910.9 23.3 888.8 Support to scientific, therapeutic & technical staff (substantive) WTE 162.0 170.5 8.5 162.2 164.9 161.0 165.2 161.7 168.8 161.9 161.6 166.3 4.6 161.9 Support to ambulance staff (substantive) WTE ------Other clinical support staff (substantive) WTE 511.6 511.6 (0.0) 505.4 498.1 509.3 504.4 510.9 514.7 511.6 508.5 505.7 (2.8) 511.6 Support to clinical staff (bank and overtime) WTE 81.8 140.0 58.2 100.0 142.8 81.8 151.5 81.8 155.0 81.8 87.9 149.8 61.9 81.8 Support to clinical staff (agency) WTE 33.0 33.1 0.1 35.7 39.2 33.0 42.3 33.0 28.1 33.0 33.9 36.5 2.7 33.0 Support to clinical staff, total demand WTE 1,676.7 1,782.3 105.6 1,689.9 1,737.2 1,673.1 1,775.2 1,675.5 1,795.3 1,677.0 1,679.5 1,769.2 89.7 1,677.1

Managers and infrastructure support Managers and infrastructure support (substantive) WTE 688.3 659.8 (28.4) 668.3 756.4 684.1 641.8 688.3 658.0 685.7 680.2 685.4 5.2 684.4 Managers and infrastructure support (bank and overtime) WTE 100.0 73.5 (26.5) 100.0 - 100.0 81.6 100.0 79.7 100.0 100.0 53.8 (46.2) 100.0 Managers & infrastructure support (agency) WTE - 23.6 23.6 - - - 36.0 - 24.0 - - 20.0 20.0 - Managers and Infrastructure Support, total demand WTE 788.3 756.9 (31.4) 768.3 756.4 784.1 759.4 788.3 761.7 785.7 780.2 759.2 (21.1) 784.4

Total WTEs WTE 4,959.3 5,060.2 100.9 4,918.6 4,839.3 4,932.5 5,004.6 4,956.4 5,058.7 4,959.3 4,935.8 4,967.5 31.7 4,959.2

Analysis of WTEs Substantive, bank and overtime staff WTE 4,876.4 4,867.7 (8.7) 4,827.3 4,721.1 4,849.5 4,791.9 4,873.5 4,890.7 4,876.3 4,850.1 4,801.2 (48.9) 4,876.3 Locum and agency staff WTE 82.9 192.5 109.6 91.3 118.2 82.9 212.7 82.9 168.0 82.9 85.7 166.3 80.6 82.9 Total WTEs WTE 4,959.3 5,060.2 100.9 4,918.6 4,839.3 4,932.5 5,004.6 4,956.4 5,058.7 4,959.3 4,935.8 4,967.5 31.7 4,959.2

Workforce KPIs

Percentage of vacancies % 7.25% 7.53% 0.28% 8.10% 8.40% 7.80% 8.40% 7.40% 7.60% 7.10% 7.25% 7.53% 0.28% 7.00% Agenda Item 17

Reappointment of Mental Health Act Panel Members

Part 1 Board Meeting 27 January 2016

Author Gavin Macfarlane Sarah Murray, Chair Mental Health Legislation Sponsoring Board Member Assurance Committee Purpose of Report To reappoint Mental Health Act Panel Members Recommendation The Board is asked to reappoint the Mental Health Act Panel Members set out in this report Engagement and Involvement Those who have been involved are the Mental Health Legislation Manager and the Chair, MHL Assurance Committee both of whom are in agreement with its contents. Previous Committee/s Dates

Monitoring and Assurance Summary

This report links to the . To provide high quality care; first time, every time; Strategic Goals . To be a valued partner and expert in partnership working with Patients, Communities and organisations; . To be a learning organisation, maximising our partnership with Bournemouth University and promoting innovation, research and evidence based practice; . To be a national leader in the delivery of integrated care; . To ensure that all of the Trust’s resources are used in an efficient and sustainable way I confirm that I have considered each of Any action required? the implications of this report, on each Yes of the matters below, as indicated: Yes No Detail in report All three Domains of Quality  Board Assurance Framework  Risk Register  Legal / Regulatory  People / Staff  Financial / Value for Money / Sustainability  Information Management &Technology  Equality Impact Assessment  Freedom of Information 

RE-APPOINTMENT OF APPOINTED MENTAL HEALTH ACT PANEL MEMBERS

1 Background

1.1 The reappointment of Appointed Mental Health Act Panel Members is subject to Board approval, following a satisfactory appraisal by the Chair of the Mental Health Legislation Assurance Committee.

1.2 Two Panel members are subject to reappointment at the end of January

• Mr Wayne French • Mr Nick Ziebland

The appraisal process for to support their reappointment is currently underway.

1.3 The terms of office of these Members come to an end on 22 January. To enable continuity of office, the Board is asked to reappoint them for a period of two years subject to a satisfactory appraisal in January and continuing satisfactory appraisals by the Chair of the Mental Health Legislation Assurance Committee.

2 Recommended

3.1 The Board is recommended to reappoint the following as Appointed Mental Health Act Panel Members for a period of two years subject to satisfactory appraisals by the Chair of the Mental Health Legislation Assurance Committee

• Mr Wayne French • Mr Nick Ziebland

Gavin Macfarlane Acting Mental Health Legislation Manager,

January 2016

Agenda Item 18

Board Annual Cycle of Business

Board Meetings

Monthly items: Patient Story Board and Committee minutes Reports from the Chair and Chief Executive Integrated Corporate Dashboard Monthly Finance Report People Management

February March April May June July Sept October November January

Safe Staffing Dorset Care Monitor Q4 Annual Annual SUI Monitor Q1 Monitor Q2 Infection Monitor Q3 six monthly Record submission Account Report submission submission Prevention six submission Report Business and monthly report Case Accounts/ Quality Report Nurse Final Board ISA 260 Annual Report Annual Equality and Revalidation Operational Register of on Reducing Complaints Diversity Update Plan Interests Restrictive report Annual Report 2016/17 Interventions 2014/15 Stages of Budget Hidden Monitor Annual Annual Organisational Excellence 2016/17 Talents self- Safeguarding patient Development update Update certification Report Experience Progress statements 2014/15 Report Report 2014/15 Draft budget Behavioural OD Strategy Annual Infection OD Progress Emergency 2016/17 Framework Update Prevention & Report Planning Control Report Resilience 2014/15 Statement Agenda Item 18

Approval of Going Quarterly Quarterly Quarterly Quarterly corporate Concern review of review of review of the review of the objectives Report Well Led Well Led Well Led Well Led action plan action plan action plan action plan Equality Proposed Quarterly Quarterly Quarterly Quarterly Objectives Quality review of the review of the review of the review of the 2016/17 Priorities for CQC action CQC action CQC action CQC action 16/17 plan plan plan plan

Staff Survey Approval of Quarterly Quarterly Quarterly Quarterly BAF results the 2016/17 review of review of BAF review review BAF 2015/16 BAF BAF

Part 2: Part 2: Part 2: Part 2: Part 2:

Quarterly Quarterly Whistle Whistle blowing blowing report report

Board Workshop Programme

Jan Feb March Apr

Annual Plan 2016/17 Annual Plan 2016/17 Prison Health Services The Business We Are In-Threats and Opportunities Participation Out of Hospital Model of Care Draft budget 2016/17