Meeting of the Board of Directors in Public

Wednesday 25 November 2015 from 09.00am

Chelm sford City Council, Civic Centre,

Duke Street, Chelmsford, Essex CM1 1JE

1 This Page Deliberately Blank

2 North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors to be held in Public on Wednesday 25 November 2015 in the Marconi Room, Civic Centre, Chelmsford City Council, Civic Centre, Duke Street, Chelmsford, Essex CM1 1JE at 09.00am

Declarations and Minutes Lead Time Page

1. Apologies for Absence [Receive] CP 09.00 005

2. Declarations of Interest in Agenda Items [Receive] CP 09.00 006

3. a) Minutes of the Meeting held on 23 September 2015 CP 09.05 007 [Receive & Approve]

b) Matters arising from the Minutes of the Meeting held CP 09.10 019 on 23 September 2015 [Discuss]

4. Chief Executive’s Report [Receive] AG 09.15 022

Quality

5. CQC Improvement Plan and Framework - Update [Receive] NH 09.25 024

6. Ligature Point Management and Removal [Receive] NH 09.40 032

7. Patient Survey 2015 – Results [Receive] MC 09.50 044

8. Service User and Patient Experience and Involvement MC 10.00 045 [Receive]

Setting Strategy

9. Mental Health Strategic review - Update [Discuss & Note] MC 10.15 053

Comfort Break 10.30

Monitoring

10. Finance Report for the Seven Months Ending 31 October DG 10.45 054 2015 (Month 7) [Note]

11. Performance: a) Operational Performance Summary to 31 October VM 10.55 069 2015 [Receive & Note]

b) Workforce Report [Receive & Note] LA 11.05 075

12. Nursing Agency Rules LA/DG 11.10 097

3 13. Quality Report [Note] NH 11.20 102

14. Ward Staffing Levels – September 2015 [Discuss & Note] NH 11.30 118

Governance

15. Nurse Revalidation NH 11.40 131

16. Monitor Compliance Report Quarter 2, 2015/16 [Note] DG 11.50 135

17. Board Committees - Verbal Reports [Note]: 11.55 a) Quality & Risk Committee (14 October 2015) BJ 144 b) Audit Committee (15 October 2015) CB c) Nominations Committee (21 October 2015) CP

18. Risk & Governance Annual Report 2015/16 [Receive] NH 12.05 145

19. Charitable Funds Accounts and Annual Report 2014/15 CP 12.15 153 [Approve]

20. Charitable Funds Forum Policy [Approve] DG 12.20 167

21. Medical and Non-Medical Education Update - Verbal Report MF 12.25 178 [Receive]

22. Reservation of Powers and Scheme of Delegation [Approve] DMc 12.30 179

23. Standing Financial Instructions [Approve] DG 12.35 200

24. Terms of Reference [Approve] 12.40 a) Audit Committee DMc/CB 237 b) Nominations Committee DMc/CP 243

Items for Noting

25. Summary of Board Decisions [Note] DMc 12.45 247

26. Execution of Deeds [Note] DMc 12.50 280

Other Items

27. Any Other Notified Business [Discuss] CP 12.50 281

28. Questions from members of the public relating to items on the CP 13.00 282 agenda only [Discuss]

Date of Next Meeting in Public: 27 January 2016 from 09.00 at Stapleford House, 103 Stapleford Close, Chelmsford, Essex CM2 0QX

4 North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 1

Date: 25 November 2015

Title of Report: Apologies for absence

Lead: Chris Paveley, Chairman

Subject, Purpose and Recommendation: The Board of Directors is invited to receive any apologies for absence.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

5 North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 2

Date: 25 November 2015

Title of Report: Declarations of Interest in Agenda Items

Lead: Chris Paveley, Chairman

Subject, Purpose and Recommendation: In accordance with Standing Orders the Board of Directors is asked to receive any declarations of interest from Board members relating to items on the agenda.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

6 North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 3a

Date: 25 November 2015

Title of Report: Minutes of the Meeting held on 23 September 2015

Lead: Chris Paveley, Chairman

Subject, Purpose and Recommendation: The Board of Directors is asked to receive and approve the minutes of the meeting held on 23 September 2015.

Any items of a non-material nature e.g. typographical errors should be communicated to the Trust Secretary in advance of the meeting.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

7 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST MINUTES OF THE MEETING OF THE BOARD OF DIRECTORS IN PUBLIC HELD ON 23 SEPTEMBER 2015 AT STAPLEFORD HOUSE, 103 STAPLEFORD CLOSE, CHELMSFORD, ESSEX CM2 0QX

Present: Chris Paveley, Chairman Andrew Geldard, Chief Executive Mike Chapman, Director of Strategy Dr Malte Flechtner, Medical Director David Griffiths, Director of Resources Natalie Hammond, Director of Nursing & Quality Jan Hutchinson, Non Executive Director Peter Little, Non Executive Director Amanda Sherlock, Non Executive Director and Deputy Chairman

In Attendance: Lisa Anastasiou, Director of Workforce & Development David Bamber, Public Governor, Harlow Sarah Burtenshaw, Member of the Public Martin Cresswell, Associate Director Communications Sydney Dyne, Member of the Public Adrian Faiers, Public Governor, Chelmsford Ray Hardisty, Deputy Lead Governor and Public Governor, Colchester Pippa Ecclestone, Public Governor Uttlesford 1 Elizabeth Mabbutt, Executive Assistant to CEO & Chairman (Minutes) Melanie Leahy, Member of the Public Rachel Lucas, Member of the Public Vince McCabe, Director of Operations Dermot McCarthy, Trust Secretary Lisa Morris, Member of the Public Nigel Mountford, Public Governor, Colchester David Paramore, Heart Essex Linda Pearson, Public Governor, Mid Gary Rayment, North East Essex CCG Paul Sargent, Nominated Governor, HMP & YOI Chelmsford Andrew Smith, Public Governor, Epping Forest Rita Usitalo, NEP Brian Weavers, Public Governor, Harlow Clive White, Lead Governor and Public Governor Colchester

1 = Part of Meeting

2015/098 Apologies for Absence Chris Paveley welcomed everyone to the meeting.

Apologies for absence were received from: • Charles Beaumont, Non Executive Director • Brian Johnson, Non Executive Director and Senior Independent Director.

8 2015/099 Declarations of Interest There were no Declarations of Interest.

2015/100 Minutes of the Meeting held on 29 July 2015 The minutes of the meeting held on 29 July 2015 were agreed as a correct record and signed by the Chairman.

2015/101 Matters Arising from the Minutes of the Meeting held on 29 July 2015 The Matters Arising were: a) Update on Commissioning for Quality & Innovation Payments (CQUINs), Dr Malte Flechtner confirmed that an action plan was in place to deliver the CQUIN re Cardio Metabolic Assessment b) People Strategy – Lisa Anastasiou advised NEP’s People Strategy had been launched c) Serious Incident Reporting – Natalie Hammond reported on the development of a new reporting format, centring on actions taken and shared learning. d) Medical and Non-Medical Education – Dr Malte Flechtner advised that this was on the agenda e) Finance Report – David Griffiths advised that an update re the cash position was included in this month’s finance report f) Introduction of Inpatient Staffing Tool – Natalie Hammond reported that this was being tested in inpatient areas g) Monitor Compliance – David Griffiths advised that as agreed the relevant note re property disposals had been added to the Monitor finance and governance return for Quarter 1 (Q1) h) Research and Development (R&D) Annual Report 2014/15 – Dr Malte Flechtner commented that funding was dependent on the success of research grant applications; the amount received by NEP was proportionate, and in line with expectations. The Board of Directors noted progress re the Matters Arising.

2015/102 Chief Executive’s Report Andrew Geldard presented this item and highlighted: a) Regulatory issues: NEP’s Monitor Risk Ratings were Continuity of Service Risk (CoSRR) ‘3’ and Governance ‘Under Review’, pending feedback from the CQC inspection b) CQC Inspection: Verbal feedback had been received at end of process; the focus was on adult inpatient facilities c) Finance: as at the end of August the Trust had an EBITDA of £1.6m and a deficit of £0.9m d) Assurance: Board to Ward visits were scheduled for rest of the year e) Contracts: Discussions with Commissioners for second part of the year continued f) Council of Governors – A successful Annual Members’ meeting had been held on 10 September 2015. Discussions continued with the relevant Governor committees regarding the proposed merger

9 g) Journeys – a post-implementation review process was underway. Andrew Geldard had written a letter of thanks to all community staff h) External Relations – The Boston Consulting Group had undertaken a piece of work centring on the sustainability of mental health services in Essex and the associated commissioning framework.

In answer to questions from Brian Johnson and Amanda Sherlock, Vince McCabe confirmed that a Board report on the implementation of Journeys would be brought to the next Board meeting. Action: Vince McCabe, Director of Operations The Board of Directors noted the Chief Executive’s Report.

2015/103 CQC Improvement Plan and Framework Natalie Hammond presented a detailed report regarding the Care Quality Commission (CQC) inspection process and outcomes. The CQC’s inspection of the Trust was conducted over five days from 24 August 2015 by a team comprising the Chair of Inspection Team, CQC lead inspector, Mental Health Act Commissioners, analysts, external advisors and experts through experience. The inspection process included reviews of the environment, clinical documentation, data and interviews with executive and non-executive directors. Focus groups were conducted with consultants, ward managers, a range of clinical staff and service users, carers governors, and visitors. The draft report, the outcomes and ratings would be presented and discussed at a Quality Summit, date pending, before the CQC publish the final report, scheduled for December 2015. The Trust would have c.4 weeks to respond to the report with a compliance action plan detailing an improvement plan.

Informal feedback included that: • There were services in the Trust that showed exemplar levels of care and patient involvement e.g. CAMHs in-patient service • Community services.

Areas of Concern included: • Derwent Centre Hub (use of the ‘hub model’ for patients during the day) • S136 facilities seclusion/de-escalation rooms (design and fabric) • Ligature risk assessments and organisational response • Care plans and individual risk assessments (need to be more personalised) • Therapeutic environment of inpatient facilities • Mixed Sex-Accommodation (improvement beyond core national standards).

Natalie Hammond focussed on the achievement of improvements through developing a Quality Improvement Framework including: . A quality dashboard for the Board as an early warning system against quality indicators . Detailed sets of ward to board quality indicators with clear procedures for escalation . Review of ward risk registers . Use of a Quality Improvement Methodology . Quality Improvement Panels operating at Ward/ Team, Area and Executive levels.

The Quality & Risk Committee would receive an exception report when there were significant delays in achieving improvement of quality indicators and/or completing risk action plans. In answer to a question from Chris Paveley, it was noted that the Quality and Risk Committee (QARC) would lead on oversight of these arrangements. In answer to concern raised by Chris Paveley regarding personalised care plans, Natalie Hammond commented on NEP’s new model care plan, to be implemented for inpatients during October 2015. Action: Natalie Hammond, Director of Nursing and Quality

The Board of Directors: i) noted the actions taken in response to the initial findings of the CQC inspection held between 24th and 27th August 2015;

ii) noted that an initial Trust action plan had been developed in response to the CQC initial feedback with Quality Improvement Panels to be implemented to progress the issues raised.

Action: Natalie Hammond, Director of Nursing and Quality

2015/104 Mental Health Strategic Review – Draft Report from Boston Consulting Group (BCG) Mike Chapman advised that Boston Consulting Group was commissioned by all of the CCGs in Essex, Essex County Council, Thurrock Unitary Authority, Southend Unitary Authority and both NEP and SEPT to carry out a Mental Health Strategic review. This was intended to clarify Commissioners’ expectations regarding their views of the future of MH services given the integration agenda. From the provider perspective, the expectation was that the report would help provide clarify the future scope and sustainability of specialist MH services.

Key findings included: • Fragmented commissioning across Essex • No system-wide strategy • A very difficult context for providers to plan.

Recommendations included: • Commissioners should align around a clear commissioning path • MH Clusters 1-3 into new Integrated Care Organisations (ICOs) • Organic pathways to move into the ICOs.

Recommendations for commissioners: • Clarify the integration agenda • Create an expert pan-Essex mental health team • Develop and track outcomes data.

Local Authority recommendations: • Review and strengthen section 75 partnership agreements

11 • Optimise how dementia is organised • Work together around ensuring all-age, cross-system care.

Provider recommendations: • Build greater depth of capability in areas highlighted by commissioners • Build brand in collaboration with stakeholders • Consider the organisational form and scale required.

Amanda Sherlock expressed the view that the BCG report did not give a clear view of the future for commissioners or providers, and risked further delay without substantive progress. Mike Chapman agreed that the report did not set a firm direction, however it was clear about the need for effective clinical engagement and the need to work with Commissioners. Andrew Geldard added that there was a meeting on 28 September 2015 to discuss next steps.

The Board of Directors noted the Mental Health Strategic Draft Report from Boston Consulting Group (BCG).

2015/105 Organisational Response to the Essex Strategic Review: Strategic Options Case Andrew Geldard advised that this item had been held under embargo until today; a public version of the document was then distributed. Andrew Geldard set the context including the challenge of setting a clear strategy for mental health services in Essex. The paper presented the Strategic Options Case (SOC) to explore the potential option of merger between North Essex Partnership University NHS Foundation Trust (NEPFT) and South Essex Partnership University NHS Foundation Trust (SEPT) to create a new Foundation Trust providing specialist mental health and community services. Mike Chapman advised that the SOC was being discussed at a meeting of the SEPT’s Board of Directors also being held on the morning of 25 September 2015. Chris Paveley commented on the importance of considering the potential for a merger to support the delivery of improved and sustainable mental health services for Essex. Mike Chapman commented that this was a key strand of an Outline Business Case, and inputs would be sought from stakeholders including clinicians and governors. Amanda Sherlock commented on the need to place the clinical model at the heart of the Outline Business Case (OBC). Vince McCabe remarked on the importance of effective and co-ordinated communication with staff and service users in both Trusts. Andrew Geldard reported on work with the relevant committees of the Council of Governors and plans for stakeholder communications.

The Board of Directors: i. approved the exploration of a potential merger with South Essex Partnership University NHS Foundation Trust (SEPT) and the submission of a Strategic Options Case to Monitor;

ii. noted the indicative timetable;

iii. noted the Project Management Structure for the development of key documents for presentation to the Board of Directors, the Council of Governors and Monitor.

12 2015/106 Finance Report for the Five months Ending 31 August 2015 David Griffiths advised that the Trust had an EBITDA of £1.61 million, with an underlying deficit of c.£1m compared to a plan of break even. Key variances included IMT & Estates non-pay pressures, professional services and secondary care placements and debt provisions. The year-end forecast was for a c.£2.8 m deficit. Monitor had introduced a new Financial Sustainability Risk Rating (FSRR) resulting in a rating for NEP of 2, primarily as a consequence of the deteriorating I&E position. In answer to a question from Peter Little, David Griffiths advised that there was further risk to the financial position, which would be discussed in the private part of the meeting. In answer to a question from Brian Johnson, David Griffiths commented on the property sales planned for the remainder of 2015/16, which were progressing well. There would be an update regarding the sale of Severalls in the private part of the meeting. In answer to a further question from Brian Johnson, David Griffiths advised that the major components of the capital programme were committed. In answer to a question from Amanda Sherlock he confirmed that priority safety works resulting from the CQC inspection would result in further cost pressure. The Board of Directors noted the Finance report for the five months ending 31 August 2015.

2015/107 Operational Performance Summary to 31 August 2015 Vince McCabe advised that the Operational Performance Summary was in 3 sections: • Monitor’s Access and Outcomes Measures • Other KPIs • Contractual Targets where performance concerns had been raised by Commissioners.

For August 2015, the Trust had met all the Monitor access and outcome measures. The number of other KPIs routinely reported to the Board had been expanded to include elements of all main contracts. With regard to Commissioners’ Contractual Targets the ‘Proportion of Patients with evidence of Care Plan shared’ was an issue as it fell below the threshold of 95% (performance at 86.5%). The Clinical Commissioning Group was therefore intending to impose a penalty of £28k per month (from October 2015) until compliance was achieved. There was therefore a strong focus on supporting clinicians with the highest number of unshared care plans. The Board received and noted the Trust’s Operational Performance at Month 5.

2015/108 Workforce Report Lisa Anastasiou introduced the report advising that: • Staff turnover had decreased 9.6% - (threshold 10.0%) • Sickness absence at 3.8% - remained low compared to other Trusts (threshold 4.5%) • Mandatory training at 82.3% - work was in place to address this (target 90.0%). An interim review of mandatory training, presented to the Quality and Risk Committee in June 2015 had set out a range of actions being undertaken to improve compliance • PDR completion at 70.5% remained an issue (target 90.0%).

The level of vacancies was a key challenge (19% FTE). This reflected a serious challenge nationally in respect of the recruitment of nurses and social workers. The use of bank and agency staff had therefore increased. This had been addressed by putting in place new NEP terms for bank staff to encourage them to remain with NEP rather than join an agency. In answer to a question from Chris Paveley, Lisa Anastasiou advised that the staff vacancy rate was also impacted on by early retirements. Lisa Anastasiou noted that new national rules regarding NHS agency expenditure came into place on 01 September 2015. The Board of Directors received and noted the Workforce Report.

2015/109 Quality Report Natalie Hammond advised that this report provided a status report including current activity, themes and trends. Significant progress had been made in the closure and completion of Serious Incident (SI) action plans. Key actions and learning related to improvement in the physical environments. Lower level incident reporting and closure/learning had also improved. Further training re incident reporting and investigation was being targeted to the lowest reporting area (West). The Patient Safety and Complaints Team was ensuring 100% compliance with acknowledgement and response targets for complaints. The Board of Directors received the Quality Report.

2015/110 Ward Staffing Levels (July 2015) Natalie Hammond advised that the report summarised the position for each ward with the planned and actual staffing as reported via Unify (National Reporting System). This identified those wards requiring exception reporting (rated as red or amber). These wards had been reviewed to ensure there have been no significant concerns regarding safety or quality of care. In answer to a question from Peter Little, Natalie Hammond confirmed that national guidelines regarding the staffing of Older Adult wards were not being breached by NEP, although there was a trend regarding difficulty in recruitment and retention. One option under consideration was the recruitment of general nurses as opposed to those with a specific mental health qualification. Action: Natalie Hammond, Director of Nursing & Quality

Improvement could also be achieved via the implementation of the full e-rostering system which could provide ‘real time’ information. The Board of Directors received the Ward Staffing Level report.

2015/111 Nurse Revalidation Natalie Hammond reported on the implementation of this new Nursing and Midwifery Council’s (NMC) revalidation system. From April 2016. registrants would be required to have declared that they met the requirements including; completing at least 450 hours practice, professional development and reflections on practice and declaring any convictions or cautions. The Trust had appointed a project lead who was working closely with the Director of Quality and Nursing and the Associate Director of Workforce. NEP had also joined the Nursing Times Group Access, which provided revalidation information and tools, supported by the use of NEP’s electronic staff record (ESR).

14 Actions to date included: • Workshops for nurses on NMC requirements • Reflective practice sessions across the Trust • Invitation to nurses to attend local sessions re portfolio development

Further actions included: • Revalidation Task and Finish Group to be convened • Review of appraisal documentation to enable the confirmation process required by NMC • Develop Intranet pages to access guidance and resources

Action: Natalie Hammond, Director of Nursing & Quality

NEP’s Project Manager would make every effort to ensure that all NEP’s registered nurses were compliant. NEP’s contingency plan was that any nurse not meeting the NMC deadline would be re-graded to Band 3 and able to work as Healthcare Assistant whilst matters were resolved. Dr Malte Flechtner asked that the legal implications of this measure be considered. Action: Lisa Anastasiou, Director of Workforce & Development

Risks included potential cost pressures as agency cover may be required re gaps in shift patterns. This was mitigated by the comprehensive process in place to implement the new arrangements. Chris Paveley asked for a regular update to the Board regarding the progress of this project. Action: Natalie Hammond, Director of Nursing & Quality

The Board of Directors received the report re Nurse Revalidation.

2015/112 Board Committee Verbal Report - Quality & Risk Committee (19 August 2015) Amanda Sherlock gave an update on behalf of Brian Johnson (QARC chairman). Discussion at QARC had centred on preparation for the CQC inspection and feedback from the work on NEP’s Quality Stars. Amanda Sherlock commented that QARC had discussed the issue raised earlier in the meeting re steps to improve compliance with mandatory training. QARC had also discussed the process for Serious Incident (SI) reporting, and had received assurance regarding progress in respect of completing investigations and sharing learning. Future work included reflecting on quality reporting structures and the interface with Audit Committee. The Board of Directors received the verbal report regarding the Quality and Risk Committee.

2015/113 Emergency Preparedness, Resilience and Response Assurance David Griffiths advised that he Health and Social Care Act 2012 set out the roles and responsibilities of NHS England, CCGs and providers of NHS funded services in relation to assuring NHS Emergency Preparedness, Resilience and Response (EPRR). NHS England required all providers to carry out a self-assessment against a set of Core Standards, and to produce an action plan to deliver any that were unmet. Under the EPRR Core Standards the Board was required to have sight off the annual self-assessment and action plan. The Board paper was therefore

15 considered by the Executive Management Team (EMT) on 14th September 2015 and an action plan approved. Against the 69 Core Standards the Trust achieved the following results regarding the core standards: • 0 - Red • 19 - Amber • 32 - Green • 18 - Not applicable to the Trust

An action plan for those standards rated as amber had been developed and was included in the detailed report. In answer to a point raised by Brian Johnson regarding the number of actions due for completion by March 2016, David Griffiths agreed to bring back a progress report to the Board in January 2016. Action: David Griffiths, Director of Resources The Board of Directors: i. noted the level of EPRR assurance achieved; ii. noted the results of the self-assessment; iii. noted the action plan for achieving full assurance.

2015/114 Medical and Non-Medical Education Update Dr Malte Flechtner gave an update including: • Appointment of 2 Education and Practice Development Facilitators • Strengthening of NEP’s ‘Grown our Own’ strategy, through an increase in the commissions for the Work-Based Learning (WBL) nurse training programme • 12 Health Care Assistants (HCAs) successfully completed their Foundation Degree in July 2015 • The next Health Education England ‘Quality Monitoring Review’ was due in October 2016 • GMC trainee survey; the Clinical Tutors were working with the Director of Medical Education to create an action plan. The Board of Directors noted the medical and non-medical education update.

2015/115 Summary of Board Decisions The Board of Directors noted the report Summary of Board Decisions.

2015/116 Execution of Deeds The Board of Directors noted the Execution of Deeds.

2015/117 Any Other Notified Business There was no other notified business.

2015/118 QUESTIONS FROM MEMBERS OF THE PUBLIC RELATING TO ITEMS ON THE AGENDA ONLY a) Workforce Report (Item 9b) - In answer to a question from Nigel Mountford relating to staff recruitment and retention, Lisa Anastasiou commented on the measures to address this including the increase to NEP’s rates for bank staff.

b) CQC Improvement Plan & Framework (Item 5) - Clive White commented on the apparent delay in work to doors at the Linden Centre. Andrew Geldard advised that works to the doors had been completed during July and August 2015; further improvements were planned.

c) CQC Improvement Plan & Framework (Item 5) - In answer to a question from Clive White, Vince McCabe advised that NEP had facilitated c.350 referrals to the Samaritans.

d) Finance Report for the 5 Months Ending 31 August 2015 (Item 8) - In answer to a question from Clive White, David Griffiths advised that the financial position was very challenging, and he did not expect the deficit to be resolved in-year. An update would be brought to the next meeting of the Council of Governors. Action: David Griffiths, Director of Resources

e) Workforce Report (Item 5b) – Clive White noted his concern at the level of PDR completion.

f) Organisational Response to the Essex Strategic Review: Strategic Options Case (Item 7) - In answer to a question from Adrian Faiers, about the need to work closely with Commissioners, Andrew Geldard commented on the difficulty of achieving this in the context of the current fragmented commissioning arrangements.

g) Organisational Response to the Essex Strategic Review: Strategic Options Case (Item 7) – In answer to a question from Andrew Smith, Mike Chapman advised that a Communications plan had been drafted.

h) CQC Improvement Plan & Framework (Item 5) – In answer to a question from Lisa Morris, Andrew Geldard advised that the timescale to implement improvements to meet regulatory requirements varied according to the source of the recommendation and the level of priority. Lisa Morris advised that it was her understanding that an internal recommendation in respect of wardrobe handles had not been actioned for over two years at the time her son died in the Linden Centre in 2008. Andrew Geldard and Chris Paveley advised that this issue would be reviewed following the meeting. Action: Andrew Geldard, Chief Executive i) CQC Improvement Plan & Framework (Item 5) - In answer to a question from David Bamber, David Griffiths advised that improvement work to NEPs’ premises in response to the CQC inspection was continuing as quickly as practicable. j) Chief Executive’s Report (Item 4) - Sarah Burchall, commented that in her experience the implementation of Journeys had not been a positive experience for service users and asked how a merger of NEP and SEPT would help service users. Chris Paveley advised that the Outline Business Case (OBC) would need to articulate the range of benefits to service users. k) CQC Improvement Plan & Framework (Item 5) – Sydney Dyne reported that his grandson had not had a care plan in place. Vince McCabe advised that having an effective care plan in place for service users was a key priority

17 for staff. Natalie Hammond commented further on the implementation of more recovery focused care plans.

l) CQC Improvement Plan & Framework (Item 5) – Melanie Leahy commented on the work to doors at the Linden Centre and asked to see the improvement works. Andrew Geldard agreed to consider this request. Action: Andrew Geldard, Chief Executive

In answer to a question from Melanie Leahy about the 60% target uptake of STORM training (for staff working with individuals who are thinking about suicide or may be self-harming), Natalie Hammond and Lisa Anastasiou advised that the training was intensive and not appropriate for all staff. In answer to a question from Melanie Leahy about the publication of staffing levels on wards, Natalie Hammond advised that this was published on the NHS Choices website. Melanie Leahy then asked if NEP provided the required staffing where additional observations were required, adding that she recalled that Natalie Hammond had commented in previous Board meeting minutes that “staff don’t really apply themselves with observations if we are short staffed then they lower the observations and they decide whether they are going to do them or not...” Natalie Hammond replied that she had not made this statement. Chris Paveley asked Melanie Leahy to produce the minutes to which she was referring as this represented a serious professional issue. Dr Malte Flechtner stated that patient safety, including maintaining appropriate observation levels was of primary importance. He added that a single person on the ward may not decide to reduce the observation level, the relevant team, including medical staff, made the decision, taking safety firmly into account. Vince McCabe added that the Ward Staffing Level report discussed earlier in the meeting evidenced a commitment to safe staffing thresholds, adding that staffing levels reflected acuity. Melanie Leahy then commented on a letter that she had circulated to Board members, which she felt was self-explanatory. She had questions about her son’s death that she felt remained unanswered.

Melanie Leahy then commented on the remuneration of executive directors which she understood to be an average of £180k with the medical director receiving £400k. Chris Paveley advised that these figures were not correct. The correct figures were noted in the Remuneration Report in the Annual report and Accounts which were posted on NEP’s website. Chis Paveley added that public sector remuneration was subject to close scrutiny from central government, and locally from stakeholders including foundation trust governors.

Signed:

Chairman 25 November 2015

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 3b

Date: 25 November 2015

Title of Report: Matters Arising from the Minutes of the Meeting held on 23 September 2015

Lead: Chris Paveley, Chairman

Subject, Purpose and Recommendation: The Board of Directors is asked to discuss matters arising from the previous discussions and actions of the Board, including any issues raised by members of the public (attached).

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

Matters Arising from the Minutes of the Meeting in Public held on 23 September 2015

Action Points

2015/102 Chief Executive’s Report In answer to questions from Brian Johnson and Amanda Sherlock, Vince McCabe confirmed that a Board report on the implementation of Journeys would be brought to the next Board meeting. Action: Vince McCabe, Director of Operations The Board of Directors noted the Chief Executive’s Report.

2015/103 CQC Improvement Plan and Framework In answer to concern raised by Chris Paveley regarding personalised care plans, Natalie Hammond commented on NEP’s new model care plan, to be implemented for inpatients during October 2015. Action: Natalie Hammond, Director of Nursing and Quality

The Board of Directors: i) noted the actions taken in response to the initial findings of the CQC inspection held between 24th and 27th August 2015;

ii) noted that an initial Trust action plan had been developed in response to the CQC initial feedback with Quality Improvement Panels to be implemented to progress the issues raised.

Action: Natalie Hammond, Director of Nursing and Quality

2015/110 Ward Staffing Levels (July 2015) . In answer to a question from Peter Little, Natalie Hammond confirmed that national guidelines regarding the staffing of Older Adult wards were not being breached by NEP, although there was a trend regarding difficulty in recruitment and retention. One option under consideration was the recruitment of general nurses as opposed to those with a specific mental health qualification. Action: Natalie Hammond, Director of Nursing & Quality

2015/111 Nurse Revalidation Further actions included: • Revalidation Task and Finish Group to be convened • Review of appraisal documentation to enable the confirmation process required by NMC • Develop Intranet pages to access guidance and resources Action: Natalie Hammond, Director of Nursing & Quality

Chris Paveley asked for a regular update to the Board regarding the progress of this project. Action: Natalie Hammond, Director of Nursing & Quality

The Board of Directors received the report re Nurse Revalidation.

2015/113 Emergency Preparedness, Resilience and Response Assurance In answer to a point raised by Brian Johnson regarding the number of actions due for completion by March 2016, David Griffiths agreed to bring back a progress report to the Board in January 2016. Action: David Griffiths, Director of Resources

h) CQC Improvement Plan & Framework (Item 5) – …Lisa Morris advised that it was her understanding that an internal recommendation in respect of wardrobe handles had not been actioned for over two years at the time her son died in the Linden Centre in 2008. Andrew Geldard and Chris Paveley advised that this issue would be reviewed following the meeting. Action: Andrew Geldard, Chief Executive

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 4

Date: 25 November 2015

Title of Report: Chief Executive’s Report

Lead: Andrew Geldard, Chief Executive

Subject, Purpose and Recommendation: The Board of Directors is asked to receive the attached update from Andrew Geldard, Chief Executive.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

22 Chief Executive’s Report Strategic Objective 3 ‘NEP will continue to improve patient experience (November 2015) 5. The proportion of Service users saying Friends & Family Test continues to be collected for inpatient areas and was extended to community they are likely or extremely likely to patients from August. The Picker Institute is managing the process and we will be able to break down Chief Executive’s Report (June 2013) recommend our services continually responses by team. First cut community data will go to RGE in December. Preparations are underway increases for the 2016 National Community Patient Survey. September inpatient data shows 71% of service users All Together Better were either ‘extremely likely’ or ‘likely’ to recommend NEP (a 4% drop on the previous month.) • “At NEP we work in partnership to enable people to be at their best in mind and body” 6. The proportion of Staff saying they are Staff are invited to give feedback via an equivalent of the ‘Friends and Family Test’ 3 times a year (in • Our communities will have total confidence in our services, our staff feels a strong sense of belonging and satisfaction, and our partners be likely or extremely likely to recommend addition to the Annual Staff Survey) on whether they would recommend our services. Q2 results show proud to work purposefully with us. our services continually increases that 70% of staff would be ‘likely’ or ‘extremely likely’ to recommend NEP’s services for care and treatment, a 10% increase on Q1 and 57% as a place to work, a 10% increase on the previous Our Values: To our commissioners and key partners: We will listen, work with quarter. There was also an improved response rate which gives a margin of error of +/- 7% Humanity Our cause, our passion you, create ideas, demonstrate our effectiveness and flexibility, and Strive for excellence Creative collaboration earn recognition as provider of choice. Strategic Objective 4 ‘NEP will continue to improve patient outcomes’’ Commercial head, Community heart Keep it simple To our Staff: We will value everyone individually, promote 7. A clear outcome measurement The Short Warwick and Edinburgh Mental Health Wellbeing Tool has now been successfully Our Commitments: wellbeing, support involvement and encourage personal framework has been agreed and a implemented and the first quarter of reports is under development to inform the Trust’s understanding of To individuals and families: To work together, building on strengths, development and leadership; baseline set for continuous improvement. patient outcomes. This will be complemented by the QOL AD tool being used for patients with a to improve mental health and wellbeing. We will support teams in their delivery of best value, innovation and dementia diagnosis. excellence. Risk Area Key Risks Mitigation Comment Performance, Targets & Outcomes: Contracts: We have submitted our metrics for the second quarter and we are The 2015/16 contract reverted back to a block basis for the first 6 External • New relationships Establish personal contact. The Mental Health Strategic Review work has now anticipating the following ratings from Monitor: months pending a further review. Discussions are now underway Relations • New ways of working Understand CCG issues. concluded with significant recommendation for around how we move forward with commissioners in the second half • Emerging financial Work constructively. commissioning structures. A work plan for mental • Governance Risk Rating (GRR) - Under Review of the year. We are beginning to formulate our negotiating position positions Create value based proposals. health services is also envisaged. The Trust is on a • Financial Sustainability Risk Rating (FSRR): 2 – Under Review for the 2016/17 contracting round commencing before Christmas. Look beyond traditional MH base. working group with ECC looking at integration Participate in ‘whole system’ responses solutions across the county. Monitor are seeking further information from the CQC prior to confirming Regulator Issues - Monitor: a Governance Rating. Monitor continue to interact with the Trust in relation to our financial position with an expectation that a ‘break-even’ recovery plan is JOURNEYS Failure to properly Clear & extensive project plan in place with The transition to the new system of working is Finance: produced. Monitor have recently released a consultation document Programme engage staff, users, agreed milestones. Specific engagement & complete. The new teams have been formed and At the end of October the Trust’s financial position indicates EBITDA of looking at change to the payment mechanism for mental health carers & external communication plan designed to inform & involve caseloads have been transferred. £2.06m, and an underlying I&E deficit (excluding profit on asset sales) services for 2016/17 and beyond. stakeholders in care in decision making. Key work streams led by of £1.54m, which is £1.8m lower than Monitor plan. The I&E deficit to pathway & service senior clinicians. Recommendations from staff, A formal post implementation review is now date primarily reflects continued high usage of agency staff and CIP Regulator Issues - CQC: delivery model redesign. external stakeholders , carers & users of service underway which will be brought to the Board for slippage, together with lower levels of income in respect of the main The focus of CQC activity has been the comprehensive assessment will inform the final care pathways, service delivery consideration. contract. There also continue to be non-pay, premises and IM&T that took place towards the end of August. We continue to models and implementation and transition plan. pressures. £2.4m (76%) of CIPs have now been actioned. anticipate the publication of the CQC’s findings toward the end of Establishment of the Journeys Implementation , Contracts have now been exchanged for the disposal of Severalls and the calendar year. Transition Steering Group (JITSG) to drive the we anticipate contract completion in December. project plan (meets fortnightly). Governor Activity: Assurance/Governance: Clive White and Ray Hardisty have been confirmed as Lead and Additional information on how new clinical and Further phases of “Ward to Board” visits have continued. The ‘quality Deputy Lead Governors for the next 12 months. The proposed leadership models will be developed and star approach’ developed prior to the summer was used as a focus for merger with SEPT continues to feature highly on Governor operationalised using a Policy Implementation discussions with staff. agendas. Guide (PIG). This will ensure that a consistent approach is adopted across the organisation. Business Development: Membership: Regular discussion and feedback re. criticality of The transfer of CAMHS services to NELFT has now been completed. Current Membership is 5,717 with 273 affiliate members. There filling posts held and decisions made on patient The Trust continues to support the service out of hours by providing an were two member events in September, one on Epping and one in safety need. all age crisis service. Clacton, and one in Suffolk on 16th November. No member events The Trust has now made a bid to the Suffolk CCGs as part of their are planned for December, but will resume with one in Uttlesford in Primary Mental Health Services Procurement. January, Chelmsford in February and south Essex in March 2016. Cost Requirement to deliver Implementation of CIPs monitored via finance £2.4m of CIPs actioned to date. Of the remaining managers and Area Directors, with escalation via £0.8m balance: £0.6m relates to Journeys, which Strategic Objective 1 ‘NEP will be recognised as a leading provider of specialist mental health care’ Improvement £3.2million (3%) Programme recurrent CIP in Performance EMT in cases of non-delivery. Final has not yet been actioned in budgets, pending 1. Income from specialist The Trust has been successful in winning two of the three national pilots for supporting Veterans with Mental & 2015/16 without reconciliation of Journey’s CIP savings underway. identification of additional posts that could be mental health services will Health and Substance Misuse issues. The Trust is also exploring opportunities in Suffolk with local partners to Cost per Case detrimental effect on released after final reconciliation of old posts in rise year on year provide a range of primary mental healthcare. Income quality/safety; Weekly finance monitoring of cost per case scope and new appointments, and £0.2m relates to Achieve cost per case activity. 2014/15 schemes brought forward that are no 2. The increase in the Media coverage in September was more positive with 70% of coverage rated either positive or indirectly income targets. longer implementable and will need to be replaced national profile of NEP can positive. 10%was negative with the remaining 20% neutral. This dropped significantly in October with more in 2015/16. be demonstrated through its than 50% rated as negative due to a number of reports on NMC cases involving former staff. Only 25% of media and clinical/research coverage was positive or indirectly positive during the month. Broadcast coverage in October was very positive with a major BBC Essex programme with 2 doctors discussing memory clinics. Visits to the website profile CQUIN Failure to achieve the Project plans for 2015/16 completed and remain constant at c. 5,500 per month with around 20,000 page views per month. The Twitter channel has milestones and targets implementation underway. Q1 milestones achieved more than 1,600 followers and NEP sends out around 50 ‘Tweets’ and ‘Re-Tweets’ per month. The Facebook in the CQUIN schemes, with the exception of 1/3rd of scheme L3 – GP Channel is also growing with more than 600 ‘likes’. now worth 2.5% of Education (£33k). Q2 milestones are on track with Strategic Objective 2 ‘NEP will be a system leader and a partner in the development and delivery of integrated community services’ contract value (£2.0m) the exception of National CQUIN scheme N4b – Communication with GPs (£33k), which was not 3. NEP continues to provide Engagement with CCG thinking around individual programmes continues. NEP is actively involved with West achieved. There are concerns about the community services across Essex’s plans for an Integrated Care Organisation, is committed to “Care Closer to Home” in North East and achievement of the local CQUIN scheme L1 – North Essex continues discussions with the selected community services provider, ACE. Activity in West Essex is most Smoking Cessation where there are challenging advanced with alignment of services being considered around GP groupings. milestones on staff training (Q3 - £93k), recording of smoking status (Q4 - £47k) and delivery of brief 4. Positive engagement with The Essex-wide Mental Health Strategic Review has been completed with recommendations/options to achieve interventions (Q4 - £93k). Action plans are in place Commissioners and Partners short & long term provider sustainability, including that commissioners strengthen their leadership and and are being monitored via Performance EMT. in the integration agenda can commissioning structures. The report is currently going through the governance mechanisms of each

be demonstrated organisation and hopes to achieve aligned commissioning intentions around the integration agenda although 23 progress in West Essex is more advanced as above, and commissioning intentions are not yet reflective of the

Boston Consulting Group work.

Agenda item No: 5

Name of Meeting: Meeting of the Board of Directors in Public

Date: 25th November 2015

Title of Report: CQC Quality Improvement Plan Update

Lead Director: Natalie Hammond, Director of Nursing & Quality

Subject, Purpose and Recommendation:

The purpose of this report is to update the Trust Board on and actions achieved against the Quality Improvement Plan initiated from the initial feedback and subsequent written feedback from the CQC Inspection in August 2015.

The Board of Directors recommended to:

• Receive assurance regarding the actions taken in response to the initial findings of the CQC Inspection held between 24th and 27th August 2015

• Receive assurance that an initial Trust Action Plan has been implemented and is on track to deliver against initial timeframes in response to the CQC initial feedback. with Quality Improvement Panels monitoring the progress

• Receive ongoing communications and engagement with respect to the Trust’s response to the CQC Report and the involvement of Stakeholders in the oversight of sustainable improvements in the quality of care we provide.

Finance Implications: Capital planning will be required against some of the stated actions. It is unknown at this stage what cost implication will arise.

The costs of compliance with the CQC essential standards of quality and safety are embedded within operational delivery costs.

Clinical Implications: As detailed in the report.

HR Implications: None to note.

Legal and/or Regulatory Implications: Timely progress and completion of the actions identified is essential to the Trust’s CQC rating and Monitor’s view of the Trust.

Equality Implications: Equality and Diversity legislation is an integral component to registration.

Risks: N/A

24 Introduction

The Care Quality Commission (CQC) inspected the Trust in August 2015 using their new operating model which sets out the principles on how they will inspect and regulate all care services.

The aim of the new model is to get to the heart of patients’ experiences by looking at the quality and safety of the care provided, based on the things that matter to people also the leadership and governance of an organisation.

They look at whether a service is: • Safe • Effective • Caring • Responsive to people’s needs • Well-led

Based on the initial inspection feedback and subsequent formal letter the Trust has initiated a Quality Improvement Plan. The Trust is not in receipt of the draft full report and this report is expected by the end of the year.

The draft reports, outcomes and ratings will be presented and discussed at a Quality Summit, date pending, before the CQC publish the final report.

The purpose of the Quality Summit, which is the final part of the inspection programme, is to formally hand over the inspection reports to the Trust and partner organisations. It also serves to agree a plan of action based on the CQC inspection team’s findings as set out in the draft inspection reports.

The Quality Summit considers whether the actions planned by the Trust to improve quality are sufficient to bring about the required improvements, or whether additional steps need to be taken.

The Trust will receive the final reports and will be given a period of time, approximately 4 weeks, to respond to the CQC with a compliance action plan describing the improvements we would make to improve outcomes for people who use the services and achieve compliance with the regulations.

The Trust can expect to receive a list of ‘must undertake’ and ‘’should undertake’ as well as ‘could undertake’ within this process.

The Trust can be re-inspected by the CQC to ascertain that required improvements have been implemented.

Quality Improvement Plan

This Quality Improvement Plan and subsequent action is considered an initial step and will require further update as we receive formal confirmation of the inspections outcomes.

• The Quality Improvement Plan was agreed by the Board in September and shared with the CQC, Commissioners and presented at a Council of Governors event

• The Quality Improvement Plan has been a focus of the area management teams and key individuals to address detailed actions

• Each of the Areas Directorates have localised action plans and have established monitoring meetings 25 • The Quality Improvement Plan has a set date for key actions to be completed by the 30th November with further phased actions required at monthly and 3 monthly intervals

• Key objectives within the Quality Improvement Plan are summarised below. Actions achieved to date are also listed

Areas of Action

1. Quality Improvement Framework The Trust’s Quality Improvement Plan aims to address areas of concern identified within the written correspondence from the CQC. This will be achieved through an enhanced structure of Quality Governance and the implementation of a Quality Improvement Framework.

2. Derwent Centre Hub The use of the Derwent Centre ‘hub model’ for patients during the day as the building work is undertaken to provide new wards and the assurance to maintain a safe and therapeutic environment during this period.

3. S136 Facilities - Seclusion/De-escalation Rooms The provision of the correct design and fabric of the 136 suites ‘Places of Safety’ and seclusion facilities that meet the compliance standards as set out by the New Code of Practice April 2015.

4. Ligature Risk Assessments and Organisational Response Ligature risk management within the inpatient facilities across the Trust that can evidence residual risk management and action.

5. Care Plans and Individual Risk Assessments Risk assessment and care plans need development to be more personalised with patient consent and depth of content.

6. Therapeutic Environment of Inpatient Facilities Improving the therapeutic environment of inpatient units and practise of individualised care. It was recognised progress had been made towards eliminating mixed sex accommodation as per national guidance, but this requires progression from the initial stages.

Progress to Date

1. Quality Improvement Framework • The Quality Improvement Framework is based on the Institute for Health Improvement (IHI) principles of creating a High Reliability Culture across the organisation. The Trust recognises the need to confirm its strategic direction and the need for a programme of sustained improvement which will focus on quality improvement, quality assurance, and the management of risk.

• To promote responsive quality governance from Board level to ward level, Quality Improvement Panels (QUIP’s) will operate at all tiers of the organisation to fulfil quality governance requirements.

• This approach aims to systematically improve the quality of services. This panel will assess progress against quality indicators and metrics, risk registers and emerging trends/themes and respond with Board level support, risk escalation and responsive action to ensure progressive mitigation of risk and quality improvement.

26 • To ensure all staff are aware of the Quality Improvement Panels that operate from Board to ward to the existing governance structure within the Trust.

Actions Achieved o Communication via ‘intranep’ to all staff on the Quality Improvement Framework and structure of Quality Improvement Panels completed o Executive Management Team has been presented the Quality Improvement Framework and the Panel process o Ward Manager Event held to identify process and their role within the QUIP and information on the ‘Plan Do Study Act’ model o Monthly Area Quality Improvement Panels set - first held in October o Team Quality Improvement Panels held in the areas o Quality Dashboard with indicators for scrutiny completed o Meeting produced action chasing tables to progress improvements o Terms of Reference for Area QUIPs for sign off at November meeting

2. Derwent Centre Hub • Premises must be fit for purpose in line with statutory requirements and should take account of national best practice. • A review into the current use of the Hub should be inclusive of the fundamental standards

Actions Achieved o West Area Management Team met in September and developed an action plan against the requirements o Patients are assessed for suitability and choice for attendance at the ‘Hub’ o A patient ‘Hub’ leaflet has been created and forms part of the Trust’s Welcome Pack o Service User feedback on safety and experience through a Patient Safety Climate Tool is informing staff o Action plans are in place from the ‘you said we did’ leaflets o Processes for the ‘Hub’ are now in place - they include a protocol/flow-chart, adapted handover sheet and patient whereabouts board to identify patients movements and management of staff resources. A separate risk register is in place to report and manage risks for the ‘Hub’ specifically. An operational policy for the ‘Hub’ exists and a review of the wards’ operational policies has taken place o Leadership responsibility of the ‘Hub’ is also identified on a daily basis o OT support has been reviewed to support key activities within the ‘Hub’ o Environmental checklist is actioned daily; this also includes emergency equipment availability o Local induction of the ‘Hub’ has been completed for all staff and continues as required, this includes emergency equipment o Resource has been identified to increase OT availability to the wards at the Derwent Centre o A new programme of activities has been established o A process of monitoring and progressing estates required actions is in place o An independent overarching review of the ‘Hub’ model is being conducted from the 16th November to the 4th December by Rachel Newson. This review will identify whether the ‘Hub’ model is ‘fit for purpose’ in light of fundamental standards set by the CQC

3. S136 Facilities - Seclusion/De-escalation Rooms The new code sets out standards for the design and fabric of these areas. The MHA Code of Practice states that seclusion should only take place in a designated seclusion facility that is not used for any other purpose.

The Code requires that the design of seclusion rooms or 136 areas should: • Allow for communication with the patient when the patient is in the room and the door is locked, for example, via an intercom • Include limited furnishings, which should include a bed, pillow, mattress and blanket or covering • Have no apparent safety hazards • Have robust, reinforced window(s) that provide natural light (where possible the window should be positioned to enable a view outside) • Have externally controlled lighting, including a main light and subdued lighting for night time • Have robust door(s) which open outwards • Have externally controlled heating and/or air conditioning, which enables those observing the patient to monitor the room temperature • Have no blind spots and alternate viewing panels should be available where required • Always have a clock visible to the patient from within the room • Have access to toilet and washing facilities . Actions Achieved An audit against compliance standards of the Mental Health Code was undertaken in the Trust in July 2015. o The Trust has implemented some actions through an estates plan. A capital program is required to be fully compliant o A group of key staff visited a new 136 suite at the Bethlem Royal Hospital to inform a capital estates plan o In some areas works have been undertaken such as appropriate viewing panels, intercoms and clocks

The Trust has undertaken a review into their prevention and management of violence and aggression training. It is compliant to the Positive and Proactive Care guidance issued by the Department of Health in April 2014. o Therapeutic and safe Intervention training has been developed for the Trust o De-escalation procedure was introduced with an escalation pathway o Phased restrictive intervention approach as per guidance o Increased focus on therapeutic engagement and de-escalation o Compliance to Code o Training Risk Manual developed o External validation of course content and approval occurred on the 9th Sept o The Trust is now part of a collaborative support network for external validation including Avon & Wiltshire, Oxford and Somerset Trusts o A quarterly Governance meeting has been established. Recent review into the use of restrictive interventions in the Trust shows a decrease in activity o All Trust Senior Tutors are receiving their training in this which will be completed by the 20th November o Full implementation of the training commences this year o The Trust will become part of the Restraint Reduction National Network in November

28 4. Ligature Risk Assessments and Organisational Response Ligature risk management within the inpatient facilities across the Trust should evidence action, risk management and residual risk informing a trust-wide ligature strategy aligned to capital planning.

• All in-patient areas have been re-assessed for ligature anchor points utilising a new risk assessment framework for anchor points • A new ligature risk tool across the inpatient pathway has provided a more detailed description of ligature risks present, the level of required management and residual clinical risk. A picture guide is being developed for each ward on their ligature risk and used to induct staff to the risk present. Clinical guidance on what constitutes a ligature anchor point risk and how to manage risk is part of this process • Emergency responsiveness and supporting systems are being reviewed by the Nurse Consultant for Physical Health • All emergency bags are being assessed and a seal-tag approach has been introduced • Ligature cutters have been assessed as to their availability and access in the ward environment • Wards will receive simulation training ‘in the event of an emergency’ to test level of awareness and competence • The Trust’s ‘intranep’ shared organisation learning website page has featured on ligature awareness how to mitigate risks and use of searching guides to assist staff learning • Safety alerts are communicated across the Trust in the event of an incident that can promote across site learning • A Strategy on ligature risk and a ligature removal programme will be presented to the Board with a Programme of Works

5. Care Plans and Individual Risk Assessments • The care and treatment of service users must be appropriate, meet their needs, and reflect their preferences

Actions Achieved o The My Care My Recovery Plan with staff and patient guides was launched in October for the acute inpatient pathway. It is now embedded within the acute adult pathway and evidenced through audit

o It is part of the multi-disciplinary ward round process for the acute inpatient pathway supported by the consultants in the acute adult pathway

o All Mid Essex acute staff have received a text book ‘Assessment and Care Planning in Mental Health’ by Nick Wrycraft 2015, and the other areas through their Area chief Nurses are utilising this book to guide staff. They are seeking monies to distribute to individual staff

o Initial feedback from staff indicates that the My Care My Recovery Plan enhances the relationship and engagement with patients

o The Care Plan Approach training which is mandatory has been reviewed in line with recovery orientated care. It does teach recovery focused care but will now be inclusive of the My Care My Recovery Care Plan

o An action-orientated Focus Group has been set up to formulate the process of all patient treatment and care planning. This Group is chaired by the Director of Nursing & Quality with medical representation, nursing representation, training and remedy (IT) representation. The outcome of the work will be to process map what treatment and care planning should occur 29 for the patient against what time frames ensuring that the IT system supports this

o Each ward is involved in an audit of care plans, reviewing them for consent, personalised care, and addressing patient needs

o Ward round review paperwork outlining and evidencing how consent to treatment has capacity to consent to treatment has been implemented

o Each of the Area Chief Nurses are overseeing care planning and risk audits within their areas with quality monitoring on the content of the planning

6. Therapeutic Environment of Inpatient Facilities Improving the therapeutic environment of inpatient units and the practise of individualised care.

Actions Achieved o An activity/therapy review of all areas has been conducted by the Lead Allied Health Professional o Progress has been made to delivering an activity programme in therapy provision that is 7 days a week and inclusive of some evenings o The programme includes groups from psychology, OT, pharmacy, community agencies, and gender specific groups. Educational groups on Maths and English are starting in Edward house o Further resources will be access to film nights with subscription to DVD film access, activity resource box and advice from employment officers. Wiis have also been procured o Difficulty exists in the recruitment and retention of gym fitness instructors’ progress has been made by sessional booking of a gym instructor to start in the Mid Essex area o OT protocols have been established and an OT & AHP Conference was held on the 5th November 2015 o Each Consultant OT is updating against their action plan weekly o Areas have increased resource in OT activity co-ordinator and/or support staff to assist in the delivery of this programme o A review of the wards against standards ensuring that no blanket restrictions are in place has been conducted by the Matrons and Area Chief Nurses o Single sex accommodation has been achieved in 6 out of 7 adult acute inpatient facilities and set admission criteria and practice informs the management of the inpatient facilities. Identified facilities are in place in accordance with the national guidance. Staff has received the guidance and senior staff monitor the use of any record breaches if they occur

SUMMARY: The above list is not exhaustive and many of the detailed actions are held with individuals or area teams.

The Quality Improvement Plan is being compiled with detailed action plans from areas and evidence of actions to be ready for the 30th November.

Leadership development and support has also been considered as key to the sustainability of the Quality Improvement Plan.

ACTIONS ACHIEVED Senior staff are conducting leadership ‘walk rounds’ to support and monitor progress. The implementation of the actions is monitored through this.

Leadership Development Days and a Ward Manager Leadership Programme are now established.

• The Director of Nursing holds quarterly Ward Manager and Clinical Service Manager events as a network of improvement • Ward Manager Development 3 day Programme was delivered on the 1st & 2nd November for 18 managers. A follow-up day is booked for the 8th December. Feedback from this event was ‘excellent’ and ‘inspiring’ • Leadership modules are being booked for managers, senior managers by Workforce Development - key topics are quality improvement and leadership of change

RECOMMENDATIONS: The Board is invited to note the report and the progress to date.

NEXT STEPS: The CQC inspection was a key milestone but not the end of our improvement journey. While the Trust waits for publication of the draft report and attends the Quality Summit, the improvement journey will continue with the support of area teams and led by the Quality Improvement Plan and Governance Framework.

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 6

Date: 25 November 2015

Title of Report: Ligature point Management and Removal Report

Lead: Natalie Hammond, Director of Nursing and Quality

Subject, Purpose and Recommendation:

The purpose of the report is to advise the Board of the proposed approach for ligature reduction across the Trust. The report describes the current compliance with national standards and work to date to manage anchor point / ligature risk and removal. The methodology is based on the presenting evidence base and a proposed risk profile to prioritise reduction and management.

The report sets out a phased approach for reduction and removal of ligature anchor points with associated costs. Therefore the first phase of the plan covers the immediate works to be completed by end of November 2015 focussing upon the issues directly raised by the CQC. The second phase covers the next six months and the content of this phase as been determined by two factors:

• the audits prioritised results of all inpatient units • the work that will require significant complex planning to achieve the best possible solution and major disruption to the ward environments.

The third phase is the future plan to reduce the risk in lower risk areas such as older adult inpatient facilities.

The report also describes how we manage current risk, the plan to further reduce this risk via the proposed work plan attached appendix (1) with oversight by Executive Team, so that reduction is achieved and risk is proportionally managed.

The Board of Directors is asked to note and approve the report.

Finance Implications: Financial implications outlined in appendix 1

Clinical Implications: Clinical mitigation part of the report and awareness training for staff.

32 HR Implications: The key implications relate to staff competency in risk assessment and safe staffing levels. Staff training, awareness raising and robust induction is essential.

Legal and/or Regulatory Implications: Focus on CQC compliance and demonstrating a robust management / governance around this area of risk

Equality Implications: N/A

Risks: N/A

33 North Essex Partnership University NHS Foundation Trust

Ligature Point Management and Removal Report

Purpose

The purpose of this report is to highlight those clinical areas where ongoing clinical risk still exists with regards to ligature. It sets out to recommend where works need to take place and why, highlighting location, cost of removal and methods used to mediate ongoing risk.

This report outlines the arrangements in place that relates to systems and actions to assess monitor and mitigate the risks to patients’ safety and welfare.

Introduction

Ongoing annual risk reduction capital expenditure for the last 5 years has focused on the removal of ligatures within the Trust, particularly in relation to the inpatient units that have not been subject of significant refurbishment.

The Risk Reduction Budget previously was informed by the results of the annual Patient Safety Audits prioritising the risk based upon the acuity of the patient group and high ligature points. The Programme of Works was reorganised when serious incidents occurred.

The Trust developed ‘Patient Safety Environmental Standards’ and these have previously been incorporated into the major capital schemes in the Trust such as the Rainbow Unit, Edward House and the Derwent Centre. The programme of redevelopment continues as the estate of the Trust is modernised further.

Previously the Trust has remained fully compliant with all Department of Health (DH) Alerts associated with high risk ligature/anchor points reported nationally.

During this period of time, additional work has taken place on existing high risk environments, namely priority 1 units, where high-point ligature anchors have been removed.

Background

34 Three-quarters of people who kill themselves while on a psychiatric ward do so by hanging or strangulation. A ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures.

Ligature removal in controlled environments (units with locked/managed doors, with acutely ill/high risk service users) is an essential control of risk; the assessment method is an ongoing environmental risk assessment.

Whilst harm from suspension has reduced, with the majority of incidents taking place in ‘uncontrolled’ environments, successful reduction within controlled environments has reduced, principally through focused ligature/anchor point reduction programmes.

The risk posed by a ligature point is greater if: • It is in a room in which patients spend time in private without direct supervision by staff (e.g. bedroom, toilet, bathroom) • It is in a ward/area used by high-risk patients (e.g. acute mental illness; high risk of suicide; challenging or chaotic behaviour; comorbid substance misuse) • The ligature point is between 0.7 metres and 4 metres from the ground • Nursing staff cannot easily observe all areas of the ward because of poor ward design or because there are too few nurses on duty

Audit Process

All inpatient units are audited every year. The audit process involves a multi-disciplinary team with representation from Risk Management, Estates and clinical staff. The Trust’s ‘Patient Safety Standards’ which incorporate the national alerts and lessons learnt from incidents both internal and external are audited and reviewed in an environmental assessment.

The audit covers all rooms on the unit where patient have access. It is critical that clinical staff participate in the audit process to ensure that all risks can be highlighted. It is also necessary too that a discussion on contingencies that staff take be integrated into the risk assessment, for example where access to facilities is only under the supervision of staff then this risk would be assessed lower than an area on the ward where observation is intermittent, such as bedrooms and bathrooms.

When touring the ward area specific checks for ligature points indicating high-risk are: • Rooms where patients spend time unsupervised • Areas of the ward that are difficult to observe because of the ward design • between 0.7 metres and 4 metres from the floor

The audit process now has a second stage that summaries and quantifies the risk for the staff. It is in this summary where the actions to mitigate the risks are agreed and acknowledged by staff.

35 The adjustment of clinical practice to mitigate risks either because the risk cannot be removed or where there will be a delay in mitigating the risk through a change to the environment. The following is a list of the likely adjustments to clinical practice that can be implemented. The appropriate clinical management of patients is of vital importance to manage the increasing attempts at self-strangulation: • Safe staffing levels that reflect the acuity and activity in the inpatient setting • Active engagement and observation with the patient, carers and family • Dynamic patient risk assessment • Clear identification of triggers and high risk times such as handover, nights and after leave and reviews • Comprehensive handover of key risks and formulated risk plan • Induction of staff particularly focusing on high risk areas/times on the ward • Allocation of rooms based on presenting risk • Searching of patients and the environment for risk items • Locking off high risk areas for limited periods – * however the use of blanket restrictions must be avoided and on each occasion it must be the least restrictive approach suitable to manage the risk • Monitoring changes in the environment and the use of environmental checks

This summary risk assessment is divided into four areas: • High risk – isolated areas such as bedrooms and bathrooms • High risk – other isolated parts of the ward environment such as quiet areas, isolated corridors • Medium risk – laundry and kitchen areas • Low risk – highly observed, communal areas and gardens

The assessment also takes into account the following: • Acuity of patient group using the P1- P3 rating developed by NPSA (appendix 1) • Designation of the room 1 - 3 rating (e.g. 3 being a bedroom and 1 being the communal area) • Rating of the ligature point: o How strong the point is and the height of the point in the room o If the ligature point is between 0.7 metres and 4 metres from the ground • Ligature point potential: o How easy would the point be to use, such as how accessible is the point • Finally the scoring takes into account the compensatory factors such as how observable is the area, what other contingencies can staff use to mitigate the risk – anti ligature design fixture, risk assessment of individual patients

The audit summary highlights the highest scoring risks and this leads to a decision in relation to the ligature point: • Remove/replace/report

36 • Adjust clinical practice • Fix and make good • Take immediate action

Doors are identified as high risk and require risk assessment. Doors are required for the purpose of a fire precaution and also for privacy and dignity reasons. Therefore all doors are risk assessed as part of the annual audit of all inpatient units.

The audits highlight doors as a significant risk for all mental health trusts. Mitigating action the Trust has taken include: • Curved /shaved doors in ensuites • Door-top alarm sensors • Outward opening doors • Introduction of piano hinges

Governance and Assurance

A programme of ligature removal which includes high anchor point and moderate anchor points will be monitored through and formally reviewed by the Risk and Governance Executive. The prioritised list of works includes a phased reduction plan agreed, based on risk profile that considers removal based on: • Acuity of patient group • Layout of the units addressing isolated areas of the ward • Length of time the unit will remain in use in its current configuration • Current plans for refurbishment/modernisation • Via staged reduction, once assessed through removal of high-level anchor points and moderate-level anchor points

There is a weekly update on progress to the Executive Team by Estates. The Patient Safety Audit Group meets every two months to review progress and identify solutions and emerging issues/risks.

The graphs below illustrate the Priority 1 Wards’ current level of risk and the risk level on the completion of the work programme. These indicate that a significant improvement in the level of environmental risks can be achieved.

37 18 Current risk level post Annual audit 2015 16 14 12 10 8 High Risk Areas 6 Medium Risk Areas 4 2 0

14 12 10 8 6 risk level after Improvement works High 4 risk level after Improvement 2 works Medium 0

The following flowchart summarises the governance arrangements around ligature point assessment and removal as outlined in the Trust Policy on the management of ligature risks in mental health units.

Patient Safety Audit Governance

Audited informed by Joint annual audit any National /local alerts / incidents All rooms / all inpatient units

Summary and Assessment

Using P1-3 system including identification of where clinical practice needs to be adjusted

Update patient safety hotspots training.

Audit results disseminated back to

teams.

Senior Clinician sign-off.

Update standards Audit results monitored by Patient Changes to document Safety Audit Group clinical policy Strong clinical representation (if appropriate) (if necessary)

Development of Risk Reduction Improvement Plan - Agreed with Estates Department. 39

Phase 1 & 2 : Current Work plan – completion by early June 2016 (see attached schedule)

a. A refresh of the systematic audit of environmental risk and ligature points has been completed and this new system promotes engagement of clinical staff in the audit process and the alignment with clinical practice – this will lead to staff members’ ability to understand where risks may present and how they can clinically manage / report these risks as per policy guidance.

b. Implementation of the work plan as detailed which covers all priority 1 areas – adult acute admissions areas across the Trust and Christopher unit. This will remove where possible high-level and moderate level anchor points in these areas.

c. The introduction of more specific heat maps and booklets to improve induction of staff to each inpatient ward and their specific issues.

Phase 3:

These are the actions detailed at the end of the plan, with dates to be advised, and principally includes the older adult wards:

a. This involves the review and reduction of the remaining ligature anchor points and future estate strategy, as it is modernised/refurbished or de- commissioned. Progress against this will be reported as part of an annual review.

Conclusion and Recommendations: Based on NPSA research, the highest risk areas should be the focus for ligature point reduction, namely acute ward environments. The attached plan highlights the areas that are the highest risk and the work required. The following units are considered a priority: Acute: The Linden Centre, The Lakes, Chelmer, Stort, Thames Hub, Peter Bruff – making all acute wards compliant and this relates to current recommended removal of ligature points Actions to date • All wards will have copies of their summarised audit results and staff to be aware of risk areas and the mitigation of risk through the adjustment to clinical practice where appropriate • All staff to undertake the patient safety hot spots training including awareness of their specific environment and high risk areas. It is anticipated that all acute inpatient units will receive this training by the end of November • Observations at high risk times is key to sustaining a safe environment for both service users and staff

40 Appendix 1

Priority Rating: Acuity of Patient Group

The Priority P rating system is used to define the risk factors, so targeting ligature point reduction can take place in a prioritised manner, these are as follows:

P1: Relates to services users who represent the highest risk of self-harm/or attempted self-harm and/or associated abscond risk, whilst managed in a controlled environment: P1 Acute adult wards where risk of self-harm is calculated as being 7 x higher

P1 Secure services, PICU and LSU

P1 Older people - functional

P1 CAMHS (outside research)

P2 Rehabilitation services

P3 Older adult organic

NPSA research around high risk times, areas and vigilant practice and should as general principles be considered in all areas of practice as a method to manage risk, if acuity is perceived to be increasing.

P2: Relates to service users who have been in a P1 unit, who are not actively at risk of self-harm or attempted self-harm, whilst managed in less controlled environments and who do not have active and associated abscond risks.

P3: Older Adult - Organic Relates to service users who require care and treatment primarily for conditions associated with organic mental illness, where risk of self-harm is low, and there is managed access and egress which mitigates the higher risks associated with wandering and falls.

41 42 43 North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 7

Date: 25 November 2015

Title of Report: Patient Survey 2015 - Results

Lead: Mike Chapman, Director of Strategy

Subject, Purpose and Recommendation: The Board of Directors is invited to receive a presentation from Mike Chapman, Director of Strategy re the Patient Survey 2015 – Results.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

44 North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No:

Name of Meeting: Meeting of the Board of Directors in Public

Date: 25 November 2015

Title of Report: Service User and Patient Experience and Involvement

Report Presented By: Mike Chapman, Director of Strategy

Subject, Purpose and Recommendation:

The Board of Directors is asked to note and approve the above approach.

1) Background This paper sets out some current thinking regarding Service User & Patient Experience & Involvement, and recommends a future approach for endorsement .

The drivers for this paper come from a number of directions:

• The continual improvement of patient experience as a key strategic objective for the organisation. • The community service user survey results which are not good enough and require clear action to address • CQC initial findings regarding service users’ involvement in their care planning • The Chairman and Executive concerns that the overall governance and reporting lines for this agenda are not as robust as they should be.

2) The Current Situation There is a lot of activity already in place to support the patient experience agenda. This includes: The Patient Experience Board (PXB) • In patient and community Friends and Family Test reporting (FFT) • Verbatim comment reporting from inpatient wards • User Involvement Forums in each Area Directorate • Service User Community Survey • Ward and team based “you said… we did” initiatives • Complaints information • PALS information • Communication Team links with Healthwatch • Governor Patient and Carer Experience group (PACE)

45 • Development of Service User & Carer Involvement strategy • Patient experience as a key strategic objective • Existing metrics which reflect user experience (e.g sharing of care plans)

Although there is lots of activity happening with the agenda, there are some key issues which need to be resolved:

• The overall leadership and reporting structures for this agenda are disparate • The reporting lines for Service User Involvement strategy development are not clear • Although all the activity above is happening it is not brought together coherently • Patient experience information could be used better to inform planning • Patient experience information could be used better to inform immediate service responses • Neither EMT nor the Board receive patient experience information in a coherent way • Although PACE reports into PXB, there is no reporting line to EMT or Board

The results of the 2015 Community Survey presented as the previous Board item also show deterioration from the position of best in region last year. Some of that deterioration may be explained by the major Journeys transformation which took place during the survey. However, the results are not acceptable and there needs to be a clear approach to improving service user and patient experience throughout the governance of the Trust and at all levels within the organisation.

3) Proposed New Approach

Although it is anticipated that the Patient Experience/user involvement agenda will transfer to the Director of Nursing in due course, the current priority for that post is the quality agenda and reaction to the recent CQC inspection.

The following is therefore proposed:

• Overall Executive Leadership will sit with the Director of Strategy until it can be transferred to the Director of Nursing next year • The Director of Strategy will Chair the Patient Experience Board • The Associate Director Lead for user involvement and Patient Experience will be added to the portfolio of the AD Social Care and will be Deputy Chair of the PXB • The Vocational Services Manager/Lead for Service User and Carer Involvement will report to the AD Social Care • The PALS function will transfer into the Quality Team in order to make complaints reporting coherent • The PXB will report to Performance EMT and Quality and Risk Committee/Board • Terms of reference for PXB to be updated with an expectation that Area Chief Nurses will act as the operation service link back to Areas for implementation • Amba Murdamootoo will co-ordinate the development of a Patient Experience “dashboard” collecting information from existing metrics, FFT, complaints, PALS etc for presentation to PXB, EMT and Board.

46 • Healthwatch to be approached as an external patient voice member of PXB

Attached to this paper are the following:

1. A structure chart showing proposed reporting arrangements

2. A draft patient experience “dashboard” to be used for collating information from a variety of sources and giving intelligence to the PXB, EMT, QARC and the Board

3. A more detailed draft overall action plan showing how and when the above will be achieved and specifically addressing issues raised by the 2015 Community survey.

The action plan will be discussed and further updated at the Patient Experience Board meeting on 27th November.

Clinical Implications: N/A

HR Implications: N/A

Legal Implications: N/A

Equality Implications: N/A

Risks: N/A

47 Patient Experience Reporting Structure Trust Board

Quality & Risk Committee

Performance Executive Management Team

Patient Experience Board

Governor Patient Local User Local User Local User & Carer Involvement Involvement Involvement Experience Group Corporate Trust Team reporting: Forum (Mid) Forum (West) Forum (NE) *Compliments *Complaints, PALS, Themes *Friends & Family Trust *Comments, Survey *PLACE metrics *Existing metrics (e.g. Care Plan Shared) *NHS Choices, Social Media Intelligence *'Pass it on' info from Chief Executive

48 Draft Improving Patient Experience Action Plan. Initiatives Key Deliverables Lead Timescale Formalise Approach for • Appoint a service user/ carer engagement lead • Mike Chapman • Completed service user/ carer • Update service user strategy • Raza Ahmed • Jan 2016 engagement • Organise a yearly service user/carer conference • Raza Ahmed • Dec 2016 • Update service user/ carer database • Raza Ahmed • March 2016 • Set up/ re-launch patient involvement board in the three CCG • Raza Ahmed/ AD’S • Feb 2016 catchment areas Operations • Themes identified from service user/ carer engagement from • AD’s operations • Ongoing Patient involvement board to be escalated to PXB for action • Transfer the function of PALS team to Making Experience • Mike Chapman • March 2016 Count Re-launch Patient Experience • Appoint Executive Director as chairperson • Mike Chapman • Completed Board • Review TOR (terms of reference) and membership • PXB members • Dec 2015 • Develop a Patient Experience Dashboard/Metrics • Amba Murdamootoo • Dec 2015 • Oversee delivery of work/ action plan. • PXB members • Ongoing • Update Action log and work plan at every meeting to address • Mike Chapman • Ongoing emerging issues • Report to Quality and Risk Committee, Performance • Mike Chapman • Ongoing Executive Management team and trust Board. • Healthwatch representative is appointed to sit on Patient • Mike Chapman • Jan 2016 experience Board Develop action plan for CQC • Improvement plan produced. • Mike • Dec 2015 Community mental health Chapman/Amba patient survey result 2015 Murdamootoo Service user/carer voice is • Consider how lived experience of services can be heard at • Chairman/Dermot • Jan 2016 heard by the Board Board meetings. McCarthy/PXB • Dates agreed for Board members visibility visits. • Karen Latham • Ongoing

• Patient Experience dashboard reported through QARC • Mike Chapman • Jan 2016 Seek patient • Roll out Family and Friends test for community teams and • Martin Creswell • Completed experience/views feedback inpatient wards. from key surveys • Facilitate next patient Community mental health patient • Martin Cresswell/ • March 2016

49 Initiatives Key Deliverables Lead Timescale survey by ensuring all the logistics are put in place in a timely May Thompson manner. • Commission a review of Journeys implementation • Vince McCabe • Underway • Facilitate next PLACE survey • Michelle Appleby • August 2016 Improve patient experience at • Roll out customer care training to all front line receptionists to • Tanise Brown • Dec 2016 every contact with services. create a culture of customer service and problem solving • Introduce “Hello my name is --- “ as a corporate welcome • Martin Creswell/ • March 2016 statement when answering phone call/ greeting service users Tanise Brown • Roll out “you said we did” poster/ newsletter to all clinical • Martin Creswell/ AD • June 2016 teams operations • Analyse key themes from complaints and compliments on a • David Wilmott/ • Ongoing monthly basis and feedback to operations staff via core Martin Creswell briefing

Research good practice and • Act on advice provided by Healthwatch at the Patient • Health watch • Ongoing feedback to Patient Experience Board. Representative Experience Board • Review and report what other leading trusts are doing to • Amba Murdamootoo • June 2016 improve patient experience Improve inpatient service user • Update inpatient therapy / activity programme to cover 7 days • AD’s operations • March 2016 experience (inpatient wards) a week and evening. • Strengthen the ward admission process to include overt • Ward Managers • March 2016 processes for involving patients in making decisions about their care and treatment • Introduce single sex wards and gender specific lounge on • Vince McCabe and • Completed inpatient units AD Operations • Launch “My care My recovery” care planning toolkit • Natalie Hammond • Completed • Daily community meeting held on wards • Ward Managers • Ongoing • “Medication Explained” groups held on wards • Lead Pharmacist • Ongoing • Roll out an agreed “Patient reported experience measure” • AD’s Operation • March 2016 tool • Design a “Meet the Matron Surgery” to enable relative, • Operational service • March 2016 visitors, and patients to have the opportunity to raise issues managers with matrons

50 Initiatives Key Deliverables Lead Timescale • Feedback from FFT cards is shared with the staff monthly in • Ward Managers staff/ business meetings Improve inpatient service user • Strengthen the care planning and involvement process by • Care coordinator/ • March 2016 experience (Community encouraging clients to fill the CPA care planning review Lead practitioner teams) template ahead of their care review meetings. • Improve communication to patients before and during their • All clinicians • March 2016 appointment by asking the following key questions? • Is there anything that you wish to discuss? • Do you feel that you had enough time to discuss the things that you wanted to? • What else can we do to help you? • Revisit CPA training to ensure that care plan formulation is • Carol Larcombe • Feb 2016 recovery orientated and addresses key aspect/ domain of service users life • Roll out an agreed “Patient reported experience measure” • AD Operations • March 2016 tool • Review access to Trustline and pathways to access support • Amba Murdamootoo • Dec 2015 in a crisis. • Review and update crisis card and information on crisis • Martin Creswell • Dec 2015 support on Trust website following review of Trust line. • Feedback from FFT cards is shared with the staff monthly in • Clinical Managers • Ongoing staff/ business meetings • Carry out a review care plans during weekly zoning meetings • Clinical managers/ • Ongoing Senior clinicians

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 9

Date: 25 November 2015

Title of Report: Mental Health Strategic Review - Update

Lead: Mike Chapman, Director of Strategy

Subject, Purpose and Recommendation: The Board of Directors is invited to receive a presentation from Mike Chapman, Director of Strategy re the Mental Health Strategic Review – Update.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 10

Date: 25 November 2015

Title of Report: Finance Report for the Seven Months Ending 31 October 2015

Lead: David Griffiths, Director of Resources

Subject, Purpose and Recommendation:

The Board of Directors is asked to note the report.

Financial Performance The detailed Financial Performance pack is attached to this report. The summary reports that the Trust has achieved EBITDA of £2.06 million before account is taken of interest, depreciation and PDC dividends.

After account is taken of depreciation, dividends and interest, the Trust is reporting an increased underlying deficit, compared to Month 6, of £(1.54) million year to date. This performance is £(1.9) million lower than the plan at Month 7. The variation to Monitor plan1 reflects: • Lower income than planned, (£0.3)m; • Significantly higher pay costs, £(1.28)m, caused by non-delivery of CIPs (£0.4m) and high agency spend; and • A small underspend on non-pay.

Once account is taken of profits received from the sale of a number of surplus properties the Trust’s final reported position as at Month 7 is a surplus of £0.19 million.

The year-end forecast has been updated for Month7. This suggests an underlying deficit of circa £(3.2m), and a surplus of £11.3m after profits on disposal. This is a small deterioration (£0.1m) from the M6 forecast, caused by lower income now expected from PICU risk share beds following the earlier closure of Shannon House.

A separate report considers the impact of the Trust’s forecast position on our 2016/17 financial assumptions and actions that could be taken to improve the position further.

1 For consistency with Monitor submissions, all variances are now recorded against Monitor Plan figures.

The Trust’s overall Cash position remains strong, with balances of £8.2m at the end of Month 7, which was £2.2m below plan. Similarly, the year-end cash forecast is below plan at £6.0m, and this assumes a further £8.2m of asset sales over the remainder of the financial year.

Monitor introduced a new Financial Sustainability Risk Rating (FSRR) from August, which includes two additional metrics (actual I&E surplus, and I&E surplus variance compared to plan) to those included in the old Continuity of Service Risk Rating (CoSRR). Under the new FSRR the Trust’s rating remains at “2”, which would be below plan, primarily as a consequence of the deteriorating I&E position.

Finance Implications: After consideration of identified risks the Trust is considered to be a going concern able to implement its approved strategic plans, although there are significant risks in maintaining a strong FSRR rating.

Clinical Implications: The financial performance of the Trust should not, of itself, constrain planned clinical performance.

HR Implications: The Trust’s reward strategy is affordable and within budget.

Legal and/or Regulatory Implications: The Trust has not been advised of legal action, or the risk of legal action, which may materially impact upon the Trust’s financial performance.

Equality Implications: N/A

Risks: The key financial risks to be managed within the plan will be: • delivery of the CIP in safe and timely fashion • achieving cost and volume targets for non-psychotic clusters for M6-12 (subject to contract) • achieving all of the CQUIN goals (value £2.3m) • achieving target occupancy for spot beds (value £4.2m) • carefully managing the cost of higher levels of observations on in-patient wards • managing sickness and other absences and the use of bank/locums • achieving forecast property disposal receipts • managing working capital and cash balances effectively in year to maximise benefit in PDC dividends calculation

55 Board Financial Performance Pack Month 7: 31st October 2015

Contact: David Lambert Associate Director of Finance [email protected] 01245 (2082) 546459 @NEPNHS NorthEssexPartnership

56 Index

Main Report: Page Page

Key Performance Indicators 3 Summary Business Areas 9 Financial Report Summary 4 Capital Programme 10 Income & Expenditure 5 Cost Improvement Programmes (CIPs) 11 Balance Sheet 6 Debtors & Creditors 12 Cash Flow 7 Glossary 13 Subjective Analysis 8

57 Page 2 Key Performance Indicators

YTD (Surplus) / Deficit against plan (Excluding Profits on Disposals) CIPs To Be Actioned (100) 3,500 3,000 100 2,500

300 2,000 1,500 500 (£'000) 1,000

700 500 0 900 M1 M2 M3 M4 M5 M6 M7 M8 M9 (£'000) M10 M11 M12 1,100

1,300 Capital Expenditure 1,500 £14,000k 1,700 £12,000k M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 Actuals Monitor Plan £10,000k £8,000k £6,000k Cash Flow Forecast £m £4,000k 14 £2,000k £0k 12 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Expenditure Committed Approved Expenditure Forecast Monitor Forecast 10

8 Disposals 8,000 6 7,000 6,000 4 5,000 4,000 Monitor Plan Updated for Severalls 2 3,000 Actual 2,000 0 Y/E Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 1,000 - Actuals / Forecast Monitor Plan Qtr 1 Qtr 2 Qtr 3 Qtr 4

58 Page 3 Financial Report Summary

Monitor Forecast YE 2014/15 Plan YE Variance I&E Summary * 2015/16 Finance Report for the Period Ended 31st October 2015 2015/16 £000 £000 £000 £000 Introduction Income (109,702) (106,634) (104,650) 1,984 This report presents the detailed financial performance for the month ended 31st October 2015 focusing on key indicators within the Pay 85,508 81,633 83,059 1,426 Monitor financial regime. It shows that to 31st October the Trust has earned EBITDA of £2.06m. The Trust's Balance Sheet shows Net Non-Pay 19,290 19,375 18,897 (478) Assets of £64.36m. Financing Costs 6,117 5,624 5,909 285 Financial Overview Net (surplus)/deficit 1,213 (2) 3,214 3,216 The Trust remains on course to deliver a surplus of circa £11.3m at year-end compared to the Monitor Plan of £14.5m surplus. Impairments & Profit on Disposals 16,067 (14,475) (14,563) (88) However, excluding exceptional items (impairments and profits on disposal) the Trust is forecasting an underlying deficit of £3.2m, Net (surplus)/deficit 17,280 (14,477) (11,349) (3,128) against a plan of breakeven. This is a small detorioration from the forecast at M6.

Monitor Balance at Forecast YE Plan YE Variance Cashflow Summary 31/03/15 2015/16 2015/16 £000 £000 £000 £000 The expected deficit in the year-end forecast is primarily as a consequence of escalating agency costs, with £6.0m spent on agency Cash Balance 10,353 8,680 6,025 (2,655) so far this year. Another contributing factor is the lower than planned delivery of CIPs. The forecast year end cash position of £6.03m assumes property sales income in line with Monitor Plan and no further income penalties. Ann Bud YTD Act YE Forecast Remaining Capital Summary The Trust Board agreed a recovery plan in September. The Trust was tasked with reducing outgoings on a month by month basis, £000 £000 £000 £000 primarly from agency spend. To date, no reduction has been demonstrated in agency spend, and £1m of savings still need to be Capital Expenditure and Loans 15,642 6,126 15,837 (195) identified. The savings of £0.99m identified in the plan are incorporated into the forecast, along with an estimated £1m income Property Disposals (General) (4,650) (3,714) (5,334) (936) reduction for contract negotiations on the main block contract. Teams have been asked to reduce discretionary spend (ie spend not directly related to patient safety or legal obligation) in order to further improve the position. Property Disposals (Severalls) (6,964) 0 (6,964) (6,964)

Financial Sustainability Risk Rating 4

Cash Low

Assuming all property sales proceed as planned, the cash balance at the end of the year will be £6.03m. This is approximately 17 - 3 day's working capital (excluding income). 2 Cost Improvement Programme (CIPs) The value of the Trust's cost improvement programme is £3.19m, of which £2.43m has been delivered or actioned from budgets at 1 Monitor Plan Month 7 in line with plans agreed with managers. £0.76m remains to be found. FSRR Level Level High of Risk: Capital 0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Spend to date is £4.82m, with a further £6.78m of orders pending delivery, against a budget of £13.03m.

The Severalls disposal has now exchanged with a target completion of December 2015 The Trust plans to dispose of a further seven properties during the year (one which was unsold last year), with expected receipts of £5.3m. To date, five properties have been sold Financial Risks resulting in a profit on disposal of £1.50m, one has had an offer accepted with the remaining property placed on the market in October EMT continues to monitor financial risks and delivering CIP opportunities for 2015/16 and beyond following granting of planning permission. - Delivering the CIP - Achieving Activity targets in Cost & Volume (Clusters 1-4) - Achieving cost per case occupancy targets Governance declaration - Ensuring CQUIN Income is secured The Board anticipates that the Trust will not be able to maintain a Financial Sustainability Risk Rating of at least 3 over the next 12 - Managing agency spend, sickness and other HR issues months. This is based on the Month 6 return to Monitor showing a FSRR of 2 and a forecast at year end of 2. - Risk Share agreements for inpatient beds - Managing cash & working capital - Planned property disposals (including Severalls) - Serco Creditor Payment Performance Assurance Statement The Financial Sustainability Risk Rating is a '2' at the end of October with a forecast of '2' for Q3 & Q4 * to ensure consistency with Monitor monthly submission, variance against Monitor plan is now shown in this table. 59 Page 4 Income & Expenditure

Overview YTD Actual against plan (Excluding Profits on Disposals) The Income and Expenditure account gives an overview of the performance of the Trust by main Income and Expenditure headings. Income is subdivided, separating Clinical Income from Other Income. Costs are analysed by main budget headings. (100) The table contains the current annual budget which may be adjusted in year and vary from the original plan. In addition to EBITDA and net (surplus)/deficit, the table also shows the year-to-date variance against the 100 phased annual budget. EBITDA and net (surplus)/deficit demonstrate the current trading position of the Trust whereas the variance gives an indication of performance against plan.

300

500 Income The Trust has had a shortfall of £321k of total income against Monitor Plan.

700 - The block contract for adults and older adults is reporting a shortfall in income YTD against the Monitor Plan of £119K for all income. This reporting line includes the adult block contract and the associate commissioner block

(£'000) 900 contracts. The variance to plan is a result the original plan being based on activity levels of 2014-15, cquin income for this year potentially at risk of achievement in Q1 and Q2, and the reflection of penalties for KPI's that have not been met. Basildon and Brentwood CCG moving to non contracted activity during this year has also impacted the plan under 1,100 this reporting line. BRU is also reported on the actuals here. The variance on Camhs is mainly due to phasing of the plan. Block contract Other is MVA and GP Services. 1,300 - Clinical Partnerships, which include the Essex County Council services and Herts County Council services are 1,500 reporting a surplus to the Monitor Plan YTD of £490K. This is a result of additional funding for the ECC S75 agreement part way through this year, the ECC Supported Employment Service Contract income moving to Central Income, and 1,700 Herts CC funding being agreed at £44K less than planned for the full year. M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 - Other Cost and Volume Contract Income includes Non Contracted Activity (including risk share), Rainbow Unit, Larkwood, PICU & Brian Roycroft Unit. The surplus income to plan YTD of £84K is a mixture of additional income from Actuals Monitor Plan the PICU risk share for the first six months, due to high occupancy on these two units, and high volume of adult risk share beds (which we charged on to commissioners). On the negative side, occupancy in the mother and baby unit is consistently lower than expected, as is the PICU cost per case income, with an occupancy of two inpatients for this year. BRU Plan is reported here.

- Other non protected clinical income includes the Criminal Justice Mental Health Team (CJMHT) contract. The original contract was believed to be in line with 14/15, however the service NEPFT provides was reduced resulting in a much smaller value contract for 2015-16. This has resulted in the large underachievement YTD to plan.

Full year YTD YTD Plan & Actuals Expenditure I&E Statement Month 7 Monitor Plan Plan Actuals Variance Total expenditure as at M7 was overspent by £1,245k compared to Monitor Plan; comprising a £1,275k overspend on £000 £000 £000 £000 Pay and £31k underspend on Non-pay. Block Contract: Adult & Older Adult (70,906) (41,343) (41,224) 119 Block Contract: CAMHS (4,246) (3,831) (4,284) (454) £615k of the Journeys CIP remains to be found. Agency spend remains high, with £6.0m spent so far ths year (£5.1m Block Contract: Specialist Services (6,373) (3,717) (3,709) 8 at M6). The Trust continues its drive to recruit to vacancies and is encouraging staff to join the bank, with a view to Block Contract : Other (2,061) (1,202) (1,460) (258) reducing agency spend, although the impact of this has been limited to date. Clinical Partnerships mandatory services (9,030) (5,268) (5,758) (491) Other - Cost and Volume Contract Income (4,390) (2,561) (2,645) (84) Other non-protected clinical income (1,616) (943) (396) 546 Spend on legal fees is high, and this is expected to continue moving forwards due to a number of upcoming court Total Clinical Income (98,622) (58,864) (59,476) (613) cases. Bad debts are higher than planned, largely due to unpaid invoices from other NHS organisations. Spend on Education and Training (5,328) (3,108) (2,832) 276 premises remains higher than planned, as buildings have not been vacated in accordance with plans, and spend on Other Income (2,382) (1,390) (614) 775 telephones and ICT remains high. Research and Development (302) (176) (295) (118) Total Other Income (8,012) (4,674) (3,741) 933 Total Income (106,634) (63,538) (63,217) 321 Pay 81,633 48,514 49,789 1,275 Drug costs 1,870 1,091 1,153 62 Income Expenditure Clinical Supplies & Services 412 240 251 11 Other Secondary Commissioning Costs 1,094 638 180 (458) 16% Non Pay - Other 15,999 9,431 9,785 354 Non-pay costs 19,375 11,400 11,369 (31) Block Total costs 101,008 59,913 61,158 1,245 Income Other EBITDA (5,626) (3,624) (2,059) 1,565 78% Drugs Clinical Total Depreciation 3,579 2,087 2,249 162 3% 14% Total Interest Receivable (31) (17) (29) (12) Total Interest Payable - inc WC facility 467 272 277 5 Unwinding Discount Provisions 0 0 79 79 PDC Dividend 1,609 938 1,022 84 Other 3% Net (surplus)/deficit before impairments (2) (345) 1,539 1,884 Pay Impairments & Profit on Disposals (14,475) (9,143) (1,735) 7,407 Ed & Train 82% Net (surplus)/deficit (14,477) (9,487) (196) 9,291 5%

60 Page 5 Balance Sheet YTD F'cast Y'end Overview Balance Sheet as at Month 7 2014/15 YTD Act Monitor 1516 The balance sheet is a snapshot of the Trust's financial position at a point in time. Plan £000 £000 It identifies: Fixed Assets, Liquid Assets, Liabilities, Taxpayers' Equity. Assets, Non-Current The Continuity of Services risk rating uses the Trust's liquidity ratio (broadly current assets less current Property, plant and equipment 79,370 81,498 85,865 89,892 liabilities) to assess the financial strength of the Trust. Inventories 57 68 57 57 Non NHS Trade Receivables - Non Current 0 0 18,341 18,341 24 YE 2014/15 Month 7 NHS Trade Receivables - Non Current 24 11 11 Provisions Total Assets, Non-Current 79,451 81,576 104,287 108,301 Due <1 Year Due >1 Year Total Due Due <1 Year Due >1 Year Total Due Assets Current Severalls Disposal 10,067 10,067 - 10,006 10,006 NHS Trade Receivables - Current 4,129 9,510 9,720 3,884 Early Retirement 184 2,066 2,250 184 2,003 2,187 Impairment of Receivables (147) (337) 0 (139) Injury Benefit 57 831 888 57 803 861 Other Receivables - Current 832 140 834 783 Serco Contract Delays ------Accrued Income 941 772 941 885 Property Costs 1,210 1,210 624 - 624 Prepayments - Current non-PFI 467 841 1,109 439 Income 406 406 683 - 683 Non Current Assets Held For Sale 15,117 13,763 186 0 Other 2,544 2,544 1,424 - 1,424 Cash (Government Banking Serv) 10,327 8,141 12,389 6,025 Total 4,401 12,964 17,366 2,972 12,812 15,784 Cash (Commercial Bank) 26 23 0 Total Assets - Current 31,691 32,852 25,179 11,877 Accruals YE 2014/15 Month 7 Total Assets 111,142 114,429 129,466 120,178 Liabilities Current Annual Leave for Staff 665 665 Bank Loan less then one Year (2,615) (2,615) (2,615) (2,615) Property and Associated Costs 53 191 Deferred Income - Current (601) (6,516) (6,367) (1,414) Staff payments 304 60 Provisions for liabilities and charges - Current (4,401) (3,391) (3,276) (2,699) STARS - 69 Tax Payables, Current (1,543) (1,422) (1,543) (1,428) Loan Interest 41 69 Trade Payables Current (1,889) (1,557) (1,556) (1,797) Other 2,859 2,215 Invoice Accruals (2,438) (752) 0 (2,320) Total 3,922 3,269 Other Trade Payables Current (486) (974) (3,901) (462) Capital Creditors (647) (894) (647) (616) Notes Accruals, Current (1,484) (2,517) (1,443) (1,412) Impairment of receivables has increased significantly due to loss of CQUIN income. Prepayments include £151,000 PDC dividend creditor 0 (146) (402) 0 of IT costs, £109,000 of lease car costs and £130,000 of rent costs. Accrued income includes £375,000 cost per Interest Payable on interest bearing borrowings 0 (69) (123) 0 case income, £144,000 ECC income, and £149,000 of CQUIN income. Total Liabilities, Current (16,103) (20,852) (21,873) (14,762) Net Current Assets/(Liabilities) 95,039 93,577 107,593 105,416 Liabilities, Non-Current Deferred income includes £5,539,000 of contract income for CCGs and £828,000 for STARS- which has been Loans Non Current (15,096) (13,789) (13,789) (12,481) invoiced early. Pension Liability - ECC (3,032) (3,032) (2,156) (3,032) Provisions for liabilities and charges - Non Current (12,964) (12,393) (12,964) (12,534) The percentage of invoices paid within 30 days for month ended September 2015 is 83%. This is a decrease on last Other Liabilities, Non-Current (31,092) (29,214) (28,909) (28,047) month (87%) and this is largely due to the overwhelming volume of agency invoices being received. We continue to Total Assets Employed 63,947 64,362 78,684 77,369 work with Serco to drive further improvements including a drive to reduce the number of old outstanding invoices. Taxpayers' and Others' Equity Total Taxpayers Equity (63,947) (64,362) (78,685) (77,369)

61 Page 6 Cash Flow Statement

YTD Monitor Overview Cash Flow Statement Month 7 Actuals Plan The detailed Cash-flow statement shows how liquid resources are generated within the organisation, £000 £000 and how they are used. Funds are generated from operations combining EBITDA with movements in Surplus/(Deficit) from Operations (1,539) 175 working capital. Funds are expended on capital expenditure or exceptional items. The net cash flow is determined when loans, interest, dividends and changes in shareholders' equity are taken into account. Finance income/charges 328 36 Depreciation and amortisation, total 2,249 298 Impairment losses/(reversals) 0 0 Gain/(loss) on disposal of property plant equipment 0 (8,262) Notes PDC dividend expense 1,022 0 The EBITDA position contributes to the positive operating cash flows of £2,059k. Non-cash flows in operating surplus/(deficit), Total 3,599 (7,927) YTD cash flows from operating activities are a net inflow of £1,631k. Operating Cash flows before movements in working capital 2,059 (7,752) YTD total cash balances have decreased by £(2,226)k and the Trust's cash balance stands at £8,163k as at (Increase)/decrease in Inventories (11) 0 31st October 2015. (Increase)/decrease in NHS Trade Receivables (5,192) 0 Cashflow forecast commentary (Increase)/decrease in Non NHS Trade Receivables 692 0 Cashflow is based on the submitted Monitor plan for income and expenditure. (Increase)/decrease in accrued income 169 0 Property sales assumed - Severalls to exchange in December (Increase)/decrease in prepayments (374) 0 Remaining buildings in Q4. Increase/(decrease) in Deferred Income (ex donated assets) 5,915 0 Final cash position pending all assumptions above is £6million. Increase/(decrease) in provisions (1,010) (125) 0 Increase/(decrease) in tax payable (120) Loans Interest Repayment Month 7 Increase/(decrease) in Trade Creditors (2,018) 0 Rate Date Due <1 Year Due >1 Year Total Due Increase/(decrease) in Other Creditors 488 0 Increase/(decrease) in accruals 1,033 0 Crystal Centre Loan 5.33% Sep-18 978 2,442 3,420 Increase/(decrease) in other Financial Liabilities 0 (43) St Aubyn Centre Loan 2.65% Sep-21 736 4,054 4,791 Total Increase/(Decrease) in working capital (428) (168) Derwent Centre Loan 1.42% Mar-22 500 3,000 3,500 Net cash inflow/(outflow) from operating activities 1,631 (7,920) Derwent Centre Loan 2 2.17% Dec-29 400 5,600 6,000 Capital expenditure, total (4,572) (899) Total 2,614 15,097 17,711 Proceeds on disposal of property, plant and equipment 3,714 8,771 Interest received on cash and cash equivalents 29 3 Cash Flow Forecast Total Net cash inflow/(outflow) from investing activities (828) 7,875 £m Net cash inflow/(outflow) before financing 802 (45) 14 Repayment of commercial loans (1,307) 0 12 Repayment of non-commercial loans 0 (436) Interest (paid) on non-commercial loans 0 (87) 10 Interest (paid) on commercial loans (209) 0 8 Interest (paid) on bank overdrafts 0 0 PDC Dividends paid (876) (259) 6 Public Dividend Capital received 0 0 4 Drawdown of non-commercial loans 0 0 Drawdown of commercial loans 0 0 2 (Increase)/decrease in non-current receivables 13 0 0 0 Increase/(decrease) in non-current payables (571) Y/E Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Other cash flows from financing activities (79) 0 Total Net cash inflow/(outflow) from financing activities (3,029) (782) Actuals / Forecast Monitor Plan Net increase/(decrease) in cash and cash equivalents (2,226) (828)

62 Page 7 Subjective Analysis - Pay

Annual YTD YTD YTD WTE WTE WTE Overview Month 7 Budget Budget Actual Variance RAG Trend Budgeted Worked Variance Pay budgets represent approximately 80% of the Trust's total £000 £000 £000 £000 costs. The management of pay costs are fundamental to the Admin and Clerical 9,762 5,866 5,024 (842) 365.6 314.8 (50.8) financial success of the organisation. Admin and Clerical Agency 902 455 1,394 939 0.0 0.0 0.0 On the whole, pay costs tend to be "fixed" costs within the Trust CIPS - Pay (752) (440) 0 440 0.0 0.0 0.0 with most staff being paid via fixed salaries. In ward areas and AHPs 10,394 6,501 5,441 (1,060) 247.0 208.0 (39.0) other 24/7 services, enhancements are paid to recognise un-social AHPs Agency 8 5 45 41 0.0 0.0 0.0 hours, but again these areas tend to have relatively fixed AHPs-ECC Partnership 3,729 2,183 1,435 (748) 94.9 57.6 (37.4) establishments and pay costs. Ancillary/Maintenance 3,268 1,906 1,514 (392) 139.6 106.1 (33.5) Ancillary/Maintenance Agency 15 6 138 132 0.0 0.0 0.0 When pay costs vary, this tends to be a consequence of vacancies and the use of supplementary hours to cover staffing shortages or Medical Agency (3) (19) 1,416 1,435 0.0 0.0 0.0 higher level patient observations. Medical -NHS 12,433 7,555 6,740 (815) 139.5 105.0 (34.6) Nursing Agency 26 26 1,954 1,928 0.0 0.0 0.0 Nursing Agency Qualified 0 0 873 873 0.0 0.0 0.0 Nursing Agency Unqualified 0 0 132 132 0.0 0.0 0.0 Nursing -Bank Qualified 1,147 677 1,067 390 34.5 60.2 25.7 Nursing -Bank Unqualified 976 570 2,630 2,060 32.5 133.4 100.9 Nursing -NHS Qualified 26,923 16,147 13,015 (3,132) 638.2 519.0 (119.2) Nursing -NHS Unqualified 9,116 5,330 3,844 (1,486) 329.2 257.5 (71.7) Key Other Payroll Costs 0 0 2 2 0.0 0.0 0.0 Redundancy Payments 0 0 0 0 0.0 0.0 0.0 = On Plan Reserves (822) (100) 0 100 0.0 0.0 0.0 = Low Risk of under-achieving Senior Manager 5,540 3,227 3,125 (102) 83.7 72.9 (10.8) = High Risk of under-achieving Total Pay 82,663 49,895 49,789 (106) 2,104.7 1,834.4 (270.3) Notes Total Agency Spend as % of Total Pay West agency spend includes £304k of medical, £1.60m of nursing, and £218k of other. NE agency spend includes £494k of medical, £191k of nursing, and A West (19.8m) 17.3% £119k of other. r Mid agency includes £192k of medical agency, £972k of nursing, and e £160k of other. a NE (21.8m) 6.4% Corporate agency spend includes £283k on medical locums, £61k on nursing, and £300k on admin and clerical. a Mid (20.9m) n 11.0% CYP agency spend includes £195k of medical, £149k of nursing, and d £119k of other.

EE (1.4m) 60.2% BIS agency spend includes £209k of other. P Agency % a Enable East agency spend of £439k reflects the staffing model of y Corp (10.3m) 11.4% Associates used to supply projects to Enable East customers.

B CIPS - Pay includes £580k of Journeys CIPS which remain to be u CYP (6.6m) 9.9% achieved. d g e BIS (2.9m) 12.5% t 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

63 Page 8 High Level Forecasts

2014/15 Month 7 Actuals YE 2015/16 Movement on Forecast Overview Spend Movt on This page shows the actual change in Summary Income and Expenditure Actual M6 Actuals M7 Actuals RAG Trend M6 Forecast M7 Forecast RAG trend forecast spend compared to prior month, and the £000 £000 £000 £000 £000 £000 £000 change in year end forecast since last Income (100,987) (8,665) (8,569) 95 (99,426) (99,334) 92 month. Business Infrastructure Services 11,572 871 989 118 11,189 10,989 (200) Children & Young People Services 9,865 694 711 17 6,606 6,519 (87) Corporate 10,390 581 720 139 10,912 11,276 364 Key Mid Essex 22,855 1,858 1,868 10 22,317 22,347 30 = On Plan North East Essex 20,850 2,061 1,943 (118) 23,482 23,518 35 = Low Risk of under-achieving West Essex 21,027 2,039 1,952 (88) 23,840 23,607 (234) = High Risk of under-achieving Reserves 60 0 0 0 44 44 0 Total EBITDA (4,367) (562) (387) 175 (1,036) (1,034) 2 = Improved from last month Overheads 5,598 521 474 (47) 4,149 4,249 100 = Same as last month Impairments & Profit on Disposals 53 20 (195) (216) (14,553) (14,563) (10) = Worse than last month Net (Surplus)/Deficit 1,284 (20) (108) (88) (11,440) (11,349) 91 Notes The forecast in service lines is an assessment of the expected year-end position. These forecasts will be refined as we move forward to more accurately reflect the expected out-turn position. Reserves have now been exhausted for 2015/16. Detailed work is required to address the 2015/16 income reductions for future years (Reserves have funded these non-recurrently for 2015/16), and to address any additional expected reductions in income for 2016/17.

Income Income - Main Block Contract

Business Infrastructure Services There is a forecast reduction in month due to Procurement being transferred into Corporate. This is somewhat offset by one off Journeys telephony and mobile costs incurred in M7. These were not accrued for in previous months. There are no firm plans for further cost reductions in BIS for 15/16. Month on month spend has increased by £118k. Children & Young People Services The forecast has improved slightly from last month, partly due to the cessation of the CAMHS community contract this month. Month on month spend has increased by £17k.

Corporate The forecast has increased largely due to the movement of the procurement team from the BIS directorate. Month on month spend has increased by £114k.

Mid Essex The forecast remains largely in line with last month. Month on month spend has increased by £10k.

North East Essex The forecast remains largely in line with last month. Month on month spend has decreased by £118k.

West Essex The forecast has reduced due to an earlier than expected closure of Shannon House. Month on month spend has decreased by £87k.

Page 9

64 Capital Investment Programme

Annual Month 7 Current YE Monitor Overview Capital Programme Budget YTD Actuals YTD Variance Forecast YE Forecast A brief overview of capital expenditure only is included in this report. More detailed reports on £000 £000 £000 £000 £000 the progress of the capital programme are made to the Strategic Capital Group and Trust Board 1. Strategic Schemes throughout the year. Business Systems Development 691 488 203 728 731 Derwent Centre, Phases 2-5 8,800 3,384 5,416 8,189 8,800 The Board approved a capital programme at the beginning of the year totalling £13,027,000 plus Severalls Reprovision 300 0 300 300 300 £2,614,000 for loan repayments. Mobility Workflow 716 18 698 716 716 Extension to Rainbow Unit 70 65 5 74 70 The source of funds for the capital programme are internally generated funds (EBITDA), Microsoft Licensing 50 36 14 54 50 ECT Services 50 0 50 50 50 accumulated cash balance, and long term loans. Extension to Christopher Unit 535 193 342 573 535 CQC Compliance 0 0 0 720 0 The property disposal budget is based on the planned proceeds for the financial year. Derwent Centre Capping Off 450 191 259 450 283 1. Strategic Schemes Total 11,662 4,375 7,287 11,854 11,535 2. Replacement & Refurbishment 510 266 244 510 575 3. Infrastructure, H&S, PLACE 802 151 651 816 837 4. Capital Development 80 35 45 65 80 5. Contingency (27) (8) (19) (8) 0 Expenditure Total Capital Expenditure 13,027 4,819 8,208 13,237 13,027 The Trust Board have approved a Capital Programme expenditure budget of £13,027,000 and as 7. Loan Repayment 2,615 1,307 1,308 2,600 2,600 at Month 7 the Trust has incurred expenditure totalling £4.82m with a further £6.78m of services / Property Disposals (General) (4,650) (3,714) (936) (5,334) (5,850) goods raised pending delivery.

Property Disposals (Severalls) (6,964) 0 (6,964) (6,964) (6,964) Additional capital scheme approvals have resulted in a budget pressure of £210,000. Unbudgetted CQC compliance actions have been approved at a cost of £720,000. There are a number of other Capital Expenditure overspends which are somewhat offset by an underspend on the Derwent Centre of £611,000.

£14,000k The Derwent Centre cash flow forecast has fluctuated in the last couple of months as the project £12,000k profile has been refined. Since the report was finalised an updated cashflow forecast from the Trust's QS has been recieived and this is currently being reviewed, along with the overall £10,000k programme progress to assess the likely final year-end outturn on this scheme.

£8,000k Monitor Forecast

£6,000k As part of the Trust's reporting requirements, a capital expenditure forecast is to be submitted each financial year to Monitor. £4,000k

£2,000k As at Month 7, the Trust has spent 85% of forecast.

£0k Disposals Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Expenditure Committed Approved Monitor Forecast Expenditure Forecast Severalls The disposal of the Severalls (non operational) site is planned for the 2015/16 financial year and continues to progress with discussions ongoing. Completion hoped for in December 2015. Derwent Centre Phases 2-5 £16,000k Others

£14,000k The Trust have planned to dispose of seven properties (one which was unsold last year) in the £12,000k 2015/16 financial year with forecast receipts of £5,850,000. This has been revised to £5,334,282 £10,000k based on proceeds recieved and offers accepted. £8,000k As at Month 7, five properties have been disposed being High Beech, Glen Avenue, 7 Oxford £6,000k Cumulative Forecast Road, 2-4 Pitfields and Creffield Road. £4,000k Cumulative Expenditure £2,000k 9 Oxford Road is under offer and Old Ivy Chimneys is being marketed following receipt of planning £0k permission. YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 16/17 17/18 15/16

65 Page 10 Cost Improvement Programmes (CIPs)

Under/(Over) Committed Actioned Overview Efficiency Programme Month 7 RAG - achieved The Trust's longer term financial model plans for significant year-on-year savings generated by an internal £000 £000 £000 efficiency programme. These savings allow the Trust to respond to inflationary pressure and also to steadily HR & Workforce 20 20 0 improve its financial performance. The target relates to the initial list of initiatives compiled by the areas whilst Medical Services 214 214 0 the agreed CIPs were limited to initiatives with a status of 'green' or 'amber' i.e. those considered deliverable Strategy 13 11 1 within FY14/15. Actioned CIPs are where specific budget lines have been adjusted and delivery is underway Finance, Contract & Performance 156 156 0 whereas those "to be actioned" are where the budget lines to be altered are yet to be confirmed. Director of Operations 130 130 0 Total Corporate 532 531 1 Business Infrastructure Services 172 163 9 Key Mid Essex 350 285 65 = On Plan = Improved from last month North East Essex 1,301 1,159 141 = Low Risk of under-achieving = Same as last month West Essex 715 170 545 = High Risk of under-achieving = Worse than last month Overheads 120 120 0 CIPS Total 3,189 2,427 762 Income 14 14 0 Pay 923 751 172 Work has begun to identify CIPS for the 2016/17 and 2017/18 financial years. Journeys 1,550 970 580 Non Pay 702 693 10 CIPS Total 3,189 2,427 762 BIS £9k remains for unidentified CIPS. Mid & Secure Services £65k for undelivered Journeys CIPS. CIPs Achievement YTD North East & Rehab 1,800 £141k for undelivered Journeys CIPS. West & Substance Misuse 1,600 £373k for undelivered Journeys CIPS; £172k other pay CIPS brought forward from prior years.

1,400

1,200

1,000 CIPs made up of: £000 (£000) CIPs as per Monitor 2,354 800 Unachieved CIPs from 2014/15 835 CIPs Total 3,189 600

400 CIPs To Be Actioned 200 4,000

0 3,000 Income Pay Journeys Non Pay 2,000

Committed 14 923 1,550 702 (£'000) 1,000 Actioned 14 751 970 693 0 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

66 Page 11 Debtors & Creditors

Debtors Overview A change to the way that Commissioners pay Total Receivables Total Overdue Debt the Trust (in Summer 2014) has led to a one off increase in NHS debtors at the end of 16,000 M12 each month. This is due to invoices being 14,000 M11 raised at the end of the month for payment 12,000 early next month (previously invoices were M10 10,000 raised and paid in the same month). This M9 leads to an improvement in cash flow as 8,000 invoices are paid approximately two weeks

£'000 M8 6,000 earlier than last year. M7 4,000 M6 2,000 M5 - Notes M4 We continue to work hard to reduce level of M3 outstanding debt. Debt over 90 days is at its lowest level this year. Debt in the 30-60 day Total Trade Receivables Trade Receivables >90 days M2 range has dramatically increased in M7, this is M1 due to late payment of invoices by ECC and NHS England. These invoices have now been paid. Receivables Balances 14/15 Average Month 7 £'000 1000 2000 3000 4000 5000 6000 NHS Receivables 6,893 7,573 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 Staff Receivables 54 59 30-60 2142 1356 597 2901 563 300 2620 - - - - - VAT Due from HMRC 88 - 60-90 1851 1934 476 372 198 131 141 - - - - - Other Receivables 898 1,981 >90 1410 2184 1407 1235 433 606 423 - - - - - Total Trade Rec 7,933 9,612 Trade Rec >90 days 390 423

Creditors Creditor 30-day payment performance has reduced since last month to 83% (from 87% in M6 and and average of 84% in 1415). This is % Invoices Processed within 30 Days (Volume) largely due to the build up of agency invoices, as the NETSS team struggle with the increased 100% Payables 14/15 Average Month 7 volume of transactions. Finance is investigating a 90% NHS - 30 Days No. £000 No. £000 workaround to support the NETSS team in the 80% Paid Over 30 Days 9 67 15 224 short term. 70% 60% Paid Within 30 Days 42 398 34 312 NHS Total 51 465 49 536 50% 40% Non NHS - 30 Days No. £000 No. £000 30% Paid Over 30 Days 375 449 418 525 20% Paid Within 30 Days 1,670 2,162 2,151 2,752 10% Non NHS Total 2,045 2,611 2,569 3,278 0% Overall Paid 2,096 3,076 2,618 3,814 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 Paid Within 30 Days 81% 84% 83% 80%

NHS Non NHS Overall

67 Page 12 Glossary

AHP Allied Health Professionals MECCG Mid Essex CCG ARU Anglia Ruskin University NCA Non Contracted Activity BIS Business Infrastructure Services NETSS North Essex Temporary Staffing Solutions BRU Brian Roycroft Unit NLF National Loans Fund C&R Control & Restraint PBL Prudential Borrowing Limit CIPs Cost Improvement Programmes PbR Payment by Results CoSRR Continuity of Services Risk Rating PDC Public Dividend Capital CQUIN Commissioning for Quality and Innovation PLACE Patient-Led Assessments of the Care Environment EBITDA Earnings Before Interest, Taxation, Depreciation and Amortisation PSPP Public Sector Payments Policy ECC Essex County Council QIPP Quality Innovation Productivity Prevention GBS Government Banking Service RAF Return After Financing I&E Income and Expenditure RCI Reference Cost Index IAPT Improving Access to Psychological Therapies ROA Return on Assets IDTS Integrated Drug Treatment Service SLA Service Level Agreement JIP Joint Improvement Partnerships SPOR Single Point of Referral Service KPI Key Performance Indicators TM This Month LCFS Local Counter Fraud Specialist WTE Whole Time Equivalent LTS Long Term Sickness YTD Year to Date MDCR Maximum Debt to Capital Ratio YE Year End

68 Page 13 North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 11a

Date: 25 November 2015

Title of Report: Operational Performance Summary to 31th October 2015

Lead: David Griffiths, Director of Resources and Vince McCabe, Director of Operations

Subject, Purpose and Recommendation:

The Board is asked to receive and note the Trust’s Operational Performance at Month 7.

The format of the Operational Performance Summary has been amended for 2015/16. There are now three distinct sections: • Monitor’s Access and Outcomes Measures as defined in the Risk Assessment Framework; • Other KPIs; and • Contractual Targets where performance concerns have been raised by Commissioners.

Monitor Access and Outcome Measures For the month of October, the Trust has recorded that it met all 7 access and outcome measures contained within Monitor’s Risk Assessment Framework. Good progress contained to be made on CPA – 12 month formal review, with Mid reversing the small dip in performance in September, achieving the target in-month in October.

There are no areas of concerns with any other Monitor Access and Outcomes Measures

Other KPIs The number of other KPIs routinely reported to the Board has been expanded to include elements of all main contracts, including S75, Suffolk Health Outreach and GP Services.

KPIs 8-12 relate to the Trust’s main contract, and where a threshold has been set (KPI 8 and 11) this was met in October, although Mid continue to struggle with achieving the threshold.

KPIs 13-15 cover the Section 75 agreement with Essex County Council, Services for Vulnerable and Marginalised Adults in Suffolk and GP services respectively and trend data will be developed over the coming months. There are no specific areas of concern.

69 Contractual Targets with concerns

This section of the report summarises those contractual KPIs where commissioners have raised concerns through the issue of formal Contract Queries and/or Notices and which have the potential for a financial consequence if performance is not improved. Internal two-weekly progress meetings are being held with Areas to ensure progress in sustained as necessary. Indicators 17-21 have formal bi-weekly recovery trajectories agreed with commissioners.

Indicator 17 (% of patients with physical healthcare check) has consistently been above trajectory since April there are no issues or concerns with this indicator.

Indicator 18, Proportion of Patients with evidence of Care Plan shared, continued to show improved performance during October and we achieved the threshold value of 95% by the end of October. The total penalty payable to the CCG’s is therefore £56k (£28k for the months of September and Octover), and this has been included in the financial position in October.

Indicators 19 (Proportion of Patients with Crisis Plan in place) and 21 (% of Patients on S117 aftercare who have received annual review) continue to perform about threshold and we have requested that the formal Contract Query be closed moving forward.

Indicator 20 (% of patients with ethnicity recorded) remains marginally below trajectory but there are no fundmantal concerns over performance moving forward.

Now that performance on these contractual KPIs has been stablilsed, the focus of the Performance Team is now on supporting Areas in meeting thresholds associated with 2015/16 CQUIN schemes, particularly around smoking and physical healthcare checks.

Finance Implications: Financial plan – ensure costs contained despite rising activity. Potential loss of Commissioners’ reward monies if CQUIN quality / innovation targets not met or KPI with contractual penalties are not met.

Clinical Implications: Actions are being taken to achieve improved standards in recording; this should deliver positive change to patient experience and access to services.

HR Implications: N/A

Legal Implications: Failure to meet the access and outcome targets in the RAF may trigger a “governance concern” by Monitor; which could potentially lead to an initial investigation and/or enforcement action re Trust’s Licence.

Legal and/or Regulatory Implications: N/A

Risks: N/A

70 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST down = i same = 1 colours will change automatically

BOARD REPORT DASHBOARD downup = # = i

Indicator Target Mid North East West C&YP Oct-15 Quarterly to Date Performance Trend/Commentary

100% Care Programme Approach (CPA) patients receiving 95% 1 95% % Followed-up within 7 Days 97.9% 96.0% 100.0% 85.7% 97.0% 97.0% follow-up contact within 7 90% days of discharge i Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/15 % 2015/16 % Target

100% 80% Care Programme Approach 60% (CPA) patients receiving a 2 95% % Reviewed within 12 months 95.8% 97.4% 98.4% 97.0% 97.0% 40% formal review within 12 20% months # 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/15 Valid 2015/16 Valid Target

10%

Minimising delayed transfers Less than or 5% 3 0.0% 0.0% 4.4% 0.0% 1.1% 1.1% of care equal to 7.5% 0% 1 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % 2014-15 % 2015-16 DToC Target

100% Admissions to inpatients 90% services had access to crisis 80% 4 95% % Gatekept 100.0% 98.2% 100.0% 98.9% 98.9% resolution home treatment 70% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Teams # 2014/15 Gatekeeping 2015/16 Gatekeeping Target

A. A. Monitor Compliance Framework Meeting commitment to 20 5 serve new psychosis cases 95% 100.0% 266.7% 38.7% 139.8% 139.8% 10 0 by early intervention teams # Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar EIP 2014/15 EIP 2015/16 EIP Target

Overall 99.0% 99.1% 98.7% - 98.9% 98.9% 100% NHS Number 97.7% 98.1% 95.5% - 97.3% 97.3% 99% 98% Data completeness – Date of Birth 100.0% 100.0% 100.0% - 100.0% 100.0% 97% 6 97% 96% identifiers (aggregate) Postcode 98.4% 98.6% 98.5% - 98.5% 98.5% 95% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Gender 100.0% 100.0% 100.0% - 100.0% 100.0% i 2014/15 % 2015/16 % Target GP Practice 98.8% 98.9% 99.4% - 98.9% 98.9%

100% Overall 87.5% 89.5% 84.6% - 87.7% 87.7% 80% Data completeness – 7 50% Accommodation 87.0% 91.8% 88.1% - 88.5% 88.5% 60% outcomes (aggregate) 40% Employment 89.8% 91.8% 88.5% - 90.1% 90.1% # Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/15 % 2015/16 % Target HoNOS in past 12 Months 86.6% 87.8% 80.2% - 86.2% 86.2%

71 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST down = i same = 1 colours will change automatically

BOARD REPORT DASHBOARD downup = # = i

Indicator Target Mid North East West C&YP Oct-15 Quarterly to Date Performance Trend/Commentary

100% 100% 80% 60% Percentage of carers who have been Carers Assessments 40% 8 75% offered an assessments and 58.2% 95.1% 92.9% 75.0% 75.0% 20% Completed subsequently accepted 0% i Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014-15 2015-16 Target

103.9% 103.9% Adults of working age 105.4% 102.9% 103.5% 120% Inpatient Occupancy Rate, Older Adults 103.5% 103.7% 93.0% 99.7% 99.7% 9i 90% 100% excl Leave PICU 48.8% 48.8% 48.8% 80%

Low Secure 88.1% 91.5% 94.5% 60%

Adults of working age 111.1% 106.6% 106.0% 107.9% 107.9% 40% Inpatient Occupancy Rate, Older Adults 104.5% 104.4% 93.0% 100.2% 100.2% i Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 9ii incl Leave PICU 49.6% 49.6% 49.6% % 2014/15 % 2015/16 OBDS Target (excl Leave) Low Secure 91.0% 91.0% 91.0%

22% Emergency Re-admissions 16% within 28 days of previous 10 % Readmissions 8.5% 16.7% 19.4% 0.0% 14.1% 14.1% discharge (Governor 10%

B. B. Other KPIs selected KPI) 4% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

100% 80% 60% 11 ICD Diagnosis 95% At Inpatient Discharge 95.8% 97.3% 100.0% 100.0% 97.6% 97.6% 40% 20% # 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

A. Monitor Compliance Framework Active Clients in Month 5,430 5,149 3,300 13,879 13,879

MH Cluster Assigned 5,533 4,817 3,459 12,557 12,557 12 MH Clusters TBA Valid Cluster Assigned 3,767 3,659 2,394 9,820 9,820

% Valid 68.1% 76.0% 69.2% 78.2% 78.2%

72 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST down = i same = 1 colours will change automatically

BOARD REPORT DASHBOARD downup = # = i

Indicator Target Mid North East West C&YP Oct-15 Quarterly to Date Performance Trend/Commentary

100% 93% 18+ years assessment in 4 wks 100.0% 61.5% 60.0% 75.0% 75.0%

% Social Care Service Users in 80% 41.7% 26.9% 38.8% 32.8% receipt of a personal budget Assessments carried out in 4 weeks has improved against 13 Essex County Council the previous month 95% Review of Secion 117 94.0% 97.0% 98.6% 96.3%

111 per month Carers Assessments Completed 133.0% 95.8% 94.7% 109.1% 109.1%

90% Registered with GP and/or Dentist 92.0%

97.2% 90% Ethnicity Recorded Little variance between months on these indicators, 14 Health Outreach however care plan performance has dropped to just above 90% Accommodation Status 98.0% target Other KPIs

95% Percentage of Service Users with a 95.3% Care Plan

Acorns 89.8%

Performance improved for Acorns and Dilip sabnis, but St 15 Dilip Sabnis 95% % of maximum QOF points achieved 87.2% Clements dropped by 3.7% A. Monitor Compliance Framework St Clements 69.9%

Note: KPI 8 (CCG set) measures the proportion of Carers who have been offered an assessment; KPI 13 (Essex CC set) measures the number of Carers who have accepted an Assessment

73 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST down = i same = 1 colours will change automatically

BOARD REPORT DASHBOARD downup = # = i

Indicator Target Mid North East West C&YP Oct-15 Quarterly to Date Performance Trend/Commentary

100% Number of Assessments at 75 76 85 234 234 A&E or Hospital 16 Psychiatric Liaison 95%

% Assessed within 4 hours 100.0% 100.0% 97.6% 99.1% 99.1%

50%

30% 17 Physical Healthcheck 35% % with healthcheck 43.9% 52.3% 50.2% 48.4% 48.4%

10% # Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/15 Valid 2015/16 Valid Target

100%

80%

60%

18 Care Plan Shared 95% % with a care plan shared 96.8% 95.4% 96.5% 96.2% 98.9% 40%

20% # Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/15 Valid 2015/16 Valid Target

100% 80% 60% Number of patients with a 40% 19 Crisis Plan in Place 95% 94.6% 97.3% 98.5% 96.6% 96.6% 20% crisis plan 0% # Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

C. C. Health Commissioners KPI's 2014/15 Valid 2015/16 Valid Target

100%

A. Monitor Compliance Framework 75%

50% 20 Ethnicity 90% % Valid Ethnicity Recorded 95.0% 89.8% 94.7% 94.9% 93.1% 93.1% 25% # Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Ethnicity 2014/15 Ethnicity 2015/16 Target

100% 80% 60% % with a formal review in 12 21 Section 117 Reviews 95% 94.0% 97.0% 98.6% 96.3% 96.3% 40% months 20% # Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/15 Valid 2015/16 Valid Target

22 DQUIP (Quarterly) Green

23 SDIP (Quarterly) Green

74 North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 11b

Date: 25 November 2015

Title of Report: Workforce Report

Lead: Lisa Anastasiou, Director of Workforce and Development

Subject, Purpose and Recommendation:

The Board of Directors is asked to receive and note the attached workforce report which details key workforce indicators at 31 October 2015.

Key points for noting are as follows:

Staff Turnover

Turnover has fallen from September and now sits at 13.4 % (9.8% excluding retirements). It should be noted that the transfer of CAHMS staff to NELFT has been excluded from this data. Turnover information for the past 6 months has been reviewed in detail and does not demonstrate any notable trends both in terms of teams or leaver destination.

Sickness Absence

Sickness absence at September 2015 remains low at 3.9% with a year to date position well below the 4.5% threshold. This report includes details of long term absence as a percentage of overall absence by locality.

Mandatory Training

The overall compliance level for mandatory training is 81.0%. The Interim Review of Mandatory Training, presented to the Quality and Risk Committee in June 2015 set out a range of actions that will be undertaken to improve training compliance. There has been a strong focus on enabling better performance management related to training compliance. To following actions have been implemented: • Increased visibility of performance - a performance dashboard is now available to managers outlining team level training /appraisal compliance. The information enables the area director, operational managers and the Director of Operations to identify and manage teams with significant levels of under-performance. The information is now visible to all staff.

75 • Monthly emails are also sent to each Ward/Clinical Manager outlining their overall compliance; the Director of Nursing and Quality is copied into the monthly emails to enable follow up.

• Mandatory training compliance is now part of the Quality Improvement Framework dashboard and is therefore discussed with teams on a monthly basis.

• The review of Ethical Care Training including risk assessment of new training is complete. The re-training of trainers has commenced and full communication with staff has taken place. The roll-out is scheduled from January – August 2016.

• The Workforce team, from October, has aligned one member of staff to each directorate to provide direct support and personalised follow up with managers and staff related to issues of training compliance/appraisals.

• A team target of 60% (by the end of the year) has been introduced for Storm Training

Appraisals

The number of recorded appraisals is 71.7%. 90 day alerts for appraisal completion (which are now RAG rated) are still being sent to staff directly and continue to receive a positive response. The new Quality Performance Framework and associated team quality dashboards now includes a range of workforce indicators ensuring that workforce issues such as appraisals, absence, turnover, mandatory training, vacancy factor etc. are considered and managed as part of a team’s overall performance.

Vacancies and Recruitment

Our vacancy factor at the end of October has fallen to 17.74% of full time equivalent posts (FTE’s). The trust is facing significant challenges in filling nursing and social worker roles which is reflective of the national shortage position. A significant amount of recruitment activity is underway.

A recruitment plan has been developed and includes the following actions: - New recruitment “branding” and materials have been developed - Work with the MOD to secure ex-military personnel - Greater presence at national recruitment events. Guaranteed roles for student nurses pre-qualification - Work with local acute trust’s to develop rotational opportunities

Bank and Agency Staff

As a consequence of the vacancy factor and difficulties in recruiting to the Bank, the use of agency cover for registered staff is relatively static. however the use of unregistered agency staff has reduced. In order to curtail the use of agency and in particular the growing trend of Bank staff moving to agencies for higher rates of pay, the following actions have been taken: - Bank rates of pay reviewed and increased - Incentives for joining the Bank and retention initiatives introduced - Vacancy control group established – weekly scrutiny by the Director of Operations and Director of Workforce and Development of all requests to recruit to non-clinical

76 - posts with a specific focus on posts currently covered with agency staff - Focus on improved roster management - New agency booking controls introduced

Finance Implications: Sickness absence and vacancies has a direct impact on bank and agency staffing expenditure.

Clinical Implications: Not applicable

HR Implications: The workforce report provides an insight into the health and satisfaction of the workforce.

Legal and/or Regulatory Implications: Not applicable

Equality Implications: Not applicable

Risks: Not applicable

77 Board of Directors - Workforce Reports

Summary Data - October 2015

78 North Essex Partnership University NHS Foundation Trust

Workforce Performance Report 31st October 2015

1. Sickness Absence (i)(ii)(iii) 2. Sickness v Long Term Sickness 2i. Sickness v Long Term Sickness - By Area 3. Sickness Comparision 4i. Turnover 4ii. Turnover - Rolling Year 5. PDR's (i)(ii) (iii) 6. Trust Training Compliance 7i. Course Training Compliance 7ii. Course Training Compliance 7iii. Course Compliance - Time Line 8. Bank and Agency Fill Rates 9. Employee Relations 10. Vacancies

79 Workforce Performance Report 31st October 2015

Summary of Performance

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

Sickness Absence * 4.5% 3.6% 4.2% 4.4% 4.7% 4.8% 4.2% 4.2% 4.0% 3.9% 3.5% 3.8% 4.3% 3.9% -

Turnover 10% 11.8% 12.3% 12.5% 12.8% 13.0% 13.3% 13.6% 14.4% 14.1% 13.7% 13.5% 13.3% 14.5% 13.4%

PDR's 90% 61.5% 66.3% 75.8% 79.8% 80.6% 80.4% 78.5% 77.9% 76.3% 73.8% 72.6% 70.5% 70.7% 71.7%

Training Compliance 90% 84.2% 84.1% 83.9% 84.9% 84.6% 84.5% 81.5% 81.9% 79.5% 81.8% 82.7% 82.3% 80.7% 81.0%

Bank and Agency Fill Rates Registered - 97.82% 98.43% 98.43% 94.47% 93.98% 95.82% 97.25% 97.67% 98.04% 97.45% 96.98% 96.97% 98.24% 97.36% Unregistered - 96.63% 96.85% 96.85% 92.72% 93.31% 92.65% 96.51% 96.16% 96.89% 97.04% 96.92% 96.62% 97.02% 95.31%

80 1(i). Sickness Absence - Performance Threshold 4.5%

1(i). Sickness Absence by Directorate

% FTE Days Lost in Month Directorate YTD Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Mid Essex Directorate 2.6% 3.0% 4.0% 4.1% 4.1% 3.4% 2.7% 3.0% 3.2% 2.6% 3.5% 4.9% 4.0% 3.5% North East Essex Directorate 3.8% 4.1% 3.4% 4.2% 4.1% 3.6% 4.0% 3.4% 3.1% 3.5% 3.8% 4.0% 3.8% 3.7% West Essex Directorate 3.8% 4.9% 5.6% 6.1% 5.8% 4.3% 4.8% 4.6% 5.0% 3.3% 3.6% 4.0% 4.0% 4.1% Children & Young People Directorate 6.0% 4.9% 4.5% 5.9% 6.7% 6.6% 5.0% 4.1% 3.8% 4.1% 3.0% 3.2% 4.7% 3.8% Corporate Directorate 2.6% 5.2% 5.2% 4.4% 4.0% 4.3% 4.2% 6.0% 5.8% 5.4% 4.6% 4.6% 3.2% 4.9% Director of Operations & Nursing Directorate 2.4% 2.8% 1.4% 0.3% 8.1% 5.7% 11.4% 6.9% 8.0% 8.7% 8.1% 8.1% 6.2% 7.7% BIS Directorate 3.1% 5.5% 6.1% 4.9% 2.8% 5.5% 5.5% 3.7% 3.5% 2.8% 4.7% 4.0% 4.3% 3.9% Enable East Directorate 0.0% 2.0% 4.4% 0.5% 0.7% 0.0% 0.0% 0.0% 0.3% 0.0% 0.0% 0.3% 0.3% 0.2% NEPFT Total 3.6% 4.2% 4.4% 4.7% 4.8% 4.2% 4.2% 4.0% 3.9% 3.5% 3.8% 4.3% 3.9% 3.9%

1(ii). Sickness Absence by Staff Group

% FTE Days Lost in Month Staff Group Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Add Prof Scientific and Technic 3.2% 5.7% 6.0% 7.0% 4.9% 3.6% 4.0% 4.8% 5.1% 5.1% 3.6% 3.8% 2.7% Additional Clinical Services 4.4% 3.3% 4.4% 5.1% 6.4% 5.0% 5.1% 5.0% 3.8% 3.7% 4.0% 4.3% 4.8% Administrative and Clerical 3.8% 4.4% 4.7% 4.5% 4.9% 3.8% 4.7% 3.9% 4.0% 3.7% 4.7% 5.5% 4.4% Allied Health Professionals 0.7% 3.6% 2.8% 0.6% 1.5% 3.2% 4.3% 6.2% 4.4% 4.4% 2.0% 0.8% 2.5% Estates and Ancillary 5.3% 6.5% 5.9% 5.6% 5.2% 5.8% 6.2% 5.6% 4.7% 3.5% 4.6% 4.2% 4.0% Medical and Dental 3.1% 2.0% 1.4% 2.3% 1.4% 1.5% 0.3% 0.0% 1.3% 0.4% 0.0% 0.0% 0.5% Nursing and Midwifery Registered 3.2% 4.3% 4.3% 4.8% 4.6% 4.5% 3.7% 3.5% 4.0% 3.5% 3.9% 4.9% 4.4% NEPFT Total 3.6% 4.2% 4.4% 4.7% 4.8% 4.2% 4.2% 4.0% 3.9% 3.5% 3.8% 4.3% 3.9%

*Psychology Teams have now been moved into their individual areas

1(iii). Top Five Sickness Absence Reasons

% FTE Days lost Oct-14 to Sep-15 Sickness Reason Percentage Lost S99 Unknown causes / Not specified 38.9% S10 Anxiety/stress/depression/other psychiatric illnesses 15.4% S98 Other known causes - not elsewhere classified 5.9% S11 Back Problems 5.8% S25 Gastrointestinal problems 5.4%

Data Source: ESR Extract Date: 04/11/2015 Contact: Lisa Fricker (01245 54) 3134 6474

81 2. Sickness Days Lost in Month Compared to Long Term Sick days Lost in Month

Trust Wide

6.00%

5.00%

4.00%

3.00%

2.00%

1.00%

0.00% Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

Long Term Sickness All Sickness Threshold

NEPFT Total Long Term Sickness = One month or longer

Produced by: Lisa Fricker Extract Date: 05/11/2015 82 Source: ESR 2i. Sickness Days Lost in Month Compared to Long Term Sick days Lost in Month - By Area

Mid North East 6.00% 6.00%

5.00% 5.00%

4.00% 4.00%

3.00% 3.00%

2.00% 2.00%

1.00% 1.00%

0.00% 0.00%

Long Term Sickness All Sickness Threshold Long Term Sickness All Sickness Target

West C&Y People 7.00% 6.00%

6.00% 5.00%

5.00% 4.00% 4.00% 3.00% 3.00% 2.00% 2.00%

1.00% 1.00%

0.00% 0.00%

Long Term Sickness All Sickness Threshold Long Term Sickness All Sickness Threshold

NEPFT Total Long Term Sickness = One month or longer

Produced by: Lisa Fricker Extract Date: 04/11/2015 Source: ESR 83 2. Sickness Comparision to Foundation Trusts in the Region

% FTE Days Lost in Month Staff Group Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 North Essex Partnership Foundation Trust 4.2% 4.4% 4.7% 5.1% 4.2% 4.2% 4.0% 3.9% 3.5% 3.8% 4.3% 4.3%

Cambridgeshire and Peterborough NHS Foundation Trust* 4.5% 4.7% 5.1% 5.1% 4.9% 4.6% 4.6% 4.7% 4.6% - - -

Norfolk and Suffolk NHS Foundation Trust* 5.0% 4.9% 5.1% 5.7% 5.4% 5.0% 4.8% 4.5% 4.4% - - -

Hertfordshire Partnership NHS Foundation Trust 4.2% 4.1% 4.5% 4.8% 4.7% 4.8% 4.1% 4.2% 4.8% - - -

South Essex Partnership University NHS Foundation Trust* 5.2% 5.5% 5.7% 5.4% 5.2% 5.3% 5.3% 4.8% 5.0% - - - Mental Health and Learning Disability (England) 5.1% 5.2% 5.4% 5.3% 5.0% 5.0% 4.6% 4.5% 4.6% - - -

NHS England (Average all Trusts) 4.4% 4.5% 4.8% 4.7% 4.4% 4.2% 4.0% 3.9% 3.9% - - -

NHS England 2013-14 (Average all Trusts) 4.1%

*Source - Heath and Social Care Information Centre, last available data is June 2015

Please note: Sickness absence data is for the period 1st to 30th March due to the implementation of Journeys on the 31st March.

Data Source: ESR Extract Date: 04/11/2015 Contact: Lisa Fricker (01245 54) 3134 6497 84 4i. Staff Turnover - Performance Threshold 10%

% Turnover Including retirements Rolling Staff Group Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Year Add Prof Scientific and Technic - - 1.2% 0.5% 2.6% 3.0% 1.8% 0.7% 2.2% 0.7% 1.6% 0.5% 16.1% Additional Clinical Services 1.8% - 1.1% 0.2% 1.2% 0.6% 0.9% 1.2% 1.1% 1.7% 1.2% 1.9% 12.1% Administrative and Clerical 1.5% 1.2% 1.4% 1.1% 2.5% 1.5% 1.0% 1.3% 1.2% 1.2% 1.1% 0.5% 14.1% Allied Health Professionals - 2.9% 2.4% 1.3% 3.2% - 1.4% - 1.4% - 1.8% - 12.3% Estates and Ancillary 1.6% - 2.8% - 1.5% - 1.6% - - - 0.6% 0.8% 7.7% Medical and Dental * 1.3% 1.1% 1.4% 1.3% 0.8% 2.4% - 1.4% 0.7% - 1.4% - 12.9% Nursing and Midwifery Registered 0.8% 1.4% 0.9% 0.9% 3.3% 1.5% 0.6% 0.6% 0.8% 0.6% 1.0% 1.4% 14.1% Total 1.1% 0.9% 1.3% 0.8% 2.5% 1.4% 0.9% 0.9% 1.1% 0.8% 1.1% 1.1% 13.4%

Rolling 12 months 12.5% 12.8% 13.0% 13.3% 13.6% 14.4% 14.1% 13.7% 13.5% 13.3% 14.5% 13.4%

Threshold 10.0% Distance from threshold -3.4%

October turnover excludes employees TUPE'd to NELFT

Excludes medical rotation grades, trainee Psychologists

In Month % Calculation Numerator : FTE of leavers in current month Denominator : FTE of staff in post as at the end of the reporting month, plus number of leavers in month

Rolling 12 Month % Calculation Numerator : FTE of leavers in previous 12 month period Denominator : FTE of staff in post as at the end of the reporting month, plus number of leavers previous 12 month period

Data Source: ESR Extract Date: 04/11/2015 85 Contact: Lisa Fricker (01245 54) 3134 6432 4ii. Staff Turnover - Rolling Year Performance Threshold 10%

% Turnover Including Retirements Directorate Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 300 Mid Essex Directorate 11.4% 10.6% 10.8% 10.2% 10.2% 10.7% 12.7% 12.7% 12.1% 12.1% 11.3% 10.2% 10.2% 300 North East Essex Directorate 12.4% 12.5% 13.6% 14.6% 15.0% 11.9% 12.2% 11.3% 10.5% 10.9% 8.9% 12.0% 10.8% 300 West Essex Directorate 12.3% 13.7% 14.3% 14.1% 15.3% 17.6% 18.0% 18.0% 17.7% 16.0% 17.3% 20.3% 16.5% 300 Children & Young People Directorate 10.3% 10.8% 12.1% 13.1% 13.7% 15.0% 16.1% 15.7% 16.5% 16.8% 17.4% 20.0% 26.7% 300 Corporate Directorate 18.7% 19.2% 18.0% 17.2% 16.3% 15.3% 15.7% 15.0% 14.1% 14.7% 14.9% 12.8% 11.9% 300 Director of Operations & Nursing Directorate 5.1% 5.0% 5.0% 5.0% 4.7% 11.4% 14.0% 16.4% 18.9% 19.4% 18.7% 18.7% 17.7% 300 Business Information Systems Directorate 10.4% 10.3% 7.1% 10.2% 9.2% 10.2% 10.9% 10.3% 10.5% 11.7% 11.7% 11.8% 10.6% 300 Enable East Directorate 13.3% 13.3% 13.3% 7.1% 7.1% 18.8% 21.4% 15.4% 15.4% 15.4% 23.1% 23.1% 33.3% Trust Total 12.3% 12.5% 12.8% 13.0% 13.3% 13.6% 14.4% 14.1% 13.7% 13.5% 13.3% 14.5% 13.4%

Trust Total Excluding Retirements 9.3% 9.7% 9.8% 10.0% 9.9% 10.7% 13.5% 10.8% 10.3% 9.9% 9.6% 11.2% 9.8%

October turnover excludes employees TUPE'd to NELFT

Data Source: ESR Extract Date: 04/11/2015 Contact: Lisa Fricker (01245 54) 3134 6432

86 5i. PDRs Compliant

Percentage Compliant Staff Group Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Add Prof Scientific and Technic 71.4% 74.7% 75.2% 75.2% 73.2% 70.3% 69.0% 69.7% 68.2% 67.3% 67.6% 64.8% Additional Clinical Services 72.7% 76.6% 78.7% 77.0% 79.5% 78.5% 76.4% 75.5% 70.8% 70.3% 70.9% 73.7% Administrative and Clerical 79.6% 84.0% 83.9% 83.5% 79.0% 79.0% 80.2% 81.2% 78.5% 74.1% 75.3% 73.7% Allied Health Professionals 68.2% 70.3% 73.0% 72.6% 71.4% 69.4% 70.5% 70.5% 65.6% 65.6% 61.3% 65.1% Estates and Ancillary 81.6% 84.5% 86.1% 91.0% 91.8% 92.9% 91.8% 88.9% 86.5% 80.0% 81.0% 72.0% Medical and Dental 88.2% 88.2% 90.1% 89.8% 81.8% 80.4% 70.1% 30.9% 77.9% 80.6% 80.6% 94.1% Nursing and Midwifery Registered 73.8% 78.8% 79.2% 79.1% 77.0% 76.7% 74.5% 73.8% 67.8% 66.0% 65.4% 67.7% NEPFT Total 75.8% 79.8% 80.6% 80.4% 78.5% 77.9% 76.3% 73.8% 72.6% 70.5% 70.7% 71.7%

5ii. PDRs by Directorate

Percentage Compliant Directorate Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Mid Essex Directorate 78.4% 79.7% 78.3% 78.2% 77.1% 75.8% 73.4% 71.5% 72.3% 69.1% 68.0% 71.1% North East Essex Directorate 72.3% 79.1% 79.8% 81.7% 80.7% 80.7% 78.6% 75.1% 69.3% 65.4% 65.8% 65.5% West Essex Directorate 77.8% 82.5% 83.9% 81.6% 77.7% 75.9% 75.2% 70.6% 70.7% 71.5% 70.5% 70.6% Children & Young People Directorate 61.8% 65.8% 68.6% 71.6% 75.3% 74.1% 74.1% 72.2% 75.5% 75.8% 76.0% 85.7% Corporate Directorate 85.8% 90.3% 91.7% 88.6% 80.4% 82.4% 79.1% 81.7% 80.1% 76.4% 81.3% 85.5% Director of Operations & Nursing Directorate 90.5% 83.3% 81.0% 69.8% 61.5% 61.5% 52.8% 62.9% 70.6% 78.8% 78.1% 68.8% BIS Directorate 77.8% 78.8% 85.7% 88.6% 86.3% 87.7% 90.4% 84.0% 80.5% 79.2% 77.6% 76.3% Enable East Directorate 90.0% 100.0% 100.0% 83.3% 100.0% 90.9% 100.0% 81.8% 81.8% 70.0% 88.9% 75.0% NEPFT Total 75.8% 79.8% 80.6% 80.4% 78.5% 77.9% 76.3% 73.8% 72.6% 70.5% 70.7% 71.7%

*Psychology Teams have now been moved into their individual areas 5iii. PDRs not compliant

Oct-15

Staff Group Headcount Headcount Invalid 0-1 Invalid 2-6 Invalid 6-12 Invalid over No PDR % PDR's PDR's Due Invalid month months months 12 months recorded Invalid

Add Prof Scientific and Technic 121 43 7 18 3 7 8 35.5% Additional Clinical Services 315 87 15 37 8 8 19 27.6% Administrative and Clerical 369 100 36 45 8 2 9 27.1% Allied Health Professionals 62 23 4 10 3 2 4 37.1% Estates and Ancillary 132 41 13 8 - 1 19 31.1% Medical and Dental 87 14 1 7 2 1 3 16.1% Nursing and Midwifery Registered 497 163 36 81 13 13 20 32.8% Trust Total 1,583 471 112 206 37 34 82 29.8%

Note: Staff with less than 12 months service are not included. Training Grade Doctors are now included.

Data Source: ESR Extract Date: 04/11/2015 Compiled by: Lisa Fricker, Information Analyst 87 Contact: 01245 546 474, Email: [email protected] 6. Overall Trust Training Compliance - Performance Threshold 90%

100.00% 90.00% 80.00%

70.00% 60.00% 50.00% 40.00%

Compliance 30.00% 20.00% 10.00% 0.00% Add Prof Scientific Additional Clinical Administrative and Allied Health Estates and Medical and Nursing and and Technic Services Clerical Professionals Ancillary Dental Midwifery Registered Staff Group

Compliance Assignment Count Required Achieved % 1,784 41,908 33,927 80.96% Assignment Compliance Staff Group Count Required Achieved % Add Prof Scientific and Technic 127 3,049 2,625 86.09% Additional Clinical Services 359 9,602 7,646 79.63% Administrative and Clerical 429 7,458 6,300 84.47% Allied Health Professionals 74 1,903 1,577 82.87% Estates and Ancillary 140 2,307 1,867 80.93% Medical and Dental 118 3,015 2,104 69.78% Nursing and Midwifery Registered 537 14,574 11,808 81.02%

The above table includes Prevent and Safeguarding Supervision Excludes employees on a career break, external secondment, maternity leave and long term sickness greater than one year

Data Source: Business Intelligence (ESR) Extract Date: 05/11/2015 Contact: Lisa Fricker (01245 54) 3134 6474)

88 7i. Course Training Compliance - Performance Threshold 90%

Course Name Includes Trainees **Excludes Trainees Meets Does not meet Meets Does not meet Requirement requirement Requirement requirement Care and Clinical Risk, including Dual Diagnosis and Mental Health Care Clustering 918 76.82% 277 23.18% 896 78.94% 239 21.06% Display Screen Equipment (DSE) 383 90.12% 42 9.88% 383 90.33% 41 9.67% Equality and Diversity eLearning, including Harassment & Bullying 1,541 86.19% 247 13.81% 1,491 86.43% 234 13.57% Ethical Care - Breakaway includes Basic Life Support 1,489 83.79% 288 16.21% 1,435 83.58% 282 16.42% Ethical Care - Control and Restraint, including Basic Life Support, Rapid Tranquilisation, and Inpatient Observation 377 67.08% 185 32.92% 342 67.99% 161 32.01% Fire Safety Awareness 1,252 75.47% 407 24.53% 1,236 75.55% 400 24.45% Food Safety - CIEHH approved 331 62.45% 199 37.55% 331 62.57% 198 37.43% Health and Safety Training for Managers - Risk Assessment including Slips, Trips and Falls Prevention (staff and others) and Major Incident Training 110 72.85% 41 27.15% 110 72.85% 41 27.15% Infection Control: Infection Prevention and You 416 73.50% 150 26.50% 416 73.63% 149 26.37% Infection Control: Principles of Infection Prevention 600 49.46% 613 50.54% 555 48.14% 598 51.86% Infection Prevention & Control - Hand Hygiene, including Inoculation Incident Training 1,393 78.43% 383 21.57% 1,346 78.48% 369 21.52% Information Governance: The Refresher Module 1,609 89.99% 179 10.01% 1,588 92.06% 137 7.94% Introduction to Information Governance 1,167 65.27% 621 34.73% 1,155 66.96% 570 33.04% Making Experiences Count, including Incident Reporting, Complaints and Claims and Record Keeping Standards 904 78.54% 247 21.46% 889 81.48% 202 18.52% Manual Handling Awareness 939 76.34% 291 23.66% 896 76.58% 274 23.42% Manual Handling including Falls Prevention - Patient Handlers only 267 69.53% 117 30.47% 267 69.53% 117 30.47% Mental Health Act 1983 Practical Application - eLearning| 564 84.81% 101 15.19% 563 84.92% 100 15.08% Prevent 867 48.74% 912 51.26% 850 49.48% 868 50.52% Rapid Tranquilisation 377 67.08% 185 32.92% 342 67.99% 161 32.01% Remedy 1,140 90.98% 113 9.02% 1,088 91.20% 105 8.80% Risk Awareness 4 66.67% 2 33.33% 4 66.67% 2 33.33% Safeguarding Adults and Children Level 1 including Learning Disability and Autism 1,697 94.91% 91 5.09% 1,643 95.25% 82 4.75% Safeguarding Adults and Children Level 2 1,023 86.62% 158 13.38% 996 88.85% 125 11.15% Safeguarding Adults and Children Level 3 including Learning Disability and Autism 897 75.95% 284 24.05% 878 78.32% 243 21.68% Safeguarding Children Level 4 including Learning Disability and Autism 65 77.38% 19 22.62% 64 78.05% 18 21.95% Safeguarding Supervision 11 13.41% 71 86.59% 10 12.50% 70 87.50%

Ethical Care - Breakaway and Control & Restraint competence expiry dates have been amended to two years in preparation for TASI

Following guidance from the Commissioners, Information Governance Refresher has changed from every two years to one yearly, however Information Governance One Off is at 89.99%.

**Excludes Trainees - Excludes the Junior Doctors and Trainee Psychologists

Excludes employees on a career break, external secondment, maternity leave and long term sickness greater than one year Medical and Dental staff group compliance is lower than trust average at 69.37%, this is correlated to the recent rotation of 23 Junior doctors in August

Data Source: ESR Extract Date: 05/11/2015 Contact: Lisa Fricker (01245 54) 3134 6474)

89 7ii. Course Training Compliance - Performance Threshold 90%

Course Name Competence Name Meets Requirement Does not meet requirement

Care and Clinical Risk, including Dual Diagnosis and Mental Health Care Clustering 300|LOCAL|CPA and Clinical Risk Management| 944 79.00% 251 21.00%

300|LOCAL|Dual Diagnosis| 969 81.09% 226 18.91%

300|LOCAL|Mental Health Care Clustering| 619 78.75% 167 21.25%

Display Screen Equipment (DSE) 300|LOCAL|Display Screen Equipment (DSE) - eLearning| 383 90.12% 42 9.88%

Equality and Diversity eLearning, including Harassment & Bullying 300|LOCAL|Equality and Diversity eLearning| 1,541 86.19% 247 13.81%

Ethical Care - Breakaway includes Basic Life Support 300|LOCAL|Ethical Care - Breakaway Training includes Basic Life Support - Refresher| 1,142 64.27% 635 35.73%

Ethical Care - Control and Restraint, including Basic Life Support, Rapid Tranquilisation, and 300|LOCAL|Ethical Care - Control and Restraint, includes Basic Life Support and Inpatient 310 73.81% 110 26.19% Inpatient Observation Observation - Refresher| 300|LOCAL|Rapid Tranquilisation - Annual| 377 67.08% 185 32.92%

Fire Safety Awareness 300|LOCAL|Fire Safety Awareness - 2 Yearly| 600 82.08% 131 17.92%

300|LOCAL|Fire Safety Awareness - Annually| 669 70.72% 277 29.28%

Food Safety - CIEHH approved 300|LOCAL|CIEH Level 2 Award in Food Safety in Catering| 331 62.45% 199 37.55%

Health and Safety Training for Managers - Risk Assessment including Slips, Trips and Falls 300|LOCAL|Health and Safety Training for Managers including risk assessment| 118 78.15% 33 21.85% Prevention (staff and others) and Major Incident Training 300|LOCAL|Major Incident Training| 111 73.51% 40 26.49%

Infection Control: Infection Prevention and You NHS|MAND|Infection Control - Level 1 - 3 Years| 416 73.50% 150 26.50%

Infection Control: Principles of Infection Prevention NHS|MAND|Infection Control - Level 2 - 2 Years| 600 49.46% 613 50.54%

Infection Prevention & Control - Hand Hygiene, including Inoculation Incident Training 300|LOCAL|Infection Prevention & Control - Hand Hygiene - Annually| 858 71.74% 338 28.26%

300|LOCAL|Infection Prevention & Control - Hand Hygiene - One Off| 544 92.05% 47 7.95%

Introduction to Information Governance: One Off NHS|MAND|Information Governance - 1 Year| 1,609 89.99% 179 10.01%

Information Governance: The Refresher Module 300|LOCAL|Information Governance elearning - One Off| 1,167 65.27% 621 34.73%

Making Experiences Count, including Incident Reporting, Complaints an 300|LOCAL|Making Experiences Count, including Incident Reporting, Complaints and Claims 904 78.54% 247 21.46% and Record Keeping Standards| Manual Handling Awareness NHS|MAND|Moving & Handling for Inanimate Load Handlers - 2 Years| 95 61.29% 60 38.71%

NHS|MAND|Moving & Handling for Inanimate Load Handlers - 3 Years| 844 78.51% 231 21.49%

Manual Handling including Falls Prevention - Patient Handlers only NHS|MAND|Moving & Handling for People Handlers - 2 Years| 267 69.53% 117 30.47%

Mental Health Act 1983 Practical Application - eLearning| 300|LOCAL|Mental Health Act 1983 Practical Application - eLearning| 564 84.81% 101 15.19%

Prevent 300|LOCAL|Prevent Classroom 3 Year| 603 49.63% 612 50.37%

300|LOCAL|Prevent eLearning 3 Year| 264 46.81% 300 53.19%

Rapid Tranquilisation 300|LOCAL|Rapid Tranquilisation - Annual| 377 67.08% 185 32.92%

Remedy 300|LOCAL|Remedy IT Training| 1,140 90.98% 113 9.02%

Risk Awareness 300|LOCAL|Risk Awareness - Annual| 4 66.67% 2 33.33%

Safeguarding Adults and Children Level 1 including Learning Disability and Autism 300|LOCAL|Autism| 1,710 95.64% 78 4.36%

300|LOCAL|Learning Disabilities Foundation Level - eLearning/classroom| 1,710 95.64% 78 4.36%

90 7ii. Course Training Compliance - Performance Threshold 90%

Course Name Competence Name Meets Requirement Does not meet requirement

NHS|MAND|Safeguarding Adults Level 1 - 3 Years| 1,724 96.42% 64 3.58%

NHS|MAND|Safeguarding Children Level 1 - 3 Years| 1,728 96.64% 60 3.36%

Safeguarding Adults and Children Level 2 300|LOCAL|Autism| 1,135 96.10% 46 3.90%

300|LOCAL|Learning Disabilities Foundation Level - eLearning/classroom| 1,133 95.94% 48 4.06%

NHS|MAND|Safeguarding Adults Level 1 - 3 Years| 1,145 96.95% 36 3.05%

NHS|MAND|Safeguarding Adults Level 2 - 3 Years| 1,061 89.84% 120 10.16%

NHS|MAND|Safeguarding Children Level 1 - 3 Years| 1,149 97.29% 32 2.71%

NHS|MAND|Safeguarding Children Level 2 - 3 Years| 1,059 89.67% 122 10.33%

Safeguarding Adults and Children Level 3 including Learning Disability and Autism 300|LOCAL|Autism| 1,135 96.10% 46 3.90%

300|LOCAL|Learning Disabilities Foundation Level - eLearning/classroom| 1,133 95.94% 48 4.06%

NHS|MAND|Safeguarding Adults Level 1 - 3 Years| 1,145 96.95% 36 3.05%

NHS|MAND|Safeguarding Adults Level 2 - 3 Years| 1,061 89.84% 120 10.16%

NHS|MAND|Safeguarding Adults Level 3 - 3 Years| 958 81.12% 223 18.88%

NHS|MAND|Safeguarding Children Level 1 - 3 Years| 1,149 97.29% 32 2.71%

NHS|MAND|Safeguarding Children Level 2 - 3 Years| 1,059 89.67% 122 10.33%

NHS|MAND|Safeguarding Children Level 3 - 3 Years| 962 81.46% 219 18.54%

Safeguarding Children Level 4 including Learning Disability and Autism 300|LOCAL|Autism| 83 98.81% 1 1.19%

300|LOCAL|Learning Disabilities Foundation Level - eLearning/classroom| 83 98.81% 1 1.19%

300|LOCAL|Safeguarding Children Level 4 - 3 Year| 65 77.38% 19 22.62%

NHS|MAND|Safeguarding Children Level 1 - 3 Years| 83 98.81% 1 1.19%

NHS|MAND|Safeguarding Children Level 2 - 3 Years| 81 96.43% 3 3.57%

NHS|MAND|Safeguarding Children Level 3 - 3 Years| 76 90.48% 8 9.52%

Safeguarding Supervision 300|LOCAL|Safeguarding Supervision - 90 days| 11 13.41% 71 86.59%

Excludes employees on a career break, external secondment, maternity leave and long term sickness greater than one year

Data Source: ESR Extract Date: 05/11/2015 Contact: Lisa Fricker (01245 54) 3134 6474)

91 7iii. Course Training Compliance - Performance Threshold 90%

Course Name Percentage Compliant Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15

Ethical Care - Breakaway includes Basic Life Support 57.80% 62.46% 65.71% 69.14% 68.23% 68.64% 68.48% 71.51% 70.52% 68.34% 65.09% 83.79% Ethical Care - Control and Restraint, including Basic Life Support, Rapid Tranquilisation, and Inpatient Observation 57.77% 64.21% 64.83% 65.77% 65.39% 69.32% 52.17% 70.85% 68.84% 68.76% 63.84% 67.08% Fire Safety Awareness 77.96% 76.36% 71.05% 67.70% 70.94% 70.42% 71.65% 75.25% 80.41% 78.72% 78.47% 75.47% Health and Safety Training for Managers - Risk Assessment including Slips, Trips and Falls Prevention (staff and others) and 75.54% 77.03% 77.08% 73.65% 73.86% 68.28% 68.24% 68.24% 75.16% 74.83% 74.17% 72.85% Major Incident Training Information Governance elearning - One Off 87.99% 88.78% 89.90% 90.09% 89.98% 89.91% 90.30% 91.22% 91.99% 90.71% 89.24% 89.99% Information Governance: The Refresher Module 82.81% 82.52% 83.09% 82.81% 30.01% 40.93% 44.04% 50.00% 57.41% 59.32% 59.68% 65.27% Safeguarding Adults and Children Level 1 including Learning Disability and Autism 92.42% 94.16% 94.50% 94.91% 94.91% 94.49% 94.68% 95.80% 96.21% 95.98% 94.43% 94.91% Safeguarding Adults and Children Level 2 87.55% 88.87% 87.40% 87.76% 89.57% 90.19% 89.92% 90.49% 90.97% 89.25% 87.32% 86.62% Safeguarding Adults and Children Level 3 including Learning Disability and Autism 76.37% 77.59% 75.20% 76.54% 78.75% 79.23% 78.93% 81.31% 83.76% 81.51% 79.32% 75.95% Safeguarding Children Level 4 including Learning Disability and Autism 75.80% 75.00% 73.08% 67.90% 73.81% 72.46% 81.16% 81.75% 81.62% 80.45% 82.48% 77.38%

Training Compliance Time Line Nov 14 - Oct 15 100.00%

90.00%

80.00%

70.00%

60.00%

50.00% Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15

Safeguarding Adults and Children Level 1 including Learning Disability and Autism Safeguarding Adults and Children Level 2 Safeguarding Adults and Children Level 3 including Learning Disability and Autism Safeguarding Children Level 4 including Learning Disability and Autism

Excludes employees on a career break, external secondment, maternity leave and long term sickness greater than one year

Data Source: ESR 06/11/2015 Contact: Lisa Fricker (01245 54) 3134 6474)

92 8. Bank and Agency Usage

Month Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 YTD Shifts Requested 1,527 1,574 1,495 1,890 2,003 1,674 1,578 1,764 1,919 2,048 1,880 1,894 21,246 Shifts Not Filled 24 87 90 79 55 39 31 45 58 62 33 50 653 Filled by Bank 1,319 1,268 1,221 1,373 1,499 1,252 1,212 1,171 1,263 1,288 1,203 1,196 15,265 Registered Filled by Agency 184 219 184 438 449 383 335 548 598 698 644 648 5,328 Shifts Total Filled 1,503 1,487 1,405 1,811 1,948 1,635 1,547 1,719 1,861 1,986 1,847 1,844 20,593 Filled by Bank % 86.4% 80.6% 81.7% 72.6% 74.8% 74.8% 76.8% 66.4% 65.8% 62.9% 64.0% 63.1% 71.8% Filled by Agency % 12.0% 13.9% 12.3% 23.2% 22.4% 22.9% 21.2% 31.1% 31.2% 34.1% 34.3% 34.2% 25.1% Total filled % 98.4% 94.5% 94.0% 95.8% 97.3% 97.7% 98.0% 97.4% 97.0% 97.0% 98.2% 97.4% 96.9%

Month Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 YTD Shifts Requested 3,015 3,267 2,928 3,100 3,786 3,409 3,503 3,446 3,443 3,673 3,257 3,260 40,087 Shifts Not Filled 95 238 196 228 132 131 109 102 106 124 97 153 1,711 Filled by Bank 2,696 2,805 2,552 2,651 3,370 3,001 3,032 2,838 2,766 2,814 2,490 2,575 33,590 Unregistered Filled by Agency 224 224 180 221 284 277 362 506 571 735 670 532 4,786 Shifts Total Filled 2,920 3,029 2,732 2,872 3,654 3,278 3,394 3,344 3,337 3,549 3,160 3,107 38,376 Filled by Bank % 89.4% 85.9% 87.2% 85.5% 89.0% 88.0% 86.6% 82.4% 80.3% 76.6% 76.5% 79.0% 83.8% Filled by Agency % 7.4% 6.9% 6.1% 7.1% 7.5% 8.1% 10.3% 14.7% 16.6% 20.0% 20.6% 16.3% 11.9% Total filled % 96.8% 92.7% 93.3% 92.6% 96.5% 96.2% 96.9% 97.0% 96.9% 96.6% 97.0% 95.3% 95.7%

The increase in demand was very slight in October. 73.2% of shifts requested were filled by bank staff (combined qualified and unqualified) and 22.9% of shifts requested were filled by agency. 203 shifts were unfilled in October this represents an increase from 2.5% in September to 3.9% in October 2015. Of the 5,154 shifts requested during October these are the top five wards with the highest number of requests:-

Topaz Ward requested 396 shifts, 7.68% of total shifts Brian Roycroft requested 379 shifts, 7.35% of total shifts Kitwood Ward requested 369 shifts, 7.16% of total shifts Edward House requested 351 shifts, 6.81% of total shifts Galleywood Ward requested 271 shifts, 5.26% of total shifts

Source: Manual (NETSS) Contact: Lisa Fricker (01245 546497) Report Date: 05/11/2015

93 9. Employee Relations by Protected Characteristic Open cases October 2015

Protected Characteristic Disciplinary Grievance

Gender Male 6 - Female 1 2 Disabled No 2 - Undefined 5 2 Religious Belief Christianity 2 - Hinduism - - Undefined 5 2 Sexual Orientation Heterosexual 2 - Undefined 5 2 Marital Status Divorced - - Married 2 1 Single 4 Undefined 1 1 Age Band 26-30 1 - 31-35 - - 41-45 3 - 46-50 - - 51-55 2 1 56-60 1 - 61-65 - - 66+ - 1 Ethnic Category A White - British 4 1 D Mixed - White & Black Caribbean 1 N Black or Black British - African 2 - Z Not Stated - 1 Assignment Status Maternity Leave - - Total Open Cases 7 2

Sep-15 3 2

Note: Gender Re-assignment is not currently a recording option on ESR, we can confirm no current cases are protected under this characteristic.

Source: ESR Contact: Lisa Fricker (01245 546474) Report Date: 10/11/2015

94 10. Vacancies by Directorate

Aug-15 Sep-15 Oct-15 FTE Vacancy FTE Vacancy FTE Vacancy Directorate Variance Percentage Variance Percentage Variance Percentage 300 Mid Essex Directorate -118.45 -22.47% -110.54 -20.93% -104.95 -19.93% 300 North East Essex Directorate -60.58 -11.35% -60.58 -11.36% -57.39 -10.77% 300 West Essex Directorate -118.05 -24.85% -117.70 -24.99% -106.79 -22.99% 300 Children & Young People Directorate -40.25 -21.63% -38.95 -20.93% -8.73 -14.55% 300 Corporate Directorate -33.63 -17.49% -32.10 -16.71% -30.19 -15.72% 300 Director of Operations & Nursing Directorate -8.50 -20.27% -8.50 -19.80% -9.70 -22.29% 300 Business Information Systems Directorate -15.16 -17.04% -16.38 -18.40% -18.68 -20.38% 300 Enable East Directorate -3.00 -23.08% -4.00 -30.77% -5.00 -38.46% NEPFT Total -397.62 -19.32% -388.75 -18.91% -341.42 -17.74%

Aug-15 Sep-15 Oct-15 FTE Vacancy FTE Vacancy FTE Vacancy Staff Group Variance Percentage Variance Percentage Variance Percentage Add Prof Scientific and Technic -41.66 -23.68% -42.97 -24.35% -40.07 -26.27% Additional Clinical Services -88.56 -21.12% -81.36 -19.40% -78.06 -19.39% Administrative and Clerical -77.34 -17.10% -77.09 -17.01% -58.86 -13.75% Allied Health Professionals -13.27 -17.67% -14.85 -19.78% -8.66 -12.15% Estates and Ancillary -39.37 -28.45% -39.88 -28.82% -39.69 -28.68% Medical and Dental -20.89 -14.12% -18.94 -13.06% -17.70 -13.05% Nursing and Midwifery Registered -116.52 -17.96% -113.65 -17.54% -98.37 -16.52% NEPFT Total -397.62 -19.32% -388.75 -18.91% -341.42 17.74% October figures exclude the CAMHS staff TUPE'd to NELFT

Vacancies by Directorate and Month

Oct-15

300 Enable East Directorate

300 Business Information Systems Directorate Sep-15 300 Director of Operations & Nursing

Directorate Directorate 300 Corporate Directorate

300 Children & Young People Directorate Aug-15 300 West Essex Directorate

300 North East Essex Directorate -140.00 -120.00 -100.00 -80.00 -60.00 -40.00 -20.00 0.00 Vacant FTE 300 Mid Essex Directorate

Data Source: (ESR) Extract Date: 06/11/2015 95 Contact: Lisa Fricker (01245 54) 3134 6474) Staff Group Appendix

Add Prof Scientific and Technic - Psychologist\Psychotherapist, Social Worker, Pharmacist, Technician

Additional Clinical Services - Assistant Psychologist\Psychotherapist, Associate Practitioners, Healthcare Assistants, STR, Technical Instructor, Trainee Practitioner

Administrative and Clerical - Chief Ex, Chair, Senior Managers, Managers, Clerical Workers, Non Execs

Allied Health Professionals - Art\Music\Multi\Occupational\Physio\Speech Therapists and Dieticians

Estates and Ancillary - Maintenance Craftsmen, Grounds person, Gardener, Domestic Support Workers

Medical and Dental - Medical Director, Consultant, Associate Specialist, Staff Grade, Trust Grade, Specialty Registrar, Specialty Doctor, GP, other Community Health Service

Nursing and Midwifery Registered - Director of Nursing, Inpatient\Community Nurses, Nurse Consultants, Nurse Practitioners, Modern Matron

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 12

Date: 25 November 2015

Title of Report: Nursing Agency Rules

Lead: Lisa Anastasiou, Director of Workforce and Development & David Griffiths, Director of Resources

Subject, Purpose and Recommendation:

The Board is asked to note the introduction of new rules issued by Monitor and the TDA in respect of the use of agency nurses.

1) Introduction On 1 September 2015 Monitor and the TDA issued new rules for the management of agency staffing across the NHS in response to a total expenditure by NHS providers of £3.3 billion on agency staff during 2014/15.

The new rules apply to: - All NHS trust's - NHS foundation trust's receiving interim support from the Department of Health - NHS foundation trust's in breach of their licence for financial reasons

Whilst the above categories did not apply to NEP, we are expected to comply with the spirit of the new arrangements. The Monitor document states "all other NHS foundation trusts are strongly encouraged to comply'.

Given the Trust’s challenging financial position, Monitor subsequently asked the Trust to confirm formally in writing that we would comply with the new arrangements, and this acknowledgement has now been given by the Chief Executive.

2) Nursing Agency Rules The new rules comprise the following: - An annual ceiling for total nursing agency spend for each trust - Mandated use of approved frameworks for procuring agency staff

3) Agency Spend Ceiling On 1 September in separate correspondence from Monitor the Trust received details of its ceiling. The ceiling applies to expenditure on qualified agency nurses only and does not include nursing/healthcare assistants. The ceiling set is based on the trust's expenditure on qualified agency nurses during 2014/2015 as a percentage of overall spend on the qualified nursing workforce. A banding is subsequently applied between A-H. The trust was banded a C (4-5%) of spend on nursing staff attributed to agency usage in 2014/15, and our ceiling was set by Monitor at 4% for Q3 & Q4 of 2015/2016 and 3% for 2016/17; 2017/18 and 2018/19.

97 The trust must submit monthly returns to Monitor detailing planned and actual spend, with a quarterly review of performance

Based on Q1 expenditure 2015/16, the trust was concerned that the ceiling set was not achievable and therefore an adjustment to the ceiling was requested. The Trust requested that our ceiling be set more in line with level H, being 14.2% Q3 and 12% Q4. This was rejected by Monitor, who subsequently confirmed that the Trust’s ceiling would be increased to 8% for Q3 and Q4.

Given the level of qualified nursing vacancies the Trust currently has, the ongoing challenges in recruitment, and the current workforce pressures particularly in inpatient facilities, the Trust considers that this revised ceiling is still too low, and is likely to be breached. Nevertheless the Trust was required to submit a plan that set qualified nursing agency spend at 8% over the last 6 months of the year and this is shown below. Revised Revised Revised Revised Revised Revised Revised Plan Plan Plan Plan Plan Plan Plan Six Month Month Month Month Month Month Months Ending Ending Ending Ending Ending Ending Ending 31-Oct-15 30-Nov-15 31-Dec-15 31-Jan-16 29-Feb-16 31-Mar-16 31-Mar-16 Qualified Nursing Agency Spend 345 214 170 128 117 107 1,081 (£k)

Total Qualified Nursing 2,876 2,135 2,135 2,135 2,135 2,139 13,555 Spend (£k)

Nursing agency costs as % 12.0% 10.0% 8.0% 6.0% 5.5% 5.0% 8.0% of total nursing costs % Actual performance for October was: Actual Actual Actual Actual Actual Actual Cumulative Spend Spend Spend Spend Spend Spend Spend Month Month Month Month Month Month Six Months Ending Ending Ending Ending Ending Ending Ending 31-Oct-15 30-Nov-15 31-Dec-15 31-Jan-16 29-Feb-16 31-Mar-16 31-Mar-16 Qualified Nursing Agency Spend 405 n/a n/a n/a n/a n/a 405 (£k)

Total Qualified Nursing 2391 n/a n/a n/a n/a n/a 2391 Spend (£k)

Nursing agency costs as % 16.9% n/a n/a n/a n/a n/a 16.9% of total nursing costs %

Further rules about other areas of agency spend e.g. medical staff is expected shortly.

4) Mandated use of Approved Frameworks With effect from 14 October 2015 trusts may only use nursing agencies that are part of an approved framework agreement (approved by Monitor and the TDA). A list of approved frameworks was published on 17 September and trusts were given until 19 October to ensure all nursing staff are booked through approved frameworks. In this context the framework arrangements include nursing/healthcare assistants.

The trust currently uses two frameworks, the London Procurement Partnership (LPP) and Crown Commercial. There are instances where agency nurses are supplied by “off framework” agents when resources are particularly hard to secure e.g. substance misuse services. In this regard pre-approval for the use of Solutions Action Management was sought from Monitor on 14th October. To date no response has been received.

If pre-approval is not sought, details of the “breach” must be included in a new monthly Monitor return. This requires the reporting, on a shift by shift basis, of all instances of the usage of an off-framework agency, or use of an on-framework agency at higher rates than provided for in the framework agreement. The first return, covering the period 19th October to 23rd November is due for submission on 25th November. A verbal update on the Trust’s first submission will be provided at the Board meeting.

New booking procedures for agency staff were agreed by EMT on 19 October. The new procedures are designed to reduce the use of agency staff through more robust authorisation arrangements. They also prohibit direct agency bookings (during normal working hours) to eliminate the risk of “off framework” agencies being used.

Prior to these new booking procedures being introduced it appears that it has been custom and practice for some areas of the Trust, particularly community teams, to directly engage agency staff. Further controls are therefore being implemented within the finance and HR teams to monitor actual expenditure to identify any such remaining off-agency spend and take further action with the relevant teams to ensure that they comply with the new booking procedures going forward.

To put the historical use of off-framework agency usage into context, around 30% of the value of nursing agency invoices (invoices coded to nursing) paid in September were with off-framework agencies (12 out of 29 agencies).

5) Framework rates Trusts must use the approved frameworks and meet the conditions set out in the frameworks. This means they must adhere to the rates published in the framework agreements for their chosen supplier, e.g. if the maximum rate for a nurse working a Saturday shift from a particular agency on an approved framework is £X, then a trust must not pay higher than this rate.

6) Further Monitor Consultation on rates paid to Agency Staff In addition to the actions that Monitor have already taken to introduce agency spend ceilings and mandate use of framework agencies they have also recently separately launched a separate consultation that seeks to cap the amounts paid to agency staff.

99 The objective is to bring agency workers’ pay into line with substantive workers’ pay by 1 April 2016. Their aim is to introduce the price caps proposed on 23 November 2015 and then subject to monitoring, reduce them in two further stages so that by 1 April 2016 capped agency rates would be equivalent to national NHS pay rates for substantive staff. Monitor, TDA, NHS England and CQC would monitor the impact of the price caps on workforce, service performance and service quality to ensure any patient safety concerns are appropriately managed. This reflects the fact that one consequence of introducing wage restraints might be for a reduction in overall supply, which would then have significant operational problems given the need to maintain safe staffing levels.

From 1 April 2016, trusts would not be able to pay more than 55% above the relevant national pay rates (AfC or doctor basic pay scales) for an agency worker, employed either via an agency or direct engagement. No additional payments to agency staff or agencies would be permitted. The 55% uplift accounts for employment on-costs including employer pension contribution, employer national insurance, holiday pay to the worker and a modest administration fee/agency charge.

Proposed date of Group 1: Group 2: Group 3: introduction Junior doctors Other clinical staff Non-clinical staff Foundation year 1 Consultants, other Administration and clerical, and 2 doctors, doctors, nurses (all infra-structure, other non- registrars bands), AHPs, clinical staff healthcare scientists, other clinical staff 23 November 2015 + 150% + 100% + 55% 1 February 2016 + 100% + 75% + 55% 1 April 2016 + 55% + 55% + 55%

In a similar manner to the existing rules, Trusts would have the ability to over-ride the wage caps, but these exceptions would need to reported on an shift by shift basis.

In overall terms, the Trust estimates that the proposed November rates will not have a material impact on current agency spend. In respect of nursing staff, current framework rates are in line with the new proposed maximums. In respect of medical staff the April 2016 proposed rates for core hours are estimated at circa 35% cheaper than current rates, although the differentials for consultants and speciality doctor rates are significantly less.

7) Other Action taken by Trust to manage Agency Spend In addition to new booking procedures for agency staff the Trust has also introduced a number of other measures to help control agency spend. These include: • Implementation of a range of initiatives to increase permanent recruitment of nursing staff including work with the MOD to secure imminent leavers from military service; attendance at employers events; one stop recruitment shops; rotation arrangements with acute partners and other initiatives. • Increasing rates paid to Bank staff and the introduction of payment incentives (converting agency to Bank). • Use of the national Agency Diagnostic Tool Kit to inform actions and best practice in the following areas: leadership; technology; agency controls and information and procurement.

Finance Implications: Nursing Agency spend year to date is £2.9m, compared to total costs of £23.5m. The premium associated with using agency staff is a significant factor in the Trust’s current deficit.

Clinical Implications: Whilst agency staffing is required to maintain safe staffing levels within inpatient units, there are clinical risks associated with high levels of agency staffing.

100 HR Implications: N/A

Legal and/or Regulatory Implications: The Trust has given an undertaken to Monitor to comply with the controls over use of agency staff. Under the new risk assessment framework, Monitor may investigate NHS foundation trusts if there is sufficient evidence to suggest inefficient and/or uneconomical spending at a trust, for instance regarding agency and management consultant spend.

Equality Implications: N/A

Risks: N/A

101

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 13

Name of Meeting: Meeting of the Board of Directors in Public

Date: 25 November 2015

Title of Report: Quality Report

Lead Director: Natalie Hammond, Director of Nursing & Quality

Subject, Purpose and Recommendation:

Recommendation: The Board of Directors is asked to discuss and note the report.

Background This report draws together the elements around patient safety, experience and clinical effectiveness. This report also highlights risk escalation from the clinical areas and the strategic risk register.

The format of this report remains under review as the quality dashboards are developing. This report identifies current activity, themes and trends against the domains of Quality and key areas for improvement: • Learning and action taken from the Quality improvement Panels is now included but requires further development.

Safety In October there have been 8 serious incidents, one ‘de-escalation’ from the commissioners, these are across a number of themes.

In the figures year to date we have 39 serious incidents and this is against a threshold of 60 for the year and this would predict that we are currently on target for a reduced number of serious incidents as an organisation

Experience In December duty of candour training will be established with the CCG for serious incident investigators so that the organisation can be clear that it is discharging all of its responsibilities in line with the guidance. The DATIX system will shortly have a duty of candour section which will clearly document how we met the guidance on individual cases.

Effectiveness The Quality Team will shortly be looking at the development of the Audit Plan for 2016/17 and there will be a development session being organised between the quality and area teams to ensure we have a unified approach to audit and outcomes.

The quality and audit teams will focus on how audit will support the quality improvement of the organisation and support the area teams in the analysis of the quality dashboard and undertake 102 improvement work that is identified through this mechanism. Finance Implications: N/A

Clinical Implications: Promoting the learning organisation, identifying and preventing harm.

HR Implications: N/A

Legal Implications: N/A

Equality Implications: N/A

Risks: N/A

103 In October there have been 8 serious incidents, with one de-escalation from the commissioners, that have been reported and these are across a number of themes. In the figures year to date we have 39 serious incidents and this is against a threshold of 60 for the year and this would predict that we are currently on target for a reduced number of serious incidents as an organisation, however the graph identifies that thereis no particular trend month by month through variabilty in cause. In October the respond management system that was used for the recording of serious incidents was migrated to the Datix System. This increases our data security and safety that data is held in one place and not across two systems. In December duty of candour training will be established with the CCG for serious incident investigators so that the organisation can be clear Serious Incidents that it is discharging all of its reponsibilities in line with the guidance. On the DATIX system we will shortly have a duty of candour section which will clearly document how we met the guidance on individual cases. The patient safety and complaints team are establishing quarterly meetings with all serious incident investigators to feedback on any changes to policy or practice and also for them to feedback any issues they need the team to be aware of. In November an inquest and police investigation policy will be circulated and then approved for use from December. In conjunction with the CCG we have now closed 31 serious incidents since June due to the assurance being provided on evidence around changes in practice being implemented and the subsequent learning that has occured.

Serious Incidents by theme Apr 15 - Oct 15 10

The themes from the serious incidents are varied across a number of key themes. There are a significant 9 number of death awaiting cause of death, these will need to be reported as a serious incident until the exact 8 cause of death is known, if this is then a death by natural causes it can be de-escalated by the Clinical 7 Commissioning Group (CCG). There are a number of themes that will require a further thematic review to look 6 at number, severity and cause to establish any common causes that will require a programme of work to 5 establish a strategy for reduction. As part of this programme of work it will be important to establish over the 4 last two years to identify any thematic trends that have occured and ensure this can be factored into a 3 Serious Incidents reduction programme. There are a number of already established meetings where this data will feed into such 2 themes as prevention of suicide group and also the Risk and Governance Executive. The implementation of a quality dashboard will soon be able to identify themes across wards and areas, this will enable us to target any hot 1 spots that can be identified and then specific training and development if identified can be targeted to ensure 0 there is a reduction. The first draft of the dashboard has ensured a triangulation approach to this work and identified hotspots that can now be furthered analysed to ensure a culture of improvement is created in these Patient SafetyPatient areas and moving forward the dashboard will be an improvement tool for ward, clinical managers and area management teams to demonstrate assurance of the quality of services and care being delivered within there areas.

104 The Datix (electronic reporting system for incidents) demonstrates a degree of stability across the number of datix being reported. However this can also signify lower level of reporting and a further monitoring across teams and clinical areas will analyse for this. Increasing levels of reporting signifies an improved safety culture therfore it is important to look at actual incidents, near misses and the degree of harm in categorising these incidents. The incident reporting policy is in the process of being revised and will provide a platform to for a robust governance process for the management of incidents within the Trust. The new policy will have an Incidents executive summary at the start of the policy and this will guide staff and management of their key responsibilities in the management and reporting of incidents within the Trust. The DATIX user group is now reviewing its form and function a key objective is the process for the triaging and management of incidents. A weekly serious incident panel meeting that has been established and will shortly provide analysis of all incidents that are moderate and above to ensure these are reviewed and identify if there are any potential serious incidents within this system. Part of the role of quality team moving forward will be to undertake an analysis of key trends within teams and across areas to ensure early identification of emerging trends.

Apr to Oct Incidents by nature

Total

1525 The themes across the datix incidents have some clear higher trends than others and it will be important to compare to the previous period last year to identify any clear higher trends or improvements across the thematic categories that we are using. The clear amounts of incidents at the higer end are the violence at 1525 and then there are several other categories that are higher such as accidents resulting in injury, access, appointments and admission. This will be an important anlysis on which to take some of the patient safety 467 work forward. The Datix user group is being reviewed and part of this work may be to look at the categories on Incident themes 218 199 178 163 the system to ensure incidents are being categorised in the most appropriate way. The final part of the work 131 77 33 30 18 14 7 6 2 1 1 moving forward will be to establish a quality control system to ensure incidents are being reported and investigated in accordance with the Trust policy. This will involve a random sample of 10 incidents per areas each month and an independent reviewer from the quality team ensuring these meet the policy criteria for mangement and reporting. This sytem will be used as a learning tool and feedback will be given to the reporter and handler of that incident if there are any lessons learnt that can be looked at for future learning.

105 There is continuous monitoring on the use of physical interventions and Rapid Tranquillisation incidents month on month. The trend this year is showing an encouraging decrease in these incidents. There is a trust action Physical plan in place to reduce the number of restrictive interventions in line with national guidance. This action plan key element is the preventative work around introduction of the new training in the therapeutic and safe Interventions interventions and a primary focus on prevention in an individual service user care plans. Roll out of new training will commence in January 2016 - currently the trainer training is being completed. 25% of the physical interventions in October occurred on Larkwood.

This graph covers all aspects of violence in the Trust.

Patient to patient violence is currently showing an encouraging downward trend.

Violence Physical assaults to staff is currently still higher than this time last year - there is no one area where physical assaults is significant.

Verbal aggression remains high and this is mostly in the older adult areas. The Risk and Governance Executive are reviewing specific wards at their next meeting particularly Topaz ward.

106 Patient falls trustwide is closely monitored on a month by month basis. The Trust has shown clear improvement in the incidence of falls year on year.

Falls data is analysed both to highlight individual patient care issues - examining careplans and the use of assistive technology, review of footwear, physical health and medication. Also falls are Falls analysed to see if there are environmental factors or specific high risk times such as a specific location or time on a ward.

No one ward is an outlier with this type of incident. There has been 10 RIDDOR reportable incidents to the HSE since April. This is a reduction on this type of incident in comparison to last year. Patient SafetyPatient

Unavailable medicines has appeared as a key theme within the medication incidents and this is being addressed both individually in supervision and within team discussions.

Peter Bruff and SAC have addressed their errors both team wide and individually , there is a need for one registered nurse to complete the competency framework. Medication Trust approach not to retain ½ tablets to avoid wrong dosage. There has been training in safe administration and SAC registered staff undertaking quality improvement through all registered staff being assessed against the competency framework.

107 Training Compliance by Directorate (Nov Continuously Improving Training- The new therapeutic and safe interventions (TASI) and personal safety 100 training will be rolled out from January 2016. The training has a greater focus on prevention in line with the most recent Department of Health (DOH) and NICE guidelines. The rapid tranquilisation policy has recently 90 been reviewed and updated and new training will be rolled out in line with the new policy. Enhancing Governance the Trust has introduced a quarterly prevention and management of violence and aggression 80

(PMVA) governance group as part of its strategy to reduce violence and aggression. It will review DATIX reports relating to instances of physical interventions and de-escalations; identify training and development needs; 70 ensure that training is continuously enhanced to reflect new evidence based practice guidance and legislation 60 and drive policy development. The group first met on 24th September to review the seclusion policy, it is Training currently developing new terms of reference and expanding the membership to include more frontline 50 clinicians. Staff from the Trust have recently attended a patient safety first conference in London with a clear focus on improving patient safety.• A moratorium has now been applied to the old Control and 40 Restraint/Breakaway training in preparation for the roll out of the new TASI and Personal Safety training

• All mandatory training provided by the Trust is currently being reviewed to ensure that they are update to (%) Percentage Compliance 30 legislation, professional guidance and evidence based practice. 20 • Monthly emails continue to be sent to each Ward/Clinical Manager outlining their overall compliance, the Director of Nursing and Quality is copied into the monthly emails and will sends a follow up email outlining 10 expectations for improved performance 0 42278 42248 42217 42186 42156 42125 42095 42064 42036 42005 41974 41

The levels of harms is identified by the accompanying graph, this demonstrates that there has been a decrease of harm across the organisation which has been a steady decrease and the numbers identified for October are one of the lowest levels that we have had. This data needs to be closely monitored and validated to ensure this is a contiuing trend or whether this is linked to any potential

Patient SafetyPatient decrease in incident reporting and the two sets of data needs to be closely linked.

108 There are two thermometers undertaken on a monthly basis. One in Older adult inpatient units (nationally agreed thermometer) covering falls, pressure ulcers, VTE and Catheter and UTI's. Falls to date this year has been the highest but this is showing a downward trend. Adult wards have developed their own thermometer covering Falls, violence, self harm and medication errors. Self harming and violent behaviour represents the most harms and these 11 harm incidents ( 5 self harm and 6 Violence) involved Chelmer, Stort, Finchingfield and Galleywood and one on Longview.

Safety thermometer

There has been a high volume of alerts over the last 3 months. Most of these relate to high voltage switch gear which is not relevant to our Trust buildings. Each alert has to be acknowledged and checked with Estates.

There have been three relevant alerts since the last meeting.

 Supporting the introduction of the national safety standards for invasive procedures - this requires a lead Director, identification of relevant procedues, test procedures against the safety standards and then implement improvements to be compliant - action to be complete by Sept 2016. CAS Alerts Support to minimise the risk of distress and death from inappropriate doses of naloxone. alert has been circulated to relevant parties, Review and revise if necessary procedures, protocols and training - this is being reviewed by the medicines procedures review group. action to complete by April 2016.

 Risk of death and serious harm by falling from hoists. No incidents of this nature have occurred. Alert has been circulated to the manual link trainers and team leaders. No immediate action has been necessary other than raising awareness. safety around the use of the hoist is a key part of the manual handling training.

109 The Quality improvement plan is the key work being undertaken in respect of the on-going work and journey towards quality improvement. The Trust has received four unit specific MHA reports as a result of the inspection only. Quality improvement panels are being undertaken in all areas and the first Trust Quality improvement panel was held in October with each area examining their risks and identifying their improvement strategies. This has been a key element to ensuring that each area is able to identify the areas that they want to focus on with regards to there identified areas of quality improvement. The quality improvement panels identify very clear escalation of areas for quality improvement and development and enables clear messages to be taken from ward to board. Quality panels are being held to ensure ward and team managers are able to discuss quality improvement between themselves and the area management teams.There will shortly be ward quality dashboards available, the area dashboards are now in place and then there will be the final development of the Trust quality dashboard.

The Quality improvement plan includes all elements around quality improvement governance, risk, patient experience and clearly identifies the path being taken for quality improvement.

CQC There are currently two action plans being implemented for the previous unannounced visits to the Lakes and the Linden centre and these are regularly being reviewed and progress is being monitored.

The Linden centre action plan is progressing well with the environmental improvements in relation to the doors and windows. The other main elements of the action plan relate to the use of an acuity tool and the improvements in relation to careplanning and risk assessments . 60% of inpatient staff in adult admissions to receive STORM training and weekly audit of careplans and risk assessments.

The Lakes and Linden centre have now implemented single sex accomodation on the wards. The Lakes action plan included the removal of door closers and this has been completed where possible and the introduction of mirrors to improve line of sight are now also being used. The Lakes seclusion room has been redesignated a de-escalation suite and there is a de- escalation pathway that we are evaluating.

Graphs show claims received/reported to the NHSLA over a 2 year period from the end of 2013/14 through 2014/15 and into Quarter 3 of 2015/16.

A total of 13 claims have been received to date in 2015/16, giving an indication of how NEP compares against the scheme member average for mental health Trusts.

The graph on the left shows clinical claim experience was comparative with other mental health Trusts across period shown, dropping in April 2015, and increasing in Q2 2015/16 with a total of 5 new clinical claims registered to date (4 of which relate to inpatient deaths where inquest support funding has been agreed with the NHS Litigation Authority).

Third party claims rose steadily through 2014/15 and then sharply in Q1 of 2015/16 to above average for mental health Trusts, levelling out in Q2/3. Q1 figures were skewed because 4 claims were received from one individual.

8 new Third Party claims have been registered to date in 2015/16. These continue to be mainly low value claims received via the Claims Portal, as detailed in the 2015/16 Half Yearly Claims report to R&GE (under £25K). There is one notable exceptions with one claim (wrist injury following assault by patient) having a reserve of in excess of £100K. l

110

Claims Causes of Claims

Clinical - Top causes continue to be Patient Suicide, Falls and Quality of Care issues.

LTPS - Top causes are falls/personal accidents. Claims related to violent incidents have reduced in the past 18 months.

Key Learning points Claims

Violent Incidents - No staff assault claims were received in the first half of 2015/16 and this unusual trend has continued into Q3. It appears likely that there is a link between this reduction and the increased LSMS resources in place to advise and support staff following violent incidents and assist with appropriate Police prosecutions. Over the next couple of weeks, surveys will be going out to staff to try to evaluate this.

Claims re Accidents - Work is now comple on the risk assessment/health & safety training process for domestic staff, following increased claims from this area. It is hoped this will reduce the number of staff accidents and, thus, employer's liability claims. It will take time for any ongoing trends to be observed and it should be noted that there are incidents currently in the sytstem where injuries have been sustained and claims could be received.

111 8 Community Complaints 2015-2016 7 6 West Community 5 Mid Community 4 CYPS 3 NE Community The analysis of complaints across in-patient and community has some key areas where complaints are being 2 received into. The west community teams have higher incidents of complaints at key points within this data 1 GPS period and these will require further analysis to understand the categories these are across. The number of in- 0 patient complaints is relatively stable and again further work will be taken forward in relation to the analysis April May Jun July Aug Sept Oct Nov Dec Jan Feb Mar of the themes across these areas. There is a clear focus now on the action plans and ensuring that learning Complaints has occured as a result off the complaint. Each complaint will have an action plan attached to it and this will 8 be held on the datix system and the evidence for the learning will be monitored via the governance meetings Inpatient Complaints 2015-2016 in each of the areas. We have identifed that there is a need for some additional training on completing 7 complaint investigations and compiling complaint responses so a complaint training package is being devised 6 and sessions have been established in all three areas and these will be targeting band 6 and above who are 5 West Inpatients involved in the management of complaints. 4 Mid Inpatients 3 NE Inpatients 2 1 0 April May Jun July Aug Sept Oct Nov Dec Jan Feb Mar

Number of complaints by theme Apr 15 - Oct 15 30 25 20 The themes across formal complaints has some clear areas where complaint themes are tending to be 15 focussed. These are predominatly focussed on access to services, clinical treatment and staff attitude and 10 behaviour. We are shortly to review the complaints policy and this should be circulated for comments in 5 December for approval in January. In October we achieved a 100% compliance against the standard for 3 day 0 acknowledgements for complaints recieved. Following on from these areas thematic reviews will be Complaint themes undertaken with regards to the top three to clearly identify specific services that may be contained within these themes and look at any improvement work that needs to be undertaken. In the new policy a complaints panel will be established this will be for higher level complaints where there is a risk of claim and litigation and also ombudsman recommendations and this will be to ensure a thorough review of actions and evidence is taken forward and that the organisation can satify itself that all actions have been taken and addressed.

Number of complaints by theme Apr 15 - Oct 15 Patient Experience

112

The data provided for our low concerns is focussed on a number of key areas namely standards of care and communication. The other catgories are all on a lower level and will also equate to some of the categories for the management of complaints within the organisation. It is also important to note that there is a high Low Level number where patients are looking for information or signposting to the most appropriate service and this numbered 36 which is 56% of the total contacts of the PALS service. In the top two categories standards of Concerns care equates to an 18.7% of the total contacts for PALS. In the future the patient safety and complaints team are interested in undertaking some routine audit work to identify how many PALS result in a formal complaint and whether there are any key themes when looking at the analysis of the conversion rates between PALS and formal complaints.

113 The quality team will shortly be looking at the development of the audit plan for 2016/17 and there will be a development session being organised between the quality and area teams to ensure we have a unified approach to audit and outcomes. The quality team are working with the strategy team around the audit of CQUIN and the development of the action plans to ensure we are achieving our CQUIN targets and ensuring that there is no risk to our income. The quality team is meeting with the Medical Director to seek support around the Area Medical Directors taking forward these actions within there areas. The Audit audit has taken place around discharge summaries and this will now need to be undertaken month on month and action plans be developed based on the results that we have achieved. The current audit plan is being reviewed to ensure that all audits are on target and that any that are not now being undertaken can be removed. Via the governance meetings we will be discussing the re-introduction of the local audit groups and if this is required or whether it can be incorporated into the existing groups within these areas. Moving forward with the quality and audit team there will be a focus on how audit will support the quality improvement of the organisation and support the area teams in the analysis of the quality dashboard and undertake improvement work that is identified through this mechanism. Clinical Effectiveness There have been 4 pieces of NICE guidance issued this year that are relevent to the Trust. NG5- Medicines optimisation- this has been reviewed and we have a robust system in place to review medicine procedures and have recently strengthened the system for examining all mediicnes related to patient safety incidents in the Trust. The review of medication for patients and reconcilliation are also key elements to address patient safety. NG 15- Antimicrobial stewardship- this is the newest guidance and this is being taken forward by the infection control and physical healthcare groups in the Trust to ensure safe and appropriate prescribing of antibiotics. NG 10- is a review of a previous guideline for violence and agression, this has led to a wider review of the rapid tranquilisation protocol and the care planning for risk of NICE Guidance violence linking to our action plan on the reduction of restrictive practices. NG 17-19- A number of guidances have been issued in relation to aspects of physical health including diabetes and obesity and this is co- ordinated through our physical healthcare group. The quality team will shortly undertake a horizon scanning piece of work to establish any NICE guidance being worked on to identify any organisational impact and this could be finacial and resources to enable us to acurately plan for its implemetation. There will also be a piece of work undertaken on compliance which will identify what the percentage of compliance is aganist the NICE guidance that applies to the Trust and what evidence we have of implementation.

114 The strategic risks that have been a key focus for October and November have been around Quality and Financial stability . Main focus for the clinical areas and estates has been on the achievement of the Quality Improvement Plan to demonstrate a significant improvement in environmental improvements and care plan delivery . Area Quality Improvement Panels have been established and Issues around Mental Health Act administration raised for all three areas as a result of a CQC report. Acheivement of Cost improvement plans to provide stability for the financial recovery plan over the next 12 months. This remains the highest Trust risk on the Trust risk register with a score of 20 Roll out of the new version of Remedy 5.1 is being closely monitored and this is expected in November. This is key to realisation of new ways of working. current score is 12. Also the Cost Benefits realisation work for the community services has started and report is expected by the end of December.- this work is intended to drive forward further change and embed the changes in practice that have already been achieved.

The first Quality improvement panels have taken place and the areas each had an opportunity to raise and escalate their pressing concerns for the area. Mid-Essex Area Management Team centred on recruitment issues for Edward House, Christopher Unit and Topaz Ward. The area has been holding Quality Improvement meetings on a weekly basis - focussing on action plans around acitvities on the ward, environmental Mid improvements , careplanning both staff training and auditing of careplans. Staff supervision and support are also being monitored by the senior team. Reported high level of incidents on Topaz was discussed and this centred around staffing and inidvidual patient issues. A further report has been commissioned for RGE to ensure the ward has appropriate support. The Modern Matron for this service will report to RGE. Improvements in 'handover' continue to be a challenge but is progressing with support - MID also following new format for ward reviews. West Area Senior Management Team discussed the closure of Shannon House and the S136 suite due to ongoign building works at the Derwent Centre and the impact of this on other clinical areas. Senior staff described the work around the Hub and this model of care was discussed in detail, also the impact on patient experience of the building works. It was agreed to undertake a noise assessment and also to commission an external review of the 'hub model' on the current issues around the implementation of this model and the impact on patient

Risk Escalation Report West experience and staffing. The area confirmed that all teams had started populating a risk register and this would be transferred to the central DATIX system very soon. Staffing issue at night were raised as a potential safety issue. An environmental issue in relation to water temperatures on Stort was raised. This was to be investigated and tested. Estates have the results of the test and are undertaking the work necessary to rectify the situation.

The main focus for the North East was in relation to the transfer of CAMHS Tier 3 Services amd the oncall arrangements, named doctor for safeguarding and the role of Area Medical Director in the oncall arrangements. CIPS savings and the Tower Ward incident was discussed - this North East was a patient suffering a fracture after visiting the local Acute Trust. This is being investigated as a serious incident. Also the serious incident on Henneage Ward - the death of a patient whilst on leave from the Ward. Older adult wards was presenting a recruitment difficulty that the area wished to highlight for action.

115 116 117

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 14

Name of Meeting: Meeting of the Board of Directors in Public

Date: 25 November 2015

Title of Report: Ward Staffing Levels – September 2015

Lead Director: Natalie Hammond, Director of Nursing & Quality

Subject, Purpose and Recommendation:

Recommendation: The Board of Directors is asked to discuss and note the report.

A monthly report to the Board containing details and summary of planned and actual staffing on a shift-by-shift basis is part of the ‘Hard Truths’ commitments.

The attached is the report as initiated by the Non-Executive Team summarising the position for each ward with the planned and actual staffing as reported via Unify (National Reporting System).

The report identifies those wards which the Nursing and Quality Team have identified as ‘ hot spots’ requiring exception reporting - these are all wards rated as red or amber via RAG rating.

These wards have been reviewed to ensure there have been no significant concerns in regards to the safety and quality of care on the individual wards identified. The exception commentary takes into account the responsibilities of the Board as specified by the CQC and NHS England, and noted in the section of this covering report that deals with ‘Legal Implications’ (a-e below).

The CQC and NHS England also require ‘a Board Report describing the staffing capacity and capability, following an establishment review, using evidence based tools where possible is presented to the Board every six months’. Separate arrangements are in place to ensure that NEP is compliant.

The current report summarises and focuses on the information that is regularly uploaded to ‘NHS Choices’ using the UNIFY system.

Finance Implications: • Potential future financial costs associated with data solutions to record and track staff usage • Reduction in reliance of temporary staff and reduction of cost associated with on-going usage of highest agency staff. 118 Clinical Implications: As described in Section 4 of the report - Exception reporting.

HR Implications: Following the implementation of Journeys a number of wards continue to actively recruit to vacant posts. A number of new staff have started within the Trust in recent weeks or have start dates in the near future.

Legal Implications: The CQC and NHS England’s requirements are laid out in a letter dated 31 March 2014 http://www.england.nhs.uk/2014/04/01/hard-truths/ and associated table of actions.

For the Board this includes the following requirement: ‘A Board Report containing details of planned and actual staffing on a shift by shift basis at ward level for the previous month. To be presented to the Board every month. Boards must, at any point in time, be able to demonstrate to their commissioners that robust systems and processes are in place to assure themselves that the nursing, midwifery and care staffing capacity and capability in their organisation is sufficient to provide safe care.’

The associated ‘table of actions’ describes the expectations of the Board in further detail, asking that the Board: a) Receives an update containing details and summary of planned and actual staffing on a shift-by-shift basis b) Is advised about those wards where staffing falls short of what is required to provide quality care, the reasons for the gap, the impact and the actions being taken to address the gap c) Evaluates risks associated with staffing issues d) Seeks assurances regarding contingency planning, mitigating actions and incident reporting e) Ensures that the Executive Team is supported to take decisive action to protect patient safety and experience.”

Equality Implications: N/A

Risks: N/A

119

NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST MONTHLY WARD STAFFING REPORT September 2015

1) Background The purpose of this report is to provide the Board of Directors with the monthly information required as part of the delivery of the Hard Truths commitments associated with publishing staffing data regarding nursing and care staff.

It is a requirement for the Board to be updated on progress being made in respect to meeting the expectation in the guidance by the Chief Nursing Officer and the National Quality Board, How to ensure the Right People, with the Right Skills are in the Right Place at the Right Time; A Guide to Nursing, Midwifery and Care Staffing Capacity and Capability.

It is acknowledged that staffing analysis alone does not give adequate assurance of patient safety, high quality care and positive patient experience. The triangulation of key measures, alongside staffing data will better inform the Board and Service Lines to identify key areas of concern, target measures to address such concerns, and enable clinicians and service management teams to have greater integrated intelligence to drive improvements in patient care.

This analysis is therefore limited but will steer focus to areas of risk and allow wards and teams to share best practice in respects to how they may have achieved more positive outcomes.

2) Overview The information returned to the central NHS collection (Unify) is reviewed to ensure the information collated is an accurate understanding of staffing needs and cover required for each shift.

This takes place on a weekly basis with Area Chief Nurses and Executive Director/s to identify any exception reporting from the previous week, any mitigations and actions taken to ensure safe staffing as well as discuss any concerns for the following week.

3) Dashboard This report has two months of dashboard data August/ September as of the time of the report writing October/November data had not been placed on Unify. This data is then shown along with previous months as a trend analysis from February to September 2015.

This report will cover the September activity in detail.

120

O Safe Staffing Dashboard - Aug 2015 data

Occupancy Occupancy No of Staff Fill rate Fill rate Pressure Ward Name rate rate Falls HCAI

Area Beds WTE Registered Unregistered Ulcers (excl leave) (incl leave)

Green = 85% or more Amber 60% to < 85 % Red < 60% Ardleigh Ward (Adult) 18 100.0% 110.8% 98.9% 136.1% 0 0 1 38.8 Gosfield Ward (Adult) 18 100.6% 110.2% 96.2% 134.2% 0 0 1

Peter Bruff Unit (Adult) 17 99.7% 116.3% 22.2 97.3% 104.5% 0 0 0

Bernard Ward (Older Adult) 14 98.8% 100.0% 18.5 81.3% 132.3% 6 0 0

Henneage Ward (Older Adult) 16 101.0% 109.0% 19.1 73.7% 132.3% 2 0 0

Tower Ward (Older Adult) 15 91.5% 96.3% 15.0 72.9% 126.3% 1 0 0

Ipswich Road (Adult) 11 91.8% 93.5% 19.6 102.2% 100.0% 0 0 0 North East / CAMHS Longview (CYPS) 15 102.2% 116.3% 20.4 89.0% 117.5% 0 0 0

Larkwood (CYPS) 10 73.3% 80.0% 21.6 94.8% 105.4% 0 0 0

Finchingfield Ward (Adult) 23 99.0% 117.6% 20.6 111.1% 179.4% 1 0 0

Galleywood Ward (Adult) 24 99.5% 115.5% 19.4 108.8% 163.9% 1 0 0

Ruby Ward (Older Adult) 17 100.0% 108.8% 17.3 73.1% 156.1% 4 0 0

Topaz Ward (Older Adult) 17 97.4% 100.3% 18.6 62.2% 243.9% 5 0 0 Mid Edward House (Adult) 20 95.0% 100.0% 27.0 87.7% 96.2% 0 0 0

Christopher Unit (Adult) 5 100.7% 102.2% 15.5 90.8% 114.2% 0 0 0

Rainbow Unit (Adult) 8 85.8% 91.0% 13.6 106.5% 99.6% 0 0 0

Shannon House (Adult) 8 91.0% 91.0% 18.0 89.8% 109.1% 0 0 0

Stort Ward (Adult) 16 100.3% 102.3% 15.0 100.0% 112.3% 1 0 0

Chelmer Ward (Adult) 16 100.7% 104.6% 14.4 103.8% 138.7% 0 0 0

West Kitwood Ward (Older Adult) 16 89.2% 91.6% 14.9 91.4% 220.0% 0 0 0

Roding Ward (Older Adult) 14 97.6% 102.8% 17.7 112.3% 169.9% 2 0 0

Brian Roycroft (Older Adult) 16 93.8% 93.8% 9.9 63.1% 302.2% 0 0 0

334 95.86% 102.45% 18.9 91.22% 145.18% 23 0 2

121

O Safe Staffing Dashboard - Sept 2015 data

Occupancy Occupancy No of Staff Fill rate Fill rate Pressure Ward Name rate rate Falls HCAI

Area Beds WTE Registered Unregistered Ulcers (excl leave) (incl leave)

Green = 85% or more Amber 60% to < 85 % Red < 60% Ardleigh Ward (Adult) 18 98.3% 116.0% 96.7% 145.3% 38.8 Gosfield Ward (Adult) 18 99.7% 108.5% 101.7% 124.0% 1 Peter Bruff Unit (Adult) 17 98.2% 110.8% 22.2 98.9% 98.7% Bernard Ward (Older Adult) 14 105.7% 109.7% 18.5 82.7% 145.0% 1 Henneage Ward (Older Adult) 16 102.6% 104.3% 19.1 85.0% 118.7% 1 Tower Ward (Older Adult) 15 99.1% 104.1% 15.0 70.7% 121.1% 2 4 Ipswich Road (Adult) 11 99.6% 102.9% 19.6 105.6% 98.7% North East / CAMHS Longview (CYPS) 15 92.7% 93.2% 20.4 82.7% 119.0% Larkwood (CYPS) 10 91.9% 92.3% 21.6 94.7% 94.8% Finchingfield Ward (Adult) 23 97.6% 113.8% 20.6 109.5% 150.7% Galleywood Ward (Adult) 24 99.4% 113.6% 19.4 94.8% 153.3% 2 Ruby Ward (Older Adult) 17 99.2% 106.1% 17.3 77.2% 155.3% 1 2 Topaz Ward (Older Adult) 17 99.7% 104.3% 18.6 68.1% 270.7% 1 1 Mid Edward House (Adult) 20 94.8% 94.8% 27.0 90.2% 98.1% Christopher Unit (Adult) 5 73.1% 74.3% 15.5 80.9% 108.5% Rainbow Unit (Adult) 8 93.7% 93.7% 13.6 87.8% 114.7% 1 Shannon House (Adult) 8 80.7% 80.7% 18.0 102.2% 81.7% Stort Ward (Adult) 16 96.5% 101.6% 15.0 99.4% 106.0% Chelmer Ward (Adult) 16 103.2% 105.6% 14.4 106.1% 137.3%

West Kitwood Ward (Older Adult) 16 92.0% 92.0% 14.9 92.8% 233.3% 1 1 Roding Ward (Older Adult) 14 102.6% 108.1% 17.7 108.7% 141.1% 1 1 Brian Roycroft (Older Adult) 16 94.8% 97.7% 9.9 66.5% 297.2%

334 96.15% 101.29% 18.9 91.03% 141.51% 12 3 6

122 North East / CAMHS

Ardleigh Registered Non Registered Gosfield Registered Non Registered 200.0% 200.0% 150.0% 150.0% 100.0% 100.0% 50.0% 50.0%

Peter Bruff Registered Non Registered Bernard Registered Non Registered 200.0% 200.0% 150.0% 150.0% 100.0% 100.0% 50.0% 50.0%

Henneage Registered Non Registered Tower Registered Non Registered 200.0% 200.0% 150.0% 150.0% 100.0% 100.0% 50.0% 50.0%

Ipswich Road Registered Non Registered Longview Registered Non Registered 200.0% 200.0% 150.0% 150.0% 100.0% 100.0% 50.0% 50.0%

Larkwood Registered Non Registered 200.0% 150.0% 100.0% 50.0%

Mid

Finchingfield Registered Non Registered Galleywood Registered Non Registered 200.0% 200.0% 150.0% 150.0% 100.0% 100.0% 50.0% 50.0%

Ruby Registered Non Registered Topaz Registered Non Registered 200.0% 300.0% 250.0% 150.0% 200.0% 100.0% 150.0% 100.0% 50.0% 50.0%

Edward House Registered Non Registered Christopher Unit Registered Non Registered 150.0% 250.0% 200.0% 100.0% 150.0% 100.0% 50.0% 50.0%

Rainbow Unit Registered Non Registered 150.0%

100.0%

50.0%

123 West

Stort Registered Non Registered Chelmer Registered Non Registered 200.0% 200.0% 150.0% 150.0% 100.0% 100.0% 50.0% 50.0%

Kitwood Registered Non Registered Roding Registered Non Registered 250.0% 250.0% 200.0% 200.0% 150.0% 150.0% 100.0% 100.0% 50.0% 50.0%

Shannon House Registered Non Registered Brian Roycroft Registered Non Registered 200.0% 350.0% 300.0% 150.0% 250.0% 200.0% 100.0% 150.0% 100.0% 50.0% 50.0%

124 4) Exception Reporting

The dashboard shows 15 out of 22 wards achieved over 85% safe staffing levels for registered nurses, meeting the staff establishment requirement. Below is a summary of the identified wards that require exception reporting.

NORTH EAST

Bernard Ward

Ward qualified established safe staffing level - at least one registered nurse per shift is required (funding established for two registered am, pm and 1 nocte): • At least one registered nurse on duty has been achieved

Sickness and vacancies accounts for the use of bank and agency: • Bank and agency used to fill rota and meet clinical need. Regular bank or substantive staff working additional hours on the bank used where possible to ensure continuity or care • Actively recruiting into vacant positions, e.g. unregistered. As from October 2015, all registered nurse vacancies recruited into excluding bank position.

Further registered/non-registered staff members available to support clinical care: • Ward Manager, Monday to Friday, 9-5pm • Deputy Ward Manager 9-5pm twice a week • OT once a week • OTA – Monday to Friday, 9-5pm • Twilight HCA 7 days a week

Henneage Ward

Ward qualified established safe staffing level - at least one registered nurse per shift is required (funding established for two registered am, pm and 2 nocte): • At least one registered nurse on duty has been achieved for the period • The ward continues to work towards full implementation of the 2014 skill mix of two registered staff on duty at night • Nights currently covered by one registered and two unregistered (at a minimum). Bank and agency used to cover shifts where necessary. Regular use of bank or substantive staff working additional hours on the bank used where possible to ensure continuity or care

Sickness vacancies and clinical activity accounts for the use of bank and agency: • Actively recruiting into vacant posts. Part time registered staff have increased their hours and newly qualified registered staff nurse due to take up post in November.

125 • Clinical activity and service user acuity (enhance observation levels) also contributed to the use of bank and agency

Further registered/non-registered staff available to manage clinical care: • Ward Manager – Monday to Friday, 9-5pm • An OT is available on the ward 5 days a week, currently on reduced hours

Tower Ward

Sickness, vacancies and clinical activity including escorts for treatment account for the use of bank and agency staff: • Actively recruiting into vacant positions. As from October 2015, all registered nurse vacancies will be recruited into. Once registered nurse post expected move to community area in January 2016 – post to be advertised

Further registered/non-registered staff available to support clinical care: • Ward Manager – Monday to Friday, 9-5pm • Twilight shifts/ 9-5pm are covered by unregistered staff where possible or otherwise bank staff • An Occupational Therapy Assistant is available on the ward Monday to Friday 9- 5pm

Longview Ward

Ward qualified established safe staffing level - at least one registered nurse per shift is required (funding established for two registered am, pm and 2 nocte): • At least one registered nurse on duty every shift • Change of shift pattern currently being explored. If adopted, will increased staffing during peak periods to assist with lunch period, escorting etc.

Sickness, vacancies and clinical activity including escorts for treatment account for the use of bank and agency staff: • A newly qualified registered Nurse and unregistered HCA start in October 2015. All registered nurse vacancies now recruited into • High level of sickness/staff secondment/nurse cover to Larkwood Ward

Further registered/non-registered staff available to support clinical care: • Ward manager available to support • Occupational therapy

126 • Ward review nurse 1 day week • Twilight shifts available across the unit

MID

Ruby Ward

Ward qualified established safe staffing level - at least one registered nurse per shift is required: (funding established for two registered am, pm and 1 nocte) • At least one registered nurse on duty has been achieved

Sickness /vacancies and clinical activity account for the use of bank and agency staff: Number of vacancies: • One registered post appointed – start date is November 2015 • 1.8 non registered posts advertised • High use of bank and agency for high level of enhanced observations • Staffing pressures due to staff being absent from the ward (one on long term sick, one on compassionate leave and annual leave)

Additional staff during the day to supplement / support clinical care: • Ward Manager – Monday to Friday, 9-5pm • Ward Manager to cover ward due to high level of observations & increased risk • Tuesday pm and Wednesday & Friday am one supernumerary registered nurse where possible to cover care review. • Twilight shifts

Topaz Ward

Ward qualified established safe staffing level – at least one registered nurse per shift is required: (funding established for two registered am, 3 registered pm and 3 nocte) • At least one registered nurse on duty has been achieved

Sickness /vacancies and clinical activity account for the use of bank and agency staff: • High use of bank and agency staff for the high number of enhanced observations

Additional staff during the day to supplement / support clinical care: • Ward Manager – Monday to Friday, 9-5pm • Tuesday pm and Wednesday & Friday am one supernumerary registered nurse where possible to cover care review. • Twilight shifts

Edward House (East & West)

Ward qualified established safe staffing level - at least one registered nurse per shift is required: (funding established for two registered am, pm and 2 nocte)

127 • At least one registered nurse on duty has been achieved

Sickness, vacancies and clinical activity accounts for the use of bank and agency: • Actively recruiting into vacant posts – Two Band 3 posts, one Band 4 post, 3 Band 5 posts plus one 9-5 registered nurse post (supernumerary due to physical health problems) • Staffing pressures due to staff being absent from the ward (one on maternity leave, two on sick leave, one on annual leave and two on study leave) One nurse Is a bleep holder and is supernumerary.

Additional staff during the day to supplement / support clinical care: • Ward Manager – Monday to Friday, 9-5pm • Ward Manager when required to meet clinical need and acuity of patients • 1.8 WTE OT Input (registered and unregistered)

WEST Brian Roycroft Unit

Ward qualified established safe staffing level - at least one registered nurse per shift is required: (funding established for two registered am, pm and 2 nocte) • No shift ran without at least one registered nurse per shift.

Sickness /vacancies and clinical activity account for the use of bank and agency staff: • Advertising for current vacancies, difficulty exist into recruiting in the West area. • Sickness and current vacancies (particular in registered staff) together with clinical activity, accounted for a significant use of both bank and agency.

The Ward continues to experience high levels of acuity which has necessitated in the use of additional staff to manage patient need and maintain quality of service and patient safety. Current daily staffing requirements 7 staff per shift.

During September the ward consistently ran with a number service users on level 4 observations due to risks of falls and deteriorating physical health, and also level 2 patient observations due to clinical need and risks.

Shannon House • Shannon House rated amber in the fill rate of non-registered nurses. There was significant impact on this for the unit. Reduced bed occupancy of the unit existed in the month of September. Shannon House is now closed due to ongoing building works at the Derwent Centre.

128 5) Summary

Within all the wards highlighted as exception reports, there have been no significant concerns in regard to the safety and quality of care on the ward when reviewing clinical incidents and safeguarding reports associated with the staffing levels:

• No incident has been received on DATIX of reported patient harm caused by inadequate staffing resource • No complaint has been received stating inadequate staffing resource as the cause

Themes presenting in September’s analysis are vacancy levels, annual leave cover, pressures of secondments, sickness, agency fill rates and high levels of acuity.

Vacancy levels vary across wards, and whilst there have been some recent improvement in recruitment, further significant progress is required to address current vacancy rates and turnover across the Trust. A number of posts have been recruited into with new starters expected in October.

Whilst overall the wards have met their planned number of hours worked for registered staff and care support staff, they continue to address current challenges in securing staff with the use of temporary staff, at times of an opposite grade.

Sickness continues to require robust management to further strengthen a consistent workforce to meet all quality and patient experience indicators.

4) Action Plan

There is continuing action and response from the safe staffing data on a weekly basis. The Areas Chief Nurses review the data and the themes and report concerns to the Director of Nursing & Quality for response.

Current Actions: • High level steering group to review recruitment strategy Trust-wide • Review of vacancy levels and current recruitment plans with ACN’s • Director of Nursing & Quality met all graduating student nurses to encourage local recruitment • Now all staff secondment proposals must be agreed by the Area Chief Nurse and assessed for their impact on safe staffing levels • Ward areas that are for more than 2 consecutive months of exception reporting in the red zone will require a management action plan • Ward areas that present with a number of significant risks, incidents of patient harm will be subject to immediate remedial action inclusive of staffing review • A skill- mix review has been undertaken. Ward managers views were sought as to the impact of the establishment, staffing pressure and delivery of safe care • The Mental Health Staffing Framework, which focuses on inpatient care safe staffing levels, is being implemented across in-patient units through the nursing

129 councils and ward managers’ forums. Initial pilot completion will be in December 2015. • ACNs and local Matrons met with NETTS to discuss the problems faced around fill rates and quality of temporary staff, a series of action to improve this are under way. • The new e-rostering steering committee project plan identifies how significant improvement can be made in delivering safe staffing levels such as on-line bank booking made remotely by bank staff, real-time safe staffing data to deploy resources as required. • The Quality Improvement Panels discuss and scrutinise staffing levels in order to be responsive to the safe staffing agenda.

5) Future Considerations

The format and presentation of this report is still under review.

There is no further update to the requirement of the publication of nursing safer staffing indicators, which will provide an overall RAG rating for the Trust.

The Mental Health Staffing Framework, which focuses on inpatient care, was commissioned as part of the NHS England’s ‘Compassion in Practice Programme’. It was developed by an independent group of directors of nurses who undertook a rigorous review of the available evidence and drew on their extensive experience.

Amongst its objectives is to equip mental health leaders with the skills and knowledge to plan and deliver safe staffing. It will also provide a means of assessing their services against agreed best practice.

Developed by nurses for mental health leaders, the framework aims to ensure that mental health inpatient wards have the right staffing level for their specific needs.

Workforce experts have suggested that NHS England's new safe staffing framework for mental health inpatient care “lacks rigour’ as reported in the Nursing Times recently and has not has service user outcomes involved in its development.

We await the outcome of the frameworks used in the local ward areas. It aims to identify the dependency and staffing requirement for a unit once a month’s retrospective data is gathered.

This is just one component of a significant on-going programme of work that NHS England and its partners are undertaking to ensure the NHS is safely staffed with the right people, with the right skills.

130

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 15

Date: 25 November, 2015

Title of Report: NMC Revalidation for Nurses

Lead: Natalie Hammond, Director of Nursing & Quality

Subject, Purpose and Recommendation: The Nursing & Midwifery Council (NMC) is proposing new requirements that Nurses and Midwives must meet when renewing their registration every three years. Revalidation replaces the post-registration education and practice (PREP). On the 8th October, 2015 the NMC made the decision to proceed with Nurses’ and Midwives Revalidation this was confirmed through announcements on the NMC Website on 8th October and 30th October, 2015. The NMC have published on their website:- • How to Revalidate Guidance • A Guide for Employers • Information for Confirmers

The Board of Directors is asked to discuss and note the update report dated 10th November, 2015

Finance Implications: • The electronic solution will need some set up funds and potentially annually recurring costs depending on the solution that is chosen • Potential cost pressures in relation to Agency cover may be required to cover gaps in shift patterns Clinical Implications: • Staff not gathering sufficient evidence in time for the sign off and revalidation to be confirmed – this will mean that the Registrant will be removed from the NMC Register and will be unable to practice within NEP in their current qualified role. The Trust will then reduce the Registrants status and pay to a Band 3 HCSW whilst processes and investigations occur to see if the Registrant can be revalidated in the near future. • Potential effect on ‘Safe Staffing’ if sufficient numbers of staff do not revalidate by their due date HR Implications: • As per bullet one in Clinical Implications • Some staff members may decide not to revalidate; therefore this may encourage staff close to retirement age to be removed from the register, which could cause a peak in unexpected vacancies

Legal and/or Regulatory Implications: • Potential legal costs through HR procedures if staff cannot revalidate or if any litigation issues arise from the revalidation processes

131

Equality Implications: N/A

Risks: • Ensuring all staff understand the Revalidation process • Additional time for Registered Nurses to complete the Revalidation process • Ensuring that managers are supplied with dates when their staff revalidate to prevent lapses in registration process which may impact on service delivery • Impact on service if staff do not submit timely revalidation requirements

132 NMC Nursing Revalidation Project Update Report to the Trust Board of Directors November 2015 1) Introduction The Nursing and Midwifery Council (NMC) is proposing new requirements that nurses and midwives must meet when renewing their registration every three years. Revalidation replaces the post-registration education and practice (PREP) standards. On the 8th October 2015, the NMC made the decision to proceed with nurses’ and midwives revalidation, from April 2016.

2) Background An initial report detailing the requirements of NMC revalidation, the Nep preparation to date, nursing profile of the number of registrants due to revalidate from April 2016, the means in place to support the process and the potential risks was presented to the Board in September 2015. This was accompanied by a detailed action plan.

The key objectives were to • Set up a Revalidation Task and Finish Group reporting to Workforce Development Group and Nursing Council to identify potential challenges • Propose a review of appraisal documentation to support the confirmation process required by NMC • Develop Intranep page to access current guidance and access to resources for professional portfolios • Review Registration of Professional staff Policy to include revalidation. • Training for managers and Trust staff who will act as confirmers • Guidance on using the electronic portfolio • An agreed process to support Bank Nurses • Further clarification and guidance around the role of Confirmers • Guidance for Team Leaders and Line Managers including non-nurse managers • Development of the high level dashboard • Develop proposal on how to gather feedback from service users and patients

3) Governance The Task and Finish group provides a robust governance system which met 23 September that outlined clear actions and responsibilities. The group has high level membership including Revalidation Lead, Area Chief Nurses, Lead for NETSS, AD workforce Development, AD HR, Education Facilitators along with staff side representation. This group will meet quarterly to review progress towards action plan. Any risks clinical, service or financial risks will be reported to Natalie Hammond.

4) Progress to date • Revalidation Task and Finish Group first meeting, all of the above objectives were discussed and are being addressed with key actions identified. • Awaiting further guidance from NMC following decision to proceed on 8th October, 2015. Recent announcements of the NMC Website dated 8th

133 October and 30th October, 2015 confirm the decision to introduce revalidation for all Nurses and Midwives. Nearly 16,000 Nurses and Midwives will be the first to revalidate in April, 2016. All 685,000 Nurses and Midwives will go through the new process as their registration becomes due for renewal over the course of the next three years. The NMC have published on their website, o How to Revalidate Guidance o A Guide for Employers o Information for Confirmers • Further Workshops and Reflective Sessions have been organised • The three Area Practice/Education and Development Facilitators will play a significant role in supporting the Nursing staff within the organisation in the Revalidation Process • All registrants are being encouraged to register with NMC online and register with Nursing Times to access the electronic portfolio and online support.

5) Potential risks and mitigation • Ensure all staff understand the revalidation process – process in place • Additional time for registered nurses to complete the revalidation process - support being offered • Supply managers with dates when their staff revalidate to prevent lapses in registration process which may impact on service delivery • Impact on service delivery if staff do not submit timely revalidation requirements – processes to mitigate as outlined above

6) Conclusion There is a comprehensive process in place to implement arrangements to enable registered nurses to complete the revalidation process. This is fully supported by the Area Chief Nurses and the Area Practice/Education and Development Facilitators.

Angie Butcher, Area Chief Nurse – North East

On Behalf of Sue Champion Revalidation Project Lead

10th November 2015

134

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 16

Date: 25 November 2015

Title of Report: Monitor Compliance Report, Quarter 2 2015/16

Lead: David Griffiths, Director of Resources

Subject, Purpose and Recommendation: The Board of Directors is invited to note the Monitor Quarter 2 Compliance Return, previously circulated to Board members via email.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

135 MONITOR COMPLIANCE

FINANCE & GOVERNANCE RETURN QUARTER 2, 2015/16

1) Background

Under Monitor’s ‘Risk Assessment Framework’ (RAF) the Trust is required to submit a quarterly return to Monitor (regulator) in respect of finance and governance.

2) Finance

As reported previously Monitor have consulted upon, and now implemented, a new Financial Sustainability Risk Rating (FSRR) that replaces the previous Continuity of Service Risk Rating (CoSRR). Like the CoSRR a scale of 1 – 4 is applied (banding 1 = high risk to 4 = low risk). The key change is the inclusion of two new measures – Underlying I&E Performance and Variation from Planned I&E Performance.

Monitor’s Risk Assessment Framework describes the new FSRR methodology:

Financial sustainability risk rating 2: this rating is likely to represent a material level of financial risk. If a foundation trust is rated ‘1’ on any individual component of the financial sustainability risk rating, its overall score will be capped at 2. Depending on the level of concern our response may include:  immediate issues requiring action: we may investigate whether the trust is in breach of the CoS licence conditions, including Condition CoS3, or the NHS foundation trust Condition FT4 – the aspects of the condition relating to finance matters (and subsequently take enforcement action if a breach or likely breach is identified). We may also collect additional information from the licence holder to examine its financial position before deciding whether further regulatory action is required

 an increased level of risk requiring closer monitoring: we may request information on a more frequent basis to pre-empt or respond quickly to any serious issues should they emerge.

136 Under the new risk assessment framework, Monitor may also investigate NHS foundation trusts if there is sufficient evidence to suggest inefficient and/or uneconomical spending at a trust. In addition they have included similar, strengthened, requirements in the Accounting Officer memorandum of responsibilities.

A full commentary on the Trust’s underlying financial performance is included within the M6 Finance Report that is separately included in the Board’s agenda.

Current and Forecast FSRR achieved are shown in the Table below.

Element Plan Actual Plan Forecast Q2 Q2 Year-end Year-end Capital Service Capacity rating 2 1 1 1 Liquidity rating 4 3 4 4 I&E Margin rating 3 1 3 1 I&E Margin Variance rating 3 1 3 2 Overall FSRR 3 2 2 2

3. Governance

3.1 Targets Monitor also assess each Foundation Trust’s performance in respect of governance according to a model described in their Risk Assessment Framework (RAF):

Page 2 137 Monitor assign one of three ratings: Green, Red or Descriptive. They will assign a green rating if no governance concern is evident however  “where we identify potential material causes for concern with the trust’s governance in one or more of the categories (requiring further information or formal investigation), we will replace the trust’s green rating with a description of the issue and the steps (formal or informal) we are taking to address it; or  we will assign a red rating if we take regulatory action.”

In addition, a rating of red may be triggered where there are 3 consecutive breaches of single metric or a penalty score of 4 or more in a single quarter.

In order to inform their assessment Monitor requires a formal return against a set of indicators, reported to the Board within the Operational Performance Report. The detailed performance against these indicators is set out below including  the Monitor performance threshold  past performance (2014/15; Q3-4)  current performance (2015/16, Q1-2)  any Monitor ‘Penalty Score’ Applied.

Monitor Access & Outcome Indicators

Risk Assessment 2014/15 2014/15 2015/16 2015/16 Penalty Penalty Framework Threshold Qrt 3 Qrt 4 Qrt 1 Qrt 2 Weight* Score Indicator no / Description 9 Care Programme Approach (i) (CPA) patients receiving 99% 99% 98% 96% follow-up contact within 7 days of discharge 95% 1.0

(ii) (CPA) patients receiving a 94.6% 95% 96% 96% formal review within 12 months

10 Admissions to inpatients services had access to crisis 95% 96.5% 95% 99% 95% 1.0 - resolution/home treatment teams

11 Meeting commitment to serve new psychosis cases by early 95% 85% 112% 194% 120% 1.0 intervention teams

16 Minimising MH delayed <7.5% 2% 2% 2% 1% 1.0 - transfers of care

17 Data completeness – 97% 98% 99% 99% 99% 1.0 - identifiers

18 50% 68% 75% 87% 1.0 - Data completeness – 85%

Page 3 138 Risk Assessment 2014/15 2014/15 2015/16 2015/16 Penalty Penalty Framework Threshold Qrt 3 Qrt 4 Qrt 1 Qrt 2 Weight* Score Indicator no / Description outcomes for patients on CPA

19 Certification against compliance with requirements regarding access to healthcare n/a Yes Yes Yes Yes 1.0 - for people with a learning disability

Penalty Score Resulting from CQC responsive reviews** N/A Up to 4.0 -

Trust Total Penalty Score

Expected Rating this Quarter Green

Performance against Indicators 9-11 and 16-18 is reported within the routine Operational Performance Summary Report included in the Board’s agenda. The Trust will declare compliance against all these indicators for Q2.

Indicator 19 is reported to the Risk and Governance Executive on a quarterly basis. The most recent report, confirming ongoing compliance, was considered in October 2015.

Whilst this would therefore suggest that a rating of Green would be expected for Quarter 2, Monitor have confirmed that, pending the publication of the CQC Full Inspection report, the Trust’s Green Rating would be over-ridden, with the following description:

“Monitor is requesting further information following concerns raised by a CQC inspection and a deterioration in the trust’s financial position, before deciding next steps.”

4. Benchmarking (Quarter 1, 2015/16)

The latest benchmarking information (152 FTs) was published in Monitor’s ‘Quarterly Performance of the Foundation Trust Sector, Quarter 1 2015/16’, which includes:

Page 4 139

2015/16 Quarter 1 Performance 2015/16 Quarter 4 Performance Governance Risk Rating (GRR) Continuity of Service Risk Rating (CoSRR)

Key: Red = CoSRR 1 Yellow = CoSRR 2 Amber = CoSRR 3 Green = CoSRR 4

Monitor publishes the ratings for all Foundation Trusts at: https://www.gov.uk/government/publications/nhs-foundation-trust-directory/nhs- foundation-trust-directorytrust-directory-and-register-licence-holders.

As widely reported in the press, the Q1 financial results reflect a significant deterioration from both 2015/16 Plans and Q4 actuals. 48% of FTs were rated 4 at Q4 and 48% planned to be rated 4 at Q1, whereas the final percentage was 26%.

5 Exception Reporting

Monitor expects licence holders to notify them in writing of any incidents, events or reports which may reasonably be regarded as raising potential concerns over compliance with their licence. They also require licence holders to inform them of particular occurrences that could have an impact on the operation of their business. They may then assess the impact of those on the Trust’s compliance with the licence.

Examples of such occurrences are set out below:

Page 5 140

The guidance for exception reporting was amended in March 2015 to require MH Trust to report all “suicides, homicides and absconsions”. During the second quarter of 2015/16 itself the Trust provided full details on all SIs that have occurred since April 2014 under this category. The Board is asked to confirm that, as far as Board members are aware, there are no other matters that should have required exception reporting under the 2015/16 requirements.

6 Process

Monitor uses a web-based reporting system for the Trust in respect of quarterly monitoring for finance and governance. Each submission is brought to the Board for sign off, or where there is no scheduled Board meeting circulated to the Board via the Chief Executive’s weekly ‘Round-Up’.

The submission deadline for the Trust (for quarter 2, 2015/16) is 30th October 2015.

In addition to the completion of financial and governance returns, the process requires that 3 standard declarations be signed by the Chief Executive and Chairman in respect of three areas:

Page 6 141

“1) 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.

This declaration can not be confirmed given the Trust’s current financial performance. Whilst a Financial Recovery Plan is being developed, outlining both short and medium terms actions, these will not be sufficient to address the significant shortfall in income that that Trust has experienced during 2015/16 and which has not been matched with equivalent reductions in expenditure.

We are currently forecasting a FSRR of 2 for Q3 and Q4, and whilst financial planning for 2016/17 has only recently started it is already clear that the underlying causes of the 2015/16 deficit will not be addressed by April 2016.

In completing the Monitor Compliance return the Board is therefore required to make an additional declaration explaining why the Trust is unable to confirm a FSRR of 3 for the following 12 months and the actions that are proposed to address this.

It is therefore proposed to include the following declaration:

The Trust’s Financial Plan for 2015/16 delivered a planned CoSRR of at least 3 across all quarters, but it was recognised that there was a significant level of risk in the plan, particularly in respect of working capital headroom. Under the new Financial Sustainability Risk Rating, and with the application of the Trigger over-ride on the Capital Service Capacity component, the planned FSRR is 2 for 2015/16.

At Quarter 2 the Trust’s actual FSRR is 2, reflecting the current I&E deficit and the corresponding pressure on working capital positions. Whilst the Trust has developed outline plans that seek to reduce the pressure on I&E, a FSRR of 2 is also forecast for Q3 and Q4.

The Trust has developed a draft Financial Recovery Plan that sets out a range of short-term actions designed to minimise the projected I&E deficit. The effects of these actions are included in the Q2 Return. Further iterations of the FRP will consider planning for 2016/17, with an initial updated LTFM due for consideration in November. However, at present it is considered unlikely that the Trust will achieve a FSRR of 3 from April 2016, reflecting both the projected size (and therefore deliverability) of the efficiency programme likely to required to achieve break-even in 2016/17, and the on-going application of the Capital Service Capacity Trigger over- ride.

The Trust does not currently anticipate requiring additional working capital facilities during 2015/16, subject to satisfactory progress in Asset Sales. In respect of the most material Asset Sale (Severalls) the Trust has now exchanged and completion is anticipated in December, in line with the Trust’s plan.

Page 7 142

2) 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 the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.

On the basis of current performance it is anticipated that the Trust will continue to ensure ongoing compliance with existing targets going forward.

3) Otherwise The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor that have not already been reported.”

The Board is asked to approve these declarations in each case to be signed off by the Chairman and Chief Executive and returned to Monitor.

Monitor’s feedback is expected by the end of November 2015.

7) Recommendation

The Board of Directors is asked to approve the Monitor Compliance Return for Quarter 2, 2015/16.

Page 8 143

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 17

Date: 25 November 2015

Title of Report: Board Committee Verbal Reports

Leads: Brian Johnson, Quality & Risk Committee (QARC) chairman Charles Beaumont, Audit Committee chairman Chris Paveley, Nominations Committee chairman

Subject, Purpose and Recommendation: The Board of Directors is asked to receive verbal reports re the: • Quality and Risk Committee (14 October 2015) • Audit Committee (15 October 2015) • Nominations Committee (21 October 2015)

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

144

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 18

Date: 25 November, 2015

Title of Report: Risk and Governance Executive Annual Report 2014/15

Lead: Natalie Hammond, Director of Nursing & Quality

Subject, Purpose and Recommendation:

The Risk & Governance Executive is responsible for the proactive management and monitoring of the risk, quality and clinical governance agendas. It provides assurance to the Chief Executive and the Trust Board/Quality & Risk Committee that the Trust’s risk management and governance systems and processes work as effectively as possible. This annual report summarises the business conducted and issues of concern, forward planning for managing the risk, quality and governance agenda for the financial year 2015/2016

The report covers in detail:- • Policy Approval and Ratification • Assurance Overview o Risk Register and Assurance Framework o Incident Reporting o Claims Reporting o Fire & Security Management o Monitoring, annual and regular reporting • Quality & Audit o Care Quality Commission o Quality Account/Quality Report o Monitor Governance Framework o Monitoring and regular reporting • Conclusion • Forward Plan for 2015/2016

This report has been received and approved by the Risk & Governance Executive on Wednesday 2nd September, 2015

The Board of Directors is asked to receive and note the Risk & Governance Annual Report for 2015/2015

Finance Implications: In August 2014 a new format of combined Risk Register and Assurance Framework was presented to Risk & Governance executive and agreed – this covered twenty strategic high level risks in which five categories were used and this included Finance/Income – loss of significant components of the block contract. Seven risks were not mitigated to the level of risk appetite one of which was Finance Viability.

145 Clinical Implications:

Clinical risks and issues are covered in detail within the report – areas of highlight:- • Total reported incidents showed a 34% increase on total over the last two years • Total number of violent incidents (physical & verbal) decreased by 28% on the previous year • Patient to patient violent incidents has reduced by 30% • Use of rapid tranquillisation has increased by 29% - the previous year had seen a decrease – 25% of all incidents were on Larkwood Ward at the St. Aubyn Centre • Physical assaults on staff reduced by 21% • A reduction of 17% in Control & Restraint incidents • Increase in RIDDOR incidents, particularly due to Older Adults and falls • 30% reduction in AWOLs for detained patients due to increased environmental security.

HR Implications:

The Risk & Governance Executive approved and ratified:- • 44 Corporate/Operational Policies • 21 Clinical Policies • 6 Health & Safety Policies

Clinical and Management Supervision of staff, Induction of new staff into the Trust alongside wider Health & Safety requirements continue to be a key part of the agenda for the Risk & Governance Executive.

Legal and/or Regulatory Implications:

The following requirements form the main element of the Risk & Governance Agenda:- • Compliance with CQC Guidance • Risk Register and Assurance Framework • Reporting of RIDDOR reportable incidents • Claims Reporting including changes made by the Ministry of Justice for small claims • Fire & Security Management.

Equality Implications:

When Policies are considered for approval by the Risk & Governance Executive a key element of the approval is equality. This is reinforced by the management of Policy Development by the Trust’s Policy Advisory Group.

Risks:

To assist the role and function of the Risk & Governance Executive the introduction of a new format of a combined Risk Register and Assurance Framework in August 2014 is a routine function of the work of the Executive.

146 North Essex Partnership University NHS Foundation Trust

Risk and Governance Executive Annual Report to the Chief Executive April 2014 – March 2015

1.0 Introduction

The Risk and Governance Executive is responsible for the proactive management and monitoring of the risk, quality and clinical governance agendas. It provides assurance to the Chief Executive and the Trust Board/ Quality and Risk committee that the Trust’s risk management and governance systems and processes work as effectively as possible. The terms of reference for this group are now reviewed as part of the risk management strategy.

This annual report summarises the business conducted and issues of concern. The report outlines forward planning for managing the risk, quality and governance agenda for the new financial year 2015-16.

The agenda remains divided into five parts: • Follow up from previous meeting • Policy approval • Assurance overview • Quality and audit • Business and reports

2.0 Membership and attendance

The Risk and Governance Executive met 10 times during the year. Membership is detailed below and the chair of the meeting transferred from John Gilbert to Vince McCabe – Director of Operations.

2 APR 7 MAY 4 JUN JUL 6 AUG 3 SEP 1 OCT 5 NOV 3 DEC JAN 4 FEB 4 MAR

ANDREW GELDARD Y Y N N Y N Y Y Y Y

MALTE FLECHTNER Y Y N Y Y Y Y Y N Y

JOHN GILBERT Y Y MICHELLE Nyash a APPLEBY Y N Mapur Y Y Y Y Y Y Y anga SUSAN BARRY Y Y Y N Y N Y Y Y N RICK TAZZINI Y Y Y Y Y Y LISA Tanise Tanise ANASTASIOU Y Y Y Y Y Brown Brown Y Y Y

MeetingNo MeetingNo MIKE CHAPMAN Y Y Y Y Y Y N Y N N

VINCE McCABE Y N Y N Y Y Y Y Y N PAUL FENTON Y N Y N Y Y Y Y Y Y PAUL Mary KEEDWELL Y Y Y Y Y Y Y N Kennedy

DAVID GRIFFITHS N Y Y

147

3.0 Policy approval and ratification

Policy development is managed by the Policy Advisory Group chaired by Dr Kallur Suresh. The annual report was received in April 2015. The group processed a large number of policies and throughout the year the following were approved and ratified in RGE. 44 Corporate/ Operational polices were approved. 21 Clinical policies and 6 health and safety policies were approved.

3.1 The following corporate, finance and HR policies were approved:

• Mental & Physical health Promotion • Remediation, Re-Skilling and strategy Rehabilitation for medical staff • Mandatory Supervision • Sickness • Datix policy • Compliance with Quality Standards • Guidance for the placement of and Regulations Volunteers, Students and work experience • GP Surgeries Protocols • NETSS Complaints Protocol • Contract Management • Research and Development • Medical appraisal and Revalidation • Intellectual property • Flexible Working • Trade Unions’ working in Partnership Agreement • Respect and Dignity Policy and • Learning and Development Guidelines • Management of Organisational change • Disciplinary guidance for investigation officers • Policy for conduct, performance and Ill • Visiting Policy Health procedures for medical staff • • Ra Consumables • Appraisal Policy and Guidance • Equality and Diversity • ICT Mobile Computing device • Replacement of Trust computers • ICT Security • Managing Close personal relationships • Remedy at work • Information sharing agreement with • Seclusion policy and procedure Essex Police • Edward House operational policy • Administration • Remedy Alerts policy • Confidentiality and information sharing protocol • NE Essex Eating Disorders • Gifts and Hospitality Operational policy • Losses and Compensation • Pets at Work • Disputes • Inclement Weather and Transport difficulties • Release of PI funds • External Visits • Recruitment

3.2 The following clinical policies were approved:

• Venepuncture • Tissue Viability • Resuscitation • Medical Devices policy and Strategy • Victim Liaison • Medical Gas Policy • Bariatric Service user • Professionals meetings guidance • Medicines Optimisation and • Change of Lead healthcare professional Governance

148 • Protocol for the prevention of MRSA • Subcutaneous fluids • ECT Policy • Patient safety standards • Respecting Privacy and Dignity • Patient belongings • Patient phone and internet policy • Emergency admission of young persons to adult inpatient units • Admission procedure • Searching service users • ADHD Protocol

3.3 The following health and safety and estates policies were approved:

• COSHH • Health and Safety • First Aid • Protocol for contractors and authorised visitors accessing disused sites • Incident reporting policy and procedure • Managing physical and non - physical violence against staff

4.0 Assurance overview

4.1 Risk register and assurance framework • At the august 2014 a new format of combined risk register and assurance framework was presented and agreed- This covered 20 strategic high level risks. The following categories were used : o Governance/ Statutory – regulator related risks o Business continuity o Human Resources o Finance /Income – loss of significant components of the block contract o Service transformation risks – impact on workforce/resources

• The risk register and assurance framework was discussed in the September 2014 meeting.

• Area risk registers were reviewed at six monthly intervals in May and November and were fed into the Trust risk register and be aligned to the same categories.

• 7 risks not mitigated to the level of risk appetite and these were :

• Finance viability, external relationships, emergency planning, IT failure, regulator compliance, local risk assessment compliance, Estates rationalisation.

• All risks were mitigated to 15 or below.

Key issue was to ensure all risks regularly reviewed and the risk register to become more dynamic.

4.2 Incident reporting • Serious incident monthly reporting – a RAG rated data table has been received monthly indicating whether 15 day report deadline has been met and whether the overall deadline for completion has been met • Total reported incidents showed a 34% increase on total over the last two years. • The total number of violent incidents (physical and verbal) decreased by 28% on previous year. • Patient to patient violent incidents has reduced by 30% • Use of rapid tranquillisation has increased by 29% - previous year had seen a decrease. 25% of all incidents were on Larkwood. • Physical assaults on staff reduced by 21% , • A reduction of 17% in C&R incidents • An increase in RIDDOR incidents particularly due to older adults and falls.

149 • Mandatory training remained a focus for the group due to maintaining the momentum to increase overall compliance particularly in relation to Physical interventions and safeguarding training • 30% reduction in AWOL’s for detained patients – increased environmental security. • After a year on year significant reduction in patient falls – the total has reached a plateau for this year. – Falls prevention monitoring remains a key focus of the group given the high number of RIDDOR reportable incidents.

4.3 Claims reporting • The claims annual report was received in September • Number of claims continues to increase as expected with more employers’ liability claims than clinical negligence claims. Violent incidents remain the primary cause of employers’ liability claims and suicide the primary cause of clinical negligence claims. • There are numerous small claims and these types of claim are increasing. The Ministry of Justice changed the rules for smaller claims and these are now less risky, come through the portal. There is a fixed fee for solicitor’s costs and the Trust has only got 30 days to provide an investigation. The importance of prompt investigation was stressed in order for the Trust to defend claims. • Reporting and thorough investigation of incidents is promoted at all levels through training, improved processes and provision of advice/support • Claims panel established with executive director input • Activity remains consistent with rising national trend

4.4 Fire and security management • Fire safety six monthly report received in October 2014 • Full and comprehensive rolling fire risk assessment for NEP buildings in place and Trust building portfolio is compliant under the fire safety order 2005 • Fire training good level of compliance • Main focus for coming year is more fire evacuation drills. • Mid year fire officer left the Trust and is currently being replaced. • LSMS - Security annual update received in October 2014 • The appointment of Finlay Carson has made a difference and positive feedback has been received from staff involved in violent incidents • Improving relationship with Police re missing persons, section 136 and joint working on memorandum of understanding, initiating single points of contact, and mapping work regarding information sharing • Trust wide focus on increasing security awareness, local lone working protocols, dealing with obsessive complainants and delivering a reliable access control system • Trust self -assessment against national standards has been presented to the RGE with an associated workplan in November 2014.

4.5 Monitoring, annual and regular reporting • CAS alerts received on a monthly basis • Registration exception reporting received on a monthly basis • Serious incident process monthly monitoring received • Complaints quarterly and annual reports received • Serious incident Annual report May 2014 • Mandatory supervision quarterly reporting received • Infection control quarterly reports received and annual report • Mandatory training reporting received quarterly • Safeguarding training monthly monitoring received • Local, NETSS and corporate induction quarterly monitoring received • Medicines management group meeting summaries and annual report received • Dignity and respect annual report received December 2014 • RGE annual report received and approved for Board

150 • Safeguarding annual report received June 2014 • CPA annual report received June 2014 • Suicide prevention and avoidable deaths group annual report received October 2014 • Green light report received – green on all indicators August 2014 • Privacy and dignity audit report received – action plan to come back for monitoring recommendations October 2014 • Education annual report received October 2014 • Physical healthcare and medical devices group annual report received June 2014 • Emergency planning annual report and EPPR mental health core standards gap analysis and action plan received October 2014 • Patient safety audit report – March 2015

5.0 Quality and audit

5.1 Care Quality Commission • A CQC exception report is received on a monthly basis and covers: o Registration – registered without conditions o Compliance inspections – all inspections are fully reported on and a monthly compliance status report has been compiled and updated for RGE, Board, Monitor, education and CCG purposes • The CQC has not taken enforcement action against the Trust in 2014/15. The following table reflects our compliance with the planned/responsive inspections received at our 15 in-patient locations. • One thematic review took place in December 2014 in relation to emergency/ crisis care.

5.2 Quality Account/Quality Report • The 2013/14 Quality Account/Report was approved and submitted to Monitor and the Secretary of State and laid before parliament • Quarterly progress reports received against the 2014/15 priority improvements • Priority improvements for 2014/15 received and approved to go to Board

5.3 Monitor Quality Governance Framework • Annual assessment against Monitor Quality Governance Framework received December 2014

5.4 Monitoring and regular reporting • Ward quality barometer received and discussed monthly and approved for Board – now includes family and friends test • Safeguarding barometer received monthly • Patient feedback received verbatim from discharge questionnaires on a monthly basis • Quarterly clinical audit reports and annual report received and approved for Quality Assurance Group – priority 1 and 2 audits reported to RGE and any limited assurance audits are discussed.

151 • Community quality barometer developed, reported and discussed monthly up to implementation of Remedy, which has caused difficulties in reporting

6.0 Conclusion

It has been another challenging year and this has been reflected in the RGE meetings, which are lengthy and always have a full agenda. Inspectorates and regulators continue to make heavy demands on the Trust and we continue to respond in a committed manner.

During this year a newly formed sub committee of the Board was established – Quality and Risk Committee and new terms of reference were approved and this will impact and these groups agendas need to be developed and confirmed to avoid duplication.

The Risk and Governance Executive provides a robust platform for providing assurance to the Trust Board and the Audit Committee.

7.0 Forward plan 2015-16

a) The Risk Management Strategy.to be reviewed and meetings to occur 9 times per year b) Quality sub-group of the Board new terms of reference to be agreed– to meet 6 times per annum and revise agenda for both these meetings. c) The risk register and assurance framework will continue to be a priority on a quarterly basis for the group with a full review of the register early in the year. d) Compliance with CQC essential standards of quality and safety will have a continued focus, in particular with data quality audits and a programme of mock assessments e) Planning on new CQC inspection regime with additional focus on community teams f) RGE will continue to make strong efforts to improve the level of mandatory and statutory training within the organisation together with effective reporting and monitoring, with a continued emphasis on safeguarding training. g) We will meet our requirements for reporting to our commissioners in line with the business schedule for its Contract Monitoring Group h) RGE will continue to develop and utilise a number of early warning data sources to ensure that the Trust is meeting its strategic objectives and robust governance in relation to quality and risk

152 North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No:

Date: 25 November 2015

Title of Report: Charitable Funds Accounts and Annual Report 2014/15

Lead: David Griffiths, Director of Resources

Subject, Purpose and Recommendation: The Trust is required to submit an annual report and accounts to the Charity Commission in accordance with Charity Law.

The Trust external auditors (Grant Thornton) have carried out an independent examination of the annual report and accounts and have not identified any issues. The accounts were considered by the Audit Committee on 15 October and further approved by the Charitable Fund Forum on 12th November. No issues were identified. The Audit Committee therefore recommends the accounts to the Board of Directors for approval.

The Board of Directors is asked to agree the annual report and accounts for the year ended 31 March 2015 and approve the signing of the accounts.

Please note that the Charitable Fund did not change its name to include ‘University’ upon NEPFT adopting University within its name.

Finance Implications: No material implications

Clinical Implications: No material implications

HR Implications: No material implications

Legal and/or Regulatory Implications: The Trust will be compliant with the Charity Commission guidance

Equality Implications: No material implications

Risks: Non compliance with Charity Law

153 NORTH ESSEX PARTNERSHIP NHS FOUNDATION TRUST CHARITABLE FUNDS

ANNUAL REPORT AND ACCOUNTS FOR THE YEAR ENDED 31 MARCH 2015

Registered Charity Number: 1053509

154 TRUSTEE’S ANNUAL REPORT FOR NORTH ESSEX PARTNERSHIP NHS FOUNDATION TRUST CHARITABLE FUND FOR THE YEAR ENDED 31 MARCH 2015

FOREWORD

The Corporate Trustee presents the Charitable Funds Annual Report, together with the Independently Examined Financial Statements, for the year ended 31 March 2015.

The Charity’s Annual Report and Accounts for the year ended 31 March 2015 have been prepared by the Corporate Trustee in accordance with Part VI of the Charities Act 1993 and the Charities (Accounts and Reports) Regulations 2005. The Charity’s report and accounts include all the separately established funds for which the North Essex Partnership University NHS Foundation Trust is the sole beneficiary.

The Charity has a corporate trustee: the North Essex Partnership University NHS Foundation Trust. The Members of the NHS Foundation Trust Board who served during the year were as follows:

Non-Executive Directors Chris Paveley Chairman of the Board of Directors Charles Beaumont Jane Crame (Resigned 1 August 2014) John Gilbert (Resigned 31 May 2014) Amanda Sherlock (Appointed 1 June 2014) Peter Little (Appointed 1 June 2014) Ray Cox (Resigned 31 March 2015) Brian Johnson (Appointed 13 March 2012)

Executive Directors Andrew Geldard Chief Executive

Lisa Anastasiou Director of Workforce & Development Mike Chapman Director of Strategy Dr Malte Flechtner Medical Director Rick Tazzini Director of Resources (Resigned 30 October 2014) David Griffiths Director of Resources (Appointed 17 November 2014) Paul Keedwell Director of Operations & Nursing (Resigned 18 January 2015) Vince McCabe Director of Operations (Appointed from previous role as Director of Community Services on 1st January 2015 ) Natalie Hammond Director of Nursing and Quality (Appointed 9 March 2015)

 = Non voting executive

The Charitable Funds are registered with the Charity Commission (number 1053509), in accordance with the Charities Act 1993.

Reference and Administrative Details

The Charity was registered on 5 March 1996. On 1 November 2011, all subsidiary funds, with the exception of the Betty Cave Legacy and the Daisy Heydon Bequest, had their funds transferred to the Umbrella Trust, and the subsidiaries were dissolved.

155 Trustee

The North Essex Partnership University NHS Foundation Trust is the Corporate Trustee of the Charitable Funds governed by the law applicable to Trusts, principally the Trustee Act 2000 and the Charities Act 1993.

The NHS Foundation Trust delegated operational management of funds to the Charitable Funds Forum, which administers the funds on behalf of the Corporate Trustee. The members of the Charitable Funds Forum during the year were:

Chris Paveley Chair Rick Tazzini (Resigned 30 October 2014) David Griffiths (Appointed 17 November 2014) Paul Keedwell (Resigned 18 January 2015) Vince McCabe (Appointed 1 January 2015) Charles Beaumont

Principal Office

The principal office, and registered address, for the Charity is:

North Essex Partnership NHS Foundation Trust Charitable Fund c/o North Essex Partnership University NHS Foundation Trust Stapleford House 103 Stapleford Close Chelmsford Essex CM2 0QX

Principal Professional Advisers: Bankers Government Banking Service C/o Citi CitiGroup Centre Canada Square Canary Wharf London E14 5LB

Natwest Government Banking Service PO Box 64388 National Westminster Bank PLC London Corporate Service Centre 3rd Floor, 2 ½ Devonshire Square London EC2P 2G

Independent Examiners Grant Thornton UK LLP Grant Thornton House Melton Street Euston Square London NW1 2EP

Investment Fund Managers CCLA Investment Management Limited 80 Cheapside London EC2V 6DZ

156 Structure, Governance and Management

The Corporate Trustee fulfils its legal duty by ensuring that funds are spent in accordance with the objects of each fund and by designating funds the Trustee respects the wishes of donors to benefit patients and staff at various locations.

The Corporate Trustee delegates operational management of the funds to the Charitable Funds Forum. The Chairman of the Charitable Funds Forum is accountable to the Corporate Trustee and presents the accounts of the Charitable Trust to the Board of the Corporate Trustee.

Objectives and Strategy

The Charity’s main fund has the Charitable Object to apply the income for any charitable purpose or purposes relating to the National Health Service.

There are three restricted funds which are part of the main charity. This includes the Betty Cave Legacy, which was set up in 2008 for the purpose of medical research.

Annual Review During the year, funds were used to purchase additional goods and services that the NHS is unable to provide. During the year, funds were used to enable staff and patients to participate in research projects, to pay for supplementary training and equipment for staff, and to provide equipment to patients that would otherwise not be available.

Reserves Policy The Trustee does not hold a predetermined level of funds as reserves.

Future Plans The Trustee reviews the spending priorities for each fund annually, and has reviewed the spending of funds in 2014-15. In 15/16 the funds will be consolidated in order to make it easier to bid for funds and also to reduce the administrative burden.

Review of Finances, Achievements and Performance The net assets of the Charitable Fund as at 31 March 2015 were £152,000 (2014: £138,000).

During the year, expenditure totalling £13,000 (2014: £8,000) was made on patients’ welfare and amenities; £0,000 (2014: £0) was spent on staff welfare and amenities, and expenditure totalling £4,000 (2014: £1,000) was made on research.

Going Concern The Trustee has reviewed its financial position and considers that North Essex Partnership NHS Foundation Trust Charitable Fund is a going concern.

Investments The Charitable Fund holds investments in the COIF Charities Investment Fund. The value of these funds as at 31 March 2015 was £79,000. (2014: £73,000)

The Charitable Funds are held in a simplified portfolio of investments and cash. Investments are managed by an investment management fund and are held in funds which do not contradict the ethics of the NHS.

157

This report was approved by the Trustee on 25th November 2015 and signed on its behalf by

Chris Paveley Chairman of the Board of Directors, North Essex Partnership University NHS Foundation Trust

Andrew Geldard Chief Executive, North Essex Partnership University NHS Foundation Trust

158 NORTH ESSEX PARTNERHSIP NHS FOUNDATION TRUST CHARITABLE FUND STATEMENT OF TRUSTEE’S RESPONSIBILITES

Law applicable to charities in England and Wales requires the Trustee to prepare financial statements for each financial year which give a true and fair view of the Charity’s financial activities during the year and of its financial position at the end of the year. In preparing the financial statements, the Trustee should:

• Select suitable accounting policies and apply them consistently; • Make judgements and estimates that are reasonable and prudent; • State whether applicable accounting standards and statements of recommended practice have been followed, subject to departures disclosed and explained in the financial statements; • Prepare the financial statements on the going concern basis unless it is inappropriate to presume that the Charity will continue its activities

The trustee is responsible for keeping accounting records which disclose with reasonable accuracy the financial position of the Charity and which enable them to ascertain the financial position of the Charity and which enable them to ensure that the financial statements comply with the Charities Act 2006. They are also responsible for safeguarding the assets of the Charity and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

159 INDEPENDENT EXAMINER’S REPORT TO THE TRUSTEE OF NORTH ESSEX PARTNERSHIP NHS FOUNDATION TRUST CHARITABLE FUNDS

I report on the accounts of the North Essex Partnership NHS Foundation Trust Charitable Funds for the year ended 31 March 2015, which are set out on pages 7 to 12. This report is made solely to the Charity’s trustee, as a body, in accordance with section 145 of the Charities Act 2011 and regulations made under section 145 of that Act. My examination has been undertaken so that I might state to the Charity’s trustee those matters I am required to state to them in an examiner’s report and for no other purpose. To the fullest extent permitted by law, I do not accept or assume responsibility to anyone other than the Charity and its trustee as a body, for my examination, for the report, or for the statements I have made.

Respective responsibilities of trustee and examiner The Charity’s trustee is responsible for the preparation of the accounts. The Charity’s trustee considers that an audit is not required for this year (under section 144 of the Charities Act 2011 (the 2011 Act) and that an independent examination is needed. It is my responsibility to: • examine the accounts under section 145 of the 2011 Act; • to follow the procedures laid down in the General Directions given by the Charity Commission under section 145(5) of the 2011 Act; and • to state whether particular matters have come to my attention.

Basis of independent examiner’s report My examination was carried out in accordance with the General Directions given by the Charity Commission. An examination includes a review of the accounting records kept by the Charity and a comparison of the accounts presented with those records. It also includes consideration of any unusual items or disclosures in the accounts, and seeking explanations from you as trustee concerning any such matters. The procedures undertaken do not provide all the evidence that would be required in an audit, and consequently no opinion is given as to whether the accounts present a ‘true and fair view’ and the report is limited to those matters set out in the statement below.

Independent examiner’s statement In connection with my examination, no matter has come to my attention, which gives me reasonable cause to believe that, in any material respect, the requirements: • to keep accounting records in accordance with section 130 of the 2011 Act; and • to prepare accounts which accord with the accounting records and comply with the accounting requirements of the 2011 Act have not been met; or • to which, in my opinion, attention should be drawn in order to enable a proper understanding of the accounts to be reached.

th ………………………………. Date: 25 November 2015

Christian Heeger, ACA-ICAEW, BSc, FCA

Grant Thornton UK LLP, Grant Thornton House, Melton Street, Euston Square, London, NW1 2EP

160

NORTH ESSEX PARTNERSHIP NHS FOUNDATION TRUST CHARITABLE FUND STATEMENT OF FINANCIAL ACTIVITIES FOR THE YEAR ENDED 31 MARCH 2015

2015 2014 Total Total Note Unrestricted Restricted Endowment Funds Funds £’000 £’000 £’000 £’000 £’000

Incoming Resources Incoming Resources from Generated Funds: Voluntary Income: 3 Donations 19 - - 19 4 Legacies - - - - - Total Voluntary Income 19 - - 19 4 Investment Income 3 - - 3 3 Other Incoming Resources 3 - - 3 3

Total Incoming Resources 25 - - 25 10

Resources Expended Charitable Activities Patient Education and Welfare (7) - - (7) (8) Staff Education and Welfare - - - - - Research - (1) - (1) (1) Other 4 (4) (2) - (6) (7) Total Charitable Expenditure (11) (3) - (14) (16) Governance Costs 4 (2) (1) - (3) (3)

Total Resources Expended (13) (4) - (17) (19)

Net Incoming Resources Before Transfers and Other Recognised Gains and Losses 12 (4) - 8 (9)

Gains/(Losses) on Revaluation and Disposal of Investment Assets 6 - - 6 2

Net Movement in Funds 18 (4) - 14 (7)

Fund Balances Brought Forward at 1 April 2014 57 53 28 138 145

Fund Balance Carried Forward at 31 March 2015 75 49 28 152 138

All incoming resources and resources expended are derived from continuing activities.

The Statement of Financial Activities includes all gains and losses recognised in the year.

The notes on pages 9 to 12 form part of these financial statements.

161 NORTH ESSEX PARTNERSHIP NHS FOUNDATION TRUST CHARITABLE FUND BALANCE SHEET AS AT 31 MARCH 2015

2015 2014 Total Total Note Unrestricted Restricted Endowment Funds Funds £’000 £’000 £’000 £’000 £’000

Fixed Assets Investments 9 51 - 28 79 73

Total Fixed Assets 51 - 28 79 73

Current Assets Debtors 10 - - - - 1 Cash at Bank and in Hand 34 49 - 83 77

Total Current Assets 34 49 - 83 78

Liabilities Creditors Falling Due Within One Year 11 (10) - - (10) (13)

Net Current Assets 24 49 - 73 65

Total Assets Less Current Liabilities 75 49 28 152 138

Net Assets 75 49 28 152 138

Funds of the Charity Capital Funds Endowment Fund 12 - - 28 28 28

Income Funds Restricted Funds 12 - 49 - 49 53 Unrestricted Funds 12 75 - - 75 57

Total Funds 75 49 28 152 138

The notes on pages 9 to 12 form part of these financial statements.

Signed on behalf of the Trustee on 25th November 2015,

Chris Paveley Chairman of the Board of Directors, North Essex Partnership University NHS Foundation Trust

Andrew Geldard Chief Executive, North Essex Partnership University NHS Foundation Trust

162 NORTH ESSEX PARTNERSHIP NHS FOUNDATION TRUST CHARITABLE FUND NOTES TO THE ACCOUNTS FOR THE YEAR ENDED 31 MARCH 2014

1. Principal Accounting Policies

The financial statements have been prepared in accordance with applicable Accounting Standards in the United Kingdom, the Statement of Recommended Practice: Accounting and Reporting by Charities (SORP 2005) and with the Charities Act 1993. A summary of the principal accounting policies, which have been applied consistently, are set out below.

1.1 Basis of Accounting The financial statements are prepared under the historical cost convention, modified by the revaluation of certain investments.

1.2 Incoming Resources

1.2.1 Donations, Legacies and Gifts in Kind Donations and legacies are credited to the Statement of Financial Activities on a receivable basis. Legacies are accounted for on receipt of correspondence from the personal representative indicating that payment of the legacy will be made. No amounts are included in the financial statements for services donated by volunteers.

1.2.2 Grants Receivable Grants receivable are credited to the Statement of Financial Activities in the year in which they are receivable.

1.3 Resources Expended All expenditure is accounted for on an accruals basis and has been classified under headings that aggregate all costs related to the category. Where costs cannot be directly attributed to particular headings they have been allocated to activities on a basis consistent with use of the resources. All expenditure is recognised once there is a legal or constructive obligation to make a payment to a third party.

1.3.1 Grants Payable Grants payable are payments, made to third parties (including NHS bodies) in furtherance of the charitable objects of the charity. They are accounted for on an accruals basis, in full as liabilities of the charity when approved by the trustees and accepted by the beneficiaries (i.e. where a third party has a reasonable expectation that they will receive the grant).

1.3.2 Charitable Activities Costs of charitable activities comprise all costs incurred in the pursuit of the charitable objectives. These costs comprise direct costs and an apportionment of support costs as shown in note 4.

1.3.3 Governance Costs Governance costs comprise all costs incurred in the independent examination of the statutory accounts. The Trustees are not entitled to either a remuneration or expenses in their capacity as Trustees of the Charitable Fund, therefore the Fund is not charged for their time commitment. There is a small charge for the financial administration of the fund, paid to North Essex Partnership University NHS Foundation Trust.

1.3.4 Allocation of Support Costs Support costs have been allocated between charitable activities and governance costs on the basis of direct costs, and apportioned by average month end balances held on each individual fund.

1.3.5 Recognition of Liabilities Liabilities are recognised when an obligation arises to transfer economic benefits as a result of past transactions or events.

163

1.4 Fund Accounting Unrestricted funds are general funds which are available for use at the discretion of the trustee in the furtherance of the general objectives of the charity.

Restricted funds are funds which are to be used in accordance with specific restrictions imposed by donors or which have been raised by the charity for particular purposes. The cost of raising and administering such funds are charged against a specific fund. The aim and use of each restricted fund is set out in the annual report.

Investment income and gains are allocated to the appropriate fund within the statement of financial activities.

1.5 Investments Investments are included at closing mid-market value at the balance sheet date. Any realised and unrealised gains and losses on revaluation or disposals are in the statement of financial activities.

1.6 Taxation The charity is a registered charity and as such is entitled to certain tax exemptions on income and profits from investments and surpluses on any trading activities carried out in furtherance of the charity's primary objectives, if these profits and surpluses are applied solely for charitable purposes. The charity is not registered for VAT and, accordingly, all expenditure is recorded inclusive of any VAT incurred.

2 Related Party Transactions

The North Essex Partnership University NHS Foundation Trust is the sole beneficiary of the Charity. The Charity has provided funding to the NHS Foundation Trust for approved expenditure made on behalf of the Charity. This funding amounted to £17,000 (2014: £19,000).

During the year no members of the NHS Foundation Trust Board or senior NHS Foundation Trust staff, or parties related to them, were beneficiaries of the Charity.

The NHS Foundation Trust received £6,000 (2014: £6,000) during the year as a contribution to expenses incurred in the administration of the Charity, and £4,000 (2014: £3,000) for the cost of the Independent Examination of the Charity. The Trustee has not purchased Trustee Indemnity Insurance.

3 Analysis of Voluntary Income

All donations were made by individuals. There were no legacies received during 2015 (2014: £nil).

4 Allocation of Support Costs and Overheads

Allocated to: 2015 2014 Charitable Total Governance Activities Total Funds Funds £’000 £’000 £’000 £’000

Administrative Services - 6 6 7 Independent Examination 4 - 4 3

Total 4 6 10 10

164 5 Analysis of Grants

All grants are made to North Essex Partnership University NHS Foundation Trust. No grants are made to individuals.

6 Transfers Between Funds

There have been no transfers between funds.

7 Independent Examiner’s Remuneration

The Independent Examiner’s remuneration of £4,000 (2013: £3,000) relates solely to the Independent Examination, with no other additional work undertaken.

8 Income From Investments

Total Held in UK 2015 2014 £’000 £’000

Fixed Asset Investments 3 3 Interest on Cash at Bank - -

Total 3 3

9 Fixed Asset Investments

Common Investment Total As At 31 Fund March 2014 £’000 £’000

Market Value at 1 April 2014 73 71

Unrealised Gains/(Losses) 6 2

Market Value at 31 March 2015 79 73

Historic Cost at 31 March 2015 61 61

All of the above investments are invested in the COIF Charities Investment Fund in the United Kingdom.

165 10 Analysis of Current Assets

31 March 2015 31 March 2014 £’000 £’000

Prepayments and Accrued Income - 1

11 Analysis of Current Liabilities

31 March 2015 31 March 2014 £’000 £’000

Accruals (-) (13)

12 Analysis of Charitable Funds

Balance at 31 March Incoming Resources Gains and Balance at 2014 Resources Expended Losses 31 March 2015 £’000 £’000 £’000 £’000 £’000

Permanent Endowment Daisy Haydon Bequest 28 - - - 28

Restricted Funds

North East Essex Finance 3 (2) 1 2 Betty Cave Legacy 50 (3) 47

Total Restricted Funds 53 - (5) 1 49

Unrestricted Funds

North East Essex Acute 8 1 (1) - 8 North East Essex Rehabilitation 3 - - - 3 North East Essex Elderly 8 3 (2) - 9 North East Essex Child and Adolescent 6 12 (3) - 15 North East Essex Finance 20 - (1) 5 24 Mid Essex 1 1 (-) - 2 Essex and Hertfordshire 11 8 (5) - 14

Total Unrestricted Funds 57 25 (12) 6 75

Total Funds 138 25 (17) 6 152

166

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 20

Date: 25 November 2015

Title of Report: Charitable Funds Policy

Lead: David Griffiths, Director of Resources

Subject, Purpose and Recommendation: The Board of Directors is asked to approve the updated Charitable Funds Policy.

Background Under Section 3.2.13 of the Reservation of Powers to the Board and Scheme of Delegation, the Board has reserved powers to approve arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for Charitable Funds.

The Charitable Funds Forum has reviewed the Trust’s Charitable Funds Policy, and this has also been considered by the Risk and Governance Executive.

No substantive changes are recommended, although there are a number of minor changes (shown in red text) including the inclusion of an Observer place on the Charitable Funds Forum for a representative of the Council of Governors.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

167

NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

POLICY DOCUMENT

Document Title Charitable Funds Policy

Reference Number FP000004

Policy Type Finance Policy

Electronic File/Location X:\Policies & Procedures\WIP

Status Draft Version

Version Number/Date Version 1

Author(s) Responsible for Head of Financial Accounts Writing and Monitoring

Responsible Director Director of Resources

Approved By Board of Directors

Approval Date

Implementation Date

Review Date July 2015

168 1. Introduction

1.1 North Essex Partnership NHS Foundation Trust Charitable Funds (the Charity) is registered with the Charity Commission, registration number 1053509. It is a separate legal entity from the North Essex Partnership University NHS Foundation Trust.

1.2 The Charity was registered under a Trust Deed on 5 March 1996.

1.3 The Objects of the Charity are for its income to be applied for any charitable purpose relating to the National Health Service.

1.4. The North Essex Partnership University NHS Foundation Trust acts as Corporate Trustee for the North Essex Partnership NHS Foundation Trust Charitable Funds. This means that the North Essex Partnership University NHS Foundation Trust (via the Board of Directors) has responsibility to ensure that money donated to the Charity is spent appropriately, and in accordance with donor’s wishes, charity law and Charity Commission Guidance.

1.5. North Essex Partnership University NHS Foundation Trust exercises its responsibilities to North Essex Partnership NHS Foundation Trust Charitable Funds by delegating operational management to the Charitable Funds Forum.

1.6. The Charitable Funds Forum (CFF) is chaired by a non-executive director, and comprises a further non-executive director, the Director of Resources and the Director of Nursing & Operations from the NHS Foundation Trust’s Board of Directors. The CFF report directly to the NHS Foundation Trust’s Board of Directors.

1.7. The lead governor or their deputy is invited to attend the CFF in an observer capacity.

1.8. This policy and procedure is to assist the CFF in discharging their responsibilities to the Trustee, as outlined above.

1.9. This policy should be read in conjunction with the following policies and procedures:

Receipt of Income and Banking Procedure (FPD2) Petty Cash Procedure

and with the NHS Foundation Trust’s Standing Financial Instructions (SFIs) which nothing herein is intended to override.

All of these documents are available on i-Connect, or on request from the Finance Team

169 1.9 For the avoidance of doubt, all transactions must comply with the North Essex Partnership University NHS Foundation Trust Standing Financial Instructions, Standing Orders and Systems of Internal Control.

2. Aim

2.1 The aim of this procedure is to provide guidance on how to deal with Charitable Funds, namely

• Receiving income into Charitable Funds • Incurring expenditure from Charitable Funds • Standard forms to use

2.2 The commitment of the Trust and responsibility of all staff is not to discriminate on any grounds. In drawing up this policy/procedure aspects of discrimination have been considered so that no groups are disadvantaged.

3. Donations to Charitable Funds

3.1 Money received by the Charitable Funds can be used for charitable purposes relating to the NHS. Money intended for anything other than this cannot be accepted by the Charitable Funds.

3.2 Occasionally, a donor may specify a further restriction upon the use of their donation (for example that it must be used for medical research). This is acceptable provided that the restriction still falls within the general purpose of the Charity (see 1.3).

3.3 For the avoidance of doubt, any donations received where the donor does not specify a restriction upon use will be available for general use by the Charitable Funds. Due to the administrative and practical implications, donations under £5,000 should not normally be accepted with restrictions, but will be considered.

3.4 Where cash or a cheque is handed in, a receipt must be issued to the donor (see Appendix 1). Any restrictions upon the use of the money must be provided in writing by the donor.

3.5 The donation should be banked via an income sheet in the Charitable Funds bank account. Where a Charitable Funds income sheet is not available, the money can be banked via the NHS Foundation Trust’s income sheet, with clear annotation that the money relates to Charitable Funds. Notification must be emailed to the Finance Team at Trust Headquarters.

3.6 Any documentation regarding restrictions should be forwarded to the Finance Team based at Trust Headquarters. If considered appropriate, a thank you letter should be issued to the donor (see Appendix 2 for an example).

170

3.7 Where a donation is to be made by post, this should be sent by cheque to Trust Headquarters. The above process for banking must be followed, and a thank you letter must be issued as a receipt cannot be.

3.8 Where donation is made by a legacy, the Finance Team at Trust Headquarters should be contacted for assistance. Confirmation must be obtained of any specified purpose for the donation, and agreement made that this is within the general purpose of the Charitable Funds.

3.9 Donations can now be made via the NEP website using the My Donate facility.

4. Legacies

4.1 There are often covenants attached to monies received via legacies. The Finance Team at Trust Headquarters must always be contacted before accepting a legacy. This will allow checks to be made that the Charity is in a position to be able to accept the legacy, and that the covenants in place do not fall outside of the Charity’s objects (see 1.3).

4.2 The terms of the will or letter of administration dictate how the asset must be used, and this will determine how the asset is treated by the Charity.

4.3 Due to the complex nature of legacies, each case will be dealt with on an individual basis.

5. Expenditure from Charitable Funds

5.1 Any expenditure of £250 or over in amount must be approved by the Charitable Funds Forum prior to the expenditure being incurred. In order to obtain approval, a bid must be submitted on the pro-forma template (Appendix 3).

5.2 Any expenditure under £250 must be approved by the relevant fund manager.

5.3 Every bid must include details of which fund the money is being requested from, ensuring that there is sufficient money available in the specified fund to cover the expenditure.

5.4 Every bid must include specific details of the item(s) being requested, including the cost (and any associated costs for example installation costs, furniture required to house the items, delivery costs etc). Any information considered relevant to the bid may be included, such as specific reasons why the item is being requested, or specific benefits relating to the item.

171 5.5. Every bid must be signed by the Fund Manager for the specified fund before being submitted to the Finance Team at Trust Headquarters. Bids should be submitted to the Finance Team no later than 7 days prior to the meeting of the CFF.

5.6. Expenditure in excess of £250 must not be incurred prior to approval by the CFF. Once the CFF have discussed the bid, notification will be made by the Finance Team at Trust Headquarters whether or not it was successful. This will usually be via email to the person submitting the bid.

5.7. It should be noted that any expenditure in excess of £250 incurred without approval from the CFF or on items not considered appropriate to purchase from Charitable Funds (see 5.10 and 5.11 below) will be charged to the relevant budget code in the NHS Foundation Trust.

5.8. Charitable Funds can be spent on items which enhance the service user’s experience. These are “extras” that the NHS Foundation Trust would not be expected to provide.

5.9. Examples of items which may be appropriate to purchase from Charitable Funds include:

• Games for service users • Garden items for service users • Entertainment items for service users / ward areas • Christmas decorations • Parties/celebrations for service users, family and carers (as a guide, the amount should be restricted to £5 per head, with a maximum of £200 per event)

5.10. Examples of items which are not appropriate to purchase from Charitable Funds include:

• Staff “leaving” parties / celebrations • Alcohol • Gratuities for staff / suppliers, etc • Satellite navigation systems • Refurbishment, furniture and equipment which is generally required for the running of the NHS Foundation Trust services • Items which would be in breach of NHS Foundation Trust policies, (eg around infection control, patient safety and confidentiality, etc)

5.11. Please note that the examples provided in 5.9 and 5.10 are not intended to be exhaustive lists and are provided for illustration purposes only.

5.12. Once the expenditure has been approved, the normal NHS Foundation Trust procedures for incurring expenditure must be

172 followed (please see The Procurement Handbook, which can be found on the Trust intranet)

6. Gift Aid

6.1 Gift Aid is a tax relief for gifts made to a charity by an individual and allows the charity to recover the basic rate of income tax from HMRC.

6.2 For each gift made, the donor is encouraged to complete and pass to the Charity a declaration form which gives full details of the payment and certifies that the donation meets all conditions necessary for relief.

6.3 The receipt form attached at Appendix 1 can be signed to allow the donation to be treated under Gift Aid.

7. Administration Charge

7.1 An administration charge is made to the Charity as the NHS Foundation Trust is not permitted to subsidise the Charity, and the Charity must correctly reflect its running costs.

7.2 The administration charge covers bank charges, audit fees, a proportion of time spent by NHS Foundation Trust staff, and other costs (such as postage, etc)

7.3 The charge will be distributed across the funds in proportion to the average monthly balances.

8. Fundraising

8.1 North Essex Partnership University NHS Foundation Trust, as Trustee of the Charity, is responsible for ensuring that any fundraising activity undertaken on behalf of the Charity is properly conducted and that funds raised are properly accounted for.

8.2 Fundraising is not a charitable object itself; it must be carried out in support of charitable purposes.

8.3 Prior authorisation must be obtained from a member of the Charitable Funds Forum before any fundraising can commence.

8.4 Where funds are raised for a specific project or purpose this implies that the money raised will be spent on that project. The donor must not be misled as to how their money will be used. Any literature must include details of how the money will be used if insufficient funds are raised, and of how any surplus funds will be utilised.

8.5 It is important to ensure that trading activities are not undertaken in the guise of fundraising. If further assistance is required to ascertain

173 whether an activity is fundraising or trading, please speak to the Finance Team in the first instance.

8.6 ALL funds raised must be paid into the Charitable Funds bank account prior to being spent. This ensures that all money is correctly accounted for.

9. Reserves Policy

9.1 The Trustee does not wish to establish any level of reserves other than those appropriate to a reasonable level of working balances. The Trustee aims to utilise funds in the manner in which they were intended with as little delay as possible.

9.2 Money given for charitable purposes should be used as such, rather than simply be deposited and retained.

9.3 Designated funds should be used only for the purpose of their designation. Where funds become too small to utilise, or where the designation is no longer appropriate, the Trustee will consider whether the fund could be more appropriately used.

9.4 Where a particular fund is increasing in value, the fund manager may be asked to provide a spending plan of how it is proposed the funds are utilised.

10. Other Matters

10.1 It is not appropriate for NHS Foundation Trust employees to donate money belonging to the NHS Foundation Trust to the Charity. For example, payment for work carried out under the contract of employment will generally be due to the NHS Foundation Trust.

10.2 Personal donations may be made by NHS Foundation Trust employees. For example, payment for work carried out outside of the contract of employment will generally be due to the employee, and may be donated to the Charity at the employee’s discretion.

10.3 Personal donations made to the Charity will be subject to the same rules as all donations, and will be under the control of the Trustee. They may not be used to supplement the NHS Foundation Trust budget of the individual, unless appropriate process has been followed, as per this document.

174

RECEIPT FOR AN INDIVIDUAL DONATION

The donor should insert their name I, here The donor should of insert their address here

give to North Essex Partnership University NHS Foundation Trust as the trustee of the North Essex Partnership NHS Foundation Trust Charitable Fund for the general the sum of £ purposes of that charity If the donor has a Without imposing any trust it specific application is my wish that my donation in mind they can be should used to: insert appropriate wording here. This is optional, but may help the trustee in allocating the donation to an appropriate designated fund

Donor’s signature

Date

Name of receiving member of NHS Foundation Trust staff If the donor wishes Please treat the enclosed gift to treat the gift as a as a Gift Aid donation. I Gift Aid Donation, confirm that I pay an amount they must sign of Income Tax and/or Capital here. This is Gains Tax for the current tax optional but allows the Charity to claim year that is at least equal to tax relief on the the amount of tax that the donation charity will reclaim on my gift

Receipt Number:

175

Stapleford House 103 Stapleford Close Chelmsford · Essex · CM2 0QX Telephone: 01245 546400 Facsimile: 01245 546401 www.nepft.nhs.uk

Dear [insert name]

Re: Receipt of donation in the sum of £xx

Thank you for thinking of us with your kind donation of £xx to the North Essex Partnership NHS Foundation Trust Charitable Fund, [please insert appropriate wording if donor has expressed a wish as to how the funds are used].

I hereby acknowledge receipt of this donation.

Kind regards

Yours sincerely

[insert name and delegation]

176

Charitable Funds – Spending Application

Title of Fund: ______

Ward/Unit: ______

Budget Code: ______

Value of Bid: £ ______

Details of Bid:

(Please include specific details of the item(s) to be purchased (eg 42” LCD TV), a quoted price, any additional costs associated (eg installation), and the benefits derived from purchasing the item(s). NB - if application is for a party or similar event, please detail the number of service users attending, and the cost per head).

Signature: ______(Fund Manager/Authorising Signature)

Name: ______Date: ______

FOR FINANCE USE ONLY

Date of Charitable Fund Forum: ______

APPROVE please tick as appropriate) REJECT

Signature: ______

Title: ______Date: ______

177

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 21

Date: 25 November 2015

Title of Report: Medical and Non Medical Education

Lead: Dr Malte Flechtner, Medical Director

Subject, Purpose and Recommendation: The Board of Directors is invited to receive a verbal update on Medical and Non Medical Education (a standing item) on behalf of Dr Malte Flechtner, Medical Director.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

178

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 22

Date: 25 November 2015

Title of Report: Reservation of Powers and Scheme of Delegation - Update

Lead: Dermot McCarthy, Trust Secretary

Subject, Purpose and Recommendation:

The Board of Directors is asked to approve the revised Reservation of Powers and Scheme of Delegation as recommended by the Audit Committee at their meeting held on 15 October 2015.

The Reservation of Powers to the Board and Scheme of Delegation. has been updated by the Trust Secretary and reviewed by the Audit Committee (15 October 2015) where it was recommended to the Board of Directors for Approval.

Board approval is required in accordance with the current Scheme of Delegation (3.2.1) which reserves to the Board “Approval of [Standing Orders] SOs, a schedule of Powers Reserved to the Board of Directors and SFIs [Standing Financial Instructions] for the regulation of its proceedings and business.”

In 2014 the Reservation of Powers and Scheme of Delegation was subject to a comprehensive review, via the Executive Management Team (EMT), the Audit Committee and the Board of Directors. It was approved by the Board of Directors on 30 July 2014, with a further review scheduled for 2015. This review process has been progressed with a revised draft considered by the Executive Management Team on 22 June 2015, which included a series of non-material changes: • Updated version control information (page 1) • Updated reference re Monitor’s Code of Governance (page 3) • Added reference to the Quality & Risk Committee (page 9) • Updated Executive Director job title re ‘Director of Nursing & Quality’ (throughout).

The review process then continued as part of the ‘Finance Recovery Plan 2015/16’ considered by the Board of Directors in Private on 23 September 2015, where revised limits for non-pay expenditure were approved. The updated signatory levels are included in the attached version.

At its meeting held on 15 November 2015, the Audit Committee recommended approval of the document, subject to the updating of one approval date; this change has now been made.

179 In addition the following changes have been recommended by the Nursing & Quality Bisness manager (page 14); • An update re the job title • An update to the detailed referencing re the Mental Health Act Code of Practice references in context of a new Code introduced on 1st April, 2015.

These changes are marked in colour on the attached daft using ‘track changes’

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

180

Reservation of Powers to the Board and Scheme of Delegation

Version No. Res/2014 Res/2015

Replaces: Version dated April 2010 July 2014

Approved by EMT: 10 February 2014 22 June 2015

Approved by Audit Committee: 17 July 2014 15 October 2015

Approved by Board of Directors: 30 July 2014 25 November 2015

File location: Exec Drive:\FT Key Trust Docs\Scheme of Delegation\Current_2014

Author: Rick Tazzini/Dermot McCarthy David Griffiths/Dermot McCarthy

Next Review: July 2015 July 2016

181

Contents

Item Page

2 BACKGROUND ...... 3 3 DEFINITIONS ...... 4 4 RESERVATION OF POWERS TO THE BOARD OF DIRECTORS ...... 5 5 PRINCIPAL POWERS DELEGATED ...... 10 6 DETAILED SCHEME OF DELEGATION ...... 13

182 1 BACKGROUND

1.1 Introduction

The NHS Foundation Trust Code of Governance (December 2013July 2014) requires the Board of Directors of NHS foundation trusts to draw up a “schedule of matters reserved for its decision” (A.1.1) ensuring that management arrangements are in place to enable the clear delegation of its other responsibilities.

The purpose of this document is to provide details of the powers reserved to the Board of Directors, and those delegated to the appropriate level for the detailed application of Trust policies and procedures. However, the Board of Directors remains accountable for all of its functions, including those which have been delegated, and would therefore expect to receive information about the exercise of delegated functions to enable it to maintain a monitoring role.

All powers of the Trust which have not been retained as reserved by the Board of Directors or delegated to a committee or sub-committee of the Board of Directors, shall be exercised on behalf of the Board of Directors by the Chief Executive. The scheme of delegation identifies those functions, which the Chief Executive shall perform personally and those which are delegated to other Directors and Officers (paragraphs 4 and 5 below). All powers delegated by the Chief Executive can be re-assumed by him/her should the need arise.

The roles and responsibilities of the Council of Governors are described in Monitor's publication 'Your Statutory Duties: A Reference Guide for NHS foundation trust governors’, August 2013, and include the following: a. Representing the interests of trust members and the public; b. Holding the Non-Executive Directors to account; c. Appointing and removing the Chairman and other Non-Executive Directors; d. Deciding the terms and conditions for the Chairman and other Non-Executive Directors; e. Approving the appointment of the Chief Executive; f. Appointing and removing the external auditor; g. Taking decisions on significant transactions, mergers, acquisitions, separations and dissolutions; h. Taking decisions on non NHS income; i. Being consulted on the forward plans for the Trust; j. Receiving the Annual Report; and k. Receiving the Annual Accounts and the auditor’s report on them.

The respective roles of the Board of Directors and the Council of Governors are clearly described in Monitors' publication ‘Your Statutory Duties’, (August 2013). Although there are no formal processes in place for the resolution of any disagreements between the Council of Governors and the Board of Directors, the Chairman of the Board of Directors and the Chief Executive meet with the Lead Governor and Deputy Lead Governor every month to discuss matters which are within the role and responsibilities of the Council of Governors, and to resolve any disagreements/issues which may be between them.

1.2 Role of the Chief Executive

As Accounting Officer the Chief Executive is accountable for the funds entrusted to the Trust. The Chief Executive has overall responsibility for the Trust's activities, is responsible to the Board of Directors for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust's system

183 of internal control. The Chief Executive should also ensure that he/she complies with the NHS Foundation Trust Accounting Officer Memorandum.

1.3 Caution over the Use of Delegated Powers

Powers are delegated to Directors and Officers on the understanding they will not exercise delegated powers in a manner which in their judgement is likely to be a cause for public concern.

1.4 Directors’ Ability to Delegate their own Delegated Powers

The Scheme of Delegation shows only the ‘top level’ of delegation within the Trust. The Scheme of Delegation is to be used in conjunction with the system of budgetary control and other established procedures within the Trust. A Director’s delegated power may be delegated to designated deputies.

1.5 Absence of Directors (or deputy) or Officer to whom powers have been delegated

In the absence of a Director or deputy/Officer to whom powers have been delegated, those powers shall be exercised by that Director or Officer's superior unless alternative arrangements have been identified in the Scheme of Delegation or approved by the Director/Officer's superior. If the Chief Executive is absent, powers delegated to him/her may be exercised by the nominated Officer acting in his/her absence after taking appropriate advice from the Director of Resources.

In circumstances where the Chief Executive has not nominated an Officer to act in his/her absence, the Board of Directors shall nominate an Officer to exercise the powers delegated to the Chief Executive in his/her absence.

2 DEFINITIONS AND INTERPRETATIONS

2.1 The following expressions shall bear the following meanings:

"AD” means an Officer who holds the position of an Area Director of the Trust;

"AMD" means an Officer who holds the position of an Area Medical Director of the Trust;

"Annual Accounts" means those accounts prepared by the Trust pursuant to paragraph 25 of Schedule 7 to the 2006 Act;

"Annual Report" means a report prepared by the Trust pursuant to paragraph 26 of Schedule 7 to the 2006 Act;

“AsD” means an Officer who holds the position of an Associate Director of the Trust;

"Audit Committee" means a committee of the Board of Directors established in accordance with the Constitution;

"Board of Directors" means the Board of Directors as constituted in accordance with the Constitution;

"Chairman" means the Chairman of the Trust;

"Chief Executive" or "CE" means the Chief Executive of the Trust;

"Constitution" means the constitution of the Trust;

"Council of Governors" means the Council of Governors as constituted in accordance with the Constitution;

"DAD” means an Officer who holds the position of Deputy Area Director of the Trust;

“Director” means a Director of the Trust;

184 “Director of Resources” or “DoR” means the Director of Resources of the Trust, also known as the Director of Finance or DoF;

"Executive Director" means an executive member of the Board of Directors;

"Funds held on Trust" means those funds which the Trust hold on the date of incorporation, receives on distribution by statutory instrument and clauses to accept under powers gained under the 2006 Act and shall include the income and interest derived from the holding of such funds all or some of which may or may not be charitable;

"Non-Executive Director" or “NED” shall mean a Non- Executive Director of the Trust;

“Officer” shall mean an employee of the Trust or a person who holds a paid employment with the Trust and may include those whose appointment is seconded by the Trust and who are employees of third parties contracted to the Trust while in either case acting for the Trust. It shall exclude Non-Executive Directors.

“SFIs” shall mean the Standing Financial Instructions of the Trust;

“SOs” shall mean the Standing Orders of the Board of Directors of the Trust;

"the 2006 Act" means the National Health Service Act 2006 (as amended);

"Trust" means the North Essex Partnership University NHS Foundation Trust;

"Trust Secretary" means the Secretary of the Trust or any other person or body corporate appointed to perform the duties of the Secretary of the Trust including a joint, assistant or deputy secretary.

2.2 Words importing the masculine gender only shall include the feminine gender, and words importing the singular shall import the plural and vice-versa in each case.

2.3 Unless specified otherwise, all amounts set out in this Reservation of Powers to the Board and Scheme of Delegation exclude Value Added Tax (VAT).

3 RESERVATION OF POWERS TO THE BOARD OF DIRECTORS

3.1 General Enabling Provision

The Board of Directors may determine any matter it wishes within its statutory powers at a meeting of the Board of Directors convened and held as provided by SO 3 (Meeting of the Board of Directors) of the SOs.

3.2 Regulation and Control

3.2.1 Approval of the SOs, a schedule of Powers Reserved to the Board of Directors and the SFIs for the regulation of its proceedings and business.

3.2.2 Approval of a scheme of delegation of powers to Officers which has been prepared by the Chief Executive under SO 4.4.2 (Delegation to Officers) of the SOs.

3.2.3 Delegation of executive powers to be exercised by committees or sub-committees, or joint committees of the Board of Directors, and the approval of the terms of reference and specific executive powers of such committees under SO 4.3 (Delegation to committees) of the SOs.

3.2.4 Requiring and receiving the declaration of Directors’ interests which may conflict with those of the Trust and determining the extent to which that Director may remain involved with the matter under consideration.

3.2.5 Approval of the disciplinary procedure for Officers of the Trust.

185 3.2.6 Disciplining Executive Directors who are in breach of statutory requirements or the SOs.

3.2.7 Approval of arrangements for dealing with complaints.

3.2.8 Adoption of the organisational structures, processes and procedures to facilitate the discharge of business by the Trust and to agree modifications thereto. For clarity, this will comprise of details of the structure of the Board of Directors and its committees and sub- committees. Organisational structures below Executive Director are the responsibility of the Chief Executive who may delegate this function as appropriate.

3.2.9 The establishment of the terms of reference and reporting arrangements of all committees of the Trust (and sub committees if required)

3.2.10 The receipt of reports from committees of the Trust including those which the Trust is required by its Constitution, or by Monitor or by the Secretary of State, or by any other legislation, regulations, directions or guidance to establish and to take appropriate action thereon.

3.2.11 Approval of the recommendations of the Trust’s committees where the committees do not have executive powers.

3.2.12 Ratification of any urgent or emergency decisions taken by the Chairman and the Chief Executive (following consultation with at least two Non-Executive Directors) in accordance with the provisions of SO 4.2.1 (Emergency Powers) of the SOs.

3.2.13 Approval of arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for Charitable Funds.

3.2.14 Approval of arrangements relating to the discharge of the Trust’s responsibilities as a bailee for patients’ property.

3.2.15 Subject to the provisions of paragraph 5.2 of this Reservation of Powers to the Board and Scheme of Delegation, the authorisation of the use of the Seal.

3.2.16 Ratification, or otherwise, of instances of failure to comply with the SOs brought to the Chief Executive’s attention in accordance with SO 4.6 (Overriding Standing Orders) of the SOs.

3.2.17 Suspension of the SOs.

3.2.18 Amendment of the Constitution, in accordance with the Constitution.

3.2.19 Approval of the Trust’s Major Incident Plan.

3.2.20 Approval and authorisation of institutions in which cash surpluses may be held.

3.3 Appointments

3.3.1 The appointment and dismissal of committees of the Trust that are directly responsible to the Board of Directors.

3.3.2 The appointment, appraisal, disciplining and dismissal of Directors (excluding NEDs), and the Trust Secretary.

3.3.3 The appointment and removal of members to any committee or subcommittee of the Board of Directors or the appointment of Trust representatives to third party organisations.

186 3.4 Strategy and Business Plans and Budgets

3.4.1 Definition of the strategic aims and objectives of the Trust.

3.4.2 Approval of the Trust's forward plan and budget in respect of each financial year setting out the application of available financial resources.

3.5 Policy Determination

3.5.1 The approval of the Trust’s policy for approval of its management policies.

3.6 Direct Operational Decisions

3.6.1 Subject to paragraph 45 of the Constitution (Significant Transactions) acquisition, disposal or change of use of land and/or buildings or the creation of any mortgage charge or other security over any asset of the Trust. Where any decision results in associated documents executed as deed, the provisions in the scheme of delegation table at paragraph 5.2 (capital schemes) below shall apply.

3.6.2 An agreement or arrangement for all external borrowing by or loan to or from the Trust or for the creation of any overdraft facility.

3.6.3 Consider a merger, acquisition, separation or dissolution of the Trust. An application for a merger, acquisition, separation or dissolution of the Trust may only be made with the approval of more than half the members of the Council of Governors.

3.6.4 Consider a significant transaction as defined in the Constitution. A significant transaction may only be entered into if approved by more than half of the members of the Council of Governors voting in person or by proxy at a meeting of the Council of Governors.

3.6.5 Subject to paragraph 45 of the Constitution (Significant Transactions), the approval of individual contracts for the provision of non-clinical services of a capital or revenue nature/ the introduction or discontinuance of any major activity income or expenditure (that is before any set off) in relation to the provision of non-clinical services in excess of £2,000,000. Major activity or operations with a gross annual income or expenditure below £2,000,000 shall be approved in accordance with the scheme of delegation.

3.6.6 Subject to paragraph 45 of the Constitution (Significant Transactions), the approval of individual contracts for the provision of clinical services of a capital or revenue nature/ the introduction or discontinuance of any major activity income or expenditure (that is before any set off) in relation to the provision of clinical services amounting to, or likely to amount to over £1,500,000 over a 3 year period or the period of the contract if longer.

3.6.7 Approval of final business cases for capital investment (infrastructure) exceeding £500,000. For the avoidance of doubt, if the transaction is caught within the definition of 'Significant Transaction' in the Constitution, the procedure set out in the Constitution must be followed.

3.6.8 Approval of individual compensation payments over £50,000.

3.6.9 Approval of proposals for or relating to any action or litigation against or on behalf of the Trust which may have a major impact on the reputation of the organisation

3.6.10 Approval of the key strategic risks.

3.6.11 Approval of the programme of risk management, which shall include insurance arrangements (see SFI 21).

187 3.6.12 Approval and monitoring of the Trust’s policies and procedures for the management of risk.

3.6.13 Approval of proposals to ensure quality and development of clinical governance and risk management in services provided by the Trust, having regard to the guidance issued by the Secretary of State and/or Monitor.

3.6.14 Approval of the Trust’s Annual Business Plan.

3.6.15 Approval of the Trust's budgets and forward plans in respect of each financial year.

3.7 Financial and Performance Reporting Arrangements

3.7.1 Continuous appraisal of the affairs of the Trust by means of the receipt of reports as it sees fit from Directors, Committees, Associate Directors and Officers of the Trust.

3.7.2 Approval of the Trust's banking arrangements (see SFI 5).

3.7.3 Consideration and approval of the Trust’s Annual Report, including the Annual Accounts.

3.7.4 Receipt and approval of the Annual Report(s) for Funds held on Trust.

3.8 Audit Arrangements

3.8.1 The receipt of reports of the Audit Committee and the appropriate action on them.

3.8.2 The receipt of the audit findings and the audit opinion on the Trust accounts received from the Auditor and agreement of action on the recommendations where appropriate of the Audit Committee.

3.8.3 Receipt of a recommendation of the Audit Committee in respect of the appointment of Internal Auditors (Note: the recommendation in respect of External Auditors is made by the Audit Committee to the Council of Governors).

3.9 Delegation regarding the Mental Health Act 1983 (as amended)

3.9.1 Approval of the arrangements to exercise the powers of the Trust, and to comply with the responsibilities of the Trust, as 'Hospital Managers' under the Mental Health Act 1983 (as amended).

3.9.2 Save as mentioned in paragraph 3.9.3 below, the Board of Directors affirms that its powers under the Mental Health Act 1983 (as amended) are delegated in the manner set out in the detailed scheme of delegation (Section 5.2 below).

3.9.3 The powers of the Trust under section 23 of the Mental Health Act 1983 (as amended) are delegated to Associate Hospital Managers to be exercised by three or more persons who shall be neither an Executive Director of the Trust nor an employee of the Trust, and who shall be appointed and administered by the Mental Health Forum of the Trust.

3.10 Delegation to Committees

The Board of Directors may determine that certain powers shall be exercised by committees of the Board of Directors. The composition and terms of reference of such committees shall be determined by the Board of Directors from time to time taking into account where necessary the requirements of Monitor and/or the Charity Commission (including the need to appoint an Audit Committee, a Remuneration Committee, and a Nominations Committee). The Board of Directors shall determine the reporting requirements in respect of these committees. In accordance with SO 5 (Committees) of the SOs committees of the Board of Directors may not delegate executive powers to sub-

188 committees unless expressly authorised by the Board of Directors. The Board of Directors have delegated decisions/duties to the following committees:

• Audit Committee

• Quality and Risk Committee

• Remuneration Committee

• Nominations Committee

A list of committees, along with their terms of reference, shall be held by the Trust Secretary.

189 4 PRINCIPAL POWERS DELEGATED

Ref. Power Delegated Delegated To

4. 1) Final authority in interpretation of SOs (SO1.1) Chairman 4. 2) Calling meetings (SO 3.2.2) Chairman 4. 3) Chair all board meetings and associated responsibilities Chairman (SO 3.6) 4. 4) Exercise in emergency of the powers the Board of Chairman and CE Directors has retained to itself following consultation with (acting together) at least two Non-executive Directors (SO 4.2.1) 4. 5) The preparation of a scheme of delegation to be CE considered and approved by the Board of Directors, subject to any amendments agreed during their discussions (SO 4.4.2) 4. 6) Health and Safety arrangements (SFI 21.2.5) CE 4. 7) Register(s) of Directors’ interests (SO 7.10) Trust Secretary 4. 8) Authorise procurement of goods and services (SFI 9) CE 4. 9) Demonstrate best value for money for all services CE provided under contract or in-house (SO 9.6.2) 4. 10) Nominate Officers with power to negotiate contracts for CE the provision of healthcare services with purchasers of healthcare (SO 9.8.2) 4. 11) Determine any items to be sold by sale or negotiation CE or nominated (SO 10.1) Officer 4. 12) Nominate Officers to enter into contracts of employment, CE to regrade staff, or to contract for employment of agency staff or temporary staff service contracts (SO 9.7.1) 4. 13) Staff, including agency staff, appointments CE 4. 14) Variation to funded establishment of any department. CE 4. 15) Keep the seal in safe place and maintain a register of CE or nominated sealing (SO 12.1 and 12.3) Officer 4. 16) Approve and sign all documents which will be necessary Chairman or CE in legal proceedings involving the Trust (SO 13.1) unless any enactment otherwise requires authorities 4. 17) Delegate budget to budget holders and submit CE monitoring returns (SFI 3.2 and SFI 3.5). 4. 18) Sign off and approval of contracts for provision of patient CE services (SFI 7) 4. 19) Sign off and approval of NHS contracts (SFI 7) CE 4. 20) Determine, and set out, level of delegation of non-pay CE expenditure to budget managers (SFI 9.1.2) 4. 21) Authorise who may use and be issued with official CE orders (SFI 9.2.5) 4. 22) Ensure that Standing Orders are compatible with CE Department of Health requirements and codes re building and engineering contracts (SFI 9.2.7) 4. 23) Grants up to £20,000 for provision of patient services CE 4. 24) Capital investment programme (SFI 13) CE 4. 25) Maintenance of asset registers (SFI 13.2) CE 4. 26) Overall responsibility for fixed assets (SFI 13.3.1) CE 4. 27) Identify persons authorised to requisition and accept CE goods from NHS Supply Chain (SFI 14.8) 4. 28) Responsible for ensuring patients and guardians are CE informed about patients’ money and property procedures on admission (SFI 17) 4. 29) Retention of document procedures (SFI 20) CE

190

Ref. Power Delegated Delegated To

4. 30) Risk management programme (SFI 21) CE 4. 31) Sign on behalf of the Trust any agreement or document CE or nominated not required to be executed as a deed the subject matter Officers of which has been approved by the Board of Directors or a committee or sub-committee of the Board of Directors with appropriate delegated authority (SO 13.2) 4. 32) Approve and sign all building, engineering, property or CE / DoR or their capital documents. respective nominated Officers 4. 33) Data Protection Act requirements (SFI 16.1.1) DoR

4. 34) Implementing the Trust’s financial policies and co- CE/DoR ordinating corrective action and ensuring detailed financial procedures and systems are prepared and documented (SFI 3) 4. 35) Form and adequacy of financial records of all DoR departments (SFI 3) 4. 36) Submit budgets for approval by the Board of Directors DoR (SFI 3.1.2) 4. 37) Monitor performance against budget, submit to Board of DoR Directors financial estimates and forecasts (SFI 3) 4. 38) Devise and maintain systems of budgetary control (SFI DoR 3.3) 4. 39) Investigate any suspected cases of fraud or other DoR irregularity (SFI 15.2) 4. 40) Annual accounts and reports (SFI 4) DoR 4. 41) Income systems (SFI 6.1) DoR 4. 42) Regular reports of actual and forecast contract CE expenditure (SFI 7.1.2) 4. 43) Arrangements for payment of NHS contracts (SFI 9.2) DoR 4. 44) Processing of Payroll (SFI 8.4) DoR 4. 45) Prompt payment of accounts and claims (SFI 9.2.2) DoR 4. 46) Advise Board of Directors on borrowing and investment DoR needs and prepare procedural instructions (SFI 11) 4. 47) Monitoring the capital programme (SFI 13.1) CE 4. 48) Ensure capital charges are accounted for as specified in DoR the Capital Accounting Manual (SFI 13.2.8) 4. 49) Responsible for systems of control over stores and DoR receipt of goods (SFI 14.2) 4. 50) Prepare procedures for recording and accounting for DoR losses and special payments and informing Monitor in accordance with “Reporting and Investigating Scheme – Fraud and Corruption” of all frauds and informing police in cases of suspected arson or theft (SFI 15.2.1 and 15.2.2) 4. 51) Responsible for accuracy and security of computerised DoR financial data and ensuring that adequate controls, procedures and management trails are in place (SFI 16.1.1) 4. 52) Responsible for ensuring that the Trust has a security DoR management strategy aligned to NHS Protect's Strategy, and that such strategy is reviewed regularly. 4. 53) Responsible for overseeing and providing strategic DoR management and support for all security management work within the organisation 4. 54) Ensure Funds held on Trust are managed appropriately DoR

191

Ref. Power Delegated Delegated To

(subject to the discretion and approval of the Charitable Funds Forum if any) (SFI 18) 4. 55) Insurance arrangements (SFI 21.4) DoR 4. 56) Maintenance and operation of bank accounts (SFI 5) DoR 4. 57) Progression of Internal and External Audit CE Recommendations (SFI 2.2.1.3.3)

4. 58) Maintenance and update on Trust Financial Procedures CE and DoR (SFI 1.2.5.2) 4. 59) Management of all cash resources and the investment of DoR any surplus cash (SFI 2.2.2.4) 4. 60) Review, appraise and report in accordance with the CE via Head of Audit Code for NHS Foundation Trusts. The Public Internal Audit Sector Internal Audit Standards, the NHS Foundation Trust Financial Reporting Manual and the NHS Foundation Trust Accounting Officer Memorandum and best practice (SFI 2.3.4) 4. 61) Compliance with the Caldicott report on protecting Medical Director patient confidentiality in the NHS 4. 62) Responsible for security of the Trust’s property, avoiding All Directors and loss, exercising economy and efficiency in using senior Officers resources and conforming to Standing Orders, and financial procedures (SFI 1.2.6.2) 4. 63) All non-pay expenditure is supported by an official order All senior Officers raised by the Procurement Department. Responsibility for security of Trust assets, including notifying discrepancies to the Director of Resources, and reporting losses in accordance with Trust procedure (SFI 9.2.5)

4. 64) Keep and review lists of frameworks and approved firms DoR and individuals for tenders (paragraph 5,Appendix 1, SOs) 4. 65) Designate an Officer responsible for receipt and custody CE of tenders before opening (paragraph 2.3, Appendix 1, SOs) 4. 66) Open tenders (paragraph 3, Appendix 1, SOs) CE or nominated Officers 4. 67) Decide whether any late tenders should be considered CE or nominated (paragraph 4, Appendix 1,SOs) Officers 4. 68) Evaluation of tenders (paragraph 4, Appendix 1, SOs) CE or designated Officers 4. 69) Waiver of tender process where the conditions of SO CE or nominated 9.3.3 are met Officers

4. 70) Ensure up-to-date copies of SOs SFIs and the Scheme CE of Delegation are readily available to all Directors/ Officers and new appointees. (SO 14.1 and SFI 1.2.4) 4. 71) Ensure that SOs and SFIs are readily available to all CE contractors who are empowered by the Trust to commit the Trust its expenditure or is authorised to obtain income for the Trust (SFI 1.2.7)

192 5 DETAILED SCHEME OF DELEGATION

The delegation shown below is the lowest level to which authority is delegated. Delegation to lower levels is only permitted with written approval of the Chief Executive who will, before authorising such delegation, consult with other senior Officers as appropriate. All items concerning finance must be carried out in accordance with the SFIs and the SOs.

In circumstances where the transactions need to be executed by Deed, pursuant to paragraph 42 of the Constitution and subject to compliance with paragraph 45 of the Constitution (significant transactions) the delegations as set out in the table at paragraph 5.2 (capital schemes) below must complied with.

5.1 General Items supported by Authorised Signatories

Authorised Signatory Description Limit Level Level 0 £nil value authoriser £0 Level 1 Up to Band 4 £1,000 £0 Level 2 Up to Band 6 £5,000 £1,000 Level 3 Manager, Band 7 and above £25,000 £5,000 Level 4 Senior Manager, Band 8 and £50,000 £10,000 above Level 5 Deputy Area Director £100,000 £25,000 Level 6 Area Director and Associate £150,000 £50.000 Director Level 7 Director £250,000 £100,000 Level 8 Finance Director £500,000 £250,000 Level 9 Chief Executive Officer £1,000,000 Level 10 Chief Executive Officer and Above £1,000,000 Chairman

For the purpose of electronic authorisations, individuals of Level 7 and above may nominate one named individual to receive invoices on their behalf. The named individual will need to seek written authorisation from the signatory to approve the invoice for payment (for example a signed copy of the invoice). This authorisation evidence must be kept and passed to the finance department of the Trust at the end of the financial year for audit purposes. For the avoidance of doubt, this would not mean that the level of authority has been delegated, only that the electronic authorisation has been delegated.

5.2 Specific Items Delegated to Officers

Capital Schemes (SFI 13.1 & SO 9) a) Selection of professional advisors within EU Area Director. Business regulations. Infrastructure Services (AD BIS) b) Financial monitoring and reporting on all capital Director of Resources schemes expenditure. (DoR) c) Deed of the sale, lease or purchase of land or a CE or DoR and, Executive building at a price or value of £250,000 or less Director or Trust Secretary d) Deed for granting and termination of leases with CE or DoR and, Executive annual rent of £100,000 or less Director or Trust Secretary e) Deed for building works or capital expenditure of CE or DoR and, Executive £100,000 or less Director or Trust Secretary f) Deed for granting and termination of leases of Chairman or CE and one >£100,000, sale, lease or purchase of land or Director building at a price or value of >£250,000 or building Deed to be supported by works or capital expenditure of >£100,000. certificate signed by DoR

Major activity or operation a) Introduction or discontinuance of any major activity CE or operation with a gross annual income or

193 expenditure (that is before any set off) up to £500,000. b) Introduction or discontinuance of any major activity CE and the Chairman or operation with a gross annual income or expenditure (that is before any set off) from £500,000 and up to £2,000,000.

Mental Health Act 1983 (as amended) ("MHA) a) a) Admission and detention of patients Any one of the following: b) Receipt and scrutiny of documents for the Director of Operations and detention or treatment of patients under Part 2, Nursing & Quality, or Part 3, or Part 4 of MHA Area Director, Deputy c) Recording the admission of patients Area Director, or d) Receipt of documents for the renewal of Service Manager, or patients detention or treatment under Part 2, Clinical Manager, or Part 3, or Part 4 of the MHA Operations/Nursing Comment [l1]: Change to Nursing & e) Authorisation for the transfer of patients Business Quality Business Manager f) Supply of information to patients and their Manager/Secretariat to the relatives Executive Management g) Withholding of patients correspondence Team, or h) Authorising persons to keep in custody patients MHA Administrator, or on leave of absence when considered Ward Manager, or necessary under Section 17(3) of the MHA Charge Nurse, or i) Authorising persons to take and convey Staff Nurse (1 Year Post patients to hospital in accordance with Registration subject to Regulations 11 and 12 (of the Mental Health successful preceptorship) (Hospital, Guardianship and Treatment) Regulations 2008) or Section 18 of MHA j) Receipt of Nearest Relative’s notice to discharge a patient and receipt of Responsible Clinician’s report under Section 25 MHA

b) a) Ratification and (rectification if appropriate) of Any one of the following: applications and of the supporting medical Director of Nursing & recommendations for the detention of patients Quality, or (S15(1) of MHA). Operations/Nursing Comment [l4]: Change to Nursing & b) Referral of patients to Mental Health Review Business Quality Business Manager Tribunals (Court of Protection- Ch32, 32.9) Manager/Secretariat to the Comment [l2]: This should read ‘Mental c) Submission of statements to Mental Health Executive Management Health Act 1983: Code of Practice, Chapter Review Tribunals (COP, CH32, 32.10) Team, or 37, Paragraph 37.39 d) Authorisation for the assignment of MHA Administrator Comment [l3]: ‘Mental Health Act responsibility for a community patient to 1983:Code of Practice, Chapter 12, another hospital and recording the agreement Paragraphs, 12.11 – 12.22 of the managers of the new responsible hospital (in accordance with Regulation 17 of the Mental Health (Hospital, Guardianship and Treatment) Regulations 2008). e) Agreement to assignment of responsibility for a community patient by receiving hospital f) Notifying local social services authorities of patients detained on the basis of applications by the nearest relative (under Section 14 of MHA)

g) Quotation, Tendering & Contract Procedures Note: The amounts set out below are the total contract value/order value of the contract and are exclusive of VAT. a) Obtaining 2 minimum verbal quotations for Head of Procurement/ goods/services up to £5,000. AD BIS

194 b) Obtaining 3 written quotations for goods/services Head of Procurement /AD from £5,001 to £30,000 BIS

c) Obtaining written competitive tenders for Head of Procurement goods/services over £30,000 d) Waiving of quotations & tenders Up to £50,000 DoR e) Waiving quotations & tenders > £50,000 CE f) Opening tenders and quotations Up to £350,000 Two ADs/DADs/AsDs g) Opening tenders > £350,000 As in f) plus a NED h) Approving expenditure greater than the tender DoR price up to the lesser of 10% or £15K. i) Approving expenditure of the tender price greater CE than in h)

Fees and charges Setting of Fees and Charges (SFI 6.2) DoR

Agreements / Licences a) Preparation and signature of all tenancy AD BIS agreements / licences for all staff subject to Trust Policy on accommodation for staff

b) Extensions to existing leases AD BIS c) Letting of premises to outside organisations AD BIS d) Approval of rent based on professional AD BIS Assessment

Disposals and Condemnations (SFI 15.1) Items obsolete, obsolescent, redundant, irreparable or cannot be repaired cost effectively: a) with current / estimated purchase price up to Head of Procurement £1,000 b) with current purchase new price > £1,000 DoR

Loss and Special Payments (SFI 15.2) a) Losses due to theft, fraud, overpayment & others, fruitless payments (including abandoned capital schemes, bad debts) • Up to £5,000 AsD Finance/DoR • Up to £25,000 DoR • Up to £50,000 DoR and CE • Above £50,000 Board of Directors

b) Compensation payments made under legal obligation • Up to £100,000 DoR • Above £100,000 Board of Directors c) Ex-gratia payments to patients and staff for loss of personal effects • Less than £100 AD/DAD/AsD • From £100 to £1,000 Executive Director • From £1001 to £5,000 DoR • From £5001 to £10,000 CE or DoR • Above £10,000 Board of Directors

d) For clinical negligence up to £1,000,000 and CE or DoR personal injury claims e) Other, up to £50,000 CE or DoR

195

Reporting incidents to the Police Reporting of incidents to the Police (SFI 15.2.2) DoR

Petty Cash Disbursements (SFI 6.4) a) Expenditure up to £50 per item Petty Cash holder b) Reimbursement of patients monies above £50 Head of Financial Accounts of AsD Finance

Receiving Hospitality Applies to both individual and collective hospitality Declaration required in receipt items. In excess of £25.00 per item Trust’s Hospitality Register received.

Establishment & Pay (SFI 8) a) Annual Leave

i) Approval of annual leave Budget Manager ii) Annual leave – approval of carry forward (up to Budget Manager maximum of 5 days or in the case of ancillary and maintenance staff as defined in their initial conditions of service). iii) Annual leave – approval of carry over in excess of Director 5 days but less than 10 days iv) Annual leave – approval to carry forward 10 days CE or more. v) Compassionate leave up to 3 days Budget Manager vi) Compassionate leave up to 6 days Director vii) Special leave arrangements: 1 • Paternity leave – up to 3 days Director/AsD/AD/DAD

Budget holder • Carers leave – up to 5 days 2 Director/AsD/AD/DAD viii) Leave without pay – up to 5 days Director/AsD/DAD3 ix) Medical staff leave of absence Medical Director and CE x) Time off in lieu Budget holder

xi) Maternity leave – paid and unpaid Automatic approval with guidance from Director of Workforce & Development xii) Approval of manual Payroll cheques Director of Resources b) Sick Leave i) Extension of sick leave on half pay up to 3 months Director or AsD/AD/DAD4 in conjunction with Director of Workforce & Development ii) Return to work part-time on full pay to assist Director or AD/DAD5 in recovery conjunction with Director of Workforce & Development iii) Extension of sick leave on full pay CE or Director of Workforce & Development c) Study Leave

1 DAD shall only have the delegated authority in the absence of the AD 2 DAD shall only have the delegated authority in the absence of the AD 3 DAD shall only have the delegated authority in the absence of the AsD 4 DAD shall only have the delegated authority in the absence of the AD 5 DAD shall only have the delegated authority in the absence of the AD

196 i) Medical Study leave outside the UK AMD ii) Medical staff study leave (UK) AMD iii) All other study leave (UK) Director/AsD/AD/DAD6

d) Removal Expenses, Excess Rent and House Purchase Authorisation of payment of removal expenses incurred by officers taking up new appointments (providing consideration was promised at interview): i) up to £5,000 Director of Workforce & Development ii) over £5,000 CE e) Grievance Procedure All grievance cases must be dealt with strictly in Director of Workforce & accordance with the Grievance Procedure and the Development advice of a Human Resources Officer must be sought when the grievance reaches the level of DAD/AsD. f) Renewal of Fixed Term Contract Director or AD/AsD/DAD7 g) Redundancy CE and Director of Workforce & Development or Remuneration Committee h) Ill Health Retirement Decision to pursue retirement on the grounds of ill Director of Workforce & Health Development via Occupational Health Team

i) Dismissal Dismissing Officers

j) Establishment Control Policy, Policy for the Director of Workforce & control to variations in funded Development Establishment Authorisations Authorisation for the purchase or use of New Drugs CE or Medical Director Authorisation of Sponsorship deals CE & Medical Director Authorisation of Research Projects CE & Medical Director Authorisation of Clinical Trials CE & Medical Director

Risk Management/ Insurance Risk Management and Insurance (SFI 21) DoR

Patients’ & and Carers’ Complaints a) Overall responsibility for ensuring that all Medical Director complaints are dealt with effectively. b) Responsibility for ensuring complaints relating to a Director directorate are investigated thoroughly. c) Medico – Legal complaints co-ordination of their AsD Quality Risk and management Patient Safety

Relationship with Press a) Non-emergency general enquiries:

• Within hours AsD Communications On call Manager

6 DAD shall only have the delegated authority in the absence of the AD 7 DAD shall only have the delegated authority in the absence of the AD

197 • Outside hours

b) Emergency general enquiries: • Within hours CE On call Director • Outside hours

Infections, Diseases and Notifiable Outbreaks Infections Diseases & Notifiable Outbreaks On call Director or AD/DAD8

Extended Role Activities Approval of nurses to undertake duties / procedure CE or Director of which can properly be described as beyond the Operations & Nursing normal scope of nursing practice.

Patient Services a) Variation of operating and clinic sessions within Director of Operations & existing numbers Nursing & Quality b) All proposed changes in bed allocation and use Director of Operations & Nursing & Quality

Facilities for staff not employed by the Trust to gain practical experience: a) Professional recognition, honorary contracts and Director of Workforce & Insurance of medical staff. Development b) Work experience students Director of Workforce & Development Reviews Review of Fire precautions AsD Quality Risk and Patient Safety Review of all statutory compliance legislation and Health & AsD Quality Risk and Safety requirements, including control of Substances Hazardous Patient Safety to Health Regulations Review of General Pharmaceutical Council guidance Medical Director Review of compliance with environmental AsD Quality Risk and regulations, for example those relating to clean air and waste Patient Safety disposal Review of Trust’s compliance with the Data Protection Act DoR Monitor proposals for contractual arrangements between the DoR Trust and outside bodies Review of Trust’s compliance with the Access to Records Act Director of Operations & Nursing & Quality Review of the Trust’s compliance with Code of Practice for DoR handling confidential information in contracting environment and the compliance with “safe haven” per EL92/60

Registers The keeping of a Declaration of Interests Register (SO 7.10) Trust Secretary Attestation of sealings in accordance with Standing Orders (SO In accordance with 12) paragraph 4.2 above The keeping of a register of Sealings (SO 12) Trust Secretary The keeping of the Hospitality Register Trust Secretary

Retention of Documents Retention of Documents (SFI 20) CE

Clinical Audit

8 DAD shall only have the delegated authority in the absence of the AD

198 Clinical Audit Medical Director

Fraud and Corruption Carry out duties relating to fraud and corruption in accordance LCFS via DoR with Monitor’s requirements (SFI 2.4)

Budget Virements i) Virements within directorates Finance Manager ii) Virements between directorates Head of Management Accounts/AsD Finance

Journals Authorisation of Journals AsD Finance

Maintenance/Operation of Bank Accounts a) Day to day operation of Trust bank accounts: DoR • Transfers between accounts.

• Account amendments (including encashment). • Authorised signatories from preset panel duties. b) Authorisation of cash limit drawdown DoR c) Management of the investment of surplus funds in DoR approved institutions – both Exchequer and Charitable d) Banking of income received in accordance with DoR appropriate financial procedure Maintenance of VAT Details DoR Authorisation of VAT return for submission to HMRC

Management of Expenditure a) Authorisation of BACs submissions in accordance DoR with agreed cashflow plan b) Authorisation of GBS payments in accordance with DoR agreed cashflow plan. Including tax (approved by payroll); NIC & Super c) Authorisation of cheque runs and additional pre- DoR signed cheque limits in accordance with agreed cashflow plan d) Authorisation of discharged / deceased patients’ AsD Finance monies balances e) Authorisation of payments relating to income AsD Finance/DoR received on behalf of other bodies / individuals

199

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 23

Name of Meeting: Meeting of the Board of Directors in Public

Date: 25 November 2015

Title of Report: Standing Financial Instructions

Presented By: David Griffiths, Director of Resources

Subject, Purpose and Recommendation: The Board is asked to approve the revised SFIs, which have been updated by the Director of Resources, Trust Secretary with the assistance of colleagues in business infrastructure services, finance, procurement and internal audit/LCFS.

The proposed SFIs (copy attached) have been reviewed by the Audit Committee (15 October 2015) which recommends their approval. Board approval is required in accordance with the Scheme of Delegation (3.2.1) which reserves to the Board “Approval of Standing Orders (SOs), a schedule of Powers Reserved to the Board and Standing Financial Instructions (SFIs) for the regulation of its proceedings and business.”

Finance Implications: • External audit • Annual Governance Statement • Financial control

Clinical Implications: N/A

HR Implications: N/A

Legal Implications: Good governance. Failure of governance may trigger a “governance concern” by Monitor; which could potentially lead to an initial investigation and/or enforcement action re Trust’s licence.

Equality Implications: N/A

Risks: N/A

200

STANDING FINANCIAL INSTRUCTIONS

FOR THE

BOARD OF DIRECTORS

Version No. SFI/2014 Replaces version – approved by the Board of Directors on Date TBC

Review date - October-November 2013September-October 2015

Presented to EMT 10 February 2014

Presented to the Audit Committee 10 April 201415 October 2015

Electronic File Location –

Author – David Griffiths, Director of Resources

Approved By -– Board of Directors 25 November 2015

Next review due - October 20152016

201

1 INTRODUCTION...... 1 2 AUDIT ...... 5 3 ALLOCATIONS, BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROL AND MONITORING ...... 9 4 ANNUAL ACCOUNTS AND REPORTS ...... 12 5 BANK ACCOUNTS & TREASURY MANAGEMENT ...... 12 6 INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS ...... 14 7 NHS SERVICE AGREEMENTS FOR PROVISION OF SERVICES ...... 16 8 TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND EMPLOYEES ...... 16 9 NON-PAY EXPENDITURE ...... 19 10 JOINT FINANCE ARRANGEMENTS WITH LOCAL AUTHORITIES AND VOLUNTARY BODIES ...... 23 11 EXTERNAL BORROWING ...... 23 12 FINANCIAL FRAMEWORK ...... 24 13 CAPITAL INVESTMENT, FIXED ASSET REGISTERS AND SECURITY OF ASSETS ...... 24 14 STORES AND RECEIPT OF GOODS ...... 27 15 DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS ...... 28 16 INFORMATION TECHNOLOGY ...... 29 17 PATIENTS’ PROPERTY ...... 31 18 FUNDS HELD ON TRUST ...... 32 19 ACCEPTANCE OF GIFTS BY STAFF ...... 33 20 RETENTION OF DOCUMENTS ...... 33 21 RISK MANAGEMENT AND INSURANCE ...... 33

202

1 INTRODUCTION

Statutory Framework

The NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST (the “Trust”) became a Public Benefit Corporation on 01 October 2007 following authorisation by the Independent Regulator of NHS Foundation Trusts (Independent Regulator and the office now known as Monitor) pursuant to the National Health Service Act 2006 (‘the 2006 Act’). The Trust was subsequently licensed by Monitor (Licence no. 120073) on 1 April 2013.

The principal place of business of the Trust is at the Trust Headquarters.

The Trust is governed by the 2006 Act, its Constitution and the Authorisation granted by the Independent Regulator (‘the Regulatory Framework’). The functions of the Trust are conferred by the Regulatory Framework. The Board has adopted Standing Orders (paragraph 30 of the constitution) for the regulation of its proceedings and business. As a Public Benefit Corporation the Trust has specific powers to contract in its own name and to act as a corporate trustee. In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable. The Trust also has a common law duty as a bailee for patients' property held by the Trust on behalf of patients.

The "Directions on Financial Management in England" issued under HSG (96)12 in 1996, require Health Authorities to adopt Standing Financial Instructions (SFIs) setting out the responsibilities of individuals. These directions are not mandatory on NHS Foundation Trusts but the Board of Directors will continue to apply them as a key element of its financial governance arrangements.

The Standing Orders, Scheme of Delegation and Standing Financial Instructions provide a comprehensive business framework and have effect as if they all are incorporated into the Standing Orders. All executive and non-executive Directors and all members of staff should be aware of the existence of these documents and, where necessary, be familiar with the detailed provisions.

The Audit Committee shall review these Standing Financial Instructions every two years and report to the Board of Directors on its review and any changes which it recommends.

The Trust is also required to comply with the Risk Assessment Framework (August 2013), NHS Foundation Trust Code of Governance (December 2013), the NHS Foundation Trust Annual Reporting Manual (March 2013) as updated from time to time and any other relevant guidance issued by Monitor or any other relevant body.

These SFIs detail the financial responsibilities, policies and procedures to be adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the Regulatory Framework in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Schedule of Powers Reserved to the Board and the Scheme of Delegation adopted by the Trust.

These SFIs identify the financial responsibilities which apply to everyone working for the Trust and its constituent organisations. They do not provide detailed procedural advice. These statements should therefore be read in conjunction with the detailed departmental and financial procedure notes. All financial procedures must be approved by the Finance Director.

203 Should any difficulties arise regarding the interpretation or application of any of these SFIs the advice of the Finance Director must be sought before acting. The user of these SFIs should also be familiar with and comply with the provisions of the Trust’s Standing Orders (SOs).

Failure to comply with “Standing Financial Instructions” is a disciplinary matter which could result in dismissal.

All members of the Board of Directors and staff have a duty to disclose any non-compliance with these Standing Financial Instructions to the Finance Director as soon as possible. If for any reason these Standing Financial Instructions are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Audit Committee for such action as it may consider to be appropriate.

1.1 Any expression to which a meaning is given in the 2006 Act, or in the Financial Directions made under the 2006 Act, shall have the same meaning in these instructions and in addition:

"Accounting Officer" means the Officer responsible and accountable for funds entrusted to the Trust. He shall be responsible for ensuring the proper stewardship of public funds and assets. For this Trust it shall be the Chief Executive.

“Auditor” means the auditor appointed under paragraph 2.5 below.

"Board of Directors" means the board of directors as constituted in accordance with the Constitution.

"Budget" means a resource, expressed in financial terms, approved by the Board of Directors for the purpose of carrying out, for a specific period, any or all of the functions of the Trust.

"Budget Holder" means the Director or Officer with delegated authority to manage finances (Income and Expenditure) for a specific area of the organisation; and

"Chief Executive" means the chief executive officer of the Trust;

“Director” means a director of the Trust.

“Executive Director” means a director who is also an officer.

"Finance Director" means the Director of Resources or the Director who may from time to time be the Chief Financial Officer of the Trust.

"Funds held on Trust" means those funds which the Trust held on the date of incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers

204 derived under the 2006 Act and shall include the income and interest derived from the holding of such funds all or some of which may or may not be charitable.

“Monitor” means the sector regulator for health service in England.

"Nominated Officer" means an Officer charged with the responsibility for discharging specific tasks within SOs and SFIs.

“Officer” means an employee of the Trust or any other person who holds a paid appointment or office with the Trust including those whose appointment is seconded to the Trust and who are employees of third parties contracted to the Trust while in either case acting for the Trust.

“Scheme of Delegation” means Reservation of Powers to the Board of Directors and Delegation of Powers approved by the Board of Directors under SOs.

"SFIs" means these Standing Financial Instructions and Instructions shall be construed accordingly.

"SOs" means the Standing Orders of the Board of Directors.

“the 2006 Act” means the National Health Service Act 2006.

"Trust" means the North Essex Partnership University NHS Foundation Trust.

“Trust Headquarters” means Stapleford House, Stapleford Close, Chelmsford, Essex CM2 0QX

Wherever the title Chief Executive, Finance Director, or other Nominated Officer is used in these instructions, it shall be deemed to include such other Director or Officer who has been duly authorised to represent him.

Words importing the masculine gender only shall include the feminine gender and words importing the singular shall include the plural and vice and versa.

Any reference to any Act shall where appropriate include any Act amending or consolidating that Act and any Regulation or Order made under any such Act.

1.2 Responsibilities and delegation

The Board of Directors

1.2.1 The Board of Directors shall exercise financial supervision and control by:

1.2.1.1 formulating and approving a viable financial strategy for the Trust;

205

1.2.1.2 requiring the submission and approval of budgets which are consistent with the Trust’s approved financial strategy;

1.2.1.3 defining and approving essential features in respect of important procedures and financial systems (including the need to obtain value for money); and

1.2.1.4 defining the specific responsibilities placed on Directors and Officers for the performance of its functions in the Scheme of Delegation.

The Chief Executive and Finance Director

1.2.2 Within SFIs, it is acknowledged that the Chief Executive is accountable to the Board of Directors and as Accounting Officer, for ensuring that the Board of Directors meets its obligation to perform its functions within the available financial resources. The Chief Executive has overall executive responsibility for the Trust’s activities, is responsible to the Board of Directors for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust’s system of internal control.

1.2.3 The Chief Executive and Finance Director will, as far as possible, delegate their detailed responsibilities but they remain accountable for financial control.

1.2.4 It is a duty of the Chief Executive to ensure to ensure that up to date copies of these SFIs are readily available to all existing Directors and Officers and to all new appointees, and that any queries raised by any of them as to their responsibilities are answered promptly.

The Finance Director

1.2.5 The Finance Director is responsible for:

1.2.5.1 implementing the Trust’s financial policies and for coordinating any corrective action necessary to further these policies;

1.2.5.2 maintaining an effective system of internal financial control including ensuring that detailed financial procedures and systems incorporating the principles of separation of duties and internal checks are prepared, documented maintained and implemented to supplement these instructions; and

1.2.5.3 ensuring that sufficient records are maintained to show and explain the Trust’s transactions, in order to disclose with reasonable accuracy, the financial position of the Trust at any time,

206 and without prejudice to any other functions of the Trust and Officers to the Trust, the duties of the Finance Director include:

1.2.5.4 the provision of financial advice to the Board of Directors and the Directors and Officers individually;

1.2.5.5 the design, implementation and supervision of systems of internal financial control; and

1.2.5.6 the preparation and maintenance of such accounts, certificates, estimates, records and reports as the Trust may require for the purpose of carrying out its statutory duties.

Board Members and employees

1.2.6 All members of the Board of Directors and employees, severally and collectively, are responsible for:

1.2.6.1 the security of the property of the Trust;

1.2.6.2 avoiding loss;

1.2.6.3 exercising economy and efficiency in the use of resources; and

1.2.6.4 conforming to the requirements of SOs, SFIs and the Scheme of Delegation.

Contractors and their employees

1.2.7 Any contractor or employee of a contractor who is empowered by the Trust to commit the Trust to expenditure or who is authorised to obtain income shall be subject to these SFIs. It is the responsibility of the Chief Executive to ensure that such persons are made aware of this.

2 AUDIT

2.1 Audit Committee

2.1.1 In accordance with SOs the Board of Directors shall formally establish an Audit Committee, with clearly defined terms of reference, which will operate in accordance with the Code of Governance and the Audit Code for foundation trusts, and all other guidance issued by Monitor which will provide an independent and objective view of internal control by:

2.1.1.1 overseeing Internal Audit services, External Audit services and Local Counter Fraud Services (LCFS).

2.1.1.2 reviewing financial and information systems and monitoring the integrity of the financial statements and reviewing significant financial reporting judgments;

207

2.1.1.3 reviewing the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the Trust’s activities (both clinical and non-clinical), which support the achievement of the Trust’s objectives;

2.1.1.4 monitoring compliance with SOs and SFIs;

2.1.1.5 reviewing schedules of losses and compensations and making recommendations to the Board of Directors; and

2.1.1.6 reviewing the information prepared to support the assurance statements prepared on behalf of the Board of Directors and advising the Board of Directors accordingly.

2.1.2 Where the Audit Committee feel there is evidence of ultra vires transactions, or of improper acts, or if there are other important matters that the committee wish to raise, the chairman of the Audit Committee shall raise the matter with the Finance Director and then at a meeting of the Board of Directors

2.1.3 When appropriate issues arise, the Audit Committee shall make a report to the Council of Governors, identifying any matters, in respect of which it considers that action or improvement is needed.

2.1.4 It is the responsibility of the Chief Executive to ensure an adequate internal audit service is provided and the Audit Committee shall be involved in the selection process when an internal audit service provider is changed.

2.1.5 The Audit Committee shall also assist the Council of Governors with the appointment of the Auditor under paragraph 37 of the Constitution.

2.2 Responsibilities of Chief Executive and Finance Director

2.2.1 The Chief Executive is responsible for:

2.2.1.1 ensuring there are arrangements to review, evaluate and Formatted: Tab stops: Not at 7.54 report on the effectiveness of internal control including the cm establishment of an effective internal audit function.

2.2.1.2 ensuring that the internal audit is adequate and meets Formatted: Tab stops: 6.5 cm, List Monitor's mandatory audit standards. tab + Not at 7.54 cm

2.2.1.3 ensuring that an annual internal audit report is prepared for Formatted: Indent: Left: 5.16 cm, the consideration of the Audit Committee and the Board of Hanging: 1.34 cm, Tab stops: 6.5 cm, List tab + Not at 7.54 cm Directors. The report must cover or include:

2.2.1.3.1 a clear opinion on the effectiveness of internal control in accordance with current assurance guidance issued by Monitor including for

208 example compliance with control criteria and standards;

2.2.1.3.2 major internal financial control weaknesses discovered;

2.2.1.3.3 progress on the implementation of all audit recommendations;

2.2.1.3.4 progress against plan over the year and a detailed plan for the coming year;

2.2.1.3.5 a strategic audit plan covering the coming three years.

2.2.2 The Finance Director shall be responsible for

2.2.2.1 giving his full assistance to the Chief Executive in the performance of his responsibilities under the provisions of SFI 2.2.1;

2.2.2.2 deciding at what stage to involve the police in cases of fraud, misappropriation, and other irregularities and liaising with Monitor as appropriate;

2.2.2.3 advising the Board of Directors regarding the financial performance legality and viability of the Trust;

2.2.2.4 the management of all cash and the investment of any surplus cash; and

2.2.2.5 it is the duty of the Chief Executive to ensure that up to date copies of SFIs are readily available to all existing Directors and Officers and to all new appointees, and that any queries raised by any of them as to their responsibilities are answered promptly.

2.2.3 The Finance Director or designated auditors and LCFS personnel are entitled without necessarily giving prior notice to require and receive:

2.2.3.1 access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature;

2.2.3.2 access at all reasonable times to any land, premises or Officer of the Trust;

2.2.3.3 the production of any cash, stores or other property of the Trust under an Officer’s control; and

2.2.3.4 explanations concerning any matter under investigation.

2.3 Role of Internal Audit

209

2.3.1 Internal audit will review, appraise and report to the Chief Executive upon:

2.3.1.1 the extent of compliance with, and the financial effect of relevant established policies, plans and procedures;

2.3.1.2 the adequacy and application of financial and other related management controls;

2.3.1.3 the suitability of financial and other related management data.

2.3.1.4 the extent to which the Trust’s assets and interests are accounted for and safeguarded from loss of any kind, arising from:

2.3.1.4.1 fraud and other offences;

2.3.1.4.2 waste, extravagance, inefficient administration;

2.3.1.4.3 poor value for money and other causes.

2.3.1.5 Internal Audit shall also independently verify the assurance statements in accordance with guidance from Monitor.

2.3.2 Whenever any matter arises which involves, or is thought to involve, irregularities concerning cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature, the Finance Director must be notified immediately.

2.3.3 The Head of Internal Audit will normally attend Audit Committee meetings and has a right of access to all Audit Committee members, the Chairman and Chief Executive of the Trust.

2.3.4 The Head of Internal Audit shall be accountable to the Chief Executive. The reporting system for internal audit shall be agreed between the Finance Director, the Audit Committee and the Head of Internal Audit. The agreement shall be in writing and shall comply with the guidance on reporting contained in the NHS Foundation Trust Accounting Officer Memorandum (April 2008) and the Public Sector Internal Audit Standards (June 2013). The reporting system shall be reviewed annually.

2.4 Fraud, and Corruption and Bribery

2.4.1 Any employee discovering or suspecting a loss of any kind must immediately inform their head of department, who must immediately inform the Director of Finance or inform an officer charged with responsibility for responding to concerns involving loss. This officer will then appropriately inform the Director of Finance. Where a criminal offence is suspected, the Director of Finance must immediately inform the police if theft or arson is involved. In cases of fraud and corruption

210 or of anomalies, which may indicate fraud, or corruption, the Director of Finance must inform the Local Counter Fraud Specialist (LCFS) in accordance with Secretary of State Directions Formatted: Font: Arial, 11 pt, Font 2.4.12.4.2 In line with their responsibilities, the Chief Executive and the color: Auto, English (U.S.) Finance Director shall monitor and ensure compliance with NHS guidance on fraud and corruption.

2.5 External Audit

2.5.1 The Council of Governors of the Trust shall appoint the Auditor of the Trust in accordance with the provisions of paragraph 37 of the Constitution and that appointment shall be on such terms as the Council of Governors and the Board of Directors may together agree.

2.5.2 The Auditor shall be responsible to the Trust for performance of the Auditor’s role in accordance with the terms of that appointment including the provision of a cost efficient service and compliance with Monitor’s Audit Code.

3 ALLOCATIONS, BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROL AND MONITORING

3.1 Preparation and approval of business plans and budgets:

3.1.1 The Chief Executive will compile and submit to the Board of Directors an annual financial plan which takes into account contract values, financial targets and forecast limits of available resources. The annual business plan will contain:

3.1.1.1 a statement of the significant assumptions on which the plan is based; and

3.1.1.2 details of major changes in workload, delivery of services or resources required to achieve the plan.

3.1.2 Prior to the start of the financial year, the Finance Director will, on behalf of the Chief Executive, prepare and submit budgets for approval by the Board of Directors. Such budgets will:

3.1.2.1 be in accordance with the aims and objectives set out in the operational plan. annual business plan;

3.1.2.2 accord with workload and workforce plans;

3.1.2.3 be produced following discussion with appropriate budget holders;

3.1.2.4 be prepared within the limits of available funds; and

3.1.2.5 identify potential risks.

211 3.1.3 The Finance Director shall monitor financial performance against the budget and business plan, periodically review them, and regularly report to the Board of Directors on them.

3.1.4 All Budget Holders must provide information as required by the Finance Director to enable budgets to be compiled.

3.1.5 The Finance Director has a responsibility to ensure that adequate training is delivered on an on-going basis to budget holders to help them to manage their budgets successfully.

3.1.6 The Finance Director shall give instructions as to the manner in which financial records are to be kept and Officers are to discharge their responsibilities under these SFIs.

3.2 Budgetary delegation

3.2.1 The Chief Executive may delegate the management of a Budget to permit the performance of a defined range of activities. This delegation must be in writing and be accompanied by a clear definition of:

3.2.1.1 the amount of the Budget;

3.2.1.2 the purpose(s) of each Budget heading;

3.2.1.3 individual and group responsibilities;

3.2.1.4 authority to exercise virement;

3.2.1.5 achievement of planned levels of service; and

3.2.1.6 the provision of regular reports.

3.2.2 The Chief Executive and delegated Budget Holders must not exceed the budgetary total or virement limits set by the Board of Directors.

3.2.3 Any budgeted funds not required for their designated purpose(s) revert to the immediate control of the Chief Executive, subject to any authorised use of virement.

3.2.4 Non-recurring budgets should not be used to finance recurring expenditure without the authority in writing of the Chief Executive.

3.3 Budgetary control and reporting

3.3.1 The Finance Director will devise and maintain systems of budgetary control. These will include:

3.3.1.1 monthly financial reports to the Board of Directors in a form approved by it showing:

3.3.1.1.1 income and expenditure for the month, their trends and the forecast year-end position;

212 3.3.1.1.2 a balance sheet prepared as at the end of that month including an analysis of aged debt;

3.3.1.1.3 a statement of cash balances, movements and forecast;

3.3.1.1.4 a statement on the current and projected outturn Continuity of Services Risk Rating (CoSRR);

3.3.1.1.5 capital project spend and projected outturn against plan; asset disposal proceeds and projected receipts against plan

3.3.1.1.6 explanations of any material variances from plan; and

3.3.1.1.7 details of any corrective action considered to be necessary and the Chief Executive’s and/or Finance Director’s views of whether such actions are sufficient to correct the situation.

3.3.1.2 the issue of timely, accurate and comprehensible advice and financial reports to each Budget Holder, covering the areas for which they are responsible;

3.3.1.3 investigation and reporting of variances from financial, workload and workforce budgets;

3.3.1.4 monitoring of management action to correct variances; and

3.3.1.5 arrangements for the authorisation of budget transfers.

3.3.2 Each Budget Holder is responsible for ensuring that:

3.3.2.1 any likely overspending or reduction of income which cannot be met by virement is not incurred without the prior consent of the Board of Directors Chief Executive;

3.3.2.2 the amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorised subject to the rules of virement; and

3.3.2.3 no permanent Officers are appointed without the approval of the Chief Executive other than those provided for in the budgeted establishment as approved by the Board of Directors.

3.3.3 The Chief Executive is responsible for identifying and implementing cost improvements and income generation initiatives in accordance with the requirements of the Annual Financial Plan.

3.4 Capital expenditure

213

3.4.1 The general rules applying to delegation and reporting shall also apply to capital expenditure in addition to the provisions contained in SFI 13.

3.5 Monitoring Returns

3.5.1 The Chief Executive is responsible for ensuring that the appropriate monitoring forms are submitted to the requisite monitoring organisation.

4 ANNUAL ACCOUNTS AND REPORTS

4.1 The Finance Director, on behalf of the Trust, will:

4.1.1 prepare financial returns in accordance with the accounting policies and guidance given by Monitor and HM Treasury, the Trust’s accounting policies, and generally accepted accounting practice;

4.1.2 prepare and submit annual financial reports to Monitor certified in accordance with current guidelines; and

4.1.3 submit financial returns to Monitor for each financial year in accordance with the timetable prescribed by Monitor.

4.2 The Trust's annual accounts shall be audited by the Auditor and presented to a general meeting of the Council of Governors with the report of the Auditor on them as provided by the Constitution and shall be available to the public.

4.3 The Trust shall publish an annual report, in accordance with guidelines on local accountability and Monitor’s NHS Foundation Trust Annual Reporting Manual, which shall be sent to Monitor and also be presented to the Council of Governors at a general meeting.

4.4 The Trust shall in each financial year give information as to its forward planning to the Council of Governors in accordance with paragraph 40 of the Constitution.

5 BANK ACCOUNTS & TREASURY MANAGEMENT

5.1 General

5.1.1 The Finance Director is responsible for managing the Trust’s banking arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance issued from time to time by Monitor.

5.1.2 The Board of Directors shall approve the banking arrangements.

5.2 Bank Accounts

5.2.1 The Finance Director is generally responsible for the proper and secure operation of the Bank Accounts of the Trust and specifically for;

214

5.2.1.1 establishing separate bank accounts for the Trust’s non-exchequer funds;

5.2.1.2 ensuring that payments made from bank accounts do not exceed the amount credited to the account where arrangements have been made; and

5.2.1.3 reporting to the Board of Directors all arrangements made with the Trust’s bankers for accounts to be overdrawn;

5.2.1.4 monitoring compliance with Department of Health guidance on the level of cleared funds.

5.3 Banking Procedures

5.3.1 The Finance Director will ensure that detailed instructions on the operation of bank accounts are prepared which must include:

5.3.1.1 the conditions under which each bank account is to be operated

5.3.1.2 the limit to be applied at any overdraft; and

5.3.1.3 those authorised to sign cheques or other orders drawn on the Trust’s accounts.

5.3.2 The Finance Director must advise the Trust’s bankers in writing of the conditions under which each account will be operated.

5.4 Tendering and review

5.4.1 The Finance Director will review the banking arrangements with the Government Banking Service (GBS) at regular intervals to ensure they reflect best practice and represent value for money.

5.5 Treasury Management

5.5.1 The Finance Director is responsible for maintaining a Treasury Management policy that promotes fiscal responsibility and prudent investment of surplus cash and both short and long-term borrowing.

5.5.2 The Finance Director will obtain the most competitive deposit rates using institutions permitted under the Safe Harbour definitions stated in the guidance issued by Monitor “Managing Operating Cash in NHS Foundation Trusts” (December 2005) and in line with deposit guidelines ratified by the Finance Director, subject to the over-riding objective of ensuring cash is available to the Trust as and when it is required for the efficient operation of its services.

5.5.3 The Audit Committee will monitor the Trust's performance against investments which will be managed under this policy on behalf of the Board.

215 5.5.4 The Treasury function must obtain due authorisation of any proposed investment (or proposal to roll over an investment) in accordance with the investment and concentration limits approved in the Treasury Management policy.

5.5.5 A list of permitted banks to place investments will be maintained by the Head of Financial Accounts. Additions and removals can only be authorised by the Audit Committee.

5.5.6 The Trust will annually review its requirement for working capital and any application for an overdraft facility. Any short term borrowing may only be made with the authority of two of those Officers approved under standing financial instructions, one of whom must be the Chief Executive or the Finance Director.

5.5.7 Long-term funding must be consistent with plans in the current annual plan. Long term funding will require the specific approval from the Board of Directors.

6 INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

6.1 Income systems

6.1.1 The Finance Director is responsible for ensuring that systems for the proper recording, invoicing, collection and coding of all monies due are designed, maintained and complied with.

6.1.2 The Finance Director is also responsible for the prompt banking of all monies received.

6.2 Fees and charges

6.2.1 The Finance Director is responsible for approving and regularly reviewing the level of all fees and charges other than those determined by Monitor or by statute. Independent professional advice on matters of valuation should be taken as necessary. Where sponsorship income (including items in kind such as subsidised goods or loans of equipment) is considered the guidance in the Department of Health’s Commercial Sponsorship – Ethical standards in the NHS shall be followed.

6.2.2 In receiving cash payments, it should be noted that the maximum value of any single transaction is limited to £10,000 as provided in The Money Laundering Regulations 2007.

6.2.3 All employees must inform the Finance Director promptly of money due arising from transactions which they initiate or deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

6.3 Debt recovery

216 6.3.1 The Finance Director shall be responsible for the appropriate recovery action on all outstanding debts, for the detection of overpayments and the appropriate action, and for ensuring that income not recoverable is dealt with in accordance with SFI 15

6.4 Security of cash, cheques and other negotiable instruments

6.4.1 The Finance Director shall be responsible for:

6.4.1.1 approving the form of all receipt books, agreement forms, or other means of officially acknowledging or recording monies received or receivable;

6.4.1.2 ordering and securely controlling any such stationery;

6.4.1.3 the provision of adequate facilities and systems for Officers whose duties include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys, and for coin operated machines; and

6.4.1.4 prescribing systems and procedures for handling cash and negotiable securities on behalf of the Trust.

6.4.2 Official money shall not under any circumstances be used for the encashment of private cheques or IOUs.

6.4.3 All cheques, postal orders, cash, etc., shall be banked promptly and intact. Disbursements shall not be made from cash received, except under arrangements approved by the Finance Director.

6.4.4 All Officers who hold cash will be provided with access to a safe, or lockable cash box which shall normally be deposited in a safe. The responsible Officer will hold one key, and shall arrange for a duplicate key to be lodged with a suitable senior Officer in the locality. Instructions for the release of this duplicate key should be prepared by the responsible Officer and approved by the Finance Director. Loss of any key should be reported immediately to the Finance Director. During the absence of the key holder, the Officer who acts in their place shall be subject to the same controls as the key holder. A written discharge of the contents of the safe or cash box on the transfer of responsibilities should be retained for audit purposes with consideration to operational practices. The holders of safe keys shall not accept unofficial funds for depositing in their safes unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss.

6.4.5 Incoming post is distributed to relevant Officers within the Trust and any cash or cheques then entered onto Income Sheets for banking.

6.4.6 An official receipt will be made out for all cash receipts when requested, showing the type of remittance and the reasons for payment.

217

6.4.7 A special receipt will be issued for all charitable fund donations which will enable the donor to express their wishes as to the purpose of the donation.above £5,000.

7 NHS SERVICE AGREEMENTS FOR PROVISION OF SERVICES

7.1 Service Level Agreements and Contracts

7.1.1 The Chief Executive, as the Accounting Officer, is responsible for ensuring the Trust enters into suitable Service Contracts with service commissioners for the provision of NHS services. In discharging this responsibility, the Chief Executive should take into account:

7.1.1.1 the standards of service quality expected;

7.1.1.2 the relevant national service framework (if any);

7.1.1.3 the provision of reliable information on cost and volume of services;

7.1.1.4 the NHS National Performance Assessment Framework;Constitution and aAnnual Performance Framework.

7.1.1.5 that Service Contracts build where appropriate on existing partnership arrangements;

7.1.1.6 that Service Contracts, where appropriate are based on integrated care pathways.

7.1.2 The Chief Executive, as the Accounting Officer, will need to ensure that regular reports are provided to the Board of Directors detailing actual and forecast income from Service Contracts.

8 TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND EMPLOYEES

8.1 Remuneration and Terms of Service

8.1.1 In accordance with SOs the Board of Directors shall establish a Remuneration Committee, with clearly defined terms of reference, specifying which posts fall within its area of responsibility, its composition, and the arrangements for reporting.

8.1.2 The Remuneration Committee will:

• Decide the appropriate remuneration, benefits and allowances for the Chief Executive Officer, all Executive Directors and all Very Senior Managers of the Trust after consultation with the Chairman of the Trust and also the Chief Executive except in the case of remuneration benefits or allowances for him or her.

218

• In the case of an Executive Director or Very Senior Manager who is to cease or has ceased to hold his or her office for any reason, decide or approve the amount payable to that Executive Director or Very Senior Manager upon or in consequence of the cessation of his or her office whether for compensation damages loss of benefits or allowances or otherwise, after consultation with the Chairman of the Trust and Chief Executive, except in the case of his or her ceasing to hold office.

• Ensure a formal and transparent procedure for developing policy on executive remuneration, including conducting research and benchmarking as the Committee considers to be appropriate amongst other Trusts.

• Ensure levels of remuneration are sufficient to attract retain and motivate executive directors of the required quality to run the Trust successfully and consider whether in any case remuneration should be linked to corporate or individual performance.

• Provide the necessary information to the Nominations Committee to support the recruitment process

• At all times have regard to the Code of Governance for NHS Foundation Trusts and guidance issued by Monitor

8.2 Funded establishment

8.2.1 The workforce plans incorporated within the annual budget will form the funded establishment.

8.2.2 The funded establishment of any department may not be varied without the approval of the Finance Director.

8.3 Staff Appointments

8.3.1 No Director or Officer may engage, re-engage, or regrade employees, either on a permanent or temporary nature, or hire agency staff, or agree to changes in any aspect of remuneration:

8.3.1.1 unless authorised to do so by the Chief Executive; and

8.3.1.2 within the limit of his approved budget and funded establishment.

8.3.2 The Board of Directors will approve procedures presented by the Chief Executive for the determination of commencing pay rates, condition of service, etc., for employees.

8.4 Processing of Payroll

8.4.1 The Finance Director is responsible for :

219 8.4.1.1 specifying timetables for submission of properly authorised time records and other notifications;

8.4.1.2 the final determination of pay and allowances;

8.4.1.3 making payment on the agreed dates; and

8.4.1.4 agreeing the method of payment.

8.4.2 The Finance Director will issue instructions regarding:

8.4.2.1 verification and documentation of data;

8.4.2.2 the timetable for receipt and preparation of payroll data and the payment of employees;

8.4.2.3 the maintenance of subsidiary records for superannuation, income tax, social security and other authorised deductions from pay and their payment to the appropriate authorities;

8.4.2.4 the security and confidentiality of payroll information;

8.4.2.5 checks to be applied to completed payroll before and after payment;

8.4.2.6 authority to release payroll data under the provisions of the Data Protection Act 1998;

8.4.2.7 methods of payment available to various categories of employee;

8.4.2.8 procedures for payment by cheque, bank credit, or cash to employees;

8.4.2.9 procedures for the recall of cheques and bank credits;

8.4.2.10 pay advances and their recovery;

8.4.2.11 the maintenance of regular and independent reconciliation of pay control accounts;

8.4.2.12 the separation of duties of preparing records and handling cash; and

8.4.2.13 a system to ensure the recovery from employees and leavers of sums of money and property due by them to the Trust.

8.4.3 Appropriately nominated managers have delegated responsibility for:

220 8.4.3.1 submitting time records, and other notifications in accordance with agreed timetables;

8.4.3.2 Completing time records and other notifications in Formatted: Indent: Left: 5.5 cm, Tab accordance with the Finance Director’s instructions and stops: 7 cm, Left + Not at 7.5 cm in the form prescribed by the Finance Director; Formatted: Indent: Left: 5.5 cm 8.4.3.3 Submitting termination forms in the prescribed form Formatted: Indent: Left: 5.5 cm, Tab immediately upon knowing the effective date of an stops: 7 cm, Left + Not at 7.5 cm + employee’s resignation, termination or retirement. 8.25 cm Formatted: 01-NormInd4-BB, Indent: 8.4.3.38.4.3.4 Where an employee fails to report for duty or to Left: 0 cm, First line: 0 cm, Tab stops: Not at 4 cm + 7.5 cm + 8.25 cm fulfill obligations in circumstances that suggest they have left without notice, the Finance Director and HR must be Formatted: Indent: Left: 5.5 cm, Tab stops: 7 cm, Left + Not at 7.5 cm + informed immediately. 8.25 cm

8.4.4 Regardless of the arrangements for providing the payroll service, the Finance Director shall ensure that the chosen method is supported by appropriate terms and conditions, adequate internal controls and audit review procedures and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.

8.4.5 The Trust shall not be obliged to pay any member of staff in cash.

8.5 Contracts of Employment

8.5.1 The Chief Executive shall delegate responsibility to a manager for:

8.5.1.1 ensuring that all employees are issued with a contract of employment in a form approved by the Board of Directors and which complies with employment legislation; and

8.5.1.2 dealing with variations to, or termination of, contracts of employment for employees who are not Executive Directors or very senior Officers.

9 NON-PAY EXPENDITURE

9.1 Delegation of Authority

9.1.1 The Board of Directors will approve the level of non-pay expenditure on an annual basis and the Chief Executive will determine the level of delegation to budget managers.

9.1.2 The Chief Executive will set out:

9.1.2.1 the list of officers who are authorised to place requisitions for the supply of goods and services; and

9.1.2.2 the maximum level of each requisition and the system for authorisation above that level.

221 9.1.3 The Chief Executive shall set out procedures on the seeking of professional advice regarding the supply of goods and services.

9.2 Choice, Requisitioning, Ordering, Receipt and Payment of Goods and Services

Requisitioning

9.2.1 The requisitioner, in choosing the item to be supplied (or the service to be performed) shall always obtain the best value for money for the Trust. In so doing, the advice of the Trust’s adviser (Head of Procurement) on supply shall be sought. Where this advice is not acceptable to the requisitioner, the Finance Director or the Chief Executive shall be consulted.

9.2.2 The Finance Director shall be responsible for the prompt payment of accounts and claims. Payment of contract invoices shall be in accordance with contract terms, or otherwise, in accordance with national guidance.

System of Payment and Verification

9.2.3 The Finance Director will:

9.2.3.1 advise the Board of Directors regarding the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained and, once approved, the thresholds shall be incorporated in SOs and regularly reviewed;

9.2.3.2 prepare procedural instructions (where not already provided in SOs or the Scheme of Delegation or procedure notes for Budget Holders) on the obtaining of goods, works and services incorporating the thresholds;

9.2.3.3 be responsible for the prompt payment of all properly authorised accounts and claims;

9.2.3.4 be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable. The system shall provide for:

9.2.3.4.1 a list of the Directors and Officers (including specimens of their signatures) authorised to certify invoices;

9.2.3.4.2 certification that:

• goods have been duly received, examined and are in accordance with specification and the prices are correct; • work done or services rendered have been satisfactorily carried out in accordance with the order, and, where applicable, the materials used are of the requisite standard and the charges are correct;

222 • in the case of contracts based on the measurement of time, materials or expenses, the time charged is in accordance with the appropriate rates, the materials have been checked as regards quantity, quality, and the price and the charges for the use of vehicles, plant and machinery have been examined; • where appropriate, the expenditure is in accordance with regulations and all necessary authorisations have been obtained; • the account is arithmetically correct; • the account is in order for payment;

9.2.3.4.3 a timetable and system for submission to the Finance Director of accounts for payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment;

9.2.3.4.4 instructions to Officers regarding the handling and payment of accounts within the Finance Department;

9.2.3.5 be responsible for ensuring that payment for goods and services is only made once the goods and services are received, (except as set out at 9.2.4 below); and

9.2.3.6 prepare and issue procedures regarding Value Added Tax (VAT).

Prepayments – to be reviewed separately

9.2.4 Prepayments of £250 or below are only permitted where they have been previously approved by the Budget Holder in writing. Prepayments in excess of £250 are only permitted in the following circumstances:

9.2.4.1 the financial advantages outweigh the disadvantages (i.e. cashflows must be discounted to net present value (NPV) using the National Loans Fund (NLF) rate plus the Public Dividend Capital dividend rate);

9.2.4.2 the appropriate executive Director must provide, in the form of a written report, a case setting out all relevant circumstances of the purchase. The report must set out the effects on the Trust if the supplier is at some time during the course of the prepayment agreement unable to meet his commitments;

9.2.4.3 the Finance Director will need to be satisfied with the proposed arrangements before contractual arrangements proceed (taking into account the EU public procurement rules where the contract is above a stipulated financial threshold); and

9.2.4.4 the Budget Holder is responsible for ensuring that all items due under a prepayment contract are received and

223 he/she must immediately inform the appropriate Director or Chief Executive if problems are encountered.

Official Orders

9.2.5 Official orders of which a copy must be retained must :

9.2.5.1 be consecutively numbered;

9.2.5.2 be in a form approved by the Finance Director;

9.2.5.3 state the Trust’s terms and conditions of trade; and

9.2.5.4 only be issued to, and used by, those duly authorised by the Chief Executive.

Duties of Officers

9.2.6 Officers must ensure that they comply fully with the guidance and limits specified by the Finance Director and that :

9.2.6.1 all contracts (other than for a simple purchase permitted within the Scheme of Delegation or delegated budget), leases, tenancy agreements and other commitments which may result in a liability are notified to the Finance Director in advance of any commitment being made;

9.2.6.2 contracts above specified thresholds are advertised and awarded in accordance with EU rules on public procurement and comply with the appropriate Quality Standards such as ISO9000;

9.2.6.3 where consultancy advice is being obtained, the procurement of such advice must be in accordance with guidance issued by the Finance Director;

9.2.6.4 no order shall be issued for any item or items to any firm which has made an offer of gifts, reward or benefit to Directors or Officers, other than:

9.2.6.4.1 isolated gifts of a trivial character or inexpensive seasonal gifts, such as calendars; or

9.2.6.4.2 conventional hospitality, such as lunches in the course of working visits;

9.2.6.5 no requisition or order is placed for any item or items for which there is no budget provision unless authorised by the Finance Director on behalf of the Chief Executive;

9.2.6.6 all goods, services, or works are ordered on an official order except works and services executed in accordance with a contract and purchases by purchase card or from petty cash; and those items in

224 the approved list managed by Procurement and authorized by Director of Finance.

9.2.6.7 verbal orders are only issued very exceptionally, and then by an Officer designated by the Chief Executive and only in cases of emergency or urgent necessity. These must be confirmed by an official order and clearly marked “Confirmation Order”;

9.2.6.8 orders are not split or otherwise placed in a manner devised so as to avoid the financial thresholds;

9.2.6.9 goods are not taken on trial or loan in circumstances that could commit the Trust to a future uncompetitive purchase

9.2.6.10 changes to the list of Directors and Officers authorised to certify invoices are maintained on an Authorised Signatories Database by the Finance Department;

9.2.6.11 purchases by purchase card or from petty cash are restricted in value and by type of purchase in accordance with instructions issued by the Finance Director; and

9.2.6.12 petty cash records are maintained in a form as determined by the Finance Director.

9.2.7 The Finance Director shall ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with all the relevant regulations and guidance. The technical audit of these contracts shall be the responsibility of the relevant Director. Formatted: 01-NormInd3-BB, Indent: 9.2.7 9.2.8 The Finance Director shall ensure that arrangements for the engagement of agency Left: 0 cm, First line: 0 cm, Tab stops: Not at 2.5 cm staff comply with requirements issued by Monitor. The appointment of agency staff in line with those arrangements shall be the responsibility of the relevant appointing officer. Formatted: 01-NormInd3-BB, Indent: Left: 0 cm, First line: 0 cm, Tab stops: Not at 2.5 cm

10 JOINT FINANCE ARRANGEMENTS WITH LOCAL AUTHORITIES AND VOLUNTARY BODIES

10.1 Payments to local authorities and voluntary organisations made under the powers in the 2006 Act shall comply with procedures laid down by the Finance Director which shall be in accordance with that Act.

11 EXTERNAL BORROWING

11.1 The Finance Director will advise the Board of Directors concerning the Trust’s ability to pay dividend on, and repay Public Dividend Capital and any proposed new borrowing, within the limits set by its Licence. The Finance Director is also responsible for reporting periodically to the Board of Directors concerning the Public Dividend Capital debt and all loans and overdrafts, and for making such applications for long term finance as may be authorised and directed by the Board of Directors.

225 11.2 The Board of Directors can authorise the Finance Director to make applications for long term loan finance, stating the purpose, sum, maximum borrowing term and any other such conditions. The Board of Directors is required to approve the acceptance of all external borrowing agreements.

11.3 The Board of Directors will agree the list of Officers who are authorised to make short term borrowings on behalf of the Trust. Any short term borrowing may only be made with the authority of two of those Officers one of whom must be the Chief Executive or the Finance Director.

11.4 The Finance Director must prepare detailed procedural instructions concerning applications for loans and overdrafts.

11.5 All short-term borrowings should be kept to a minimum period of time possible, consistent with the overall cashflow position, represent good value for money, and comply with the latest guidance issued by Monitor.

11.6 The Board of Directors must be made aware of all short term borrowings at the next board meeting.

12 FINANCIAL FRAMEWORK

12.1 The Finance Director shall ensure that members of the Board of Directors and the Executive Management Team are aware of the directions and guidance regarding the Financial Framework issued from time to time by the Department of Health and Monitor and that these are followed by the Trust

12.2 The Finance Director must also ensure the NHS Foundation Trust Annual Reporting Manual is followed in the production of the Trust’s annual accounts and annual reports.

13 CAPITAL INVESTMENT, FIXED ASSET REGISTERS AND SECURITY OF ASSETS

13.1 Capital Investment

13.1.1 The Chief Executive:

13.1.1.1 shall ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon business plans;

13.1.1.2 is responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost; and

13.1.1.3 shall ensure that the capital investment is not undertaken without confirmation of purchaser(s) support and the availability of resources to finance all revenue consequences, including capital charges.

226 13.1.2 For every capital expenditure proposal the Chief Executive shall ensure that all relevant guidance or regulations are complied with and (where appropriate):

13.1.2.1 that a business case (in line with the guidance contained in Monitor’s ‘Risk Evaluation for Investment Decisions’ (REID) by NHS Foundation Trusts (February 2006) is produced setting out:

13.1.2.1.1 an option appraisal of potential benefits compared with known costs to determine the option with the highest ratio of benefits to costs; and

13.1.2.1.2 appropriate project management and control arrangements; and

13.1.2.1.3 the involvement of appropriate Trust personnel and external agencies; and

13.1.2.1.4 the appropriate advice obtained upon it.

13.1.3 For capital schemes where the contracts stipulate stage payments, the Chief Executive will issue procedures for their management, incorporating the recommendations of all relevant NHS guidance and EU regulations. The Finance Director shall assess on an annual basis the requirement for the operation of the construction industry tax deduction scheme in accordance with Inland Revenue guidance. The Finance Director shall issue procedures for the regular reporting of expenditure and commitment against authorised expenditure.

13.1.4 The approval of a capital programme shall not constitute approval for expenditure on any scheme. The Chief Executive shall issue to the manager responsible for any scheme:

13.1.4.1 specific authority to commit expenditure;

13.1.4.2 authority to proceed to tender;

13.1.4.3 approval to accept a successful tender.

13.1.5 The Chief Executive will issue a Scheme of Delegation for capital investment management in accordance with “Protection of Assets Guidance for NHS Foundation Trusts” issued by Monitor and the SOs.

13.1.6 The Finance Director shall issue procedures governing the financial management, including variations to contract, of capital investment projects and valuation for accounting purposes. These procedures shall fully take into account guidance issued by Monitor relating to the Risk Assessment Framework and the best practice advice issued by Monitor in “Risk Evaluations for Investment Decisions for Foundation Trusts”.

13.2 Asset Registers

227

13.2.1 The Chief Executive is responsible for the maintenance of registers of assets, taking account of the advice of the Finance Director concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

13.2.2 The Trust shall maintain an asset register recording fixed assets. The minimum data set to be held within these registers shall be as specified in the “Protection of Assets Guidance for NHS Foundation Trusts” issued by Monitor.

13.2.3 Additions to the fixed asset register must be clearly identified to an appropriate budget holder and be validated by reference to :

13.2.3.1 properly authorised and approved agreements, architect’s certificates, supplier’s invoices and other documentary evidence in respect of purchases from third parties;

13.2.3.2 stores, requisitions and wages records for own materials and labour including appropriate overheads; and

13.2.3.3 lease agreements in respect of assets held under a finance lease and capitalised.

13.2.4 Where capital assets are sold, scrapped, lost or otherwise disposed of, their value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).

13.2.5 The Finance Director shall approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on fixed asset registers.

13.2.6 The value of each asset shall be depreciated using methods and rates as specified in the Trust’s Accounting Policies.

13.2.7 The Finance Director shall ensure that depreciation and Public Dividend Capital dividend are accounted for.

13.3 Security of Assets

13.3.1 The overall control of fixed assets is the responsibility of the Chief Executive.

13.3.2 Asset control procedures (including fixed assets, cash, cheques and negotiable instruments, and also including donated assets) must be approved by the Finance Director. This procedure shall make provision for:

13.3.2.1 recording managerial responsibility for each asset;

13.3.2.2 identification of additions and disposals;

228

13.3.2.3 identification of all repairs and maintenance expenses;

13.3.2.4 physical security of assets;

13.3.2.5 periodic verification of the existence of, condition of, and title to, assets recorded;

13.3.2.6 identification and reporting of all costs associated with the retention of an asset; and

13.3.2.7 reporting, recording and safekeeping of cash, cheques, and negotiable instruments.

13.3.3 All discrepancies revealed by verification of physical assets to the fixed asset register shall be notified to the Finance Director.

13.3.4 Whilst each employee has a responsibility for the security of property of the Trust, it is the responsibility of Directors and senior Officers in all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined by the Board of Directors. Any breach of agreed security practices must be reported in accordance with instructions.

13.3.5 Any damage to the Trust's premises, vehicles and equipment, or any loss of equipment, stores or supplies must be reported by Directors and Officers in accordance with the procedure for reporting losses.

13.3.6 Where practical, assets should be marked as Trust property.

14 STORES AND RECEIPT OF GOODS

14.1 Stores, defined in terms of controlled stores and departmental stores (for immediate use) should be :

14.1.1.1 kept to a minimum;

14.1.1.2 subjected to annual stocktake;

14.1.1.3 valued at the lower of cost and net realisable value.

Control of Stores, Stocktaking, condemnations and disposal

14.2 Subject to the responsibility of the Finance Director for the systems of control, overall responsibility for the control of stocks and stores shall be delegated to an Officer by the Chief Executive. The day-to-day responsibility may be delegated by him to departmental Officers and stores managers or keepers, subject to such delegation being entered in a record available to the Finance Director.

14.3 The responsibility for security arrangements and the custody of keys for all stores and locations shall be clearly defined in writing by the designated manager. Wherever practicable, stocks should be marked as health service property.

229 14.4 The Finance Director shall set out procedures and systems to regulate the stores, including records for receipt of goods, issues, and returns to stores, and losses.

14.5 Stocktaking arrangements shall be agreed with the Finance Director and there shall be a physical check covering all items in store at least once a year.

14.6 Where a complete system of stores control is not justified, alternative arrangements shall require the approval of the Finance Director.

14.7 The designated manager shall be responsible for a system approved by the Finance Director for a review of slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. The designated Officer shall report to the Finance Director any evidence of significant overstocking and of any negligence or malpractice. Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods.

14.8 For goods supplied via the NHS Supply Chain central warehouses, the Chief Executive shall identify those Officers authorised to requisition and accept goods from the store. The authorised person shall check receipt against the delivery note before forwarding this to the Finance Director who shall satisfy himself that the goods have been received before accepting the recharge.

15 DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS

15.1 Disposals and Condemnations

15.1.1 The Finance Director must prepare detailed procedures for the disposal of assets, including condemnations, and ensure that these are notified to managers.

15.1.2 When it is decided to dispose of a Trust asset, the head of department or authorised deputy will determine and advise the Finance Director of the estimated market value of the item, taking account of professional advice where appropriate.

15.1.3 All unserviceable articles shall be :

15.1.3.1 condemned or otherwise disposed of by an Officer authorised for that purpose by the Finance Director;

15.1.3.2 recorded by the condemning Officer in a form approved by the Finance Director which will indicate whether the articles are to be converted, destroyed or otherwise disposed of. All entries shall be confirmed by the countersignature of a second Officer authorised for the purpose by the Finance Director.

15.1.4 The condemning Officer shall satisfy himself as to whether or not there is evidence of negligence in use and shall report any such evidence to the Finance Director who will take the appropriate action.

15.2 Loss and Special Payments

230 15.2.1 The Finance Director must prepare procedural instructions on the recording of and accounting for condemnations, losses, and special payments. The Finance Director must also prepare a ‘fraud response plan’ that sets out the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it.

15.2.2 Any Officer discovering or suspecting a loss of any kind must either immediately inform their head of department, who must immediately inform the Chief Executive and the Finance Director or inform an Officer the Trust Local Counter Fraud Specialist charged with responsibility for responding to concerns involving loss or fraud confidentially; in line with NHS standards for investigating fraud and corruption. Where a criminal offence is suspected, the Finance Director must immediately inform the police if theft or arson is involved, but if the case involves suspicion of fraud, then the particular circumstances of the case will determine the stage at which the police are notified.

15.2.3 For losses apparently caused by theft, fraud, arson, neglect of duty or gross carelessness, except if trivial and where fraud is not suspected, the Finance Director must immediately notify:

15.2.3.1 the Board of Directors,

15.2.3.2 the Head of Internal Audit, and

15.2.3.3 Local Counter Fraud Services.

15.2.4 Within limits delegated to it by Monitor, the Board of Directors shall approve the writing-off of losses.

15.2.5 The Finance Director shall be authorised to take any necessary steps to safeguard the Trust’s interests in bankruptcies and company liquidations.

15.2.6 For any loss, the Finance Director should consider whether any insurance claim can be made.

15.2.7 The Finance Director shall maintain a Losses and Special Payments Register in which write-off action is recorded.

15.2.8 No special payments exceeding delegated limits shall be made without the prior approval of Monitor.

16 INFORMATION TECHNOLOGY

16.1 Responsibilities and duties of the Finance Director

16.1.1 The Finance Director shall be responsible for the accuracy and security of the computerised financial data of the Trust and shall:

231 16.1.1.1 devise and implement any necessary procedures to ensure reasonable protection of the Trust’s data, programs and computer hardware and networks for which he is responsible from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998 and any subsequent legislation;

16.1.1.2 ensure that reasonable controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system

16.1.1.3 ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment;

16.1.1.4 ensure that an adequate management or audit trail exists through the computerised system and that such computer audit reviews as he may consider necessary are being carried out.

16.1.2 The Finance Director shall satisfy himself that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurance of adequacy will be obtained from them prior to implementation.

16.2 Responsibilities and duties of other Directors and Officers in relation to computer systems of a general application

16.2.1 In the case of computer systems which are proposed general applications, all responsible Directors and Officers will send to the nominated Head of ICT:

16.2.1.1 details of the outline design of the system;

16.2.1.2 in the case of packages acquired either from a commercial organisation, from the NHS, or from another public sector organisation, the operational requirement.

16.3 Contracts for computer services with other health bodies or outside agencies

16.3.1 The Finance Director shall ensure that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.

232 16.3.2 Where another health organisation or any other agency provides a computer service for financial applications, the Finance Director shall periodically seek assurances that adequate controls are in operation.

16.4 Risk Assessment

The Finance Director shall ensure that risks to the Trust arising from the use of Information Technology are effectively identified and considered and appropriate action is taken to mitigate or control risk. This shall include the preparation and testing of appropriate disaster recovery plans.

16.5 Requirements for computer systems which have an impact on corporate financial systems

16.5.1 Where computer systems have an impact on corporate financial systems the Finance Director shall satisfy himself that:

16.5.1.1 systems acquisition, development and maintenance are in line with corporate policies such as an Information Technology Strategy;

16.5.1.2 data produced for use with financial systems is adequate, accurate, complete and timely, and that an adequate management or audit trail exists;

16.5.1.3 Finance Directorate staff have access to such data; and

16.5.1.4 such computer audit reviews as are considered necessary are being carried out.

16.5.2 The Finance Director will devise procedures which ensure that orders for the acquisition of computer hardware, software and services (other than consumables) are placed in accordance with the Trust’s information strategy.

16.5.3 The Finance Director will ensure that separate control procedures are put in place for computer systems. This procedure will include:

16.5.3.1 the acquisition and disposal of IT, systems and equipment;

16.5.3.2 the decommissioning of systems containing confidential data and in accordance with guidance issued by the Department of Health.

17 PATIENTS’ PROPERTY

17.1 The Trust has a responsibility to provide safe custody for money and other personal property (hereafter referred to as “property”) handed in by patients or their

233 guardians, or in the possession of unconscious or confused patients, or found in possession of patients dying in hospital or dead on arrival.

17.2 The Chief Executive is responsible for ensuring that patients or their guardians, as appropriate, are informed before or at admission by:

17.2.1 notices and information booklets;

17.2.2 hospital admission documentation and property records;

17.2.3 the oral advice of administrative and nursing staff responsible for admissions;

that the Trust will not accept responsibility or liability for patients’ property brought into Health Service premises, unless it is handed in for safe custody and a copy of an official patients’ property record is obtained as a receipt.

17.3 The Finance Director must provide detailed written instructions on the collection, custody, investment, recording, safekeeping, and disposal of patients’ property (including instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all staff whose duty is to administer, in any way, the property of patients. Due care should be exercised in the management of a patient’s money.

17.4 Where Monitor’s instructions require the opening of separate accounts for patients’ moneys, these shall be opened and operated under arrangements agreed by the Finance Director.

17.5 In all cases where property of a deceased patient is of a total value in excess of £5,000 (or such other amount as may be prescribed by any amendment to the Administration of Estates, Small Payments, Act 1965), the production of Probate or Letters of Administration shall be required before any of the property is released. Where the total value of property is £5,000 or less, forms of indemnity shall be obtained.

17.6 Staff should be informed, on appointment, by the appropriate departmental or senior manager of their responsibilities and duties for the administration of the property of patients.

17.7 Where patients’ property or income is received for specific purposes and held for safekeeping the property or income shall be used only for that purpose, unless any variation is approved by the donor or patient in writing.

18 FUNDS HELD ON TRUST

18.1 SOs identify the Trust’s responsibilities as a corporate trustee for the management of Funds held on Trust and define how those responsibilities are to be discharged. They explain that although the management processes may overlap with those of the organisation of the Trust, the trustee responsibilities must be discharged separately and full recognition given to the dual accountabilities to the Charity Commission for charitable funds held on trust and to Monitor for all Funds held on Trust.

234 18.2 The Scheme of Delegation makes clear where decisions regarding the exercise of dispositive discretion are to be taken and by whom. Directors and Officers must take account of that guidance before taking action. SFIs are intended to provide guidance to persons who have been delegated to act on behalf of the corporate trustee.

18.3 The overriding principle is that the integrity of the Trust must be maintained and statutory and trust obligations met. Materiality must be assessed separately from Exchequer activities and funds.

19 ACCEPTANCE OF GIFTS BY STAFF

19.1 The Finance Director shall ensure that all staff are made aware of the Trust policy on acceptance of gifts, hospitality and other benefits in kind. This policy should follow the requirements of relevant legislation including the Bribery Act 2010 and guidance contained in the Department of Health’s Standards of Business Conduct for NHS Staff and The Code of Conduct for NHS Managers.

20 RETENTION OF DOCUMENTS (awaiting confirmation from Jackie Stockwell) 20 Formatted: 01-Level1-BB 20.1 The Chief Executive shall be responsible for maintaining archives for all documents required to be retained under the guidance Records Management: NHS Code of Practice (April 2006).

20.2 The documents held in archives shall be capable of retrieval by authorised persons.

20.3 Documents held under HSC 1999/053 (replaced by Records management: NHS code of practice: Parts 1 and 2 of April 2006) shall only be destroyed at the express instigation of the Chief Executive, records shall be maintained of documents so destroyed.

21 RISK MANAGEMENT AND INSURANCE

21.1 The Chief Executive shall ensure that the Trust has a programme of risk management which will be approved and monitored by the Board of Directors.

21.2 The programme of risk management shall include:

21.2.1 a process for identifying and quantifying risks and potential liabilities;

21.2.2 engendering among all levels of staff a positive attitude towards the control of risk;

21.2.3 management processes to ensure all significant risks and potential liabilities are addressed, including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk;

235 21.2.4 contingency plans to offset the impact of adverse events;

21.2.5 audit arrangements, including internal audit, clinical audit, health and safety review;

21.2.6 a decision on which risks shall be insured;

21.2.7 arrangements to review the risk management programme.

The existence, integration and evaluation of the above elements will assist in providing a basis to make a statement on the effectiveness of Internal Control within the Annual Report and Accounts as required by current Monitor guidance.

21.3 The Finance Director shall report to the Board of Directors at intervals of not more than fifteen months on the insurances in respect of its operations of which the Trust has the benefit, and shall make recommendations to the Board of Directors (consistent with any guidance issued by Monitor) as to whether the Trust should insure through the risk pooling schemes administered by the NHS Litigation Authority for some or all of the risks covered by the risk pooling schemes, or insure with commercial insurers.

21.4 The Finance Director shall ensure that the insurance arrangements entered into are appropriate and complementary to the risk management programme of the Trust and that there are adequate documented procedures to cover those arrangements.

236

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 24a

Date: 25 November 2015

Title of Report: Audit Committee Terms of Reference

Lead: Charles Beaumont, Audit Committee Chairman & Dermot McCarthy, Trust Secretary

Subject, Purpose and Recommendation: The Board of Directors is asked to approve the update Terms of Reference of the Audit Committee of the Board of Directors.

Background The terms of reference of the Audit Committee are subject to review by the Committee and the Board of Directors on an annual basis. The most recent review was carried out by the Committee at its meeting held on 15 October 2015

No substantive changes are recommended; the only change will be to the Board approval date (final page).

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

237 AUDIT COMMITTEE OF THE BOARD OF DIRECTORS TERMS OF REFERENCE

1. CONSTITUTION The Board of Directors of the Trust (‘the Board’) has resolved to establish a committee of the Board to be known as the Audit Committee ( ‘the Committee’) which shall have the following terms of reference but no executive powers save as specifically delegated to it by these terms of reference.

2. DUTIES OF THE COMMITTEE 2.1 Governance, risk management and internal control The Committee shall ensure that the Trust establishes and maintains effective systems of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical) that support the achievement of the organisation’s objectives, and shall bring to the attention of the Chief Executive any concern which it may have regarding those systems. In particular, the Committee will satisfy itself as to the adequacy and effectiveness of the Trust’s: • internal financial controls • risk and control related disclosure statements and declarations of compliance (in particular the Annual Governance Statement), together with any accompanying Head of Internal Audit statement, External Audit opinion or other appropriate independent assurances, prior to endorsement by the Board • underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements • underlying assurance processes supporting the preparation and issue of the Trust’s Quality Accounts • policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements • policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by the Local Counter Fraud Service • arrangements by which staff of the Trust may, in confidence, raise concerns about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters, the objective being to ensure that arrangements are in place for the proportionate and independent investigation of such matters and for appropriate follow-up action

In carrying out this work the Committee will: • ensure that an effective Assurance Framework has been established to guide its work and that of the audit and assurance functions that report to it. • utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions • seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, internal financial control, risk management and other internal controls, together with indicators of their effectiveness.

238

2.2 Internal Audit The Committee shall ensure that there is an effective internal audit function established by management that meets the requirements of the Public Sector Internal Audit Standards and provides appropriate independent assurance to the Committee, the Chief Executive and the Board. This will be achieved by: • considering the effectiveness of the internal audit service, and the cost of the audit, including any question of resignation or dismissal; • considering and approving the internal audit strategy, operational plan and more detailed program of work, ensuring that this is consistent with the audit needs of the organization as identified in the Assurance Framework • considering the major findings of internal audit work and management’s responses • ensuring co-ordination between the Internal and External Auditors to optimise audit resources • ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation • undertaking a market-testing exercise for the appointment of an Internal Auditor at least once every five years • the holding of a private meeting with the Head of Internal Audit at least once a year.

2.3 External Audit The Committee shall: • discuss and agree with the External Auditor, before the audit commences, the nature and scope of the audit as set out in the proposed Annual Plan, and ensure coordination, as appropriate, with other external auditors in the local health economy; • discuss with the External Auditors their local evaluation of audit risks and assessment of the Trust and the associated impact on the audit fee • review all External Audit reports, the Annual Governance report and the Auditor’s report on the Financial Statements before submission to the Board and any work outside the annual audit plan, together with the appropriateness of management responses • assess the External Auditor’s work and fees on an annual basis to ensure that the work is of sufficiently high standard and that the fees are reasonable • make recommendations to the Council of Governors, in relation to the appointment, re-appointment or removal of the External Auditor, and approve the remuneration and terms of engagement of the External Auditor • review and monitor the External Auditor’s independence and objectivity and the effectiveness of the audit process, taking into consideration relevant UK professional and regulatory requirements • in considering the engagement of the External Auditor to supply non-audit services, take into account relevant ethical guidance regarding the provision of non-audit services by the external audit firm in accordance with the Monitor’s Audit Code for NHS Foundation Trusts which requires the prior approval of the Council of Governors • hold a private meeting with the External Auditor at least once a year

2.4 Local Counter Fraud Specialist The Committee shall ensure that there is an effective local counter fraud function established by management that meets the requirements set out in the ‘General Conditions’ section of the NHS Standard Contract.

239

The Committee shall:

• consider the appointment of the Local Counter Fraud Specialists (LCFS), the LCFS’ scope and any question of resignation and dismissal

• consider and approve the counter fraud strategy and the annual workplan, ensuring that this is consistent with the needs of the organisation

• monitor the performance of the LCFS in the provision of both reactive and proactive fraud work in line with the requirements set out in the ‘General Conditions’ section of the NHS Standard Contract regarding fraud and corruption

• review LCFS reports, consider the major findings of fraud investigations, and management’s response, and ensure co-ordination between the LCFS, internal and external auditors.

2.5 Other Assurance Functions The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation.

These will include, but will not be limited to: • any reviews by Department of Health arms’ length bodies regulators inspectors or professional bodies with responsibility for performance • the work of other groups teams or committees within the organisation, whose work can provide relevant assurance to the Committee’s own scope of work, particularly in the fields of clinical governance (including clinical audit) and risk management. • the Committee shall be responsible for the monitoring compliance with the Trust’s Treasury Management Policy and the performance of the Trust’s treasury management activities. The Committee will approve the Treasury Management Policy and any subsequent changes to the Treasury Management Policy.

2.6 Financial Reporting The Committee shall satisfy itself as to the integrity of the financial statements of the Trust and any formal announcement relating to the Trust’s financial performance including any significant financial reporting judgments contained in them.

The Committee shall also ensure that the systems for financial reporting to the Board, including those of budgetary control, are sound and effective and provide appropriate and accurate information to the Board.

The Committee shall review the Annual Report and Financial Statements before submission to the Board, focusing particularly on: • the wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the Committee • changes in, and compliance with, accounting policies and practices • unadjusted mis-statements in the financial statements • major judgemental areas, and significant adjustments resulting from the audit. • the Letter of Representation.

240

2.7 Quality Account The Committee needs to satisfy itself that: • the data used is reported accurately in terms of reliability and interpretation • the content of the Quality Account is a fair representation of the services provided by the Trust including issues of concern to the Trust’s stakeholders and encompasses planned improvements.

3. MEMBERSHIP The Committee shall be appointed by the Board from amongst the non-executive directors of the Trust. Its membership shall consist of not less than three independent non-executive directors and one of the members shall have recent and relevant financial experience. A quorum shall be two members. The Board will appoint one of the members Chair of the Committee. The Chairman of the Trust shall not be a member of the Committee.

4. ATTENDANCE The following persons shall attend meetings of the Committee: • The Director of Resources or his or her deputy, and • appropriate Internal Audit, the Local Counter Fraud Specialist (LCFS) and External Audit representatives • any executive director or officer of the Trust asked by the Committee to attend, particularly when the Committee is discussing areas of risk or operation that are the responsibility of that director or officer • the Chief Executive when requested, to discuss the internal audit plan, the process for assurance that supports the Annual Governance Statement and the annual Financial Statements when presented • the Trust Secretary to provide appropriate support to the Committee.

5. FREQUENCY OF MEETINGS Meetings shall be held not less than five times a year. The External Auditor or Head of Internal Audit may request the Chair of the Committee to call a meeting if they consider that one is necessary. The Chair of the Committee or any two members of the Committee may also call a meeting at any time. Committee members shall also meet once a year with no other person present.

6. AUTHORITY The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee of the Trust or from any provider of goods or services to the Trust and all employees of the Trust are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

7. REPORTING The minutes of Committee meetings shall be formally recorded by the Trust Secretary and submitted to the Board. The Chair of the Committee shall draw the Board’s attention to issues that the Committee feel require disclosure to the full Board, or executive action.

The Committee will report to the Board annually on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the Assurance 241 Framework, the completeness and embeddedness of risk management in the organisation, the integration of governance arrangements and the appropriateness of all declarations of compliance.

The Committee will, when appropriate issues arise, make a report to the Council of Governors, identifying any matters in respect of which it considers that action or improvement is needed and making recommendations as to the steps to be taken.

The Committee shall also report to the Council of Governors in relation to the performance of the External Auditor including detail of the quality and value of their work, the timeliness of reporting and their fees, to enable the Council to consider whether or not to reappoint them.

The Terms of Reference of the Committee, including its role and the authority delegated to it by the Board and by the Council of Governors, shall be publicly available and a separate section of the annual report shall describe the work of the Committee in discharging these responsibilities.

8. ANNUAL REVIEW AND SELF ASSESSMENT These Terms of Reference shall be reviewed annually by the Committee and the Board. The Audit Committee will also conduct an annual self-assessment of its own performance and effectiveness.1

Approved by the Board of Directors: 25/11/2015 26/11/14

1 These Terms of Reference are based on the recommendations contained in the NHS Audit Committee Handbook published by the Healthcare Financial Management Association (HFMA) for the Department of Health, and the NHS Foundation Trust Code of Governance published by the Independent Regulator. 242

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 24b

Date: 25 November 2015

Title of Report: Nominations Committee Terms of Reference

Lead: Chris Paveley, Chairman & Dermot McCarthy, Trust Secretary

Subject, Purpose and Recommendation: The Board of Directors is asked to approve the update Terms of Reference of the Nominations Committee of the Board of Directors.

Background The terms of reference of the Nominations Committee are subject to review by the Committee and the Board of Directors on an annual basis. The most recent review was carried out by the Committee at its meeting held on 21 October 2015

There is one change recommended; an update of a job title from ’Director of HR’ to ‘Director of Workforce and Development’ (this is marked via a tracked change).

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

243

NOMINATIONS COMMITTEE OF THE BOARD OF DIRECTORS TERMS OF REFERENCE

1. CONSTITUTION The Board of Directors of the Trust (‘the Board’) has resolved to establish a committee of the Board to be known as the Nominations Committee (‘the Committee’) which shall have the following terms of reference but no executive powers save as specifically delegated to it by these terms of reference.

2. MEMBERSHIP The Committee shall be appointed by the Board from amongst the non-executive directors of the Trust. Its membership shall consist of not less than three independent nonexecutive directors. The Board will appoint one of them to be chairman of the Committee but if he or she is not present the members present shall appoint one of their number to be chairman of the Committee for that meeting.

The Board shall keep the membership of the Committee under regular review and having regard to any potential conflict of interest of any member may remove an existing member and or appoint an additional independent nonexecutive director to be a member of the Committee at any time.

3. QUORUM A quorum shall be two members but no member shall be able to form part of the quorum for or be present at the meeting at a time when its business concerns the search for or identification or nomination of candidates to fill the vacancy which will arise on that member’s ceasing to hold office unless that vacancy is not expected to arise during the following twelve months or that member has already declared his or her irrevocable intent not to stand as a candidate for that vacancy.

4. ATTENDANCE The following persons shall attend meetings of the Committee: • the Chief Executive or his or her deputy • the Director of HR Workforce & Development or his or her nominated deputy • the Trust Secretary to take minutes of the meeting and provide appropriate administrative support to the Committee • external advisers as appropriate

but no person shall be present at the meeting at a time when the Committee is discussing any office or position held by that person or for which that person might be a candidate or applicant if it is or were to become vacant unless that vacancy is not expected to arise during the following twelve months or that person has already declared his or her irrevocable intent not to stand as a candidate for that vacancy.

244 5. FREQUENCY OF MEETINGS Meetings shall be held as required and not less than once a year. The chairman of the Committee or any two members of the Committee may call a meeting at any time.

6. AUTHORITY The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

7. DUTIES OF THE COMMITTEE The Committee will at all times have regard to the Code of Governance for NHS Foundation Trusts and guidance issued by Monitor and will;

7.1 keep the size, structure, and composition of the Board of Directors under regular review, having regard to the challenges and opportunities facing the Trust, and give full consideration to the need for succession planning

7.2 prepare role descriptions and person specifications for the position of each of the executive directors and each of the nonexecutive directors to reflect the balance of skills, knowledge and experience required by the Board from time to time and review those role descriptions and person specifications and the terms and conditions of each director’s employment or appointment whenever it is necessary to do so and at least once in every fifteen month period

7.3 report to the Chairman of the Trust regarding the executive directors, and to the Council of Governors regarding the nonexecutive directors as to its conclusions on the matters referred to in clauses 7.1 and 7.2 and make recommendations for any change which the Committee may consider to be desirable

7.4 whenever appropriate, instigate searches for and identify suitable candidates for appointment to the position of executive director, and make recommendations to the committee consisting of the Chairman, and all the nonexecutive directors of the Trust and, except in the case of the appointment of the Chief Executive, the Chief Executive, as to the candidate or candidates whom it considers to be appropriate for that appointment

7.5 whenever necessary, agree with the Council of Governors the process for the recruitment of a new chairman or nonexecutive director of the Trust, including but not limited to the manner by which candidates for the position will be sought and identified, applications from candidates will be considered, candidates will be shortlisted, and the shortlisted candidates will be interviewed, and make recommendations to the Council of Governors as to the candidate or candidates whom it considers to be appropriate for that appointment

7.6 have power to facilitate any recruitment process by using an executive recruitment and selection company and/or the in house Human Resources team of the Trust and/or any other public sector provider as the Committee considers to be appropriate

245 8. REPORTING The Committee will report to the Board annually on its work, specifically on changes in Board membership and the process it has used in relation to appointments. The chairman of the Committee shall draw the Board’s attention to issues that the Committee feel require disclosure to the full Board, or executive action.

These Terms of Reference of the Committee shall be made available on reasonable request.

9. REVIEW AND INTERPRETATION These Terms of Reference shall be reviewed annually by the Committee and the Board. References in these Terms to the “Council of Governors” shall include any committee or working group which may be constituted by the Council and whose purpose is to assist and make recommendations to the Council regarding the remuneration and appointment of non executive directors.

(Approved by the Board of Directors 24/09/1425/11/15)

246

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 25

Date: 25 November 2015

Title of Report: Summary of Board Decisions

Lead: Dermot McCarthy, Trust Secretary

Subject, Purpose and Recommendation: The Board of Directors is asked to note the report, which consists of a ‘rolling year’ of Board decisions.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

247 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 26.11.2014 Public 2014/123 Mid Area and Secure Services Business Plan The Board of Directors received the presentation regarding the Mid Area and Secure Services Business Plan. 2014/127 Minutes of the Meeting held on 24 September 2014 - The Minutes of the meeting held on 24 September 2014 were agreed as a correct record and signed by the Chairman.

2014/129 Chief Executive’s Report The Board of Directors received the Chief Executive’s Report 2014/130 Update on the NEP Five Year Strategy ‘All Together Better’ – Following Stakeholder Consultation The Board of Directors noted: a) the publicly circulated version of the NEP Five Year Strategy, “All Together, Better” and; b) the guidance to areas and directorates for the completion of business plans, which will deliver the new Trust Strategy. 2014/131 Carers’ Strategy Action Plan Update The Board of Directors noted the Carers’ Strategy Action Plan Update.

248 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2014/132 Patient-Led Assessment of the Care Environment (PLACE) Inspection 2014 The Board of Directors noted the PLACE 2014 results and action plan.

2014/133 Finance Report as at 31 October 2014 The Board of Directors received the Finance Report as at 31 October 2014.

2014/134 Losses and Special Payments Approval - The Board of Directors approved the write-off in respect of this debt for £54,570.

2014/135 Performance Summary - The Board of Directors received and noted the Performance and the Workforce Reports.

2014/136 Safe Staffing Levels - The Board of Directors received the Safe Staffing Monthly Update Report for each of the Trust’s Wards.

2014/137 Quality and Risk Report - The Board of Directors received the Quality and Risk Report.

249 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2014/138 Risk Management Strategy - The Board of Directors approved the Risk Management Strategy on an interim basis, until 31 May 2015.

2014/139 Audit Committee Terms of Reference - The Board of Directors approved the revised Terms of Reference of the Audit Committee.

2014/140 Revised Anti-Fraud & Bribery Policy The Board of Directors approved the revised Anti- fraud & Bribery Policy.

2014/141 ECC and NEP Annual Partnership Report - The Board of Directors received the report.

2014/142 Register of Directors’ Interests - The Board of Directors received the update to the Register of Directors’ Interests.

2014/143 Summary of Board Decisions The Board of Directors received the Summary of Board Decisions.

250 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2014/144 Execution of Deeds - The Board of Directors noted the report re the Execution of Deeds.

26.11.2014 Private P2014/089 Minutes of The Meeting Held In Private on 24 September 2014 – The Minutes of the meeting were agreed as a correct record and signed by the Chairman. P2014/090 Commercial & Service Integration Report Board of Directors received the Commercial and Service Integration Report.

P2014/091 Severalls Disposal Update The Board of Directors agreed to the recommendations as presented

P2014/092 Journeys High Level Summary Progress Report The Board of Directors: i) Noted the progress re Journeys to date and the risks identified ii) Noted the establishment of the Journeys Implementation and Transition Steering Group. (JITSG) iii) Noted the detailed Implementation and transition plan and progress rating.

251 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference P2014/093 Serious Incident Panel Investigation Report The Board of Directors received the Serious Incident Panel Investigation report including the findings and recommendations

P2014/094 Board Committee Reports/Minutes The Board of Directors noted the: • Quality and Risk Committee Report • Audit Committee Draft Minutes (09 October 2014) • The Nominations Committee Draft Minutes (22 October 2014).

28.01.2015 Public 2015/003 Chief Executive’s Report The Board of Directors received the Chief Executive’s report. 2015/004 Update on progress and future plans implementing “All Together, Better”, the Trust’s 5 year strategy plan The Board of Directors received the report.

2015/006 Monitor Annual Planning Process for 2015/16 and Beyond The Board of Directors received the report.

2015/007 Assessment Of Monitor’s Quality Governance Framework by the Board Of Directors The Board of Directors agreed to defer consideration of the report pending the outcome of the Quality and Risk Committee.

252 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/008 Finance Report for the period ending 31 December 2014 The Board of Directors received the Finance Report for the period ending 31 December 2014.

2015/009 Operational Performance Summary The Board of Directors received the Operational Performance Summary.

2015/010 Workforce Report The Board of Directors received the Workforce Report.

2015/011 Quality & Risk Report The Board of Directors received the Quality & Risk Report

2015/012 Journeys Programme Report The Board of Directors noted the Journeys high lev summary progress report.

2015/013 Ward Staffing Levels The Board of Directors noted the Ward staffing levels report.

2015/014 Mental Health Act (MHA) Report (2013/14) The Board of Directors noted the MHA Report for 2013/14

253 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/015 Equality & Diversity Annual Report The Board of Directors:

a) Received the report on progress against the delivery of last year Equality Delivery System (EDS) objectives and proposed actions for the coming year. b) Noted the introduction of the new national Race Equality Standards which would take effect across the NHS from 1 April 2015. c) Noted a comprehensive analysis of current workforce and patient information from an equality and diversity perspective for the period January to December 2014 in comparison with the previous two years. 2015/016 Monitor Compliance – Finance And Governance Return for Quarter 3 2014/15 The Board of Directors approved the Monitor Compliance Finance and Governance Return for Quarter 3 2014/15.

2015/017 Quality & Risk Committee The Board of Directors a) approved the establishment, membership and Terms of Reference of the Quality & Risk Committee b) approved the changes to the Trust’s Constitution, subject to approval by the Council of Governors.

254 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/018 Summary of Board Decisions The Board of Directors received the Summary of Board decisions.

2015/019 Execution of Deeds The Board of Directors noted the report.

28.01.15 Private P2015/004 Outline Financial Plan The Board of Directors received the presentation re the outline financial plan 2015/16.

P2015/005 Commercial and Service Integration Update The Board of Directors received the Commercial and Service Integration update.

P2015/006 Non NHS Income – Position Paper The Trust Board of Directors received the Position Paper on Non NHS income. P2015/007 Severalls Disposal Update The Board of Directors: i. approved the recommendation of the appointment of the preferred bidder for the purchase of the Severalls Phase 2 at the recommended sale price subject to the progression of contractual negotiations

255 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference forthwith in executing the sale.

ii. approved the retention of the reserve bidders. P2015/008 Staff Survey Presentation The Board of Directors noted the embargoed Staff Survey report 2014/15. P2015/009 Contracts Report The Board of Directors noted the Contracts Report. P2015/010 Mental Health Cost & Volume Contract Update The Board of Directors: i. Noted the current position in respect of the payment arrangements for Clusters 1-4; ii. Supported a course of action to recover payment for work done. P2015/011 Items Previously Considered Under Emergency Powers The Board of Directors ratified decision/s previously made under its Emergency Powers (Standing Order 4.2.1) at its Seminar meeting held on 10 December 2014 re: i. Provision for Substance Misuse Services for Adults in Suffolk – bid submission ii. Supported Employment Services for people with Mental Health needs across Essex - bid submission iii. Charitable Funds Accounts and Annual Report 2013/14 – approval.

256 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference P2015/012 Board Committees - Quality & Risk Committee (16 December 2014) The Board of Directors received the verbal report from Brian Johnson, chairman of the Quality and Risk Committee regarding the proceedings of the meeting held on 16 December 2014. P2015/013 Board Committees – Audit Committee (08 January 2015) The Board of Directors received the verbal report f Charles Beaumont, chairman of the Audit Committee regarding the proceedings of the meeting held on 08 January 2015.

P2015/014 Risk Register The Board of Directors received the report re the Risk Register 25.03.15 Public 2015/028 Chief Executive’s Report The Board of Directors noted the Chief Executive’s Report. 2015/029 Financial Plan/Contract 2015/16 The Board of Directors noted: i. the current progress in developing a financial plan for 2015/16 ii. that the Board would consider in Private Session a draft Financial Plan for 2015/16 and opening Budgets iii. that the Financial Plan would need revision post conclusion of 2015/16 contract negotiations and a further update would be provided next month.

257 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/030 The Monitor Planning Process - Update The Board of Directors: i. noted the new timetable ii. agreed the completion of the draft and final plan iii. noted the Declaration of Sustainability and Availability of Resources. iv. noted that the final plan would be brought back to the Board for formal approval.

2015/031 National Staff Survey 2014 The Board of Directors noted the Staff Survey report.

2015/032 Carers’ Strategy The Board of Directors agreed the Carers’ Strategy Action Plan.

2015/033 Finance Report for the Period Ended 28 February 2015 The Board of Directors noted the Finance Report for the Period Ended 28 February 2015.

2015/034 Operational Performance Summary to 28 February 2015 The Board received the Operational Performance Summary to 28 February 2015.

258 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/035 Operational Performance – Workforce The Board received the Operational Performance for Workforce. 2015/036 Ward Staffing Levels - February 2015 The Board of Directors: i. confirmed that the revised format of the Safer Staffing report met their current needs ii. noted the Safer Staffing report.

2015/037 Quality and Risk Report The Board received the Quality and Risk report. 2015/038 Journeys High Level Summary Progress Report The Board of Directors: i. Noted the progress re Journeys to date and the risks identified. ii. Noted that the re-organisation of the workforce and associated appointments were complete with redundancies avoided; fifty four staff securing promotions and only fourteen members of staff demoted with pay protection. iii. Received verbal feedback on the clinical transition assurance process following meetings with Area Directors on 16 March 2015. 2015/039 Inquest Recommendation The Board of Directors i. approved the recommendation based on legal advice not to proceed with a further inquiry into ML’s death.

259 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference ii. agreed to reconsider the matter in the light of any material issues advised in the future e.g. within correspondence from the Coroner. 2015/040 NEP Insurance Arrangements 2015/16 The Board of Directors: i. noted the purchase of ‘top-up’ insurance cover for 2015/16 ii. supported a ‘long term agreement’ to the end of 2016/17 for top-up property cover guaranteeing the premium.

25.03.15 Private P2015/019 Matters Arising Severalls Disposal Update (P2015/007) The Board of Directors noted the Severalls report including the update re risks.

P2015/020 Implementing the Strategy - Update The Board of Directors noted the update report on Implementing the Strategy

P2015/021 Financial Plan 2015/16 The Board of Directors: i. Approved the initial Financial Plan for 2015/16 ii. Noted that the Plan would need revision post conclusion of 2015/16 contract negotiations and further update/s would be provided.

260 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference P2015/022 Medium Term Capital Plan The Board of Directors noted the revised forward plan for capital investment 2015/16 to 2019/20.

P2015/023 Commercial and Service Integration Update The Board of Directors received the Commercial and Service Integration Update report. P2015/023 Report in Income Contract Performance The Board of Directors noted the report on Contract Performance Income.

P2015/024 Items Previously Considered Under Emergency Powers In accordance with the Standing Orders of the Board of Directors (SO4.2.1) the Board of Directors ratified the decision previously made under its Emergency Powers at its Seminar meeting held on 25 February 2015: to proceed with Emotional Wellbeing & MH Service (CAMHS) Bid (as a sub-contractor to South Essex Partnership University NHS Foundation Trust) P2015/025 Board Committees – Audit Committee (08 January 2015) Draft The Board of Directors received the draft minutes of the Audit Committee held on 08 January 2015.

261 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference P2015/025 Board Committees – Quality & Risk Committee (QARC) (20 March 2015) Verbal Report The Board of Directors received the report re the Quality & Risk Committee (QARC) held on 20 March 2015.

27.05.15 Public 2015/047 Minutes The Minutes of the meeting held on 25 March 2015 were agreed as a correct record and signed by the Chairman

2015/048 Matters Arising The Board noted progress re matters arising.

2015/049 Chief Executive’s Report The Board noted the Chief Executive’s report.

2015/050 Approval of the Annual Plan 2015/16 – Submission to Monitor The Board noted the submission. 2015/051 Board Committees – Annual Reports The Board received and approved the Board Committees’ annual reports.

262 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/052 Annual Accounts 2015/16 – Directors’ Assessment of Gong Concern The Board of Directors provided confirmation regarding the Statement of Going Concern.

2015/053 CQC Preparation Update The Board of Directors noted the report. 2015/054 Risk Management Strategy The Board of Directors approved the Risk Management Strategy for 2 years.

2015/055 Compliments and Complaints Annual Report 2014/15 The Board of Directors received the report. 2015/056 Finance Report for the Period Ending 30 April 2015 The Board of Directors approved the Month 1 Finance Report 2015/16.

2015/057 Operational Performance Summary to 30 April 2015 The Board received and noted the report.

2015/058 Workforce Report The Board received and noted the report.

263 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/059 Quality & Risk Report The Board received and noted the report.

2015/060 Ward Staffing Levels – March 2015 The Board received and noted the report

2015/061 Board Committees Verbal Reports The Board received the reports from the Quality & Risk Committee (20 Mar) and the Audit Committee (07 Apr and 21 May 2015)

2015/062 Board Members’ Register of Interests The Board received the updated register.

2015/063 Fit & Proper Persons Test – Trust Protocol The Board approved the protocol.

2015/064 Quality Account Priority Improvements 2015/16 The Board approved the report.

2015/065 Chairman & Non Executive Directors – Summary of Committee and Associated Responsibilities The Board of Directors approved the schedule of responsibilities.

264 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/066 Medical and Non Medical Education The Board of Directors noted the report.

2015/067 Monitor Compliance The Board of Directors noted the Q4 (2014/15) return.

27.05.2015 Private P2015/029 Minutes of the Meeting of 25 March 2015 The minutes were agreed as a correct record and signed by the Chairman.

P2015/031 Minutes of the Meeting of 11 May 2015 The minutes were agreed as a correct record and signed by the Chairman.

P2015/032 Meeting of 11 May 2015 – Matters Arising The Board of Directors noted the update on matters arising.

P2015/033 Commercial & Service Development Update The Board of Directors received the report.

P2015/034 Update re CAMHS tender The Board of Directors noted the report.

P2015/035 Annual Report, Quality Account and Financial Accounts for the period ending 31 March 2015 The Board of Directors: i) approved the Annual Report 2014/15, including the Quality Account, subject to any non

265 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference material changes approved by the Chief Executive ii) Adopted the Accounts for 2014/15 iii) Approved the Letter of Representation to be Provided to the External Auditors iv) Agreed to present the Annual Report and Accounts as the Annual Members’ Meeting on 10 September 2015.

P2015/036 Report on Income Contract Performance The Board received the report. P2015/037 Board Development Plan The Board approved the Board Development Plan.

P2015/038 Board Committees Draft Minutes The Board received the draft minutes of the Quality and Risk Committee (20 March 2015) and the Audit Committee (07 April 2015). P2015/039 Board Assurance Framework (BAF) / Risk Register The Board of Directors: i) received the BAF/Risk Register ii) approved new reporting arrangements. 29.07.15 Public 2015/074 Minutes The minutes of the meeting held on 27 May 2015 were agreed as a correct record and signed by the Chairman.

266 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/075 Matters Arising from the Minutes of the Meeting held on 27 May 2015 The Board of Directors noted progress re the Matters Arising.

2015/076 Chief Executive’s Report The Board of Directors noted the Chief Executive’s Report.

2015/077 Strategy Implementation Update The Board of Directors; a) noted progress re Strategy Implementation to date; and b) confirmed the future programme of work.

2015/078 NEP - Our People Strategy 2015/20 The Board of Directors approved The People Strategy, subject to the inclusion of “co-production”.

2015/079 Suicide Prevention Discussion Paper The Board of Directors noted the Suicide Prevention Discussion Paper.

2015/080 Serious Incidents Annual Report 2014/15 The Board of Directors received the Serious Incidents Annual Report 2014/15

267 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/081 Medical Revalidation Annual Report 2014/15 The Board of Directors: a) noted the Medical Revalidation Report b) agreed that the Statement of Compliance be signed on behalf of NEP by Chris Paveley, Chairman.

2015/082 Medical and Non Medical Education: General Medical Council (GMC) National Training Survey 2015 The Board of Directors Received and noted The Presentation Regarding General Medical Council National Training (NTS) Survey 2015

2015/083 Finance Report for the 3 Months Ending 30 June 2015 Finance Report for the 3 Months Ending 30 June 2015

2015/084 Operational Performance Summary to 30 June 2015 The Board of Directors received and noted the Operational Performance at Month 3.

2015/085 Workforce Report The Board of Directors received and noted the Workforce Report.

268 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/086 Monitor Compliance – Finance & Governance Return for Quarter 1 2015/16 The Board of Directors approved the Monitor Compliance Return for finance and governance for Quarter 1 2015/16 and the associated Board Declaration, subject to an additional sentence relating to property disposals.

2015/087 Quality & Risk Report The Board of Directors noted the Quality and Risk Report.

2015/088 Ward Staffing Levels The Board of Directors noted the Ward Staffing Levels report.

2015/089 The Board of Directors noted the Ward Staffing Levels report. The Board of Directors noted the update report on the progress of the Derwent Centre Phases 2 to 5 Construction Project (approved in June 2014).

2015/090 Board Committee Verbal Reports The Board of Directors received and noted the verbal reports from the QARC and Audit Committee Chairmen.

269 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/091 Research & Development (R&D) Annual Report 2014/15 The Board of Directors received and noted the Research & Development (R&D) Annual Report 2014/15.

2015/092 Major Incident and Business Continuity Plan The Board of Directors approved the Major Incident and Business Continuity Plan.

2015/093 Remuneration Committee Terms of Reference The Board of Directors approved the updated Terms of Reference of the Remuneration Committee.

2015/094 Summary of Board Decisions The Board of Directors noted the report Summary of Board Decisions.

2015/095 Execution of Deeds The Board of Directors noted the Execution of Deeds

2015/096 Any Other Notified Business There was no other notified business.

270 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 29.07.15 Private P2015/043 Minutes of the Meeting held on 27 May 2015 The minutes of the previous meeting held on 27 May 2015 were agreed as a correct record and signed by the Chairman.

P2015/044 Matters Arising from the Minutes of the Meeting held on 25 March 2015 The Board of Directors noted the Matters Arising.

P2015/045 NEP and SEPT Development of the Strategic Outline Case The Board of Directors agreed to explore a path to merger with SEPT subject to the completion of all due diligence, business cases, stakeholder engagement and regulatory review.

P2015/046 Commercial and Service Integration Update The Board of Directors received the Commerc Service Integration Update.

P2015/047 Provision of PICU Services from 2016/17 and Section 136 Facility (S136) The Board of Directors: a) Noted the requirement to temporarily close ‘Shannon House’ PICU by May 2016

271 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference b) Approved the Business Case for a 2 bedded extension to the Christopher Unit at a cost of £535k. c) Asked the Executive Management Team to produce a plan for the effective future operation of S136 facilities.

P2015/048 Derwent Centre Capping Off Proposals The Board of Directors: a) approved the proposed works required for ‘capping off’ the Derwent Centre project at the end of Phase 5 following the deferment of Phases 6 to 10 in accordance with the scope of works detailed within the report and the total capital costs of £3.7m (including VAT, fees, etc). b) noted that the Board of Directors would receive an updated Medium Term Capital Programme for 2016/17 onwards in September, outlining proposals for future funding of capital developments including the requirement for additional bridging or long-term loans.

272 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference P2015/049 Report on Income Contract Performance The Board of Directors noted the report which gave an overview of the Trust’s performance against each of its income contracts.

P2015/050 Ratification of Emergency Powers The Board of Directors ratified the decision previously made under its Emergency Powers (Standing Order 4.2.1) at its Seminar meeting held on 24 June 2014 re confirming that: “The Board of Directors is satisfied that the Trust has considered and followed the requirements for a material transaction as set out in Appendix C of the Risk Assessment Framework (RAF) and also in Monitor’s Risk Evaluation for Investment Decisions by NHS Foundation Trusts (REID)”.

P2015/051 Board Committees Draft Minutes The Board of Directors received the minutes of the Board Committees (held in private): a) Quality & Risk Committee (10 June 2015) b) Audit Committee (09 July 2015).

P2015/052 Any Other Notified Business There was no other notified business.

273 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 23.09.2015 Public 2015/102 Chief Executive’s Report The Board of Directors noted the Chief Executive’s Report.

2015/103 CQC Improvement Plan and Framework The Board of Directors: noted the actions taken in response to the initial findings of the CQC inspection held between 24th and 27th August 2015;

noted that an initial Trust action plan had been developed in response to the CQC initial feedback with Quality Improvement Panels to be implemented to progress the issues raised.

2015/104 Mental Health Strategic Review – Draft Report from Boston Consulting Group (BCG) The Board of Directors noted the Mental Health St Report from Boston Consulting Group (BCG).

2015/105 Organisational Response to the Essex Strategic Review: Strategic Options Case The Board of Directors: i. approved the exploration of a potential merger with South Essex Partnership University NHS Foundation Trust (SEPT) and the submission of a Strategic Options Case to Monitor;

274 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference

ii. noted the indicative timetable;

iii. noted the Project Management Structure for the development of key documents for presentation to the Board of Directors, the Council of Governors and Monitor.

2015/106 Finance Report for the Five months Ending 31 August 2015 The Board of Directors noted the Finance report for the five months ending 31 August 2015.

2015/107 Operational Performance Summary to 31 August 2015 The Board received and noted the Trust’s Operational Performance at Month 5.

2015/108 Workforce Report The Board of Directors received and noted the Workforce Report.

2015/109 Quality Report The Board of Directors received the Quality Report.

275 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/110 Ward Staffing Levels (July 2015) The Board of Directors received the Ward Staffing Level report.

2015/111 Nurse Revalidation The Board of Directors received the report re Nurse Revalidation.

2015/112 Board Committee Verbal Report - Quality & Risk Committee (19 August 2015) The Board of Directors received the verbal report regarding the Quality and Risk Committee.

2015/113 Emergency Preparedness, Resilience and Response Assurance The Board of Directors: i. noted the level of EPRR assurance achieved; ii. noted the results of the self-assessment; iii. noted the action plan for achieving full assurance.

2015/114 Medical and Non-Medical Education Update The Board of Directors noted the medical and non-medical education update.

276 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference 2015/115 Summary of Board Decisions The Board of Directors noted the report Summary of Board Decisions.

2015/116 Execution of Deeds The Board of Directors noted the Execution of Deeds.

2015/117 Any Other Notified Business There was no other notified business.

23.09.2015 Private P2015/055 Minutes of The Meeting held on 29 July 2015 The minutes of the meeting held on 29 July 2015 were agreed as a correct record and signed by the Chairman.

P2015/056 Matters Arising from the Minutes of the Meeting held on 29 July 2015 The Board of Directors noted Progress re Matters Arising.

P2015/057 Discussion re Meeting in Public The Board of Directors noted the discussion re the Meeting in Public.

277 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference P2015/058 Financial Recovery Plan The Board of Directors considered the report and requested an update at the next meeting (25 Novembe

P2015/059 Commercial & Service Integration Update The Board of Directors: i. received the report ii. approved the recommendation to seek to termi contract for the GP practices.

P2015/060 National NHS Community Mental Health Service Users Survey This item was deferred.

P2015/061 Section 136 Provision – Derwent Centre Section 136 Place of Safety The Board of Directors approved Option A as preferable in terms of clinical risk and affordability. A detailed plan to mitigate the patient experience and r issues would be prepared by the West Clinical Board by December 2015 and monitored by Risk and Governance Executive during the period of closure. The current S136 suite would be mothballed, to be reopened and staffed, if necessary, during the closure period.

P2015/062 Report on Income Contract Performance This item was deferred

278 North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

Date of Type of Minute Decision Item Received/Noted etc Meeting Meeting Reference P2015/063 CCG contract – second 6 months The Board of Directors supported the principle of remaining on a Cost and Volume contract for M6-M12 of 2015/16 with the minimum additional exposure. P2015/064 Severalls Update This item was deferred.

P2015/065 Any Other Business There was no other notified business.

279

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 26

Date: 25 November 2015

Title of Report: Execution of Deeds

Lead: Dermot McCarthy, Trust Secretary

Subject, Purpose and Recommendation:

The Board of Directors is asked to note the report. Since the last report to the Board the following deeds have been executed: i. No 176. Agreement for the sale and development of Severalls Hospital, Colchester Essex CO4 5HG between the Homes and Communities Agency (HCA), NEP and Bellway Homes Ltd, and Bloor Homes Ltd and Taylor Wimpey UK Ltd. (dated 16.09.15) ii. No 177. Co-operation agreement re Severalls Hospital, Colchester Essex CO4 5HG between the HCA and NEP (dated 16.09.15) iii. No 178. Land transfer document re 14 Creffield Road Colchester Essex C03 3JA between NEP and Mr and Mrs H Atkin (19.10.15) iv. No. 179. Agreement for sale of freehold re 9 Oxford Road, Lexden, Colchester Essex CO3 3HN between NEP and GP Smith and KLN Smith (dated 09.11.15) v. No. 180 Land transfer document re 9 Oxford Road, Lexden, Colchester Essex CO3 3HN between NEP and GP Smith and KLN Smith (dated 09.11.15) vi. No. 181 Deed of variation relating to Severalls Hospital Colchester Essex CO4 5HG between the Homes and Communities Agency (HCA), NEP, and Bellway Homes Ltd, and Bloor Homes Ltd and Taylor Wimpey UK Ltd. (dated 11.11.15) vii. No. 182Deed of variation to the Section 106 Agreement relating to Severalls Hospital, Colchester Essex CO4 5HG between Colchester Borough Council, Essex County Council, the HCA and NEP (dated 13.11.15).

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

280

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 27

Date: 25 November 2015

Title of Report: Any Other Notified Business

Lead: Chris Paveley, Chairman

Subject, Purpose and Recommendation:

The Board is invited to discuss any items of urgent business notified in advance of the meeting to Chris Paveley, Chairman or Dermot McCarthy, Trust Secretary.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

281

North Essex Partnership University NHS Foundation Trust

Meeting of the Board of Directors in Public

Agenda item No: 28

Date: 25 November 2015

Title of Report: Questions from members of the public relating to items on the agenda only

Lead: Chris Paveley, Chairman

Subject, Purpose and Recommendation: The Board of Directors is invited to reply to any questions from members of the public relating to items on the agenda only.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

282