Board Agenda Thursday, 6 October 2016, 9am – 12 noon Training Room 1, Recovery College, Springfield Hospital 61 Glenburnie Road, London SW17 7DJ
STRATEGIC OBJECTIVES • We will provide consistent, high quality, safe services that represent value for money. • We will develop stronger external partnerships and business opportunities that improve, access responsiveness and service range. • We will have reciprocal relationships, which value service users, carers, staff and the community as co-producers of services. • We will enable increased hope, control and opportunity for our service users. • We will become a leading innovative provider of health and social care services. • We will develop leadership and talent throughout the organisation.
9am Part A Board meeting Open
Standard Items
1 Apologies for absence Chair
2 Minutes of the meeting held on 1 TB(16-17) 5A For Chair September 2016 approval
3 Action Tracker/matters arising TB(16-17) 5Ai Chair
4 4.0 Report from the Chief Executive TB (16-17 91 For Chief information Executive 4.1 Report from Chair Oral For information Chair
Strategy
5 Corporate Objectives: Key Priorities TB(16-17) 92 For Chief information Executive
6 BAF Quarterly review TB(16-17) 93 For DoN&QS discussion
Quality and Performance
7 Service User Story TB(16-17) 94 For Medical discussion Director
8 Quality and Performance: Report from Quality Safety and Assurance Committee (QSAC) key variations to performance and actions in place to address these
Board Agenda 6 October 2016 and risks to quality and performance.
8.1 QSAC Minutes of Meeting held on TB(16-17) 95 For QSAC Chair 5 July and Oral report from information Meeting on 4 October 2016
8.2 Quality and Performance Report TB(16-17) 96 For QSAC Chair / discussion COO
Finance & Investment
9 Finance & Investment: - Report from Finance & Investment Committee
9.1 Minutes of Meeting held on TB(16-17) 97 For F & I Chair 25 July and Oral report from meeting information on 26 September 2016
9.2 Finance Report Month 5 (August) TB(16-17) 98 For F & I Chair /Int discussion DoF
9.3 New Single Oversight Framework: TB(16-17) 99 For Int DoF Financial Metrics information
9.4 EMP TB(16-17) 100 For decision F & I Chair /Int DoF Other items for discussion
10 Audit Committee Report
10.1 Minutes of the meeting held on 25 May 2016 and Oral report from For 12 September 2016 meeting TB(16-17) 101 discussion Audit Chair
Items for information
11 Annual Safeguarding Report:
12.1 Adults For TB(16-17) 103 information DoN&QS 12.2 Children For TB(16-17) 104 information DoN&QS
12 Annual Business Plan Requirements for TB(16-17) 105 For CEO 2017/19 information
13 Mental Health Annual Report TB(16-17) 106 For DoN&QS information
14 Any Other Business
Board Agenda 6 October 2016 15 Questions from Members of the Public
Exclusion of the public To resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted; publicity on which would be prejudicial to the public interest. (Section 1 (2) Public Bodies Admission to Meetings) Act 1960.)
Board Agenda 6 October 2016 DRAFT TB (16-17) 5A
Minutes of the meeting of the Trust Board held in the Recovery College on 1 September 2016
Part A
Present: Mr Peter Molyneux Chair Mr David Bradley Chief Executive Ms Dawn Chamberlain Chief Operating Officer Ms Jean Daintith Non-Executive Director Mr Clive Field Interim Director of Finance Mr Richard Flatman Non-Executive Director Ms Vanessa Ford Director of Nursing and Quality Standards Dr Ali Hasan Non-Executive Director Prof Andy Kent Non-Executive Director Ms Suzanne Marsello Director of Strategy and Commercial Development Mr Jonathan Thompson Non-Executive Director Ms Barbara Greenway Non Executive Director Dr Emma Whicher Medical Director
In Attendance: Ms Sola Afuape Associate Non-Executive Director Mr Stephen Guile Interim Head of Corporate Governance Mr Ranjeet Kaile Head of Communications and Stakeholder Engagement Ms Jayne Halford Deputy Director of HR
The Chair welcomed staff and members of the public to the meeting.
133-16/17 Apologies for absence
133.1 Mr Michael Parr, Director of Finance and Performance. Alfredo Thompson, Joint Director of HR and Organisational Development.
134-16/17 Minutes of the meeting held on 7 July 2016 TB (16-17) 4A
134.1 The Minutes of the meeting held on 7 J uly 2016 were approved as a true record.
135-16/17 Actions Tracker/Matters arising TB (16-17) 4Ai
135.1 Action 27 – Quality and Performance Report TB(15-16) 191: Well led Indicators (Mins 105.1) This is now referred to the Audit Committee. The Board approved the closure of this item on the Board Actions Log.
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135.2 Action 9 – The Five Year Forward View for Mental Health: Stakeholder Engagement TB(16-17) 11 (Mins105.5) A report was on the agenda for part B of the meeting. The Board approved the closure of this item.
135.3 Action 12 – Service User Story: Safeguarding (Mins105.8) The Board approved the closure of this item.
135.4 Action 15 (combined with Action 38 following– Quality and Performance Report – Lengths of Stay (TB16017) 37 ((Mins105.11) The Board noted that further information was included in the Quality and Performance report to the meeting. The Board recognised that it would continue to require reporting on lengths of stay. A further report on lengths of stay would be brought to the Board’s meeting on 6 October. Action: Chief Operating Officer
135.5 Action 16 – Recruitment of Band 5 Nurses and other multidisciplinary staff. (Mins 105.12) A paper on Nursing Establishments was on the agenda (item 9). The Board approved the closure of this item.
135.6 Action 19 - Control of Agency Spend- & 20- Management of the CIP Programme- (Finance Report Month 1 TB(16-17) 38) (Mins105.15) See the paper on Financial Results, on the agenda (item 8). The Audit Committee would be reviewing the position further when it met on 12 September. Action: Interim Director of Finance
135.7 Action 20 - Cost Improvement Programme (Mins105.15) See the paper on Financial Results, on the agenda (item 8). The Audit Committee would be reviewing the position further when it met on 12 September. Action: Interim Director of Finance
135.8 Action 21: Annual Report and Accounts 2015/16 TB(16-17) 39 (Mins105.16) Following discussions with Grant Thornton, a report on lessons learned from the annual audit was due at the Audit Committee’s meeting on 12 September. Action: Interim Director of Finance
Board Assurance Framework The updated Risk Register would be reported to the Audit Committee at its meeting on 12 September and to the Board at its 6 October meeting.
135.9 Action 23 - Bed Pressures TB(16-17) 41 (Mins105.18) The Risk Register had been updated. The Board approved the closure of this item.
135.10 Action 24 - Stakeholder Management (Mins105.19) The Risk Register had been updated. The Board approved the closure of this item.
135.11 Action 25 - Workforce (Mins 104.20) The Risk Register had been updated. The Board approved the closure of this item.
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135.12 Action 26 – Community Services (Mins 105.21) The Risk Register had been updated. The Board approved the closure of this item.
135.13 Action 27 - Risks arising from Grant Thornton’s value for money report (Mins 105.22) Due for report to the Audit Committee’s meeting on 26 October 2016. Action: Interim Director of Finance
135.14 Action 28 - Board Risk Appetite (Mins 105.23) Due for consideration at a Board Development Session. Action: Director of Nursing and Quality Standards
135.15 Action 29 - Board Assurance Framework TB(16-17) 41 (Mins 105.24) The Audit Committee would, at its meeting on 12 September, check that the Trust’s strategic risks and corporate risks were fully aligned and there was appropriate risk mediation across all risk registers. Report for the Board at its 6 October meeting. Action: Director of Nursing and Quality Standards
135.16 Action 32 - Service User Involvement (Mins 105.27) The Medical Director was undertaking mapping of local service user groups and that she would bring a report on service user involvement to the 1 December Board meeting. Action: Medical Director
135.17 Action 33 - Financial Position from NHS Improvement (Mins 106.1) A report on collaboration on potential sharing of services with Oxleas and South London and Maudsley Trusts would be brought to the Board’s 6 October meeting. Action: Chief Executive
135.18 Action 34 - Deep Dive – Audit Committee September 2016 (Mins 106.1) The Audit Committee would be undertaking a deep dive on project management and the delivery of CIPs at its meeting on 12 September. Action: Interim Director of Finance
135.19 Action 35 - Shadow Governors (Mins 107.2) The Chair confirmed that he would continue to work with the Shadow Council of Governors on their programme of activity. Action: Head of Communications and Stakeholder Engagement.
135.20 Action 36 - Service User Story TB(16-17) 54 Neurodevelopmental Assessment Team (part of CAMHS) (Mins 108.5) The Chief Operating Officer was continuing to monitor delivery of the service and risk in the referrals backlog. Action: Chief Operating Officer
135.21 Action 37 - Service User Story TB(16-17) 54 Neurodevelopmental Assessment Team (part of CAMHS) (Mins 106.1) QSAC would continue to monitor progress on achieving improvement of communications with commissioners, being clear about risk-sharing which anticipated demand, reporting back to the Board. Action: Chief Operating Officer
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135.22 Action 38 - Quality and Performance Report TB(16-17) 55 (Mins 109.1) The Board approved the closure of this item as it was now combined with Action 15.
135.23 Action 39 - Quality and Performance Report TB(16-17) 55 (Mins 109.1) The Board looked forward to proposals for a meeting with Kingston CCG to discuss the absence of commissioning for personality disorder service. Action: Head of Communications and Stakeholder Engagement.
135.24 Action 40 - Mortality Report TB(16-17) 57 (Mins 111.2) QSAC was due to receive the annual Report on Mortality at its October meeting. Action: Medical Director
135.25 Action 41 - Medical Education Annual Report TB(16-17) 59 (Mins 113.2) Changes at St George’s medical School were to be recorded as a risk on the Trust’s risk register. Action: Director of Strategy and Commercial Development
135.26 Action 42 - Finance Report TB(16-17) 62 (Mins 116.1): Sustainability and Transformation Fund. The Board noted the update and approved the closure of this item.
135.27 Action 43 - Finance Report TB(16-17) 62 (Mins 116.1): Update on financial performance and CIPs The Board noted the update. A further update will be included in the Finance Report to the 6 October Board meeting. The Board approved the closure of this item.
135.28 Action 44 - Finance Report TB(16-17) 62 (Mins 116.4) The Interim Director of Finance would advise to the Board whether income given up by the Trust to the Department of Health would come back to the Trust via its External Financing Limit. Action: Interim Director of Finance
135.29 Action 45 - Finance Report TB(16-17) 62 (Mins 116.5) Year to Date Financial position and Year End forecast. The Board noted the update and approved the closure of this item.
135.30 Action 46 - Finance Report TB(16-17) 62 (Mins 116.5) The Chair had asked for updates on the following key Trust action plans over the past two years: The Chair also asked for a report on the Trust’s key action plans over the past 2 years: • Previous CQC reports to September Board. Action: Director of Nursing & Quality Standards
• An updated review of the action plans arising from the Trust’s FT process including the Board Governance Assurance Framework (BGAF); Quality Governance Assurance Framework (QGAF); and HDD1 and 2 to September Board. Action Chief Executive
• Quality Improvement Plan. Action Director of Nursing & Quality Standards
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135.31 Action 47 - Urgent Care Pathway – from Planning to Implementation TB(16-17) 64 (Mins 106.1) The Board asked that quarterly reports on the acute care pathway be made to EMC and QSAC. Action: Chief Operating Officer: Quarterly report to EMC and QSAC.
136-16/17 Report from Chief Executive TB(16-17) 72
136.1 The Chief Executive highlighted the following:
136.1 Strengthening financial performance & accountability in 2016/17
The Board noted the Chief Executive’s summary of NHS Improvement and NHS England’s strategic direction document recently setting out the approach they expect to see implemented across the NHS, especially in relation to control of finances. There was an objective of cutting the combined provider deficit to around £250 million in 2016/17 and an ambition that, in aggregate, the provider position commences 2017/18 in run-rate balance. None of the additional funding would be given to mental health trusts. The initiatives included replacing current one year plans with two yearly plans. Copies of the report were available on BoardPad for Board members to review.
The Chief Executive said that the Trust was working with two other mental health trusts: South London and Maudsley (SlaM) and Oxleas, on collaboration on “back office” and pathology services.
136.2 Implementing the five year forward view for Mental Health
The Chief Executive said that the Trust coninued to seek to secure a more prominent part for mental health services in the South West London Sustainablity and Transformation Plan (SWLSTP).
Mr Thompson said that the Board needed to prepare for the STP regime and the new two-year plans.
The Director of Strategy and Commercial Development said that there were tight timescales for the progression of the plans. Discussion and information flows were being maintained with the principal officer for the SWLSTP. The Interim Director of Finance said that a key lesson learned from the 2016/17 contracting round had been to concentrate upon one key objective- to improve our acute care pathway Jointly commissioned research with commissioners had helped to establish a common approach and funding of £3 million on the acutecare pathway. Money remained tight.
Mr Thompson said that the Trust needed to accelerate its plans, given the need for two year commitments. This included financial and other information - the STP engagement represented another major project to add to our programme.
Summing up, the Chair said that the Trust would continue with the SWLSTP process. Continuing to manage stakeholder engagement and mangement of activities and costs that were within the Board’s control, would be key.
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136.3 South London Mental Health Partnership
See Minute 136.1 above. There would be further discusssion in Part B of the meeting.
136.4 Changes to Ministerial Health Team
The Board noted the changes. The Secretary of State, Jeremy Hunt, MP, had taken personal responsibility for mental health.
136.5 Trust Website
The Board noted that the launch had taken place and that there had been good feedback from service user groups.
136.6 New CEO in Kingston
The Board noted the appointment of Charlie Adan.
136.7 Employee of the Month
The Board congratulated Sharleen Mandondo as Employee of the Month.
137-16/17 Report from the Chair TB(16-17) 73
The Chair presented his report.
137.1 Support for the Executive South London Initiative There would be further discussions on this at Board level. Audit Committee Chairs had met to consider risk management.
Health and Work Innovation Fund The Trust would be leading a bid for South West London, working with SLaM and Oxleas.
Quality and Performance
138-16/17 Service User Story TB(16-17) 74 Safeguarding Adults 138.1 The Medical Director presented the Service User Story on Safeguarding Adults requested by the Board. The Trust’s Safeguarding Lead, Patrick Bull was working hard to improve service user experience. Safeguarding was a key element of the Trust’s approach to its Quality Account, for example in seeking to minimise violence and aggression.
138.2 Dr Hasan said that Safeguarding was discussed at QSAC- especially in relation to the experience of service users. The Medical Director said that service users need to find our processes personal and helpful. We were seeking to build trust and to change our polices and practice to reflect feedback. In response to a question from the Chair, the Medical Director said that our people and our services should be collaborative; helpful; provide solutions and be empowering to others.
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138.3 In response to a question from Ms Greenway, the Medical Director said that safeguarding alerts may be triggered by staff, service users, social workers and others. The Trust had a responsibility to work with local authorities. Mr Bull said that the Trust’s safeguarding activities were being broadened and processes were being linked. The Medical Director agreed that there could be a safeguarding element in whistleblowing. The Director of Nursing and Quality Standards said that she believed the Trust had good systems, with various opportunities for staff to raise issues. The CQC visit in March had found we have robust safeguarding processes.
In response to a question from Mr Flatman on whether the trust had a confidential hotline, the Chief Executive said that EMC was due to receive a presentation by a potential guardian service the following week.
In response to a question from Ms Afuape, the Medical Director said that the boroughs audit sample safeguarding cases regularly. Safeguarding continuity was followed through. Dr Hasan asked for further information on safeguarding to be reported to QSAC and the Board, to include outcomes. The Annual Reports on Adult and Children’s Safeguarding were due at the Board’s meeting on 6 October.
Summing up, the Chair said that partial assurance had been provided, with plans in place. The Board would review the Annual Reports on Adult and Children’s Safeguarding at its meeting on 6 October.
139-16/17 Report from Quality and Safety Assurance Committee (QSAC) Oral report from 30 August 2016 Meeting 139.1 Prof Kent said that QSAC had discussed the risk register; The Committee had noted that the hundredth risk had been added.
Key areas reviewed at QSAC’s meeting on 30 August included: • Bed occupancy • Risks, including reputational risk, in relation to the Trust Quality, with the CQC re-inspection due in late September. • The quality of CPAs • Restrictive Practice- all forms together • The Mental Health Act Report. This was due to come to the Board’s 6 October meeting.
140-16/17 Quality and Performance Report TB(16-17) 76
140.1 The Chief Operating Officer presented the report. The data was one month older than usual, due to holiday timings.
Key matters discussed by the Board were as follows:
• Staff recruitment and retention had improved, with a co-ordinated approach across the Trust. • There had been a breach in the timescale for psychiatric assessments- The Chief Operating Officer said that there had been a more than doubling of referrals, • There was an increased need for efficiencies. Independent review by Mental Health Strategies of demand and capacity in adult services had
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showed that more capacity was needed in community services. The Director of Nursing and Quality Standards and the Chief Operating Officer confirmed that there was an action plan to strengthen community services by the end of the financial year including clinical standards and staffing. Staff supervision standards and practice had been refreshed, including supporting staff in reporting any concerns. A progress report would be made to QSAC and the November Board Meeting. Action: Chief Operating Officer / Director of Nursing and Quality Standards. Prof Kent said that one of the root causes of demand was a shortage of GPs nationally. In response to a question from Dr Hasan, the Chief Operating Officer said that Mental Health Strategies had modelled alternatives in the light of demand. The Trust was in block contracts and was holding a dialogue on risk share for community contracts.
• In response to a question from the Chair, the Chief Executive said that the Trust had had a relatively good outcome from the CQC’s March 2016 visit and now had a good opportunity in the late-September re- inspection, to show further improvements. Actions were under way to reverse the Trust’s worsening finances. Other actions included understanding and learning from recent deaths in Kingston and Richmond, continued improvements to recruitment to staff vacancies, the aggressive cap from regulators on agency spend. South West London health system was financially challenged, with other organisations in significant deficit and in NHS Improvement supervision.
• The Chair said that more analysis was needed to understand pressures for services and to mitigate those pressures. The Chair said that it was important to have an overview of the key drivers, risks and mitigations on bed management- managing “upstream”- working on demand, improving services in the community- and “downstream”- on lengths of stay. The Chief Executive said that the need to improve our staffing and quality of community services was being acted upon. The Trust was working with others to reduce demand. The Chief Operating Officer said that there would be discussions on demand at the next meeting of the Transformation Board. Mental Health Strategies had been commissioned to provide a report by the end of October for the 2017/18 contract round discussions.
• In response to a question from Mr Thompson, the Director of Nursing and Quality Standards said that the CQC was due to Inspect specific services at the end of September.
• In response to a question from the Chair, the Director of Nursing and Quality Standards said that plans were under way to ensure that at least 85% of staff had up-to-date six-weekly supervision sessions with their line managers and that there were suitable spans of control, demonstrated by having organograms in place. She acknowledged the support and commitment of Staff-Side. Progress would be reported to the Board. Action: Director of Nursing and Quality Standards
• In response to a question from Ms Afuape, the Director of Nursing and Quality Standards said that the executive Team would review the effectiveness and sustainability of the staff supervision system. This was
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a key element of a quality improvement system
Finance
141-16/17 Report from Finance & Investment Committee (F & I Committee)
Oral report from 25 July 2016 meeting
142-16/17 Finance Report Month 4 (July) TB(16-17) 78
142.1 The Director of Finance presented the report. There had been some improvements to the run rate, but at Month 4, there was a deficit of £1.1 million, which was £1 million adverse to plan. The over-spend was primarily on pay, particularly under-achievement on budgeted Admin and Clerical Review costs and a continuing high level of agency staff spend.
The Director of Finance said that average monthly spend on agency staff in the current year, 2015/16, was £1.4m and, for the month of July, this had reduced to £1.3m. The current spend on agency was not sustainable. The plan was to reduce monthly agency spend by £350k. The Executive Team was reviewing all agency staff, against three essential criteria: where a role directly related to patient safety or a statutory requirement or represented a spend-to-save scheme. For an agency staff member employed against a vacancy in a permanent post, to be retained it would also be necessary to show that recruitment to the vacancy was taking place. We were encouraging agency staff, especially those working in community services, to join our in-house staff bank in order to save the agency premium. The Trust was mindful of the effects on individual members of staff. The Chief Operating Officer said that we had had success with inpatient recruitment. The Agency Control Panel hoped to repeat this community services.
The Director of Finance said that financial governance was being strengthened, especially within monthly departmental performance reviews (DPR). Greater centralised controls over non-pay costs were being imposed.
Achieving the planned year end surplus of £2.1m, before impairments, would be difficult.
142.2 The Chair said that he wanted the Audit Committee to establish why we were in such an adverse financial position at Month 4 (July). The Board needed, by its 6 October meeting, evidence of improved control over agency staff spend and any impact on quality resulting from that, and advice on what activity the Trust could not do as a result. The Risk Register should be amended in respect of the financial position. Action: Director of Finance
142.3 Mr Flatman said that he was most concerned that overspending on agency staff had continued and was forecast to be overspent by £2 million for the year. The Director of Finance said that local management has not resolved agency spend so centralised control via the Agency Control Panel was now being imposed.
The Chair expressed concern about the capability and capacity to resolve the financial position. Mr Thompson said that the agency tap could be turned off but that may still make recovering the year-to-date overspend of £1 million very
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challenging. The report showed that there was significant agency send in the Project Management Office (PMO) - if we cut that, there would be an impact on delivering our projects and programmes. Priorities would have to be assessed and assurance reported to the Board for review.
142.4 Dr Hassan said that it was important that the quality implications of our Cost- Improvement Programme (CIP) plans were identified. £12,2m of new saving had to be delivered over 2016/17 and 2017/18, with £1m per month being achieved from October. Schemes needed to be developed as locally as possible.
142.5 The Board noted the Trust’s financial position with concern and agreed that the Executive Team pursue and report back to the next Board meeting upon the identified actions (see Minute 142.3 above).
143-16/17 Review of Nursing Establishments TB(16-17) 79
143.1 The Director of Nursing and Quality Standards presented the report. The board had received a report earlier in the year and the proposals had now been updated with further financial information.
143.2 The Board noted the Review of Nursing Establishments report and that implementation had to be within our existing resources.
144-16/17 Complaints and Compliments Annual Report TB(16-17) 80
144.1 The Board noted and accepted the Complaints and Compliments Annual Report.
145-16/17 Five Year Forward view for Mental Health – implementation plan TB(16- 17) 81 145.1 The Board noted the Implementation Plan.
146-16/17 Revalidation (Medical) TB(16-17) 83
146.1 The Board noted the Report.
147-16/17 Report from the Workforce and Organisational Development Committee Oral Report 147.1 The Board noted that its new Committee had held its first meeting.
148-16/17 Any Other Business
148.1 None
148.2 Opportunities for Members of the Public to hold the Board to Account
148.2.1 In response to a question from Mr John Morrell, the Chair confirmed the impact that the Trust’s planned move to Service Line management on relationships with voluntary organisations would be carefully considered. The Trust was
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planning to adopt a matrix model that retained a borough structure and borough relationships, particularly for community services.
In response to a further question, the Director of Nursing and Quality Standards said that she would look into why in Trust person specifications, personal experience of Mental Health- desirable- had been removed. The Chair emphasised that the Trust fully supported and encouraged those who had suffered mental ill-health into jobs- and the Desirable characteristic should be retained. Action: Director of Nursing and Quality Standards
148.2.1 Suresh Desai, Staff Side Chair, said that it had been refreshing to hear from the Board discussion, that there was a realisation about the need to improve the Trust’s financial position. Staff needed support, encouragement and guidance. Unison had written to Trust Execs about STP plans, asking them to remember the impact on staff, for example: agency costs’ control refreshing. The Chair thanked Mr Desai for his comments about establishing value for money.
148.3 Exclusion of the Public and the Press The Board then resolved that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted; publicity on which would be prejudicial to the public interest. (Section 1 (2) Public Bodies (Admission to Meetings) Act 1960.)
Peter Molyneux Chairman September 2016
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6 October 2016 updated Board Tracker - Part A TB(16-17) 5Ai
Dates of Originatin Tracke Mins Lead Required Board g Board Issue/Action Progress Ref Exec by Board r Meeting Meeting
Lengths of Stay For inclusion in Quality and
02/06/2016 Performance Report due to September
15 TB(16-17)3A The Chair emphasised the importance Board meeting of triangulating data better and of
understanding the causes of lengths of 07/07/2016 Update: stay. He asked that the Quality and In order that the Board should better Performance report to the September understand the causes of length of
Board meeting highlight lengths of stay, stay,
variations and information sufficient to COO Sept 2016 the Quality and Performance Report to the 1 September Board meeting would understand outliers, modelling how we will be able to reduce the additional further highlight lengths of stay and
acute beds, plans to open crisis cafes variations the discharge planning
and recovery houses; bringing housing process, bed occupancy and measures
professionals into the discharge for improving understanding of patient 07/07/2016 74.1 planning process, bed occupancy and experience. TB(16-17)4A measures for improving understanding of patient experience. 01/09/2016 Update: 01/09/2016 The Board noted that further information TB(16-17)5Ai was included in the Quality and Performance report to the meeting. The Board recognised that it would continue to require reporting on lengths of stay. A further report on lengths of stay would be brought to the Board’s meeting on 6 October. Action: Chief Operating Officer
6/10/2016 Update– See Q & P Report item 7 1
Control of Agency Spend & All Board Members received the 27 June Int DoF 02/06/2016 75.1 Management of the CIP Programme- F & IC papers: these included a report on 19 and Int July 2016 TB(16-17)3A control of agency spend. Dep Dir of Finance Report Month 1 TB(16-17) HR 38 A further report will be made to the 1
A report on how recruitment and September Board meeting. 07/07/2016 retention has been and will continue to TB(16-17)4A be improved, and agency spend 07/07/2016 Update: Paper for September Board reduction, would be provided for the July board meeting. 01/09/2016 Update: (Mins105.15) See 01/09/2016 the paper on Financial Results, on the TB(16-17)5Ai agenda (item 8). The Audit Committee would be reviewing the position further when it met on 12 September.Action: Interim Director of Finance
The Audit Committee discussed this at meeting on 12/09/16. The Board is recommended to close this item.
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20 02/06/2016 Cost Improvement Programme Int DoF TB(16-17)3A 75.1 All Board Members received the 27 June Mr Flatman expressed concern that Was F & IC papers: these included a report on CIP savings were significantly back- control of agency spend. loaded in the budget and he asked for July 2016
a detailed plan for savings to come to the July Board. He also said that he Now would wish to see targets for agency A further report will be made to the 1 spend and for the controls to be Sept September board meeting. 07/07/2016 brought to the Audit Committee for TB(16-17)4A review. 01/09/2016 Update: See the paper on Financial Results, on the agenda (item 8). The Audit Committee would be reviewing the 01/09/2016 position further when it met on 12 TB(16-17)5Ai September. The Audit Committee discussed this at its meeting on 12/09/16. There is a report back from the Audit Committee on the 6 October Board Agenda. The Board is recommended to close this item.
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02/06/2016 Annual Report and Accounts A post-audit meeting with Grant Thornton 21 TB(16-17)3A 76.1 2015/16 TB(16-17) 39 was held on 23.6.16 There will be an Audit Mtg item on the next Audit Committee There would be discussion with Grant Int DoF Sept/Oct Agenda to discuss this. Thornton and a lessons learned review 07/07/2016 Update: Discussion had on audit processes for report to the taken place with Grant Thornton and a next Audit Committee meeting. report on lessons- learned would be 07/07/2016 made to the next Audit Committee TB(16-17)4A meeting (rearranged from 25 July to 12 September).
01/09/2016 Update: Following discussions with Grant Thornton, a report on lessons learned for the annual audit was due at the Audit Committee’s meeting on 12 September.
Action: Interim Director of Finance
The Audit Committee discussed this at
meeting on 12/09/16 and The Board is
recommended to close this item.
A paper on Auditors will be on the Board’s October Agenda. 01/09/2016 Board Assurance Framework TB(16-17)5Ai Risk Register to be reported to Board Updated Risk Register and BAF were at 6 October meeting reported to Audit Committee on 12/09/16 and are on the board 06/10/16 Agenda. The Board is recommended to close this item.
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Risks arising from Grant Thornton’s Int DoF to take Report to next Audit 27 02/06/2016 78.1 value for money report: Int DoF Committee Meeting. TB(16-17)3A 07/07/2016 Update: To be reviewed and These would be reviewed and brought taken to next Audit Committee meeting in to the Audit Committee’s next meeting. 07/07/2016 September. Risk Register and BAF to be TB(16-17)4A The Risk register/BAF would then be Nov 2016 amended accordingly. amended as necessary. 01/09/2016 Update: Due for report to report to the Audit 01/09/2016 Due for report to the Committee’s meeting on 26 October Audit Committee’s meeting on 26 TB(16-17)5A 2016. October 2015. Action: Interim Director of Finance
Board Risk Appetite: The Chair said 07/07/2016 Update: The Chair and the 28 02/06/2016 78.1 that he and the Audit Committee Chair Jan 2017 Audit Committee Chair to consider when TB(16-17)3A would consider when and how the Trust and how the Board should consider and Board should consider and decide its Chair decide its Risk Appetite for 2016/17. To
07/07/2016 Risk Appetite for 2016/17. This would link with Trust’s objectives. TB(16-17)4A link with the Trust’s quality objectives. 01/09/2016 Update:
01/09/2016 Due for consideration at a Board TB(16-17)5A Development Session. This will be programmed in discussion with Chair Action: Director of Nursing and Quality Standards
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Board Assurance Framework 07/07/2016 Update: Audit Committee to 29 02/06/2016 78.1 TB(16-17) 41 (Mins 78.1) check whether the Trusts strategic risks TB(16-17)3A DoNQ&S and corporate risks were fully aligned and Oct 16 The Board decided that the Audit there was appropriate risk mediation 07/07/2016 Committee would check whether the across all risk registers. This action will TB(16-17)4A Trust’s strategic risks and corporate be completed by the end of September risks were fully aligned and that there 2016 when the BAF is due to be was appropriate risk mediation across presented back to the Board in full at all risk registers October meeting. 01/09/2016 TB(16-17)5A 01/09/2016 Update: The Audit Committee meeting on 12 September received a report on the BAF
For report to Board at 6 October meeting. Action: Director of Nursing and Quality Standards
Service user involvement: In 07/07/2016 Update: The Medical Director 32 02/06/2016 83.3. response to a question about service MD was undertaking mapping of local service TB(16-17)3A user involvement and linking up with Dec 2016 user groups was being undertaken and the Patient Quality Forum the Medical that she would bring a report on service 07/07/2016 Director said that mapping of local user involvement to a future Board TB(16-17)4A service user groups as being meeting. undertaken and that she would be bringing a report on service user 01/09/2016 Update: The Medical Director involvement to a future board meeting. was undertaking mapping of local service 01/09/2016 user groups, she would bring a report on TB(16-17)5A service user involvement to the 1 December Board meeting. Action: Medical Director
6
33 07/07/2016 Financial Position from NHS CEO TB(16-17)4A Improvement (Mins 106.1) Oct 16 106.1 Work was under way with SLAM and 01/09/2016 Update: A report on Oxleas to identify opportunities for collaboration on potential sharing of collaboration to secure efficiencies services with Oxleas and South London across all three providers in response and Maudsley Trusts would be brought to to a request from NHS Improvement. the Board’s 6 October meeting. There is The Trust was working on its own a paper on Part B of the Board’s October efficiency plans, including a Corporate Agenda. Action: Chief Executive Services Review (CSR) over several 01/09/2016 stages. It was agreed that an update The Board is recommended to close this item. TB(16-17)5A would be presented to the Board in the next Chief executive’s Report.
01/09/16 Update – Summary Savings
DEEP Dive – Audit Committee Int DoF Report on September Board Agenda. 34 105.28 07/07/2016 September 2016 Report on Delivery Further details will be provided to TB(16-17)4A of Projects including Ownership, Audit Committee Assurance and Governance to hold to account including Wider cultural 01/09/2016 Update: The Audit Processes and SIRO with a Diagnostic Committee would be undertaking a deep 01/09/2016 Section to explain drivers. dive on project management and the TB(16-17)5A delivery of CIPs at its meeting on 12 September. Action: Interim Director of Finance
06/10/2016 These deep dives were undertaken and will be reported under the Audit Committee item on this Agenda. The Board is recommended to close this specific item in the Actions Log.
7
Shadow Governors Head of 35 Comms 07/07/2016 107.2 & S E 01/09/2016 Update: The Chair confirmed TB(16-17)4A The Chair confirmed that our Shadow that he would continue to work with the Governors wish to continue and that Shadow Council of Governors on their 01/09/2016 he would be working with them to programme of activity. Action: Head of TB(16-17)5A develop their programme of activity for Communications and Stakeholder the coming year. Engagement.
A programme of meetings has been arranged. The Board is recommended to close this item.
Service User Story TB(16-17) 54 36 07/07/2016 108.5 Neurodevelopmental Assessment COO TB(16-17)4A Team (part of CAMHS)
The Chief Operating Officer said that QSAC had discussed the difficulties in 01/09/2016 Update: The Chief Operating Officer was delivering the service. A meeting with commissioners was due to take place continuing to monitor delivery of the 01/09/2016 on 21 July and it was hoped to make service and risk in the referrals backlog. Action: Chief Operating Officer TB(16-17)5A progress on how best to meet demand. New referrals were being 6.10.16 Update: seen in time but the backlog still had to be worked through. COO recognised A Paper went to the CCGs – being that it was important to check for considered and NHS England is now increased risk in referrals, due to advising CCGs on the next steps. changed circumstances.
8
Service User Story TB(16-17) 54 37 COO 07/07/2016 Neurodevelopmental Assessment 01/09/2016 Update: QSAC would continue to monitor TB(16-17)4A Team (part of CAMHS) progress on achieving improvement of The Chair said that it was clear that communications with commissioners, improved communications with being clear about risk-sharing which Commissioners were necessary, being anticipated demand, reporting back to the clear about risk sharing which Board. Action: Chief Operating Officer 01/09/2016 anticipated demand. TB(16-17)5A QSAC would monitor progress, A Paper went to the CCGs – being reporting back to the Board. considered and NHS England is now advising CCGs on the next steps.
Quality and Performance Report 01/09/2016 Update: 39 07/07/2016 108.7 TB(16-17) 55 Head of TB(16-17)4A Comms The Board looked forward to proposals It was agreed to arrange a Board to & S E for a meeting with Kingston CCG to Board with Kingston CCG to discuss a discuss the absence of commissioning number of issues including the for personality disorder service. 01/09/2016 absence of commissioning for a TB(16-17)5A personality disorder service. Head of Communications and Stakeholder Engagement to update at 6.10.16 meeting.
Mortality Report TB(16-17) 57 40 07/07/2016 111.2 01/09/2016 Update: TB(16-17)4A The Chair said that the Board had QSAC was due to receive the annual been assured in relation to mortality MD Oct 16 Report on Mortality at its October processes. meeting. Action: Medical Director 01/09/2016 QSAC was due to receive the Annual TB(16-17)5A Report on Mortality at its October QSAC is due to receive a report on meeting. Mortality at its 4 Oct 2016 meeting. The Board is recommended to close this item.
9
Medical Education Annual Report 41 07/07/2016 113.2 TB(16-17) 59 Dir of TB(16-17)4A Strat & Director of Strategy & Commercial Com Dev Oct 16 01/09/2016 Update: Development highlighted changes in Changes at St George’s Medical School St George’s NHS Trust which may were to be recorded as a risk on the 01/09/2016 impact on its Medical School and this Trust’s risk register. TB(16-17)5A would be registered as a risk on the Action: Director of Strategy and Board Assurance Framework. Commercial Development
The risk has been reviewed. The Board is recommended to close this item.
Finance Report TB(16-17) 62 44 07/07/2016 116.4 01/09/16 Update – as at 25/8 NHSE had
TB(16-17)4A In response to a question from Mr not confirmed the Trust’s CRL and EFL Thompson about the additional income received from the Department of Int DoF Sept 16 An update will be pr ovided at the Board Health 2015/16, in return for the Trust meeting. The Interim Director of Finance
giving up an equivalent amount of would advise to the Board whether income given up by the Trust to the Capital, the interim Director of Finance said that he expected that funding to Department of Health would come back come back via the Trust’s External to the Trust via its External Financing Financing Limit (EFL) and he would be Limit. confirming this. 01/09/2016 Action: Interim Director of Finance to TB(16-17)5A report at the 6.10.16 meeting
10
46 07/07/2016 TB(16-17)4A 116.5 Report TB(16-17) 62 The Chair also asked for a report on the The Chair also asked for a report on Trust’s key action plans over the past 2 the Trust’s key action plans over the years: past 2 years:
• Previous CQC reports to DoNQ&S Sept 16 September Board. 6.10.16 updates:
• Previous CQC reports have has
now been reported to QSAC.
The Board is recommended to
close this item.
• An updated review of the CEO Sept 16 action plans arising from the • Trust’s FT process including FT Action Plans will be
the Board Governance Will be reported as part of the
Assurance Framework (BGAF); FT Programme to a later meeting, beginning with the 3 Quality Governance Assurance November 2016 meeting. Framework (QGAF); and HDD1 and 2 to September Action: CEO
Board.
116.5 01/09/2016 • Quality Improvement Plan • The Quality Improvement Plan is TB(16-17)5A DoNQ&S Sept 16 reported through the Quality and Performance Report and in detail to QSAC. The Board is
recommended to close this item. •
11
Quarterly Reports to EMC/QSAC. Urgent Care Pathway – from 47 07/07/2016 118.2 Planning to Implementation TB(16- 01/09/16 Update TB(16-17)4A 17) 64 COO The Board asked that quarterly reports on the acute care pathway be made to The Board asked that quarterly reports EMC and QSAC. on the acute care pathway be made to Action: Chief Operating Officer: 01/09/2016 EMC and QSAC. Quarterly report to EMC and QSAC. TB(16-17)5A 106.1 The COO confirms that these reports are being made quarterly to QSAC and EMC.
48 Quality and Performance Report 01/09/2016 140.1 TB(16-17) 76 TB(16-17)5A Community Services COO/ Progress Report due to QSAC and There was an increased need for DoNQ&S then to 3 November Board meeting. Nov 2016 efficiencies. Independent review by 6.10.16 Update: Mental Health Strategies of demand and capacity in adult services had An update on the summary showed that more capacity was Community Improvement Plan is needed in community services. The included in this month’s Quality & Director of Nursing and Quality Performance Report. A full report has Standards and the Chief Operating been commissioned by the DoNQS Officer confirmed that there was an into the quality of our community action plan to strengthen community services through examining key services by the end of the financial quality indicators and will be reported year including clinical standards and through QSAC to the Board. staffing. Staff supervision standards and practice had been refreshed, including supporting staff in reporting
any concerns.
12
Quality and Performance Report
TB(16-17) 76 DoNQ&S 49 01/09/2016 140.1 Nov 2016 Progress to be reported to 3 TB(16-17)5A Staff Supervision November 2016 Board meeting. Plans were under way ensure that at least 85% of staff had up-to-date six- 6.10.16 Update: weekly supervision sessions with their line managers and that there were An update is in this month’s Quality & suitable spans of control, Performance Report. At 26.9.16, the demonstrated by having organograms Trust had achieved its target in place. She acknowledged the performance of 85% of supervision support and commitment of Staff-Side. sessions carried out. Monthly Progress would be reported to the monitoring will be through the Q&P R. Board. The Board is recommended to close this item.
Finance Report Month 4 (July) 142.2 50 01/09/2016 TB(16-17) 78 TB(16-17)5A The Chair said that he wanted the DoF Oct 2016 6.10.16 Update: Audit Committee to establish why we were in such an adverse financial See reports on the 6.10.16 Board position at Month 4 (July). The Board agenda. needed, by its 6 October meeting, evidence of improved control over agency staff spend and any impact on quality resulting from that, and advice on what activity the Trust could not do as a result. The Risk Register should be amended in respect of the financial position.
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51 01/09/2016 148.21 Opportunities for Members of the TB(16-17)5A Public to hold the Board to Account 6.10.16 Update: The Director of Nursing and Quality DoNQ&S Standards said that she would look All new job descriptions have this as into why in Trust person specifications, desirable and this is built into personal experience of mental health - templates. desirable- had been removed. The Board is recommended to close The Chair emphasised that the Trust this item. fully supported and encouraged those who had suffered mental ill-health into jobs - and the Desirable characteristic should be retained.
14
Chief Executive Report
TB(16-17) 91
Document Information
Date: 28 September 2016 Status: Final Report Current Version: 1.0 Transparency level: Public
Author: David Bradley Chief Executive Owner: David Bradley Chief Executive Commissioned by:
File location:
Chief Executive Report
1 Part A Board Meeting, 6 October 2016
Reconfiguration of Local CCGs and Management Arrangements
As part of the changes brought about by the STP, our local CCGs have agreed to propose to the six SWL CCG Governing Bodies and to NHS England that from April 2018, five CCGs (Kingston, Merton, Richmond, Sutton and Wandsworth) will work collectively under one Accountable Officer alongside Croydon CCG. This proposed model will be presented shortly to all six SWL Governing Bodies for final ratification. This does not reduce the number of CCGs, but entails a change to the leadership model. The proposed operating model will be subject to the approval of NHS England.
There will be a staged approach, with the high level timetable as follows:
For the remainder of 2016/17 - The current operating arrangements within the six CCGs will remain in place throughout the remainder of this financial year.
2017/18 - From April 2017, an interim model will operate made up of three groupings of CCGs:
• Croydon (retaining Chief Accountable Officer) • Kingston, Merton, Richmond, Wandsworth (one Accountable Officer for all 4) • Sutton (retaining Chief Accountable Officer)
2018/19 - From April 2018, the operating model will fully apply, consisting of two CCG groupings:
• Croydon • Kingston, Merton, Richmond, Sutton, Wandsworth.
There will be a phased approach to setting up this new model due to some specific local work. In Sutton there are a range of significant discussions taking place or planned between commissioners and providers. These discussions/ negotiations are vital for local delivery and will contribute to the delivery of the SWL STP, therefore it was agreed that these should progress as planned, with Sutton joining to make five CCGs from April 2018.
Croydon will retain separate management accountability and local delivery arrangements from the other SWL CCGs both in the transition year of 2017/18 and the operating model going forward from 2018/19, due to the OBC health and social care integration programme within the local Croydon economy.
NHS Improvement Single Oversight Framework
On 13th September NHS Improvement published their revised Single Oversight Framework, following a period of consultation, with the aim to bring about a more joined-up approach and improved partnership working between national bodies. This consolidated approach will be introduced from 1st October and, from that point, the Monitor ‘Risk Assessment Framework‘ and TDA ‘Accountability Framework‘ will no longer apply.
2 The framework will enable NHS Improvement to identify the support providers need across five themes:
- Quality of care - Finance and use of resources - Operational Performance - Strategic Change - Leadership and improvement capability
The document is provided for further discussion in item 8.4. I will be meeting with the acting Delivery and Improvement Director for South London from NHSI in the coming weeks to discuss how the framework will be applied locally.
Meeting with Kingston Hospital Executive
Last week the Chief Operating Officer, Dorector of Nursing and I met with our counterparts at Kingston Hospital to discuss how we work together and address some of the joint difficulties we are facing.
This was a productive meeting at which we were able to highlight some of the positive developments to date, including closer working between liaison Psychiatrists and A&E leads, and the forthcoming Psychiatric Decision Unit.
At the meeting we agreed the need for a focus on CAMHS services, particularly tier 4, in the STP proposals, and discussed the opportunities and challenges relating to Queen Mary’s Hospital in Roehampton. We have therefore agreed to hold a Queen Mary’s Hospital summit in the next few months in order that, along with CCG partners, we can discuss and agree what part this plays in the STP proposals.
Wandsworth IAPT Tender
On 28th September, a team from the Trust including Ian Petch (Director of Psychology & Psychotherapy), Hendrik Hinrichsen (Lead Clinical Psychologist), and myself presented to Wandsworth CCG our lead bid for provision of ‘Talk Wandsworth’, a remodeled talking therapies service for the borough for adults with common mental health problems.
The proposed model will provide wider choice and greater accessibility for patients, delivering service in non-stigmatising settings, with an access target of 15%, and recovery target of 50%. The critical changes to the previous service include a new, ‘stepped’ clinical model with greater digital provision, and a revised skill mix with community partners and subcontractors providing some aspects of the service. Using subcontractors will allow a reduction in costs. These subcontractors include The Awareness Centre to provide counselling, SilverCloud and Ieso providing digital services. There will be a range of community partners including Wandsworth Community Empowerment Network, YMCA, Family Action and Citizens Advice Wandsworth.
We expect to hear within ten days whether we have been successful in our bid.
3 Employee of the Month
August’s employee of the month was Liam Ford, Principal Information Analyst in the Performance and Information tea.
The Trust had a need to develop an electronic system to enable managers and supervisors to record supervision with staff. This improved managerial supervision was a must-do from the CIH inspection. Off-the-shelf IT solutions were considered, but instead, Liam has developed a bespoke system to allow the Trust to record and monitor supervision sessions and pulled out all the stops to make this a success
Feedback from managers, supervisors and staff has been very positive: the system is user-friendly and captures the essential elements of the supervision sessions, with both the manager/supervisor and staff member receiving an automated email once the supervision record has been submitted.
Liam has been responsive to comments and suggestions and developed a system that is truly fit for purpose, and we are grateful for his hard work that deserves to be recognised.
David Bradley Chief Executive September 2016
4
Trust Board Meeting
6 October 2016 Paper Reference: TB(16-17) 92 Report Title: Corporate Objectives: Key Priorities
Executive Summary: The Chairman has identified six of the corporate objectives as being high priority and requested a more detailed plan for delivery including milestones for reporting to Trust Board. This information is provided in the Board cover sheet and supporting paper.
Action Required: Trust Board is asked to note the detailed delivery plans provided for the priority objectives; and confirm if they require monthly reporting of these.
Link to Strategic Objectives: Links to all strategic objectives
Risks: Links to all BAF risks
Quality Impact: None identified
Resource Implications: N/A Legal/Regulatory Implications: N/A
Equalities Impact: None identified Groups Consulted: Executive Management Committee
Author: Suzanne Marsello, Director of Strategy and Commercial Development
Owner: Suzanne Marsello, Director of Strategy and Commercial Development
Summary During the Part B September Board meeting, there was a discussion regarding the corporate objectives, and their continued importance as the prime driver of the organisations business, and therefore as priorities for delivery by each director and their teams.
Page 1 of 2 As a result of this, seven of the objectives were identified as being the highest risk for the organisation, and the Chairman requested that more detailed milestones and timescales are provided for these, to reflect the significance of them.
These six corporate objectives are:
• Delivery of the Quality Innovation and Improvement Programme: Medical Director and COO • Delivery of CIP Programme: Director of Finance and Performance • Bed capacity plans (and in particular): COO o Demand reduction plans o Crisis management in the community o Increasing efficiency o Improving discharge rates (length of stay reduction) o Recovery rates • Estates Modernisation Programme: Director of Finance and Performance • Recruitment and retention (including agency rates): Director of HR • Reputation and stakeholder management: Head of Communications
The detailed delivery plan with milestones is provided in the supporting paper, where this information is available.
It is proposed that the Trust Board continues to receive a quarterly update on progress with all corporate objectives; but for the six priority areas, that there is a monthly progress update provided to give Board assurance that progress is being made in line with agreed timescales.
Action for Trust Board: Trust Board is asked to note the detailed delivery plans provided for the priority objectives; and confirm if they require monthly reporting of these.
Page 2 of 2
Making Life Better Together
Corporate Objectives 2016-17
This document sets out the proposed corporate priorities, and key actions and milestones that the Trust will take to ensure these are delivered during 2016-17.
Strategic Objectives:
1. Improve quality and value 2. Improve partnerships 3. Improve co-production 4. Improve recovery 5. Improve innovation 6. Improve leadership and talent
We will provide innovative, high quality, personalised services that support people to manage their own health and wellbeing
The priority objectives that the Board will oversee delivery of are linked to the agreed strategic objectives for the organisation. There will be quarterly reporting of progress against delivery to the Trust Board. The corporate objectives are not intended to represent all priorities that the organisation will address in 2016-17
1 of 16 Strategic Objective 1: Improve quality and value We will provide consistent, high quality, safe services that represent value for money In 2016-17 our core business remains the provision of modern high quality community, inpatient and specialist services delivered in state-of- the-art clinical settings at all our sites.
QUALITY
Ref 1.7a Date to Complete Executive Lead Key Deliverables: COO Deliver the agreed service development priorities for 2016-17: Open the Psychiatric Decision Unit (PDU) for south west London
Milestones Q1:
Develop sector-wide Engagement Programme. Establish a PDU Project Group. Q1 16/17
Milestones Q2:
Engagement Programme to include wider stakeholders, Met Police, LAS, AMHP leads. Provide Q2 16/17 project plan, Operational Policy and Service Specification. Recruit staff.
Milestones Q3: Nov 16 Mobilisation of PDU by end of November
Milestones Q4:
Evaluate 4 month effectiveness and develop year 2 CQUIN with commissioners. Q4 16/17
Measure of Success:
Quarterly report to EMC, Transformation Board and CQRG.
2 of 16 Ref 1.7b Date to Complete Executive Lead Key Deliverables: COO Deliver the agreed service development priorities for 2016-17: Open two crisis/recovery cafes in south west London
Milestones Q1:
Establish a Crisis Recovery Café Project Group. Q1 16/17 Hold a Market Warming Event. Milestones Q2: Q2 16/17 Go to Tender and complete a formal procurement process for two Crisis Recovery Cafes. Milestones Q3: Q3 16/17 Successful tender, providers identified and sub-contract agreed. Milestones Q4: March 17 Mobilise Recovery Cafes by end of March. Provide and submit year-end progress report. Measure of Success:
Quarterly report to EMC, Transformation Board and CQRG. Ref 1.7c Date to Complete Executive Lead Key Deliverables: COO Deliver the agreed service development priorities for 2016-2017: Open a crisis/recovery house for Wandsworth, Sutton and Merton
Milestones Q1:
Potential for Crisis Recovery House to be progressed to be confirmed by Trust Board Milestones Q2:
Support or not from CCGs to be established. Milestones Q3: 3 of 16
N/A Milestones Q4:
N/A Measure of Success:
Decision taken at September F&I not to progress further at this stage. Ref 1.7d Date to Complete Executive Lead Key Deliverables: COO Deliver the agreed service development priorities for 2016-17: Create an enhanced street triage service 24/7
Milestones Q1: Q1 16/17 Submit full Implementation plan. Implement Street Triage to an enhanced level Milestones Q2:
Mobilisation of sector-wide integrated out of hours service incorporating Crisis Assessment, Street Q2 16/17 Triage, Medical Rotas, Liaison Psychiatry. Milestones Q3:
Provision of monitoring and reporting of performance/outcomes focused on Integrated Out of Hours Q3 16/17 services Milestones Q4:
Produce and submit a year-end progress report comparing 2015/16 to 2016/17. Q4 16/17 Measure of Success:
Quarterly report to EMC, Transformation Board and CQRG. Ref 1.7e Date to Complete Executive Lead Key Deliverables: COO Deliver the agreed service development priorities for 2016-17:
4 of 16 Implement the output of the Acute Care Pathway Lean project through the Purposeful Admissions Project
Milestones Q1:
Acute Care Pathway Lean Project output to be shared with Executive Directors Q1 16/17 Milestones Q2:
Purposeful Admissions Project Group to be established. Q2 16/17 Acute Inpatient Dashboard to be agreed with Inpatient and HTT Consultants. Milestones Q3:
Unified Gatekeeping tool and pathways into PDU to be agreed. Q3 16/17 Engagement workshops with staff to be held. Visit to Bradford re Discharge Coordinator 7-day working. Milestones Q4:
Enhanced Discharge Coordinator role to be agreed. Q4 16/17 Standardised systems for EDD and discharge planning. Evidenced reduction in bed occupancy. Measure of Success:
Quarterly report to EMC. Ref 1.7f Date to Complete Executive Lead Key Deliverables: COO Deliver the agreed service development priorities for 2016-17: Additional Acute ward Ellis to open on approx. one-year basis to mitigate out of area bed use whilst service developments above are implemented.
Milestones Q1:
Ellis ward to open mid-April. Completed
Milestones Q2:
N/A
5 of 16 Milestones Q3:
N/A Milestones Q4:
N/A Measure of Success:
Achieved
VALUE
Ref 1.12 Date to Complete Executive Lead Key Deliverables: DoFP Make progress with the Estates Modernisation Plan
Milestones Q1:
Promissory note issued by DH approving the OBC. Completed Procurement of the master developer begins. Milestones Q2:
Milestones Q3:
Longlist of six bidders appointed on 12 September 2016 to continue within the procurement. Completed
Milestones Q4: Shortlist of three bidders appointed to continue within the procurement on 9 January 2017.
Steps to deliver include: • regular dialogue meetings with each of the longlisted bidders; • Evaluation of bids in Nov and Dec 16 and; Dec 16 • Evaluation of presentation to the Trust of proposals in Nov 16. Nov 16 Q2 2017/18
6 of 16 Preferred Bidder appointed to proceed to financial close July 2017.
Steps to deliver include: • regular dialogue meetings with each of the shortlisted bidders; and • Evaluation of bids in June 17. July 17 Measure of Success: • Longlist of bidders appointed by Q3 16/17 • Shortlist of bidders appointed by Q4 16/17 • Preferred Bidder appointed by Q2 17/18
Ref 1.13 Date to Complete Executive Lead Key Deliverables: DoFP Community estates strategy – co-location of clinical staff with GP surgeries/ in community premises
Milestones Q1:
Letter of comfort received from Richmond Planners on both the Barnes and Richmond schemes Completed
Milestones Q2:
Continued marketing of both Richmond Royal and Barnes.
N.B. This has been delayed due to Brexit and need to finalise planning position for both Richmond and Barnes sites.
Milestones Q3:
Barnes closed and staff moved to Garden House Building. Q3 16/17
SWLTSG Richmond Royal footprint reduced to 500m2. Q3 16/17
Steps to deliver this include: • Meeting with Non-Exec to establish commercial position to be adopted with the planning team at Richmond; • Sites to be marketed as community use and residential use at both Richmond Royal and
7 of 16 Barnes and; • Staff at Richmond Royal and Barnes to be presented to around the proposals
Milestones Q4:
Planning applications submitted for the redevelopment of both the Richmond Royal and Barnes sites.
Preferred developer appointed for both Richmond Royal and Barnes sites.
Steps to deliver this include: • Planning applications to be discussed with the planning team at Richmond for both sites and; • Marketing exercise for both sites to have been completed and bidders’ evaluated for each of Q4 16/17 the sites.
Re space utilisation. Steps to deliver this include: • Plans to be submitted to EMC for approval; and • All GP Federation Leads to be met to understand available space for our services.
Steps to deliver this include: • regular dialogue meetings with each of the longlisted bidders; • Evaluation of bids in Nov and Dec 16 and; • Evaluation of presentation to the Trust of proposals in Nov 16.
Measure of Success:
• Closure of main Barnes Hospital building and relocation of staff to alternative accommodation by Q3 16/17; • Reduction in areas used at Richmond Royal from approx. 2000m2 to 500m2 by Q3 16/17; • Space rationalisation programme to be implemented for Springfield by Q4 16/17.
NB: Targets and delivery reliant on separate space rationalisation programme led by Clinical Efficiency Board (CEB)
Ref 1.14 Date to Complete Executive Lead Key Deliverables:
8 of 16 DoFP Minimise agency spend requirements and meet TDA / NHSI requirements
Milestones Q1: Plans developed to: • Improve Retention On-going • Reduce Recruitment Lead Time On-going • Control Agency fees Agency Control Panel Monthly reports re. agency usage presented to EMC established Sept 16
Milestones Q2: New initiatives introduced in Sept 16 to All plans Implemented and agency usage minimised encourage agency staff to:- • Join Permanent Staff or • Work via Bank Milestones Q3:
All plans Implemented and agency usage minimised
Milestones Q4:
All plans Implemented and agency usage minimised
Measure of Success:
Agency Controls Established and Operating. Regular Board reviews of agency usage and effectiveness of controls
9 of 16 Strategic Objective 2: Improve partnerships We will continue to develop strong partnerships to create and develop accessible and responsive services In 2016-17 we will become more sophisticated in our customer relationship management and key account management.
Ref 2.5 Date to Complete Executive Lead Key Deliverables: Head of Stakeholder engagement and reputation management: priority area – commissioners. To have Comms developed a situational model of stakeholder management and activity to track reputation
Milestones Q1: To develop stakeholder engagement toolkit based on output from Henley Reputation Leadership May 2017 event
Align executive leads to boroughs Complete Milestones Q2: Workshops held with all service and clinical directors to develop situational model September 2017
Scope internal CRM requirements and produce guidance August 2017
Milestones Q3: Pilot internal CRM system, refine guidance and ensure the sharing of stakeholder intelligence is November 2017 included on expanded EMC agenda.
Milestones Q4: Refine CRM from pilot findings. January 2017
Rollout CRM with training for each service directorate. February 2017
Stakeholder intelligence shared weekly at EMC and monthly at expanded EMC. March 2017
Measure of Success:
Each borough management will have a detailed stakeholder map and programme of engagement.
10 of 16
Strategic Objective 5: Improve innovation We will lead the way in providing health and social care services In 2016-17 the organisation will be increasingly recognised for innovative services and related research and thought leadership, building on the recent research grant success.
Ref 5.3 Date to Complete Executive Lead Key Deliverables: COO/ Implement Transformation by Continuous Improvement and Transformation by Complete Redesign Medical across the organisation Director
Milestones Q1: The Business case has Agree specification for Quality Improvement Programme for Training & Outcomes been completed and is coming to Board October 2016
Milestones Q2: The training of senior leaders will commence Commence training of senior leaders quality improvement/lean methodology with the implementation of SLM in Jan 2017 with a 2 year programme Milestones Q3:
Evaluate training March 2017 Milestones Q4: April 2017 Roll out training across the organisation Measure of Success:
All Senior Leaders in Trust training in Quality Improvement Methodology
11 of 16 Strategic Objective 6: Improve leadership and talent We will nurture the very best people at all levels of our Trust In 2016-17 we will engage our workforce in the development of a care and service culture that is based on quality, patient safety, and strong operational performance and financial sustainability.
Ref 6.6 Date to Complete Executive Lead Key Deliverables: Director of Develop a staff bank facility across SWL in partnership with other providers HR and OD
Milestones Q1: Approval of Business Case Complete
Milestones Q2:
Milestones Q3: Procure technology/service: • Specification document completed December 16 • Procurement of Technology on-going • Decide on Provider
Milestones Q4: Implement SWL regional bank: • Align rosters across region March 17 • Align all rostering policies • Standardise bank recruitment policies across region
Monitor success Q1 2017/18 April 17 Measure of Success:
Reduction in number of agency workers by 5%
12 of 16 Ref 6.7 Date to Complete Executive Lead Key Deliverables: Director of Develop and implement a recruitment and retention plan to include annual priorities for hard to HR and OD recruit to areas.
Milestones Q1: Complete: Recruitment Obtain EMC approval for recruitment and retention strategy and Retention plans signed off by EMC and Board
Milestones Q2:
Milestones Q3:
Cost recruitment and retention plan and obtain sign off from EMC for implementation
Implement recruitment campaigns for; December 16 • Nurses - completed and new campaign to commence for Community Team Managers • OTs – to commence • Psychologists/Psychotherapists
Launch Trust recognition programme December 16
Launch coaching and mentoring programme for all staff groups:
• Build awareness of programme November 16 • Identify candidates • Identify coaches/ mentors • Train coaches/mentors December 16
Decide on harmonisation of High Cost Allowance: December 16 • Conduct financial modelling Milestones Q4:
13 of 16 Launch coaching and mentoring programme for all staff groups: • Launch Programme January 17
Decide on harmonisation of High Cost Allowance: • Present paper to Operational Leadership Group, Terms and Conditions Group and EMC if there January 17 is support • Obtain sign off from Workforce and OD Committee March 17
Measure of Success:
Reduction in agency spend as % of pay bill
Reduction in number of leavers within 1 year
Increase in fill rate
14 of 16 Trust Objective: Deliver Operational and Financial Performance
Ref 7.3 Date to Complete Executive Lead Key Deliverables: DoFP Deliver CIP plans recurrently
Milestones Q1: Plans identified to date Development of plans to deliver £12.1m with effect from 1/10/16 completed totalling £10.8m
Further work undertaken re:- • Reducing agency Spend • Reducing Asset Values and Capital Charges • Corporate Services / Back Office Functions Milestones Q2: • All proposed plans Proposed plans assessed, approved and implementation started:- have been • Internal Assessment by QIA assessed by QIA • Externally by CQRG • Monthly reports to • Approved by Board FIC & Board re- Plans • Introduction of Qii Board to provide robust governance of project delivery for Board Milestones Q3: • Plans totalling
15 of 16 Plans fully implemented and assessed via PMO structure £12.1m be finalised by 31/10 • All directorates to be held accountable at DPRs & SROs at Qii Board – Sept 16 • Review of PMO function to improve project delivery – Oct 16 • Development of Project Leadership and Project Mgt Skills – Nov / Dec 16
Milestones Q4:
Ideas for additional 3 year plans for 2018/19 – 2020/21 developed • Delivery of identified projects – Mar 17 • Implementation of Qii Academy to ensure clinical & corporate services have maximised effectiveness and efficiency – Jan 17+ Measure of Success:
CIPs delivered recurrently
All plans subject to QIA & CQRG assessment
16 of 16
Trust Board Meeting
6 October 2016
Report title: BOARD ASSURANCE FRAMEWORK TB(16-17) 93 Executive lead: Vanessa Ford Executive Director of Nursing and Quality
Report author: Peter Hughes Interim Head of Risk
Report discussed Audit Committee (6 September 2016) / previously at: QSAC( 4 October 2016)
Purpose and action required:
This report presents the revised Board Assurance Framework following For approval y review by the Audit committee.
The Board Assurance Framework is presented to highlight the key risks to the Trust achieving its objectives, reflecting the Trusts risk management For discussion processes to identify risks.
To note
Key summary: (Please add bullet points drawing main area attention linked to the 5 domains – safe, effective, caring, responsive and well-led) There are three risks identified at red (high) risk score. The risk in relation to bed management has been reduced to a risk score of 12 (Amber). The report identifies the current risk profile from the risk register and a copy of the corporate risk register. The BAF identifies 6 core risks in relation to: 1 A failure to ensure regulatory compliance caused by inadequate review and monitoring processes resulting in regulatory action by the CQC and reputational damage. 2 A failure to provide consistent and responsive community services caused by an increase in demand, leadership vacancies and dependence on agency use resulting in not enabling recovery, escalation to crisis care and poor service user experience. 3 The Trust is unable to attract, recruit and retain high quality staff to meet the needs of changing services which will impact on the quality of care and a continued dependency on the need for temporary staffing impacting on the quality of care delivered and financial costs to the organisation. 4 Failure to modernise the estate may detrimentally impact on quality and safety of service. The scheme may not be affordable within the construction period. (Estates Modernisation Project)
Page 1 of 8 5 Bed Pressures: A failure to manage the significant presure on beds caused by high demand / occupancy and a reliance on out of area placements resulting in significant impact on the quality of patient care. 6 A failure to achieve recurrent saving plans resulting in not meeting financial targets In addition the risk relating to: A failure to effectively build trust with key stakeholders caused by the introduction of SLM resulting in poor relationship management and reputational harm. Is also identified although this has been assessed at risk score 9.
Relationship to board assurance framework (risks) and/or Directorate Risk register? Are any existing risks in the board assurance Contained within report. framework or directorate risk register affected? If yes, insert relevant risk reference:
Do you recommend a new entry to the board Not applicable. assurance framework (i.e. Trust-wide level 1 risk) is
made? Relationship to Trust strategic objectives and our values of openness, respect, compassion, fairness and collaboration? 1. Improve Quality We will provide consistent, high quality, safe services that represent X and value value for money. 2. Improve We will develop stronger external partnerships and business Partnerships opportunities that improve access, responsiveness and service range. 3. Improve We will have reciprocal relationships which value service users, Co-Production carers, staff and the community as co-producers of services. 4. Improve Recovery We will enable increased hope, control and opportunity for our service users. 5. Improve We will become a leading innovative provider of health and social Innovation care services. 6: Improve ‘We will develop leadership and talent throughout the organisation. X
Leadership and talent Acronyms / terms used in the report CQC Care Quality Commission BAF Board Assurance Framework
Supporting documents and/or further reading
Page 2 of 8 BOARD ASSURANCE FRAMEWORK (BAF) REPORT. Introduction This report presents the revised Board Assurance Framework (BAF) which has been reviewed by the Audit committee in September. The report includes the updated Corporate Strategic Risk register to provide overall assurance of risks which are reflected in the BAF. The BAF was last presented to the Audit committee / Trust Board in May.
Background The Trust has previously accepted the following principles for the development of the risk register and BAF: • A defined risk management process established which is accessible to and utilised by front line teams alongside a strong audit trail to show the Boards efforts to keep these arrangements under regular review. • Evidence that risk assessments are captured and recorded in Ulysses (Electronic Risk Management System) • Evidence of discussion, debate and challenge of the outputs of the risk management system at DPR and EMC meetings. Further work was highlighted in the last report • To develop greater input into the risk register from front line teams, ensuring that there is an effective and understood process for staff to be able to raise concerns within teams and these can be demonstrated to be escalated to team or Directorate level risk registers. • To ensure that risks in component risk registers are reviewed and informed by relevant committees / sub committees and systems are developed to support this. • Develop a clearer understanding of risk thresholds at local level to challenge risk ‘blind spots’.
Progress This version of the Board Assurance Framework is the first to reflect risks reviewed against the Trusts Business Plan for 2016 / 17. Reviews have been held with all Directors to identify any risks arising from their corporate objectives and where identified these have been included in the risk register. As reported separately to Trust Board, over the past three months all recommendations from the CQC inspection in March have been translated to risks on the risk register with appropriate actions for improvement. These are being actively monitored and reviewed as part of the CQC action governance process. This approach has further reinforced the use of the risk register by managers and teams and a range of support and additional training has been provided to teams for this purpose. The Trust Board Assurance Framework has been slightly modified for reporting this year. Top Risks There are three new risks which are identified at red score, one risk (bed Pressures previously identified at red has been reviewed and the risk amended to risk score 12 (Amber) The red risks highlighted are: Score ID Risk Description: 15 966 A failure to ensure regulatory compliance caused by inadequate review and monitoring processes resulting in regulatory action by the CQC and reputational
Page 3 of 8 damage
Risk Score Rationale: Risk Criteria Score Rationale: (Risk Management Policy) Risk 5: Expected to occur The Trusts has been issued with a five regulatory Likelihood notices arising from the recent CIH inspection. These issues were not all identified prior to the assessment through Trust processes. Risk 3: Moderate loss of The CQC process allows for regulatory actions to Severity confidence National Media < be appropriately addressed and there are no 3 days financial penalties unless requirements are issued.
There are a range of actions identified in the risk register arising from the CQC inspection reports, however this risk also focuses on ensuring that the Trust has appropriate assurance arrangements to maintain compliance which will be undertaken through the relevant Governance processes.
Score ID Risk Description: 16 1024 A failure to provide consistent and responsive community services caused by an increase in demand, leadership vacancies and dependence on agency use resulting in not enabling recovery, escalation to crisis care and poor service user experience. Trust Board has previously identified the need to include a specific HR risk relating to recruitment within community teams. Following review and reflecting on issues raised from the CQC inspection report this has been revised to be incorporated in the above.
Risk Score Rationale: Risk Criteria Score Rationale: (Risk Management Policy) Risk 4: ‘Likely - Probably will occur Evidence of shortfalls identified within the CQC Likelihood assessment. Risk 4: Non-compliance with national The CQC report highlighted a number of risks of Severity standards with significant risk to standards not being met. patients if unresolved
Score ID Risk Description: 16 1025 A failure to achieve recurrent saving plans resulting in not meeting financial targets
Following review the Trusts current financial risk in relation to meeting its savings target is identified as follows
Risk Score Rationale: Risk Criteria Score Rationale: (Risk Management Policy) Risk 4: ‘Likely - Probably will occur |Highlighted in the Trust Board financial paper Likelihood presented in August, Risk >600,000 - Savings gap is currently over £1,000,000 Severity 1% to 2% of Trust turnover
Page 4 of 8 Issue/proposal A summary profile of all risks included on the risk register (ie at all levels across the organisation) is set out in appendix 1. This information is presented to provide an overall assessment of risks currently identified. A copy of the corporate risk register (CRR) reflecting top risks to the organisation is set out in Appendix 2. The revised Board Assurance Framework reflecting the Corporate risk register is presented in Appendix 3. There are five key risks identified in the BAF which arise from the corporate risk register. The Estates Modernisation Project is subject to its own specific risk monitoring in line with Project Management arrangements. Four of these risks related to the Trust Strategic priority of Quality and one risk relating to Delivering operational and Financial Performance.
Conclusions The current risk profile highlights a focus on risks to Quality. Whilst the top category of Quality risks relate to risks arising from the CQC inspection the next highest categories relate to Patient Experience and Clinical Effectiveness.
Recommendation The committee is asked to review the adequacy of internal control to mitigate the Board’s strategic risks to the extent that the Board is satisfied it has prudent control, and in doing so consider and challenge the assurances outlined in the Board Assurance Framework. To review whether the BAF as presented adequately reflects the Board’s view of risks as identified within its work. Consider and review the progress made against the top risks which are identified and the reduction in risk scores highlighted. Advise the Executive on any other actions required to enhance internal control and assurance;
Appendices
1 Risk Profile report 2 Corporate Strategic risk register 3 Revised Board Assurance framework
Page 5 of 8 APPENDIX 1
RISK PROFILE REPORT Across all risk registers the risk profile (All active risks - 22/08/16) is currently as follows Corporate Directorate Risk Profile:
Pharmacy
Operations
Nursing and Governance
Medical Green
IM&T Yellow Amber Human Resources Red Finance
Estates & Facilities
Corproate
0 10 20 30 40 50
Operational Directorate Risk Profile:
Wandsworth
Sutton & Merton Green
Specialist Yellow Amber Kingston & Richmond Red
CAMHS
0 10 20 30 40 50 60 70 80
Key: Green Risk Score: 1 - 3 Yellow Risk Score: 4 - 6 Amber Risk Score: 8 - 12 Red Risk Score: 15 - 25 (Ref Risk Management Policy)
The levels of risks identified at Operational Directorate level are in general much higher than those identified at corporate / strategic level.
The overall risk profile in relation to core risk groups are set out below:
Page 6 of 8 Workforce Safety Reputation Green Quality Yellow Information Governan Amber Finance Red Business Continuity
0 20 40 60 80 100 120 140 160 180 200
The proportion of identified risks against Risk Group is reflected below:
Business Continuity Workforce Finance Information Governan
Safety
Reputation
Quality
Top risk categories (Risk categories identified in at least 10 risks)
Fire Safety Medicines Management Staff Training Unsafe Or Unsuitable Premises Green Technology Yellow Security Amber Contracts Red Clinical Effectiveness Patient Experience CQC
0 10 20 30 40 50 60
Page 7 of 8 CORPORATE RISK REGISTER
There are currently 30 risks identified on the corporate risk register (as attached) these are broken down as follows (changes from the December report are identified in Brackets if different to this month): BAF Director <12 >8 12 15 + Chief Operating Officer 1 1 2 Director of Finance (+4) 5 2 0 Director of HR and OD (-1) 1 2 0 Director of Nursing and Quality 4 4 1 Standards (+5) Medical Director (+5) 5 0 0 Strategic Development (+1) 1 1 0
It should be noted that changes in risk numbers from the last report may be a little misleading due to the addition of all CQC related actions. Some risks previously identified have been replaced by risks identified by the CQC and to avoid duplication the former risks have been closed.
Page 8 of 8 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
1024 Quality A failure to provide consistant and responsive community services Dawn Chamberlain 4 4 16 As per Recruitment Strategy (RISK ID 192) 30/12/2016 4 2 8 07/09/2016 caused by an increase in demand, leadership vacancies and dependance on temporary staff resulting in not enabling recovery, Establishment of CLinical Standards group. 30/09/2016 escalation to crisis care and poor service user experience. Commission review of Demand and Capacity for all 30/12/2016 community services. Develop team through Community Team away days 23/12/2016 Implementation of Service Line Management (DIstinct 31/03/2017 unified management stucture for COmmunity Services). Lead in contract negotiations to obtain additional 27/01/2017 support. 1025 Finance A failure to achieve recurrent saving plans resulting in not meeting Clive Field 4 4 16 Achieve savings from A&C review 31/03/2017 3 2 6 29/11/2016 financial targets Implementation CSR reviews and achievement of 31/03/2017 savings. Achieve savings from Community Modernisation 31/03/2017 review Savings plan actions - being undertaken a) ensure 31/08/2016 See Board report 1/9/16 no further slippage on existing schemes, b) mitigate, non recurrently the in year shortfall, and c) evaluate Date Entered : 31/08/2016 16:41 and further consider options available to the Trust to Entered By : Peter (Risk) Hughes address the recurrent shortfall, by EMC. 966 Quality A failure to ensure regulatory compliance caused by shortfalls in Vanessa Ford 3 5 15 Implement revised Quality Governance Structure 31/01/2017 3 2 6 07/09/2016 governance arrangements not adequately identifying weaknesses from CRS2. in compliance and risks resulting in regulatory notices. Review of Peer review and 15 step visits to develop 25/11/2016 Quality Assessment programme. Achieve improvement against current CQC action 30/09/2016 plan to achieve 'Good' from review in Spetember. Achieve Compliance against all regulatory notices (as 31/01/2017 per CQC actions on risk register). 758 Quality FOR1/ CMI2 A failure to ensure least restrictive care caused by Vanessa Ford 4 3 12 Review current seclusion policy to ensure it fully 07/10/2016 An up to date policy has been uploaded onto insite giving a clear 4 2 8 18/09/2016 staff not having a clear understanding of seclusion and inadequate meets code of practice requirements. POlicy to be structure for Nurses and Doctors to manage seclusion. There is safeguards in place resulting in harm to service users which is ratified with full implementation plan and quick further work needed on this policy to incorporate flow charts for non compliant with the code of practice. reference guide. other restrictive practices.
Date Entered : 26/08/2016 11:37 Entered By : Sharon Spain ------The seclusion policy has been amended and uploaded on insite. This policy needs to be continuously reviewed to reflect any new restrictive practices that arise from the ward managers and incident reporting.
Date Entered : 11/08/2016 08:31 Entered By : Peter (Risk) Hughes Establish least restrictive practice group, reporting to 07/09/2016 A board report has been completed and will be presented to QSAC IGG. September
Date Entered : 26/08/2016 11:39 Entered By : Sharon Spain ------Group established.
Date Entered : 07/06/2016 09:49 Entered By : Peter (Risk) Hughes Review the physical interventions training and 30/09/2016 PPI trainer will add restrictive training practice to the current PPI supervision programme to consider how this can be training. further enhanced to include restrictive practice Training session to Ward Managers to be disseminated to all ward reduction work.. staff.
Date Printed: 23/09/2016 17:10:02 Page 1 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
Date Entered : 10/06/2016 09:47 Entered By : Sharon Spain Operational Policies ammended to identify local 07/10/2016 Will be reviewed in line with the other restrictive practices that will be arrangements for compliance with seclusion policy added to the policy. and blanket restrictions. Date Entered : 26/08/2016 11:40 Entered By : Sharon Spain Staff training to reflect requirements of the policy. 30/09/2016 Training session for inpatient ward managers delivered 3/8/16 on restrictive practice and management of time out and seclusion
Date Entered : 11/08/2016 08:31 Entered By : Peter (Risk) Hughes All policies which have impact on restrictive practices 30/09/2016 Policies currently under review by the restriciive practice group to be reviewed by end Sept (NG Tube feedning, Rapid Tranquilisation, engagement and supportive Date Entered : 10/06/2016 09:49 observation) Entered By : Sharon Spain Brief guide on the clinical implications of restrictive 09/09/2016 Still in draft form. to be agreed by the restrictive practice group. practice and how to monitor and record seclusion. Issued. Date Entered : 26/08/2016 11:41 Entered By : Sharon Spain ------Flow charts are being developed in-line with the policy to give clear guidelines to the junior staff on the management of seclusion, timeout and other restrictive practices.
Date Entered : 11/08/2016 08:32 Entered By : Peter (Risk) Hughes Quarterly report of Least Restrictive Practice group to 31/08/2016 Restrictive practice paper being prepared for September QSAC / be presented to QSAC. Board.
Date Entered : 11/08/2016 08:33 Entered By : Peter (Risk) Hughes ------Report being prepared
Date Entered : 10/06/2016 09:50 Entered By : Sharon Spain Develop ward to Board KPI on restrictive practice. 29/07/2016 Seclusion exception report completed monthly with narrative on each seclusion - significant increase in the reporting of incidents of seclusion for the month of July which indicates the ward staff are much more aware of restrictive practices.
Date Entered : 11/08/2016 08:34 Entered By : Peter (Risk) Hughes ------Awwaiting feedback from 1st restrictive practice - will follow up with Deputy Director of Nursing
Date Entered : 29/07/2016 15:14 Entered By : Gwyn Davies Staff development plan to reflect requirements of New 28/10/2016 policies.
765 Quality ACT6 Failure to ensure that effective administrative processes Dawn Chamberlain 4 3 12 To review and feedback timescales of current project. 30/06/2016 Admin update provided to OLG on 4/7/16 and Qii on 4/7/16 4 1 4 18/09/2016 are in place resulting in patients not receive appointment details and information about their reviews in a timely manner. Date Entered : 21/07/2016 17:08 Entered By : Nicola Mladenovic Also OPC2 Standard admin protocol in place re timeliness of 29/07/2016 Letter priorities have been looked at and agreement made: letters for all teams (including all element of process end to end). Emergency - 24hrs Admin project group Urgent - 7 calendar days (baseline reviewed of present position) Standard - 14 calendar days Date Printed: 23/09/2016 17:10:02 Page 2 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
BigHand has now been updated with the priority details
Date Entered : 22/07/2016 13:22 Entered By : Nicola Mladenovic COO to attend all 5 Directorate Consultant meetings 26/08/2016 Consultant meetings have been scheduled in the diary for either by end of August to ensure engagement of COO or SRO to attend with consultant representative. Date to take Consultants. place within July and August.
Date Entered : 22/07/2016 13:24 Entered By : Nicola Mladenovic Admin support KPIs for DPR to be reviewed and 29/07/2016 amended if necessary Development of admin hub to support service user 15/06/2016 Following the A&C Review teams are now in place in Harewood and needs. K&R. Hubs created, buddy system implemented as IT enablers come on board more developments will be realised. Contact Centre implemented and as this service expands then team calls will be diverted away from teams to the CC and will free up admin time to divert to other tasks.
Date Entered : 22/07/2016 13:29 Entered By : Nicola Mladenovic Mapping of admin support across every team and any 29/07/2016 All teams have an aligned administrator. Supervision structure is in gaps identified place within K&R and Wandsworth. Further work to be undertaken in other teams.
Date Entered : 22/07/2016 13:09 Entered By : Nicola Mladenovic Develop standard protocol responses to telephone 02/09/2016 - Contact Centre operational policy drafted, agreed by project group identified. - To be agreed at OLG on 1/08/2016 - Call configuration completed to enable internal automated calling
Date Entered : 22/07/2016 13:02 Entered By : Nicola Mladenovic MAST training defined for admin teams. 29/07/2016 Customer Service training e-module has been drafted and forwarded to the T&D Team for further action to be taken
Date Entered : 22/07/2016 13:06 Entered By : Nicola Mladenovic Establish define Clinical services support manager 29/07/2016 Clinical Support Services Manager has been established and role and associated support structure. post-holder is in the role. Admin structure has been develeoped in K&R and Harewood (Wandsworth)
Date Entered : 21/07/2016 17:04 Entered By : Nicola Mladenovic Admin project group membership to be reviewed 29/07/2016 A&C project comprises of SRO, A&C project manager, operational lead, admin leads for Harewood and K&R, HR, finance, room booking project manager and autotranscription project manager
Date Entered : 22/07/2016 13:11 Entered By : Nicola Mladenovic Admin Lean project output to be implement for further 29/07/2016 Clinical Support Services Manager to bring the lean project output system improvement back into the A&C group. Sub group has been created.
Date Entered : 22/07/2016 13:13 Entered By : Nicola Mladenovic roll out of Big Hand and ensure auto-transcription is 01/07/2016 Phase 1 - BigHand (iCloud) has been implemented in Harewood and switched on K&R Phase 2 - BigHand (enterprise) roll out is being brought forward and new users are using this w/c 25/7/2016 Future roll outs to incl CAMHs
Date Printed: 23/09/2016 17:10:02 Page 3 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
Date Entered : 22/07/2016 13:17 Entered By : Nicola Mladenovic Admin freeze to be unfrozen 29/07/2016 The admin post freeze had been lifted and teams have been informed to recruit to the vacant posts.
Date Entered : 21/07/2016 17:02 Entered By : Nicola Mladenovic Admin Forum to be established 29/07/2016 Admin Forums have been created in each directorates. An Trust-wide admin away day has been planned for 14/09/2016
Date Entered : 21/07/2016 17:06 Entered By : Nicola Mladenovic 2 stage process - target risk reduction to 9 by 30/12/2016 September and to 4 by 30 December 2016, per Vanessa Ford. 934 Workforce A failure to recruit and retain adequate staff within Community Jayne Halford 4 3 12 SEE ACTIONS AS PER RISK ID 192 24/06/2016 AS per Risk 192 0 0 0 31/08/2016 services caused by delays in recruitment or poor staff retention resulting in significant impact on patient care and service delivery. Date Entered : 12/08/2016 16:05 Entered By : Peter (Risk) Hughes 985 Finance A failure to be able to meet the requirements of the proposed Suzanne Marsello 4 3 12 Continue to build relationships as per controls. 07/04/2017 4 2 8 07/09/2016 Outcome based commissioning contract with Richmond in April 2017 resulting in significant loss of income (Contract value Buid relatiobships with any new providers identified by 07/04/2017 £25m). commissioners. Meeting with commissioners once most capable 30/09/2016 provider group has been confirmed. to clarify exact requirements of contract. eg clinical pathway priorities and finance. 714 Workforce RHB2: A failure to ensure adequate supervision is provided to all Vanessa Ford 4 3 12 Task and Finish group to review reflective practice 15/06/2016 2 2 4 18/09/2016 staff caused by a lack of appropriate training and mechanisms to and examples internally / from other Trusts (long monitor resulting in deficiencies of patient care and staff term) development Review use of SIREN for monitoring supervision. 15/06/2016 ALSO: ACT5 KPI to be developed for reporting and monitoring of 29/07/2016 A supervision recording tool has been added to the Dashboard supervision which allows managers to record supervision. This went live on Monday 25th July.
Date Entered : 29/07/2016 15:12 Entered By : Gwyn Davies Pulse checks to be undertaken to track staff 30/09/2016 The supervision task and finish group has approved a quality experience of supervision measure questionnaire to be issued to all staff in the first two weeks of sept and then issued on a 6 monthly basisi thereafter. This action is slightly delaid as we made a decision not to issue the questionnaire during the holiday period and also due to the volumes of work that were being completed to get the supervision tool and policy in place.
Date Entered : 16/08/2016 11:29 Entered By : Peter (Risk) Hughes Task and Finish working group to oversee the 30/12/2016 Group established development of the policy and implementation plan. Date Entered : 28/07/2016 11:25 Entered By : Christopher Barton Monitoring system developed to be able to accurately 24/06/2016 On track and timescales have been agreed with the group charied monitor supervision (Both occurance and experience by Vanessa Ford. The tool has been developed and demoed to the as per action 10) Leadership Group. Expected to go-live by 31/7 (tbc) (KW) (Note initial system developed for short term) Date Entered : 04/08/2016 10:26 Entered By : Peter (Risk) Hughes Monitoring system developed to be able to accurately 30/09/2016 Monitoring system has been designed and approved using monitor supervision. Dashboards. (Detailed long term solution identified - both This is now 'live' and guidance has been developed for its use. occurance and experience) Use of this system will also be covered with the Supervision Training. Date Printed: 23/09/2016 17:10:02 Page 4 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
Date Entered : 28/07/2016 11:27 Entered By : Christopher Barton Team organograms developed for each team 15/07/2016 Communications gone out - team and directorate organograms to be identifiying role and person. completed
Date Entered : 02/08/2016 13:04 Entered By : Mark Clenaghan Standard template (defined by working group) for 29/07/2016 Template agreed, loaded on to dashboard. Monitored and compliant each team to define supervision cascade structure. against target - close.
Date Entered : 23/09/2016 07:32 Entered By : Mark Clenaghan ------Template created and cascaded to all teams. Central record of structures is maintained by HR. Deadline set for 1st August for all templates to be submitted
Date Entered : 28/07/2016 11:28 Entered By : Christopher Barton All staff to have next management supervision 09/09/2016 23.9.16 - Monitored through dasboard and compliant - close booked with their manager in advance. Date Entered : 23/09/2016 07:30 Entered By : Mark Clenaghan ------12.8.16 Supervision template specifying future supervision dates now rolled out and implemented. Compliance being monitored weekly and trajectory to meet target by mid-Sept.
Date Entered : 12/08/2016 06:38 Entered By : Mark Clenaghan
1027 Finance A failure to achieve in year I&E control target resulting in not Clive Field 4 3 12 a) mitigating action plans being evaluated and 30/12/2016 3 2 6 07/09/2016 meeting financial targets. implemented to reduce the run rate including a review of all non front line agency staff, a review of community agency, a review of discretionary non pay and centralisation of non pay budgets b)Improved reporting at DPRs and EMC to ensure 30/12/2016 action plans in place to ensure expenditure is minimised where overspends are being incurred. 192 Workforce The Trust is unable to attract, recruit and retain high quality staff to Alfredo Thompson 4 3 12 Recruitment strategy presented and reviewed at EMC 29/07/2016 4 2 8 02/09/2016 meet the needs of changing services which will impact on the for approval by Trust Board in July. quality of care and a continued dependency on the need for Assessment and selection framework introduced. 28/10/2016 temporary staffing impacting on the quality of care delivered and financial costs to the organisation. Targeted recruimtne tdrive (As per Recruitment 28/10/2016 strategy) 165 Quality The Trust fails to act on and apply the learning following Reported Ian Higgins 4 3 12 Review of SIG to improve monitoring and assurance 30/09/2016 3 2 6 29/11/2016 Incidents. Caused by lack of staff engagement in the reporting process. process, delays in investigation, delays in the sharing of All SI reviews to be included on the Ulysses system to 09/09/2016 completed RCA reports. This may result in repeat avoidable harm enable tracking and follow up of actions. and/or warning/improvment intervention by the CQC. 590 Quality A failure to appropriately assess clinical risk caused by a lack of Vanessa Ford 4 3 12 Undertake Risk Assessment training programme 30/12/2016 4 2 8 29/11/2016 training or appropriate skills and practice resulting in risk management plan not adequately safeguarding individuals and the public from significant harm. 564 Quality Bed Pressures: A failure to manage the significant presure on Dawn Chamberlain 4 3 12 Acute care pathway reinvestment proposal 27/11/2015 Urgent Care Pathway business case approved by commissioners 4 2 8 18/09/2016 beds caused by high demand / occupancy and a reliance on out of incorporating 5 workstreams: area placements resulting in significant impact on the quality of patient care. - Integrated Out of Hours Service - street triage now operating across all boroughs, and move to hub/spoke out of hours servie planned for Sept'16 - Psychiatric Decision Unit - due to open in Nov'16 - Crisis House - further discussions on funding model and Date Printed: 23/09/2016 17:10:02 Page 5 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
commissioner support required. - Crisis Cafe - tenders for 2 Crisis Cafes expected to be placed in market in Sept'16 - Purposeful admissions - inproved discharge planning standards being developed and implemented through project group
Date Entered : 12/08/2016 07:04 Entered By : Mark Clenaghan ------Schemes agreed Oct 15: Investment in HTT's and Discharge co-ordinators Extend ACC to 24/7 Bed and Breakfast Increased medical input
Date Entered : 02/11/2015 10:01 Entered By : Peter Hughes Integrated Out of Hours Service established. 25/11/2016 In patient Consultant Workshops to develop 25/11/2016 dasbboard for reviewing consistancy of practice across in patient teams. Psychiatric Decision Unit established and working. 30/11/2016 Contact Centre Established. 30/12/2016 Crisis cafes opened. 01/04/2017 Tedner spec for Crisis Cafes approved by EMC - progress to tender with new services due to operate by 1.4.17
Date Entered : 23/09/2016 07:28 Entered By : Mark Clenaghan Outcome of purposeful admissions work programme. 24/02/2017 Purposeful Admissions Project group meeting - products due to be operationalized by 31.10.16
Date Entered : 23/09/2016 07:24 Entered By : Mark Clenaghan Bed Management Escalation Protocol developed and 09/09/2016 Bed Management Escalation Protocol due to be operationalized introduced. 31.10.16
Date Entered : 23/09/2016 07:26 Entered By : Mark Clenaghan 573 Quality A failure to be able to comply with admission criteria for individual Mark Clenaghan 3 3 9 As per bed pressure risk 23/11/2015 Criteria revised. Compliance is monitored. 3 2 6 18/09/2016 wards via Bed Management process caused by significant bed pressures will result in further CQC compliance actions and Date Entered : 26/05/2016 17:08 penalty. Entered By : Peter (Risk) Hughes 511 Finance A lack of timely and accurate clustering assessments; caused by Clive Field 3 3 9 Project manager and expert trainer appointed on a 31/03/2016 |Risk under review by new lead Justin Earl 1 3 3 17/11/2016 a lack of prioritisation and understanding, may result in a loss of one year basis to develop and implement training income for clinical work strategy. Date Entered : 22/08/2016 17:23 Aim to offer classroom training to all clustering Entered By : Peter (Risk) Hughes clinicians to improve understanding of clustering and ------therefore improve accuracy. Training is available however attendance has been poor. Reported to To develop long term training strategy. Operational Leadership Group for support. Application made to Training and development to make cluster training mandatory.
Date Entered : 23/10/2015 17:07 Entered By : Gemma Matthews New Tarrif and Training Manager to be recruited to 16/12/2016 support Project. 527 Information A failure to communicate accurate information related to medicines Emma Whicher 3 3 9 Training for staff due to start in Q3 2015/16 29/02/2016 Training commenced. 3 2 6 22/12/2016 and physical health in the CPA and community discharge summaries documents caused by care co-ordinators lack of Date Entered : 26/05/2016 17:06 knowledge resulting in patient harm in their subsequent care and Entered By : Peter (Risk) Hughes treatment Date Printed: 23/09/2016 17:10:02 Page 6 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
In order to continue awareness, consolidate & embed 08/04/2016 CQUIN 2016/17 was not approved, hence unable to consolidate and good practice, a second year of the CQUIN is embed good practice proposed for which additional resource will be required. A decision is awaited. Date Entered : 23/09/2016 13:08 Entered By : Dianne Adams ------CQUIN approved
Date Entered : 26/05/2016 17:07 Entered By : Peter (Risk) Hughes 189 Quality Failure of Clinical Leadership and staff engagement with recovery Miles Rinaldi 3 3 9 Continue with Care planning audit programme 30/06/2016 Audit has commenced and due to report erly February. 4 1 4 29/11/2016 approach caused by resulting in negatively impacting on quality of care. Date Entered : 22/01/2016 16:20 Entered By : Peter (Risk) Hughes ------Programme due to commence Dec 15.
Date Entered : 23/11/2015 11:18 Entered By : Peter Hughes Develop a care/crisis planning procedure. 30/11/2015 This is linked to the redevelopment of the CPA policy with the practice standards being developed first (as advised by Michael Hever).
Date Entered : 23/09/2016 10:53 Entered By : Miles Rinaldi Develop and undertake programme of Care planning 28/10/2016 A care and crisis planning e-learning training module has been training. developed and is available on Compass.
Date Entered : 23/09/2016 10:50 Entered By : Miles Rinaldi Complete Review of CPA policy to ensure that 30/11/2016 CPA policy will be reviewed but advised by Michael Hever that the requirements are clearly udnerstood by staff and practice standards need to be developed first before reviewing adhere to best practice. policy.
Date Entered : 23/09/2016 10:49 Entered By : Miles Rinaldi Undertake Cirisis care plan audit to assess 11/11/2016 Revised target date for completion. adherence to standards and identify areas for improvement. Date Entered : 23/09/2016 10:52 Entered By : Miles Rinaldi 665 Quality Clinical Audit: A failure to ensure a strong programme of clinical Emma Whicher 3 3 9 Develop Business Case for strengthening Clinical 26/05/2016 Secondment of member of Nursing staff to be advertised. 3 1 3 08/09/2016 audit caused by a lack of resourced staff resulting in none Audit support. compliance with CQC regulation 16 / inadequate review of quality Date Entered : 26/05/2016 17:10 monitoring processes. Entered By : Peter (Risk) Hughes ------Business Case in development.
Date Entered : 26/05/2016 17:09 Entered By : Peter (Risk) Hughes Annual review of Audit programme to be undertaken 26/08/2016 by IGG 674 Finance A failure to engage in business planning and tendering processes Suzanne Marsello 3 3 9 Review processes for lessons learned and present 26/08/2016 2016/17 business planning lessons learned report has been 4 2 8 28/09/2016 by service and corporate leads caused by lack of capacity, action plans to address ongoing issues of completed. A lessons learned review will be carried out on the capability issues, lack of ownership and lack of clarity around engagement. Identify additional capacity within current development of the Crisis/ Recovery Cafes project as agreed by priorities or need to engage. This results in inadequate processes roles and clarify expectations for business planning EMC. A lessons learned review on the development and submission and potential loss of business through tenders now being won or and tenders in advance. Develop relationships with all of the Wandsworth IAPT tender will be carried out in October 2016. service developments not being agreed. parties and improve communication around deadlines Lessons learned around culture change still require implementation. and requirements. This work is ongoing.
Date Entered : 29/08/2016 16:09 Entered By : Amy Scammell ------Lessons learned reports on Merton Substance Misuse bid
Date Printed: 23/09/2016 17:10:02 Page 7 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
development and Sutton INSPIRE mobilisation have been sent to EMC 14.06.16. These will go to the F&I Committee 27.06.16. Key areas around culture, ownership and prioritisation remain and a specific action plan is required. Business planning lessons learned will be reported to EMC and F&I Committee in July 2016. Furhter updates will be provided.
Date Entered : 14/06/2016 15:01 Entered By : Amy Scammell 679 Safety A failure to correctly assemble medicinal products within Dianne Adams 3 3 9 an options appraisal is in development 11/04/2016 Options approved 3 3 9 18/09/2016 emergency ILS bags caused by lack of control of the assembly process (no procedures, worksheet, training etc) resulting in Date Entered : 19/08/2016 15:58 patient harm (lack of product or incorrect product given) Entered By : Peter (Risk) Hughes ------first draft has been completed
Date Entered : 04/04/2016 17:48 Entered By : Dianne Adams Roll out of New Bags is planned to commence in Mid 30/09/2016 September and be completed by the end of September. 715 Quality OPC6: A failure to learn from incidents consistently across the Vanessa Ford 3 3 9 Learning Bulletin issued monthly. 30/06/2016 The learning bulletin is produced following the monthly Learning 3 2 6 01/10/2016 Trust caused by poor structures to communicate and embed Group and approved at the Integrated Governance Group. It is learning resulting in recurring incidents. circulated widely and it is also available on InSite
Date Entered : 12/08/2016 11:33 Entered By : Theresa Pardey All actions from serious incident recommendations 28/10/2016 This is work in progress. Action Plan is set up to review actions. are reported to IGG for review and to ensure closure. Agenda item under Patient Safety of the IGG Agenda.
Date Entered : 12/08/2016 11:36 Entered By : Theresa Pardey Review of Serious Incident Group terms of reference. 08/07/2016 All serious incidents to be completed using Ulysses to 28/10/2016 Ulysses is currently used to track actions from RCA's however the enable tracking of actions and wider circulation. full functionality of circulating the actions is not being used. This is a work in progress with Ulysses the provider.
Date Entered : 12/08/2016 10:45 Entered By : Theresa Pardey Implement internal risk alert process to ensure key 02/09/2016 Trust CAS alert process handover w/e 21/7/16. Revised Alert improvement requirements are communicated and process to be defined. confirmed by managers. Purchase of ALert module for Ulysses under consideration.
Date Entered : 27/07/2016 18:18 Entered By : Peter (Risk) Hughes Theme sharing arrangements to be defined to ensure 29/07/2016 1)The new Learning Bulletin provides cross Directorate learning that learing in one directorate in a particular core from incidents and is produced monthly following approval at IGG. service areas are shared with others. 2)Directorates are required to share the learning/outcomes of their themed learning events at IGG. This enables Trustwide sharing of the core service themes.
Date Entered : 12/08/2016 10:44 Entered By : Theresa Pardey Learning lessons bulletin are reviewed at team level 07/07/2016 19.8.16 - Agreed with and that Director of Nursing & Quality will governance meetings. review Directorate Clinical Governance agendas to ensure that Monthly Learning Lessons Bulletin is incorporated as standing item.
Date Entered : 19/08/2016 07:52 Entered By : Mark Clenaghan ------12.8.16 Current directorate governance templates being reviewed to ensure consistency and Learning Lessons bulletin incorporated. Date Printed: 23/09/2016 17:10:03 Page 8 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
Date Entered : 12/08/2016 06:42 Entered By : Mark Clenaghan Evidence that teams are reviewing incidents that 25/11/2016 Feedback to reporters on the incident system is automated and have occurred in their area through team meeting therefore staff will receive feedback. minutes and confirmation that staff have received A review of team meeting minutes will need to be undertaken to feeedback on Ulysses. provide assurance that this is completed
Date Entered : 12/08/2016 11:30 Entered By : Theresa Pardey Actions from SI's and incident reviews to be tracked 15/07/2016 to completion and reported to SIG Review undertaken of the communication of lessons 30/06/2016 New action to be added to put all serious incident recommendations learnt undertaken and recommendations onto the Ulysses action plan. implemented. Date Entered : 12/08/2016 08:54 Entered By : Peter (Risk) Hughes ------Corporate recommendations / lessons are not being escalated. Arrangements to put actions on to Ulysses being confirmed.
Date Entered : 27/07/2016 18:20 Entered By : Peter (Risk) Hughes Arising from action 10. All Serious Incident review 07/10/2016 recommendations to be reported on Ulysses action plan to be able to demonstrate progress / completion. 756 Workforce TST6: A failure to review the whistle blowing process to make it Jayne Halford 3 3 9 Options paper presented to EMC to consider role of 21/06/2016 Agreed to consider external organisation and receive presentation at 3 2 6 30/09/2016 more accessible to staff and introduce a speak up champion. external Speak up Champion. future meeting.
Date Entered : 24/06/2016 15:58 Entered By : Peter (Risk) Hughes Existing policy reviewed and updated to reflect 30/09/2016 national framework / standards. 757 Workforce ACT 19: A failure to ensure that staff feel sufficiently supported byJayne Halford 3 3 9 Staff survey action plans to be developed by local 30/09/2016 2 3 6 30/09/2016 senior staff and that team managers have enough time to carry teams. out their role caused by...... resulting in New HR corporate structure incorporates the post of 31/08/2016 Employee Engagement Manager and Facilitator once OPC10: The trust should continue to review staff engagement post filled. processes across the teams to ensure staff feel involved in Health and Wellbeing manager role incorporated into decisions and valued 31/08/2016 new HR corporate structure. _ Implement reward and recognition programme (as 28/10/2016 per Recruitment strategy) Wellbeing programme (as per recruitment strategy) 30/09/2016 566 Safety Failure to establish clear health and safety management Peter (Risk) 3 3 9 Areas identified and reported to H&S committee. With 16/09/2016 Further review due to be undertaken at next H&S meeting on 15/9 4 1 4 18/09/2016 arrangements with third party partnerships as part of service Hughes follow up actions to establish. specification/contract that may lead to liability exposure resulting in Date Entered : 19/08/2016 16:00 legal action/prosecution. Entered By : Peter (Risk) Hughes 760 Quality CSS3: A failure to respond to feedback caused by not ensuring Vanessa Ford 3 3 9 Review to confirm where all hand held devices are 29/07/2016 IM&T have provided a schedule of all asset tagged tablet devices 2 3 6 26/08/2016 that the technology and systems used to obtain views and placed and how they are used / and confirmation that and identified which service they are allocated to and where they are feedback work consistently resulting in inadequate service they are working. placed. The exercise to ascertain whether each devide is working provision with media publicity. has not yet been complete and will be done so by 30 September 2016.
Date Entered : 27/07/2016 16:31 Entered By : Victoria Gregory Data reporting and review arrangements reinforced 29/07/2016 The Patient Experience Manager has reinforced with Service for each Directorate Directors the need to ensure that patient experience is dicussed at their governance groups and given enough time on the agenda. Patient Experience data is sent every month to the directorates for their governance groups.
Date Printed: 23/09/2016 17:10:03 Page 9 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
A report has also been submitted to the Director of Nursing and Associate Director of Quality andf Risk to move forward 3 areas of development that would improve the efficacy and data reporting of RTF.
Date Entered : 27/07/2016 16:48 Entered By : Victoria Gregory Review of feedback systems undertaken with patient 28/10/2016 A review of feedback systems has been scheduled for carers and carer engagement. consultation on 19 September 2016 and for service user consultation on 21 September 2016.
Date Entered : 27/07/2016 16:54 Entered By : Victoria Gregory Brief User guide issued on how feedback is collected 29/07/2016 A RTF User Guide has been sent to Service Directors, Operational and how it is used. Managers, Service Managers, Ward Managers, Deputy Ward Managers, Modern Matrons and Team Leaders and also made available as a news item on the Trust's intranet.
Date Entered : 27/07/2016 16:50 Entered By : Victoria Gregory Position statement from all teams about how they are 29/07/2016 currently finding the systems in place and what actions are required to address this. Confirmation that Patient experience is on each 29/07/2016 Confirmation has been recievecd from all Service Directors that Directorate Governance agenda. patient experience is alreadty or shall be an agenda item on governance meetings.
Date Entered : 27/07/2016 16:52 Entered By : Victoria Gregory 763 Workforce CMC5: A failure to ensure that all teams complete the outstanding Jayne Halford 3 3 9 Agree class based training dates with all SME's for 23/06/2016 Training dates for courses have been agreed, with the excpetion of 3 2 6 30/09/2016 mandatory training cauased by not reviewing performance data the next 12 months and make these available for Basic Life Support. HR is working with the Nursing Directorate to resulting in staff not being trained to adequate standards. booking on COMPASS employ a bank BLS trainer to provide all our training. As an interim measure, an external provider is providing training for the Trust,
Date Entered : 18/07/2016 08:28 Entered By : Christopher Barton Review of capacity to deliver training with all SME's, 29/04/2016 agreeing the number of sessions required to enable compliance throughout 2016/17 Provide automated reporting on MAST DNA's via 30/06/2016 DNA's are now reported on Dashboards, and a breakdown per dashboards, for review at supervision and DPR subject and per directorate included within the new bi monthly Training and Development report. The Trust has recently launched a new Supervision Policy and Framework, and so discussion of DNA's will be included within the 'performance' section of sessions, though this has not yet been embedded within the Trust.
Date Entered : 18/07/2016 08:26 Entered By : Christopher Barton ------Work ongoing with Information management to enable this
Date Entered : 09/06/2016 14:29 Entered By : Christopher Barton Review provision of class based training throughout 15/08/2016 the year, based on analysis of when certificates are due to expire, thus enabling supply of training to meet differing levels of demand throughout the year. 565 Business A failure to replace the SAN (Storage Area Network), caused by Dave Dowsett 3 3 9 19/08/2016 SAN now procured and awaiting implementation 3 2 6 10/11/2016 the lack of an approved business case, resulting in a failure of the eRostering system and a failure to sufficiently staff patient care. Date Entered : 19/08/2016 12:30 Leading to not knowing rotas, and staff errors. Entered By : Peter (Risk) Hughes
Date Printed: 23/09/2016 17:10:03 Page 10 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
1026 Finance A failure to achieve recurrent funding for the Acute Care Clive Field 3 3 9 Actions are reflected in the Acute Care PAthway 31/08/2016 3 2 6 07/09/2016 development proposals and a failure to manage costs for 2016/17 project reported against risk ID 564 within the funding available, resulting in not meeting Trust Financial targets. 574 Workforce A failure that staff concerns are not appropriately escalated by Alfredo Thompson 3 3 9 Revised Whistle blowing policy approved. 28/10/2016 3 2 6 17/11/2016 individual teams caused by staff not feeling empowered to be able to speak up where concerns or risks are apparent resulting in Speak up guardian identified and in post. 28/10/2016 shortfall of care / staff concerns not responded to.. 1028 Finance A failure to reduce agency costs to targeted level resulting in not Clive Field 3 3 9 All non-front line agency staff posts are being 31/08/2016 3 2 6 08/09/2016 achieving financial targets. reviewed and further tightening the use and governance of agency spend. See also Corporate risk 192 regarding Trust 31/08/2016 Recruitment Strategy 551 Quality A failure to manage all inherent ligature risks within our old Niall Smyth 3 3 9 Review learning from Serious incident reviews arising 30/11/2016 4 1 4 02/09/2016 buildings, caused by inadequate assessments or weakness in from ligature risk incidents. local controls resulting in patients harming themselves. Actions to implemented to reduce top ligature risks 30/12/2016 identified at QMH. (Estates programme) Identify costs and progress works to adapt en suite 30/12/2016 doors in ward 2 to ensure uniform provision in Storey building. 948 Reputation A failure to effectively build trust with key stakeholders caused by Ranjeet Kaile 3 3 9 3 3 9 03/08/2016 the introduction of SLM resulting in poor relationship management and reputational harm. 646 Finance A failure to achieve aggregate financial balance across the systemClive Field 4 2 8 Proposal to EMC for permanent contracting funtion. 10/06/2016 The proposal has been accepted. The post is confirmed following 3 2 6 10/11/2016 caused by the proposed STP geographical area has two provider Corporate Services Review Phase 1, and will be recruited to on a organisations (both Foundation Trusts) formally placed in special permanent basis. measures due to financial performance resulting in Trust not receive proprtional commissioner investment.
Date Entered : 12/08/2016 14:09 Previously each provider/ commissioner was assessed on an Entered By : Paul Hunt individual basis regarding financial performance - this assessment ------will be made on a system-wide basis going forward. The risk is Proposal for permanent contracting function made through that the organisation may not have access to commissioner Corporate Services Review. Written response to be published 10th investment on a proportionate basis, and/or access to the parity of June 2016. Target date amended. esteem funding for 2016-17, due to the new requirement for there to be financial balance across a wider system rather than at Trust has agreed 2016/17 contract local commissioners. organisational level Commissioners have supported the changes the Trust is making to increase community services in order to reduce the pressure we have had on beds over the last year: an additional £3m of investment into community services that will include: a new Psychiatric Decision Unit; opening of two new crisis cafés out in the community; more investment in street triage.
Date Entered : 26/05/2016 12:03 Entered By : Paul Hunt 764 Quality ACT4: A failure to ensure safe systems for storage and Dianne Adams 2 4 8 Reinforce use of delivery note - clarification of what 15/06/2016 1 3 3 28/08/2016 transportation of medication, medical waste and sharps. Caused should be undertaken. by a lack of physical controls such as lockable bags resulting in a Annual Medicines Management Audit to be 30/09/2016 reduced level of security. undertaken. (STANDARD ACTION ACROSS ALL DIRECTORATES) Also OPC1 15/06/2016 Appropriate bags and combination locks to be 26/06/2016 purchased and thereafter arrangements will be made distributed to all staff within the Trust who transport medicines. Team managers to sign receipt of bags and sign 28/06/2016 Community Matrons to receive confirmation from Team Leaders thet confirmation of appropriate use. they have received bags and locks. Six monthly sign up to be required. (Form issued to Follow up audit to be carried out in January 2017 team managers to then forward to each member of Date Printed: 23/09/2016 17:10:03 Page 11 of 12 Corporate Risk Register for September 2016
Risk No. Risk category Risk description Risk Lead Action Plan to Address Gaps Target Date Progress to Date Target Review date for Risk completion Score of action plan
Which category What could prevent the Trust's objectives from being achieved? Risk Owner I L S Plans to address the gaps in control and/or assurance? I L S Date this risk is due does the risk for review best fit?
team) Date Entered : 06/09/2016 23:40 Entered By : Michael Hever Trust Medicines Code will be amended to allow 30/09/2016 Non-nursing staff (and unregistered nursing staff) can transport or deliver individually dispensed medicines, which are labelled with directions for use, to service users.
Date Printed: 23/09/2016 17:10:03 Page 12 of 12 Appendix 2 Board of Directors Assurance Framework For the Board's 2016/17 Corporate Objectives
DRAFT Update September 2016
Trust Board Meeting
4 October 2016
Paper Reference: TB(16-17) 94
Report Title: Service User Story
Executive Summary: The Trust Board has a v ital role to play in ensuring the organisation is creating a culture of “putting patients first”, both through direct involvement of service users at Board level and through the assurances non-executive directors seek. The Trust Board agreed in July 2015 t o take forward the key recommendations in respect to presentation of patient stories to each Board meeting. The Service User Story for October focusses on experiences of care planning as told through a complaints, triangulated with ratings by service users on Real Time Feedback and the out- come which shows an improvement over the past 5 months of and the outcome of the 2015 CQC Community Survey which had also improved from the previous year.
It also provides a summary of Trust recent developments including care planning training and an audi t framework. The audits, CQC Community Mental Health Patient Survey and the complaints received show there is still work to do to increase the quality of our care plans and the care planning process.
Action Required: The Board is asked to note the Service User Story and demand for this service.
Link to Strategic Objectives: • Provide consistent, high quality, safe services that represent value for money • Enable increased hope, control and opportunity for our service users Risks: None Quality Impact: Patient Experience is a domain of the Quality Strategy. Resource Implications: None Legal/Regulatory Implications: None Equalities Impact: None Groups Consulted: The stories are taken directly from the feedback we have received from service users and co-production attendees
Author: Victoria Gregory, Patient Experience Manager
Owner: Dr Emma Whicher, Medical Director
Page 2 of 2
Patient Stories
October 2016
Experiences of Care Planning
Care Planning
Conceptually care planning describes the processes involved in proactively reviewing a patient’s current situation and their priorities, and planning for their forthcoming care and support. It aims to provide person-centred care and actively increase involvement in decisions and health care.
A care plan sets out a patient’s assessed health and social care needs and promotes recovery by focusing on improving outcomes that matter to the patient (Department of Health, 2008). It provides a description of the services and support offered to a patient and the activities they can pursue to achieve their goals over a defined reviewable timeframe, that together aim to support the patient to:
Self-manage their own condition
Pursue their own recovery journey towards managing and maintaining their health and well-being
To identify reasonable adjustments where there is a disability or limitation that will enable them within the service and in their life beyond the service.
A care plan is a dynamic, individualised document that changes in accordance with the patient’s needs, recovery goals and individual circumstances. Care plans also contain physical, psychological and social needs; a risk assessment with a safety management plan where necessary; recovery capital i.e. coping strategies for friends, family and carers; and a collaborative crisis plan. It is recognised that involving people directly in the development of their care plan is critical to creating better outcomes.
All care plans should describe the steps to be taken towards achieving those Patients 1st goals with clear review points along the way. These steps and review points need to be realistic and achievable, agreed with the patient and extended to those who support the patient within their social network, namely carers, family, General Practitioner and other agencies.
We know that recovery goals and aims set out are best achieved if they have been designed collaboratively between the patient and their care team. Whilst it is not always possible to mutually agree the goals and the steps to achieve the goals, the care plan can reflect differences of opinion with explanations as to how the patient can be supported through the process. (NICE (2011) People using mental health services jointly develop a care plan with mental health and social care professionals, and are given a copy with an agreed date to review it)
A care plan is developed irrespective of whether the patient is subject to a Care Programme Approach (CPA) or not. There is the expectation that all patients within the Trust will have a care plan that is meaningful to them and those who help sup- port them. Traditionally care plans have been written by professionals based on problems, weaknesses, diagnosis and risk, and not always sought to include pa- tients in a meaningful way. As a consequence the care planning process is often poorly understood by patients who are being served and, as such, care plans are seen as being relatively meaningless to them. It is essential that all patients are offered a copy of their care plan and it is developed and written in such a way that it is simple to read and understandable. The Trust has two electronic systems in place where care plans are documented. For those patients subject to CPA there is a clear format to complete and a copy given to the patient. If this is not conducive to the patient, it must still be completed by the relevant clinician and the patient helped to devise a paper care plan they can understand. For those patients who are not subject to the CPA, the plan of care is written within a letter that is sent to the patient’s GP and a copy given to the patient. (Quality statement 8 NICE (2011) and are given a copy with an agreed date to re- view it) Experiences shared about Care Planning
Care planning is the daily work of mental health services and underpins all aspects of care and support. The process of care planning involves supporting self- management, shared decision-making, coproduction and supporting patients to achieve their goals. As a consequence feedback about the quality of experience of care plans and the care planning process tends to be directly related to those as- pects rather than the actual care plan or planning process itself.
However, there have been a cluster of complaints in the last 6 months recently about care planning. Below are summaries of a selection of those complaints and the Trust response.
Complainant explained that she had been admitted to the ward and she had another admission. She was a voluntary patient and said that during her ad- missions she was not given a care plan and she was not given a diagnosis. She was ignored by staff and was only given medication, which they would not give an explanation why she needed to take it, just that she had to.
The complaint was upheld and a consequent action was for the ward manager to remind staff to give patients care plans. An explanation given about the use of care plans and apology given that she was not given a copy.
Complainant is concerned as to the way her son has been discharged from
Patients 1st the ward. Firstly there was no care plan, secondly he was discharged into po- lice custody. Also, she was not informed of this discharge although the ward have her contact details and are aware that she is his next of kin. To date, she is still unclear of any diagnosis. He has visited his doctor in relation to his health after such events, the doctor confirms that he is understandably stressed and anxious following a difficult year but even he doesn't understand what has been going on.
An explanation was given regarding the events surrounding the patient's discharge, the subsequent arrest by police and diagnosis
A husband raised a compliant in relation to The inappropriate discharge of his wife from Hospital without a proper care plan and discharge letter to the GP. Also to justify why they have excluded him from discharge planning following the meeting. The complaint response letter explained that the discharge plan was worked out prior to discharge of the patient and that the complainant told staff members he would not be attending the meeting. An apology was provided for any confusion that had occurred as a result of this. Further explained that the care agency plans were appropriate and that his wife had agreed to these and had capacity to make the choice to do so.
The complainant called to find out how to make a complaint about her daugh- ter`s sudden discharge from the ward. Her daughter was admitted to the ward 2 weeks ago. She has diagnoses of Aspergers and Autism, however she was admitted following a breakdown. She was doing well on the ward however was discharged suddenly with no warning. Her daughter has never seen a copy of her care plan whilst on the ward
The Trust apologised if the patient was not provided with a copy of her care plan, Ward manager to discuss this with staff. Explained that she was not discharged without warning and it was recorded in the medical record that complainant had agreed that she could be discharged then. Evidence that discharge planning had been ongoing for some time. Explained that she was asked to remain outside the ward when she came to collect the patient and this was because there was con- cern it might disrupt other patients due to the time of day rather than the fact she had become distressed the previous day.
These complaints demonstrate the importance of effective care planning in empow- ering service users in making joint decisions around their care, and when this does not work effectively it can leave service users and their families feeling excluded.
Patients 1st
Feedback on care planning
The Trust’s Real Time Feedback system has a survey domain of care planning in which the following questions are asked. See Table 1 below: Table 1
332332 II havehave beenbeen involvedinvolved inin decidingdeciding mymy crisiscrisis planplan 411411 II feelfeel thatthat carercarer conconfifidenden alityality isis beingbeing respectedrespected 439439 InIn thethe lastlast 1212 monthsmonths II havehave beenbeen invitedinvited toto aa carecare reviewreview meemee ngng 352352 MYMY viewsviews werewere listenedlistened toto whenwhen decidingdeciding mymy carecare planplan 353353 II havehave aa carecare planplan forfor mymy needsneeds 369369 II havehave beenbeen involvedinvolved inin planningplanning mymy dischargedischarge 368368 II havehave anan upup toto datedate crisiscrisis planplan 331331 II havehave hadhad aa carerscarers assessmentassessment 372372 II waswas oofffferedered aa carerscarers packpack 370370 II havehave aa wriwri enen copycopy ofof mymy carecare planplan 336336 II havehave beenbeen involveinvolve inin carecare planningplanning 365365 MyMy carecare planplan isis upup toto datedate 350350 DidDid youyou getget choiceschoices aboutabout youryour carecare
Over the past 5 months the scores against care planning have improved from 46 to 60 but this remains an area of development as this improved score is still below the aver- age score of all RTF questions. See table 2 below:
Table 2
RTF domain April May June July Aug Care Planning 46 56 55 56 60 score Average over‐ 50 60 59 60 63
all RTF score
There were two RTF positive text comments in July 2016 about care planning: Patients 1st ‘Very polite staff and considerate scheduling if appointments plus realistic goals in care plan discussion’ ‘My care plan is up to date’ Table 3 below shows the Trust’s 2015 CQC Community Mental Health Patient Survey results for planning of care. In 2015, the overall patient experience for the planning of care improved with patients stating they were involved as much as they wanted to be in agreeing the care they would receive and in that their personal circumstances were taken into account in comparison with 2014 results.
Table 3
Accessibility of Care Plans
It is important that care planning is tailored to different groups and there is not a “one size fits all approach” Within CAMHS a new care plan document was developed in 2015 and is being rolled out across CAMHS. The aim was to make the care plan more youth friendly. For people with a diagnosis of dementia care planning involves families and carers where appropriate. The Merton Older People’s Team are current- ly in the process of redesigning the care plan for patients under the Memory Assess- ment Service to align with the dementia care pathway. One redesigned this could be applied consistently across Memory Assessment Services across the Trust. Patients with a Learning Disability and for Deaf patients care plans are translated into easy read versions on an individual basis.
Trust Developments
In 2014, a care planning training course aimed at staff was coproduced by the Recov- ery College with senior nurses in the Trust. Feedback from staff who attended the courses has been very positive. An E-Learning module on care planning was also developed for staff in 2015. The Trust developed an audit framework to assess the quality of care planning based on the NICE 15 quality statements of service user experience in adult mental health (NICE, 2011) and the locally coproduced Service User Reference Group (SURG), Quality Group Care Planning Principles. The table below shows the Trust wide com- parison in the scores for the quality of care planning between the last two audit peri- Patients 1st ods. In February 2016, n=360 care plans for patients on CPA were audited. There had been an increase in the proportion of care plans being jointly developed with pa- tients, the collaborative development of crisis plans and with small increases in scores for shared decision making of treatment goals, the care plan containing recovery goals, progress in recovery goals and the care plan being written in simple and mean- ingful language. There was however decreases in scores in supporting self- management and the involvement of family, friends and carers in comparison with 2015. See table 4 over page:
Table 4
Scale [1 = to no extent; 2 = to little extent; 3 = to some extent; 4 = to a great extent] The audits, CQC Community Mental Health Patient Survey and the complaints received show there is still work to do to increase the quality of our care plans and the care plan- ning process. Since the summer of 2015 each ward and team nominated a designated Care Planning Champion whose role it is to embed care planning into the team’s day- day practice through: Monitoring the uptake care planning training within the team, Conducting 3 random qualitative care planning audits monthly and sharing the learning within the respective team Monitor the dashboard re; distribution of care plans on behalf of team leader and other relevant care planning activity. Identify changes to be made on RiO to support practice
Patients 1st Patients Link up with other care planning champions in the trust to improve practice Upon request, contribute to the development of the New RIO The Care Planning Champions meet as a peer group on a quarterly basis. This work continues in light of the CHI visit in March 2016, where services were rat- ed as good for caring specifically noting People and where appropriate their carers, were usually involved in decisions about their care. However in some services it was noted staff completed risk assessments for all patients. However, not all identi- fied risks were addressed in care or management plans
Trust Board meeting 6 October 2016 Paper TB (16-17) 96 Reference: Report Title: Trust Board – Quality & Performance Report August 2016 Executive The Board Report is scheduled to be presented at the Quality Standards and Summary: Assurance Committee on the 4th October 2016 and subsequently presented to the Trust Board on the 6th October 2016.
The quality and performance report includes both performance and quality metrics aligned to six domains Monitor and the five Care Quality Commission Domains of Safe, Effective, Caring, Responsiveness and Well Led.
Key risks for the organisation are reviewed to provide the Board with assurance that actions to mitigate concerns are in place and effective. The key risks to the organisation are CQC requirement notices, the demand for beds and nursing recruitment.
A number of new metrics added to the Performance and Quality Dashboard for August 2016 following a review of quality metrics by the Director of Nursing and Quality, Governance Department and t he Information and P erformance Department.
The metrics reported in the Safe domain now incorporate a more comprehensive review of levels of harm. T he incidents relating to self-harm now medication errors will also incorporate information on the levels of actual harm (low to severe) recorded. Additionally, serious incidents reporting has been expanded to include serious incidents not reported on S TEIS and the mortality levels for clients that have deceased within 6 months of discharge from Trust service are also now reported. The majority of the deaths within six months of discharge will be from natural causes but all deaths are reviewed to ensure there were no missed opportunities. Such cases will be scrutinised by the Trust’s Mortality Committee and also by the Director of Nursing.
The Trust’s restrictive practices (reported in Caring Domain) are now reported in more detail. The use of rapid tranquilisation, prone restraint, naso-gastric feeding and s eclusion will now be r eported separately following recommendation by the Director of Nursing and will receive scrutiny on a monthly basis by Physical Intervention Lead. Reporting by exception will still be provided especially when performance is outside the normal range (e.g. prone restraint in this report). The volumes recorded will vary month on month which can be a r eflection of the client acuity/presentation at the time of reporting so as a c onsequence there are no t hresholds assigned although mean reporting is incorporated in the dashboard and in the charts further on in this report.
The Board agreed on 1st September to proceed with the focused re-inspection by the CQC on 27th & 28th September to home treatment teams, older people community teams and Crocus Ward. T he visit focused on s upervision, medication management and adm inistration and the CQC provided verbal feedback at the end of the inspection. T hey thanked the staff for their warm and professional approach and c ommended their hard work. They were impressed by the level of significant improvements made in all three areas and verbally confirmed that the trust had met its regulatory requirements meaning that the Trust should be rated as good. The results and c onclusions need confirmed through the CQC internal assurance processes and they will provide a written report and confirmation in the next 6 weeks.
The Trust met the 85% target for supervision on the 26th September 2016 and the teams visited by the CQC all exceeded 95% compliance for supervision. A questionnaire on t he quality of supervision has been i ntroduced to provide further assurance in terms of staff experience of supervision. Please see Appendix 14 section for additional information on supervision.
The Quality & Performance report will be developed over the coming months to aligned with the Trust plans to move into Service Line Management in early 2017. The proposed divisions are Acute & Urgent Care, Community Adults, CAMHS, Cognition & Frailty and National Services so reporting will need to reflect these service areas.
The Trust has seen in 2015/16 an unprecedented demand for beds. Occupancy rate for adult acute remains high averaging consistently above 105% occupancy rate excluding leave; position has improved in September and at the time of reporting the occupancy rate was 92%. Delayed transfer of care has increased over the last three months and the Trust continues to work collaboratively with commissioners in order to minimise the number of days delayed.
The Trust overall vacancy rate is 18.6% and the nursing vacancy rate is currently 24.5%. A nursing recruitment drive was initiated in order to speed up the recruitment process further details are provided in the executive summary.
Performance Review Against Monitor Targets and the Five Domains
An overview of performance against monitor and the five domain metrics is given below.
The Trust is compliant in 42 out of 62 (67.7%) of in-month metrics and 40 out of 65 (61.5%) on YTD metrics. Forecast position 44 out of 65 (68.0%) on metrics. An explanation in regard to non-compliance is given below.
For further details please see full executive summary. Link to Quality and Value - We will provide consistent, high quality, safe services that Strategic represent value for money. Objectives: Risks: Non-compliance is included in directorate and/or department operational risk
Page 2 of 3 registers. Monitor non-compliant metrics are reported quarterly to the TDA and included in the Board BAF (Risk no. SO1-03) Quality impact: The risk to service quality are assessed and included in individual exception reports and recorded on operational risk registers. Resource Financial consequences are identified in individual exception reports. implications: Legal/regulator Monitor compliance – Trust complaint in all bar one metric. y implications: Trust currently has five outstanding compliance actions. Equalities None, except if identified in individual exception reports. impact: Groups Executive Management Committee & Chief Operating Officer consulted: Author: Gwyn Davies, Performance Lead & Keith Williams, Head of Information and Performance Owner: Dawn Chamberlain, Chief Operating Officer
Page 3 of 3
Minutes of the meeting of the Quality and Safety Assurance Committee Part A - held on 5 July 2016 – 09:30 to 12:10
Present: Professor Andy Kent Non-Executive Director (Chair) Dr Ali Hasan Non-Executive Director Ms Barbara Greenway Non-Executive Director (from 09.40) Dr Emma Whicher Medical Director Ms Vanessa Ford Director of Nursing and Quality Standards Ms Dawn Chamberlain Chief Operating Officer
In attendance: Mr Peter Hughes Interim Head of Risk Ms Carol Anne Brennan Service User Representative Ms Christine Lewis Carer Representative
Additional Ms Elizabeth Jones Infection Control and Physical Health Nurse Attendees: (Agenda item 8: Infection Control Annual Report only) Ms Victoria Gregory Patient Experience Manager (Agenda item 9: Complaints and Compliments Annual Report 2015-16 only) Mr Niall Smyth Head of Health & Safety and Emergency Planning (Agenda item 10: Health and Safety Annual Report only)
Observer(s): None
50-16/17 Apologies for Absence and Introductions
50.1 Apologies noted from:- • Mr David Bradley (Chief Executive); • Ms Patricia Hymas (Associate Director of Quality, Governance & Risk) • Mr Ian Higgins (Named Nurse for Safeguarding Children and SI Lead Investigator); • Mr David Parry (Merton CCG).
51-16/17 Minutes of the meeting held on 31 May 2016 QSAC(16-17) 2A
51.1 The minutes of the meeting held on 31 May 2016 were reviewed and approved as being an accurate record of the meeting.
52-16/17 Action Tracker/Matters Arising QSAC(16-17) 2Ai
52.1 The Committee reviewed and updated the Action Tracker as follows:-
I. Action 2015/16: 41 Dr Whicher updated that the Annual Meds Report is being presented to the Board on Thursday (07.07.2016). An action plan has been developed. Follow-Up Action: Dr Whicher was asked to distribute the link to the Annual Meds Report to the QSAC members.
II. Action 2015/16: 43 Ms Ford confirmed the review of the QSAC work planner had been completed. Future reviews will be ongoing. However, this specific action is noted as complete.
SWLSTG minutes of the Quality and Safety Assurance Committee, 05 July 2016 (Part A) Page 1
III. Action 2015/16: 45 Ms Chamberlain explained how waiting times were reviewed and confirmed the Neurodevelopmental Services would be discussed during a meeting with the Commissioners later this month. Ms Chamberlain further explained this issue had been raised as a quality issues by CQRG. Dr Hasan questioned whether there was a potential to set up a voluntary additional funded service. Ms Ford noted assurance regarding waiting times was required.
Follow-Up Action: Ms Chamberlain is to provide a r eport to the next QSAC meeting following discussions with the CAMHS Commissioners.
IV. Action 2015/16: 47 Noted action complete.
V. Action 2015/16: 50 No progress noted. Dr Whicher to progress action with Ms Hymas and Mr Higgins.
VI. Action 2015/16: 56 Noted for review in September 2016.
VII. Action 2016/17: 01 Noted action complete.
VIII. Action 2016/17: 02 Noted action complete.
IX. Action 2016/17: 03 Noted area of development. Action to be closed for QSAC.
X. Action 2016/17: 05 Completion date revised to November 2016.
XI. Action 2016/17: 06 No update discussed.
XII. Action 2016/17: 07 Completion date revised to September 2016.
XIII. Action 2016/17: 08 Ms Chamberlain noted this action had been incorrectly allocated to her. Ms Ford requested to review the minutes of the meeting held on 3 May 2016. [06.07.2016: Post meeting note - minutes of the meeting held on 3 May 2016 reviewed by Ms Ford]. Update to QSAC as follows: This action has been referred to the new Workforce and Organisational Development Committee to progress. Noting QSAC strong support of service user and carer involvement in MAST training.
XIV. Action 2016/17: 09 Noted action complete.
XV. Action 2016/17: 10 Ms Ford explained an increase in the use of Section 2s had been noted by the Integrated Governance Group. Ms Ford explained this was a peak and not a risk and it had been reviewed at the MHA Law meeting. Ms Ford confirmed a report will come back to QSAC in September/October 2016.
XVI. Action 2016/17: 11 Dr Whicher requested further clarification of the action. The Chair clarified the
SWLSTG minutes of the Quality and Safety Assurance Committee, 05 July 2016 (Part A) Page 2
issue was around the information being provided to services users about their medication, the side effects and t he opportunities offered to service users to raise concerns. Ms Lewis confirmed it is important to manage a service user’s experience. Ms Brennan confirmed this issue had also been raised at a recent Patient Quality Forum.
XVII. Action 2016/17: 12 Update on agenda for discussion during today’s meeting.
XVIII. Action 2016/17: 13 Noted action complete. Dr Whicher confirmed her PA, Clara Williams, will attend to minute the Patient Quality Forum when Anselm Lionel-Rajah is unavailable.
XIX. Action 2016/17: 14 Ms Ford confirmed a S moke-Free Group has been established. A report is currently being prepared and will be presented to QSAC in september 2016. The concerns expressed by Ms Brennan on behalf of the service users were noted by the Committee. M s Ford explained this issue will be added to the agenda of the Patient Quality Forum for discussion. Ms Ford confirmed approval for the use of e-cigarettes had been granted by the Integrated Governance Group.
53-16/17 Quality and Performance Report QSAC(16-17) 29
53.1 Ms Chamberlain presented the report and explained she wished to draw the Committee’s attention to the national bed crisis. Ms Chamberlain confirmed there were presently no mental health beds available nationally.
53.2 Ms Chamberlain confirmed work was ongoing to establish the urgent care pathway. Ms Chamberlain noted an increase in delays experienced within Kingston & Richmond. Ms Chamberlain noted barriers to discharge should be reviewed within 72 hours. Dr Whicher confirmed there was a c onsultant workshop planned for September 2016 to review the impact of short stay admissions and to reduce the length of stay variation.
53.3 Ms Greenway questioned what support was being provided to those currently awaiting admission. Ms Chamberlain assured the Committee that all those awaiting admission were receiving appropriate care in A&E or within the community. The current breakdown is as follows:- • 3 patients awaiting Mental Health Act assessments. • 1 patient in the 136 suite. • 1 patient awaiting admission from A&E at Epsom hospital. • 2 patients were to be repatriated to the UK from France. T he two individuals had recently absconded from the Trust but had been located and det ained in France. Ms Chamberlain confirmed the UK has a reciprocal agreement within the EU at present. Ms Chamberlain confirmed the Virtual Risk Team were involved in the process.
53.4 The Chair acknowledged a better understanding of the drivers and the national picture was required. Ms Greenway commented, in her view, the current national position was scandalous. The Chair questioned at what point the Committee should become concerned. Ms Chamberlain explained the Trust had opened more beds (Ellis Ward), however, this had not sufficiently addressed the issues and bed management remained a concern. It was important to ensure that individuals were receiving the correct support. Ms Ford noted there was limited assurance to the Committee at present.
ACTION: For assurance purposes, the Committee requested that Ms Ford undertakes a review of incidents relating to bed management with a report to QSAC in October 2016.
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Ms Brennan questioned why there was a lack of beds within the Trust. Ms Chamberlain explained work was ongoing to reduce avoidable admissions and investment had been made in community services.
Ms Lewis explained it was important to note how these issues were discussed with patients, their families and carers. Ms Chamberlain confirmed a number of events were being set up by Mark Clenaghan for patients and their families to better understand the process. Ms Lewis requested the burden of care for carers and the families is included within the report.
Dr Hasan noted the current pressure and confirmed the increased clarity provided in the report was welcomed by the Committee but questioned what discussions had taken place with the Commissioners. Ms Chamberlain explained the Commissioners had provided non-recurrent funding for Ellis Ward and C QUIN funding for the street triage and Psychiatric Decision Unit. The current situation was being monitored via the Transformation Board with the CCGs.
53.5 Ms Chamberlain confirmed there was work underway within the community services following the recent CQC inspection.
53.6 Ms Chamberlain provided an update in respect of the recruitment of nurses. The focus is on recruitment and retention within the community services, with a programme of work currently underway.
53.7 The Chair noted the number of self-harm incidents had recently increased. Dr Whicher confirmed work was ongoing in building a r eporting culture within the Trust. T his information will be triangulated with more input from the Mortality Committee.
53.8 Ms Chamberlain confirmed a new style report will be presented to QSAC in September for review prior to the October Board meeting.
53.9 The Committee resolved to note the report.
54-16/17 Serious Incident Summary (May 2016) QSAC(16-17) 30
54.1 Ms Ford presented the report and confirmed the following for May 2016:- • 0 reports overdue. • 10 incidents added to STEIS. • 1 case required further information. • 7 reports submitted. • 5 reports closed. • 0 never events. • 0 duty of candour breaches. • 1 Safeguarding Adult Review. • 1 Safeguarding Children Review.
Ms Ford reported on an inpatient death that had occurred last week. Ms Ford explained an update will be provided to QSAC next month. It was noted that the service user had physical health concerns.
The Committee resolved to note the report.
55-16/17 Integrated Governance Group (IGG) QSAC (16-17) 31
55.1 Ms Ford provided a summary of the IGG meeting and assured the Committee that the high number of safeguarding incidents reported for Wandsworth were due to the rise in awareness of incident reporting and escalation.
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The Committee noted the update and last set of approved minutes.
56-16/17 CQC Inspection Report QSAC (16-17) 32
56.1 Ms Ford presented the report. Ms Ford explained key dates as:- • 16 June 2016 - the final CQC report was published. • 25 July 2016 - the Trust will submit the Quality Improvement Plan to the CQC. • 27 July 2016 – Quality Summit. • Early September 2016 – the Trust will undertake mock inspections. • Late September 2016 - the focussed re-inspection will be undertaken. However, the Trust can request a delay of this re-inspection by two months.
Ms Ford confirmed the Trust had been given an overall rating as “required improvement”. Ms Ford explained there were four areas that had a n overall rating as “good”. Ms Ford also highlighted that the areas of “caring” and “ well-led” were rated “good”.
56.2 Ms Ford highlighted the key areas for improvement were supervision and administrative processes within community services.
The Trust received no enforcement actions, 5 new requirement notices, 15 “must do’s” and 78 “should do’s”. Overarching themes included:- • Supervision; • administrative processes; • restrictive practice; • adult community; • rehabilitation pathway; • risk assessments and care plans; and • medication transportation.
56.3 Engagement with service users in the implementation of the improvement plan will be via the Patient Quality Forum.
56.4 Ms Ford wished to note thanks to the Trust staff for the work undertaken during the CQC inspection. The Chair wished to also congratulate the senior Exec Team in respect of their “well-led” rating.
The Committee resolved to note the Report and approve the content of the improvement plan which was considered in detail.
57-16/17 Infection Control Annual Report, including Medical Devices and Tissue Viability Report QSAC (16-17) 33
57.1 Ms Jones attended to presented the Infection Control Annual Report. Ms Jones confirmed the report will be presented to the Board on 7 July 2016.
57.2 Ms Jones confirmed the key achievements for 2015/16 as follows:- • A reduced loss of bed days due to outbreaks as a result of prompt reporting by staff. • Maintaining the zero trajectory targets for MRSA bacteraemia and C lostridium Difficile toxin infections. • A reduction in sharps injuries. • Overall infection control audit scores achieving 85%. • The appointment of a M edical Devices Officer, who has compiled the Trust’s Asset Register and is undertaking management of the Trust’s medical equipment. • The prevention of pressure ulcers and t he management of tissue viability has resulted in a reduction of over-ordering of inappropriate dressings.
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• The appointment of an Infection Control Doctor.
57.3 Ms Jones reported good progress had been noted in relation to anti-microbials and no loss of bed days were reported in the period due to infection control issues.
57.4 Ms Jones reported a CQUIN target of 75% of all frontline staff to be vaccinated against flu. This requires Trust-wide engagement if this is to be achieved.
57.5 Ms Jones confirmed there was a workstream reviewing dental practices. The review was being by Ms Ford as DIPC.
ACTION: The Committee agreed to receive the dental suit update report in September.
The Committee resolved to approve the Annual Report.
58-16/17 Complaints and Compliments Annual Report 2015-16 QSAC (16-17) 34
58.1 Ms Gregory attended to present the Complaints and Compliments Annual Report 2015- 16. Ms Gregory reported the highlights as:- • 502 complaints received. The figures have been broken down per directorate within the detail of the report. • 1,651 compliments received. This indicates an improvement in staff engagement. • Communication is the top upheld theme, followed by clinical treatment. • Complaints handling performance indicators met (save for March 2016 due to lack of Executive sign-off for complaint responses). • 42% of complaints were well-founded (upheld or partially upheld), 46% were not upheld. • 2 referrals to the Ombudsman. In one instance, Crocus Ward had misplaced the medication card for a p atient. T here was, therefore, no assurance that the medication had been reviewed and the Ombudsman awarded a financial remedy to the complainant. • The Patient Experience team received national recognition at the PEN awards. • Developments underway to address customer service and communications. • The complaint handling survey has been launched.
The Committee requested that the number of patients is used as a d enominator in addition to the number of bed days.
58.2 Ms Ford requested that the Committee acknowledge the high standard of work being undertaken by the Complaints department.
The Committee resolved to approve the Annual Report.
59-16/17 Health and Safety Annual Report QSAC (16-17) 35
59.1 Mr Smyth attended to present the Health and Safety Annual Report.
Mr Smyth assured the Committee that appropriate workstreams were in place.
Ms Ford commended the Health and Safety department for their completion of ligature assessments and the action plans. Ms Ford noted a signification level of assurance had been provided to the Committee.
The Committee resolved to approve the report
60-16/17 Risk Register QSAC (16-17) 37
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60.1 Mr Hughes presented the Risk Report. Mr Hughes confirmed the top risk (risk score of 16) remained in relation to bed pressures. Mr Hughes reported that if the Trust mitigations continue to be successful and bed pressures continue to be managed without recourse to any placement to the private sector, the risk score will be reduced during the next quarter.
Mr Hughes confirmed he continues to update the report and to ensure that actions are added within one month.
Dr Hasan challenged that the second highest risk appeared to have been last updated in October 2015. Mr Hughes to review.
• ACTION: The Committee agreed to revise the agenda to move the Risk Register to the first agenda item to ensure focussed attention.
The Committee resolved to note the report.
61-16/17 Any Other Business
61.1 No other business issues raised.
62-16/17 Date of Next Meeting:
62.1 Tuesday 30 August 2016, 09:30-13:00, Meeting Room 1, Trust HQ, Building 15
Meeting closed 11:50.
Professor Andy Kent Chair, Quality Safety and Assurance Committee July 2016
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Trust Board Quality & Performance Report August 2016
Date: Status: Final Current Version: 1.0 Transparency : Public Commissioned by: Clive Field, Director of Finance and Performance
Distribution & approvals history
Version Distributed to Date Action required / taken 0.1 Vanessa Ford 28/09/2016 For additions 0.2 Dawn Chamberlain 29/09/2016 For final edit and sign off 1.0 Trust Board 30/09/2016
Contents
1. Introduction 2
2. Executive Summary 3
3. APPENDIX 1: Monitor Performance 34
4. APPENDIX 2: Safe Domain 39
5. APPENDIX 3: Effective Domain 46
6. APPENDIX 4: Caring Domain 48
7. APPENDIX 5: Responsiveness 51
8. APPENDIX 6: Well Led 57
9. APPENDIX 7: Benchmarking 60
10. APPENDIX 8: Exception Reports 63
11. APPENDIX 9: Explanation of Data Quality Assurance Scores 82
12. APPENDIX 10: Summary of Assurance against Performance Indicators 86
13. APPENDIX 11: Waiting Times by Directorate/Team level (July & August) 92
14. APPENDIX 12:CQUIN and Quality Account 97
15. APPENDIX 13: CQC Intelligent Monitoring Report (Feb 2016) 107
16. Appendix 14: CQC Improvement Plan 108
17. Appendix 15: Acute Care Pathway Dashboard 112
1
Introduction
The Quality and Performance Report provides a monthly position on the Trust’s integrated quality and performance metrics. The dashboard is set out in six domains: Monitor, and the five Care Quality Commission (CQC) domains of Safe, Effective, Caring, Responsive and Well Led.
Narrative is provided on ar eas of good performance and concern, together with trend analysis and benchmarking where available.
In order to provide assurance on data validation, a RAG-rated system of evidenced assurance against every metric can be found in appendix 10.
2
Executive Summary
The Trust Quality and Performance Report reflects the five domains defined by the CQC together with the national Monitor targets – please refer to the Quality and Performance Report and associated Quality and P erformance Dashboard in relation to this Executive Summary. References such as ‘M1’ refer to the measures on the Dashboard.
A number of new metrics have been added to the Performance and Quality Dashboard for August 2016 following a r eview of quality metrics by the Director of Nursing and Quality, Governance Department and the Information and Performance Department.
The metrics reported in the Safe domain now incorporate a more comprehensive review of levels of harm. The incidents relating to self-harm now medication errors will also incorporate information on the levels of actual harm (low to severe) recorded. Additionally, serious incidents reporting has been expanded to include serious incidents not reported on STEIS and the mortality levels for clients that have deceased within 6 months of discharge from Trust service are also now reported. The majority of the deaths within six months of discharge will be from natural causes but all deaths are reviewed to ensure there were no missed opportunities. Such cases will be scrutinised by the Trust’s Mortality Committee and also by the Director of Nursing.
The Trust’s restrictive practices (reported in Caring Domain) are now reported in more detail. The use of rapid tranquilisation, prone restraint, naso-gastric feeding and seclusion will now be reported separately following recommendation by the Director of Nursing and will receive scrutiny on a m onthly basis by Physical Intervention Lead. Reporting by exception will still be provided especially when performance is outside the normal range (e.g. prone restraint in this report). The volumes recorded will vary month on month which can be a reflection of the client acuity/presentation at the time of reporting so as a c onsequence there are no thresholds assigned although mean reporting is incorporated in the dashboard and in the charts further on in this report.
The metrics relating to absconds (reported in Responsiveness domain) have been amended to include all inpatient wards except the rehabilitation wards of Phoenix and Burntwood Villas and the hospital hostels. The metric has been refined to only report absconds that are greater than twelve hours.
Key risks – Quality, Finances and Reputation:
Care Quality Commission (CQC) update
The Board agreed on 1st September to proceed with the focused re-inspection by the CQC on 27th & 28th September to home treatment teams, older people community teams and Crocus Ward. The visit focused on supervision, medication management and administration and the CQC provided verbal feedback at the end of the inspection. They thanked the staff for their warm and professional approach and commended their hard work. They were impressed by the level of significant improvements made in all three areas and verbally confirmed that the trust had met its regulatory requirements meaning that the Trust should be rated as good. The results and conclusions need confirmed through the CQC internal assurance processes and they will provide a written report and c onfirmation in the next 6 weeks.
Supervision
3
It was agreed at the July Board that levels of staff supervision would be added t o the Performance and Quality Dashboard. An electronic system to record details of individual supervision was launched at the end of July 2016.
The Trust met the 85% target for supervision on t he 26th September 2016 and the teams visited by the CQC all exceeded 95% compliance for supervision. A questionnaire on the quality of supervision has been introduced to provide further assurance in terms of staff experience of supervision. Please see Appendix 14 section for additional information on supervision.
Medicine Management – the CQC advised that the trust must ensure good medicines management practice, ensuring the safe transportation of medication between the team bases and patient’s homes and keeping a record of medicine stock levels.
The Trust put the following mitigations in place to address.
• Lockable bags in place and being used – assurance provided by spot checks by Matrons. Staff have indicated the ordinary look of the bag is reassuring as it is not likely to be linked with carrying medication. • Stock medicines management in the community – an audit has confirmed all required procedures and process are in place.
Administration – The CQC have advised that the trust must ensure the Kingston teams have effective administration support. This is to ensure all letters are sent to patients and GPs in a t imely manner, and i nformation needed t o deliver care is stored securely and available to staff when they need it.
The Trust put the following mitigations in place to address.
• The establishment of an Administrative Support Services Manager and [professional structure for administrative staff across the organisation to allow for regular supervision and annual Performance and Development Reviews (PADR’s).
4
• The creation of administration hubs to ensure administrative efficiency. The hubs are currently in Harewood House and K ingston& Richmond Services with Sutton & Merton to follow. • Administrators aligned to teams with buddying system to manage sickness and annual leave cover. • Creation of an admin handbook to include standard operating procedures • Customer care e-learning module created, launched 26th September and over 60% compliance achieved at the time of writing. • IT software enablement of letters through digital dictation. This includes auto transcription which is being phased in across all directorates (as part of the Big Hand project) this will provide efficiencies in the generation and timely completion of letters.
It has been clearly identified by both the CQC and the Trust that focused quality improvement work is required in our working age adult community services. The trust with the CCG’s agreed the principles of a community modernisation programme over two years ago and whilst some positive local steps have been taken in terms of implementation, for example single point of access. However some of this work has not occurred at the scale and pace required in order to consistently improve and m anage the resources within the community. Some of the barriers have occurred in relation to commissioning intentions, other have been in relation to cultural and practice changes.
Building on the success and learning from the quality improvement work undertaken in the acute care pathway the Trust is now undertaking a similar model for the community services. The Director of Nursing will be the SRO for community clinical standards and the Chief Operating Officer for the demand and capacity review and system changes. The programme will report to the CCG Transformation Board to ensure the commissioners have the appropriate level of oversight..
Below is a high level summary of the work streams for the community quality improvement programme:
1. Commission Mental health strategies to Chief Operating Dec 2016 review demand and capacity within the Officer community adult services 2. Implementation of the systems and Chief Operating March 2017 processes agreed through the Officer community modernisation work stream that are already in progress 3 Full Quality review-analysing all current Director of Nursing Nov 2016 quality metrics and producing an assurance report with clear recommendations 4 Establish clear minimum practice Director of Nursing Dec 2016 standards which will inform the with support of development of Quality metric Clinical Directors and dashboard to be presented on a senior clinicians monthly basis to QSAC and to track through to the quality and performance board report. 5 Visit top performing community ) Dec 2016 services and bring back the learning to Director of Nursing
5
inform future service development with support of Clinical Directors and senior clinicians 6 Ensure that clear governance Chief Operating Dec 2016 frameworks are in place and embedded Officer at team level, through to directorate (Standardised agenda’s and monitoring) 7 Focused community services Chief Operating Oct 2016 recruitment and retention plan Officer/ Director of • Building on the workforce and HR recruitment and retention strategy • Weekly Agency control panel 8 Implementation of service line Chief Operating Jan 2017 management Officer
An overview of quality and per formance measures in relation to community services is provided below.
Targe 2015 Year to Date Code Indicator Actions to Improve t -16 2016-17 Community follow up within seven days 95.7 M1 95% 96.1% On target for 16/17. post inpatient % discharge
The Trust has implemented a report at 9 months to assist teams to prevent CPA review cases from breaching at 12 % Annual CPA 99.1 M2 95% 98.7% months. Review %
The Trust remains compliant and benchmarks as having the best performance in London. Achieved in 2015/16 and Compliance performance being maintained with Monitor 100 in 2016/17. M7 Learning 100% 100% % Disability A full update is provided in the Standards Monitor section of this report.
Achieved in 2015/16 and YTD Referral to performance is compliant but Treatment – position has deteriorated. Incomplete M10 pathway 92% 97.7% 92.8% Metric has been am ended to (waiting to exclude those services that commence provide assessment and not treatment) treatment following guidance from NHS England
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Achieved in 2015/16 and Face to face M12 95% 97.0% 98.0% performance being maintained gatekeeping in 2016/17. Achieved in 2015/16 and performance being maintained % CPA patients in 2016/17. C16 in settled 61% 86.1% 85.6%
accommodation The Trust has benchmarked as the best in London. Achieved in 2015/16 and performance being maintained % CPA in 2016/17. C17 Patients in 7.1% 9.9% 9.4%
employment The Trust has benchmarked as the best in London. The Trust however has archived the old crisis plan forms and has moved to reporting against collaborative 85.2% crisis plans. Performance is Collaborative (Year on an upw ard trajectory here C19 82.0% 83.2% Crisis Plan end and is monitored at DPR. 90%) A trajectory target has now been set and the Trust expects to achieve compliance in q4 16/17. There has been an overall improvement in performance against this metric since autumn 2015 following the introduction of a single point of access in Kingston and Richmond and tighter referral % adult CMHT management protocols in clients Sutton. R2 80% 74.0% 82.0% assessed within 28 days The Wandsworth commissioners have agreed to a single point of access model which commenced at the end of September 2016.
YTD position is currently compliant with target.
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In 2015/16 the Trust met its compliance target for seeing clients within seven days of referral.
% Urgent 71% The target for 16/17 is more referrals to be 15-16 challenging at 90% and adults seen within 86.5% R3/R4 - and older people are now seven days for WAA only 90% reported separately. The adults and 16-17 denominator is generally low older adults on this indicator and in August 2016 four breach cases were reported; all breaches are subject to audit and were been seen. % CAMHS clients seen Achieved at year end (87.9% R8 80% - 90.1% within 8 weeks in March 2016) and into 16/17. of referral Reporting has been widened to % CAMHS incorporate urgent referrals via Urgent referrals R9 95% 88.3% 89.6% CAMHS Liaison – All breach seen within 5 cases are subjected to audit working days and were subsequently seen.
Demand for Adult Acute beds (E4, E5 & M8)
Over the last year there has been an unpr ecedented demand for acute mental health beds nationally and this has impacted London in particular. The demand for adult acute beds in 2015-16 and into 2016-17 has exceeded the Trust bed capacity and t he Trust has had to admit clients to beds in other NHS Trusts and private hospitals.
Following the opening of Ellis Ward on the Springfield site in April 2016 there has been a reduction in the numbers clients admitted to East London Foundat ion Trust and private hospital; it is a little early to draw conclusions and the Trust continues to monitor the impact. Bed Occupancy including out of area use and excluding leave is presented in the chart below. T he chart shows an increase in bed oc cupancy in November 2015 ( week 23) following the introduction of recording of out of area placements on the Trust’s RiO clinical system. The chart shows occupancy rate at a consistent level above 106%; week 16 16/17 has the highest recorded occupancy rate at 114.3%.
There has been a significant decrease in demand for acute beds since mid-August. It is too early to determine whether this is as a r esult of the more effective bed management measures developed through the Urgent Care Pathway project, or a result of a more random variation. Whilst the sustainability of this decrease is unclear at present, the imminent Urgent Care Pathway developments such as Integrated Out of Hours Crisis Service, Psychiatric Decision Unit and C risis Recovery Cafes will improve the ability of the Trust to sustain people in crisis in the community, and thus create further downward pressure on demand for beds. It should be no ted that the bed occupancy chart is reflective of September 2016’s recent decrease in occupancy – the decrease should start to reflected in admissions (next month) and length of stay (although there will be a reporting time lag in length of stay as it is reported as rolling 12 months.
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As the demand for beds exceed the total number of available beds there have been periods where adult acute clients have been placed in older people’s wards and this has been controlled through a clear clinical protocol. In 2016-17 there have been just two days used by adult acute clients on older people’s wards.
Adult acute admissions have average 117 per month over the last 15 months. The last four months has seen an i ncrease in admissions (Ellis ward opened in April 2016) however it should be not ed that the Trust had 13 admissions to ELFT and non E LFT wards in June which is a reflection of high demand. Admission rates will be further reviewed in the coming months.
During those times of excessive demand for adult acute beds the Trust does have to use the Specialist Services wards of Seacole and B luebell (see chart below) in order to ease pressure for beds. There has been no usage adult acute usage in Specialist wards since July 2016.
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Length of Stay Increase and Variation across Acute Wards
Over the last year the average length of stay has been increasing and the rate of increase has slowed over the last three months. It should be noted that mean over the last rolling twelve months has risen from 30.3 – 36.7 days.
The Trust continues to implement a number of improvements to the acute care pathway system and these are articulated separately in the Urgent Care Pathway Implementation Plan also included in the August Trust Board papers.
The Trust has undertaken an audit to understand barriers to discharge which impact on length of stay. The audit considered current patients with a length of stay of over 180 days and patients discharged during 2015-16 following duration of stay that exceeded 350 days. The audits found that severity of need and resistance to treatment rather than difficulties in discharging to appropriate accommodation were the main factors contributing to the length of stay. Those clients with the longest length of stay tend to be resistant to treatment and this requires a long period of admission. These clients tend to have a diagnosis of schizophrenia/bipolar disorder and unde rgo numerous medication trials. The findings suggested that barriers to discharge once medically fit were not a factor in these cases. An audit on those patients with longest length of stay will be repeated on a quarterly basis as sample sizes were low.
The Trust has undertaken analysis on client with a length of stay greater than 90 days. The chart below highlights the increase in average length of stay for this cohort; the mean level increasing from 156 – 168 days. Discharge levels for the cohort have remained constant.
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Delayed Transfer of Care:
In recent months there has been an increase in the number of delayed transfer of care patients in beds between 90 and 180 days, particularly in Kingston and Richmond. At the time of writing there were seventeen delayed transfer with Richmond having the highest number of delays at (7) clients. In Richmond there have particular difficulties in finding suitable housing/placement/residential care for Richmond residents who are a del ayed transfer of care. The Trust continues to work collaboratively with both local authority and CCG commissioners. The T rust is trying to further engage Richmond Housing (i.e. to have representative at Trust weekly DTOC meeting).
Monitoring the Impact of Urgent Care Pathway Developments
In Kingston and Richmond a new Crisis called the Retreat opened in May 2016. Based in New Malden the service is for clients with relative low acuity and who can be supported via HTT whilst in the crisis house. The service is run by Comfort Care who specialise in providing supported housing for individuals with mental health needs.
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The new service will need further embedding into the acute care pathway in the coming months to ensure use is further increased and the impact of preventing admissions to adult acute bed can be further reviewed. In 2016/17 thus far 20% of adult acute admissions are for this short duration (0-5 Days). Increased use of crisis house should assist to reduce the number of short stay admissions.
Because bed pressures can be affected by a number of factors which will include discharge planning, average length of stay and prevention of admission.
The Trust commissioned Birch Foundation to provide accredited training to a group of frontline leaders across the acute care pathway to develop lean system solutions locally; the output of their work was presented to the Chief Operating Officer and M edical Director in June 2016 and this work will be taken forward through the Purposeful Admissions work- stream under the Urgent Care Programme Board – details are set out in the Urgent Care Pathway Implementation Plan see the July Trust Board papers.
As part of the acute care pathway work supported by Birch a better understanding of variation in length of stay is being progressed through workshops with inpatient consultants; the first workshop was held in June 2016 i n partnership with Birch Foundation and t he second workshop is planned for September 2016. It has been agreed as an output from the first workshop that length of stay variation needs to be presented across a 2-year timeline to understand trends and compare across wards robustly.
The acute inpatient consultants will receive revised dashboards in August and final versions will be agreed in September; these will be presented as ‘run charts’ of data over time that will distinguish between predictable variation in performance and unexpected variation which may have been caused by unforeseen events. The reports will allow consultants to ‘drill- down’ into the data to view outliers in the data and address directly.
The agreed metrics for the revised dashboards will include average length of stay, readmission rates, delayed transfers of care and patients under section. The reports will allow for the comparison of a single set of metrics across all wards as well as showing all indicators for a single ward. (see appendix 15).
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There is significant work being progressed across London in relation to understanding urgent care for mental health and to developing collaborative plans to mitigate the bed pressures; the Trust’s Chief Operating Officer and Medical Director are both in London-wide leadership roles in relation to this work.
Recruitment and Retention
Inpatient Nurses (W5)
The London H uman Resources Development Network highlight significant issues in recruiting to nursing posts in community services and general practice, mental health, rehabilitation, CAMHS, specialist children’s nursing, neonatal nursing, Emergency Nurse Practitioner’s & Advanced Nurse Practitioner’s in urgent emergency care.
The Trust’s vacancy rate at the end of August 2016 was 18.6% however nursing vacancy levels remains high but improved at 24.5%. Additional issues linked to nursing recruitment are highlighted below.
Previously there had been an individual and not a coordinated recruitment drive across community teams often resulting in no appointments. Selection criteria and thresholds from the hiring managers at times have been too restrictive. The Trust has introduced standardised testing to further assist with the selection process. Trust turnover rate for nursing staff has decreased to (16.3%) above the above the Trust’s 15% target. The chart demonstrates an upward trend in turnover from October 2014 with an overall mean of 16% which rises to 19.1% when applied from April 2015. T here has been m onth on month decline since February 2016 and August is just above target. position is in line with overall mean. Wandsworth and Kingston and Richmond directorates were below the 15% target in August whilst Sutton and Merton was just above at (17.2%). Specialist Services still experience the highest level of nursing turnover at (19.3%). It should be noted that Specialist turnover has seen a significant (5.5%) decrease in nursing turnover since June 2016.
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The chart above highlights increase in nursing staff turnover in 2015/16 across all directorates. The Trust is conscious of the need to retain staff and recruitment and retention strategies are being developed and were issued to Trust Board in August 2016. In addition a preceptorship programme for newly qualified nursing staff is in place in order for them to receive developmental support whilst starting their careers. The current London t urnover threshold for nursing is 14.28%.
The rise in turnover has increased this has led to an increase in the nursing vacancy rate which has slightly increased to 24.5%; (0.1% higher than July 2016). As clinical services are not fully established there has been increased agency usage/spend although the Trust has moved to mitigate the financial risk by increasing the numbers of staff available via the staff bank. In May 2016 the Trust spent average agency spend was £476k which is £40K (9.1%) higher than the monthly average in 2015/16.
The number of nurse starters and leavers by month are shown in the chart below. The Trust had higher numbers leaving over the last two years (218 starters to 252 leavers) April 2014 – August 2016. However from January 2016 this trend has altered where the number of starters has been higher than the leavers (68 starters to 55 leavers).
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Since the start of the recruitment campaign in January 2016 the trust has made 171 offers of appointment to prospective candidates of which 91 (53.2%) have been recruited; 9 (5.3%) of the offered have a s tart date booked; 38 (22.2%) are in pre-employment checks/ready to start; and 33 (19.3%) of candidates have withdrawn from the process. It is expected that the numbers starting will further increase as the recruitment campaign progresses further into the year.
Nurse Role Offered Started Cleared with Checks OK Pre- Employment Start Dates Employment Booked Checks Inpatient Bank 2 18 7 0 7 Band 5 Inpatient substantive 102 52 7 7 16 Band 5 CPN Band 6 40 26 2 0 4 HTT Band 6 9 6 0 0 2 Community Team Leader 2 0 0 0 0 Band 7 Total 171 91 9 9 29 Please note: as figures reported cumulatively (+/-) denotes change from previous month).
It should be noted that there has been over reporting of the Nursing Recruitment figures in previous reports. A review on the data has found that duplicate entries had been added in some instances. The new Nursing Recruitment Manager has re-reviewed and assured the revised figures. Systems for monitoring the figures will be subject to tighter scrutiny going forward and will have monthly oversight from the Nursing Recruitment Manager. Actions to Mitigate Vacancies
• In-year the Trust introduced assessment centres to improve the candidate selection processes and so increase the number of nurses being recruited. The frequency of assessment centres has increased from one per month to three times per week. • The nursing recruitment process has been redesigned and the Trust now interview nurses within one week of applying for a job. • The recruitment team has also been g iven short term funding for two Band 4 HR Administrators.
In addition there is currently a nursing recruitment campaign for five hard-to-fill positions:
1. Inpatient Band 5 Registered Nurses 2. Bank Band 5 Registered Nurses 3. Home Treatment Teams Band 6 4. Community Nurse Practitioners Band 6 5. Community Team Leaders Band 7
The Human Resources Team have produced a currently developing the recruitment and retention strategy that was approved at EMC on 21/06/16 and will be discussed during July’s Board meeting with a schedule for implementation in quarter two 2016/17.
The recruitment campaign is now live on various forms of social media and the Trust has high quality brochures and information in place.
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The following actions relating to strategy development and recruitment fairs are highlighted below.
• The Trust has developed a recruiting strategy for all other Trust staff groups. The strategy was launched in August 2016/17. • The Trust has developed a retention strategy to slow down the pace of leavers. The strategy was launched in August 2016/17
Agency Use
• Community agency use excessive overall - £4.6m YTD • Corporate agency spend excessive for size - £1.4m YTD • Inpatient agency use down - £1.2m YTD • Agency spend for Month 5 - £1,440k against internal target of £1,271k and NHSI target of £666k • Month 5 agency = 14.9% of pay budget against internal target of 13.1% and NHSI target of 6.9% • Immediate action required involving operational, corporate and HR collaboration on solutions • Key Issues: – Agency control system established – returns by 30th September 2016 – Community recruitment campaigns to go-live ASAP – Recruitment and retention incentives to be signed off at EMC 27th September 2016
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• Total Agency Spend • Of total agency spend some £4.6m (65%) in Community • £1.4m (19%) Corporate and £1.2 (16%)m Inpatient • Community Analysis • Of Community spend of £4.6m, biggest area = Nursing with £2.0m (43%), includes small HCA amount • £0.9m (20%) relates to Psychologists with a further £0.2m (4%) for Psychotherapists • £0.7m (14%) for non-clinical staff (A&C and Managers) • £0.2m on AHPs and £0.2m on Social Workers • £0.1m on other staff (mainly interpreters') •
Actions and Next Steps to Reduce Agency Use
• Immediate focus on Community and Corporate agency use • Agency Control Panel established 2nd September, chaired by Chief Operating Officer • Agency control forms launched 20th September, returned by 30th September; both current and new agency • Criteria agreed: – Direct impact on patient safety – Statutory post – Spend to Save • Transfer of agency staff to bank • Terms of agency transfer tba EMC 27the September • Community Recruitment and Retention group established 2nd September also chaired by Chief Operating Officer; creative recruitment solutions being developed in partnership with HR due for sign-off at EMC on 4th October 2016
Waiting Times
Following guidance and discussions with NHS England and commissioners it is now agreed that the CAMHS Neurodevelopmental Service does not meet the definition of service that should be i ncluded within the referral to treatment metric. The Trust is compliant with Monitor target at 96.8%. Appendix 11 provides waiting time by team.
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All service users waiting over 18 weeks are regularly reviewed by the team manager and consultant. Personal contact is made with people waiting over 18 weeks and on occasions they are reprioritised based on need rather than by length of wait.
A summary of the final August 2016 position is below.
Board Assurance Framework (W9)
The Board Assurance Framework (BAF) is reported separately to Trust Board. The revised Quarterly BAF – now includes 3 Risks at red score (score 15 or above).
• A failure to provide consistent and responsive community services caused by an increase in demand, leadership vacancies and dependence on agency use resulting in not enabling recovery, escalation to crisis care and poor service user experience.
• A failure to achieve recurrent saving plans resulting in not meeting financial targets
• A failure to ensure regulatory compliance caused by inadequate review and monitoring processes resulting in regulatory action by the CQC and reputational damage
Directorate News
CAMHS
New dashboard comes on line for collecting outcome measures on the experiences of CAMHS by children and young people
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New ‘Transition service’ to be operated by the Trust for young people up to 25 years old commissioned by Wandsworth CCG
CAMHS Community Eating Disorder service operating from its new dedicated team base at Springfield and offering a day service for families from across SWL.
Wandsworth
Soft launch of single point of access on 26th of September for Wandsworth Community Secondary Care Services.
As a partner of the local Clinical Reference Group, Trust participation in a new programme with the local Carers Centre and Wandsworth Council to improve the experience of carers.
SilverCloud on line therapy has started in Wandsworth IAPT.
Trust submitted IAPT tender bid.
Kingston & Richmond
Street triage was launched in Kingston on Saturday 24th September.
A new Consultant for the Kingston Home Treatment Team commenced in post on the 1st September 2016.
Specialist Services:
NHS Wales CAMHS Tier 4 framework: We have been successful in joining the providers of inpatient beds (Aquarius, Corner House and Wisteria) when capacity in Wales is full.
We received very positive feedback from NHS Wales inspection of our medium secure wards. This forms part of the NHS Wales provider framework
BSL Charter award: Our CAMHS and Adult Deaf services have been assessed by the BDA against the Deaf Charter. The BDA were so impressed with our services that they have awarded the Deaf Charter PLUS a second certificate for ‘Mark of Excellence’. There is only one other service in UK that has received the Mark of Excellence award!
Avalon ward: The service received QED accreditation and NHSE has confirmed the service is not in derogation. The service is now expanding according to the business case following the successful recruitment of the full consultant establishment for the ward.
Wisteria capital works completed. Ward is now expanded from 10 to 12 beds. The ward is gender segregated, improved bedrooms and better dining facilities. The MHA CQC report for Wisteria ward following the unannounced CQC MHA visit on 2 September 2016. Overall it’s a very positive report and makes reference to new improvements too. Well done to the team!
Perinatal bid submitted as part of South London STP collaborative. The bid will cover the 5 boroughs plus Croydon
Performance Review Against Monitor Targets and the Five Domains
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An overview of performance against monitor and the five domain metrics is given below.
The Trust is compliant in 42 out of 62 (67.7%) of in-month metrics and 40 out of 65 (61.5%) on YTD metrics. Forecast position 44 out of 65 (68.0%) on metrics. Information on those metrics that are not compliant are given below.
Monitor: The Trust is compliant against all ten Monitor metrics.
Safe Domain: In-month the Trust is meeting nine of the twelve (75.0%) rag rated safe domain metrics. Please some metrics are not rag rated but included due to importance the metrics are:
Serious incidents (average / month) (inclusive of incidents not added to STEISS) (S6) Reported a month in arrears): This is not a rag rated metric however as linked to serious incidents and newly reported to board it is included in the executive summary. All serious incidents are subject to review at the Serious Incident Governance Group (SIGG) and a small number are deemed to require to be added to STEISS for root cause analysis.
There is an expectation that incidents are appropriately managed on the Ulysses system post review and subsequently managed down if required; this process going forward will be further assured through the pre SIGG Management Group.
Incidents Reported to STEISS (S3): In August 2016 thirteen serious incidents were recorded which is 8 above the overall mean which has increased to 5 per month over the period below. The number of serious incidents does fluctuate month on month but levels have increased in quarter 4 2015/ 16 and into 2016/17. R eported position can change post review by Serious Incident Governance Group.
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Medication Errors (S16): In August 2016 seven medication errors were reported and position is just above threshold (amber rated) there were no cases of medication with moderate harm recorded.
Falls Resulting in harm (S5): This is a two year Quality Account target that commenced in 2014-15 which aims to change behaviours among staff to improve the physical health of mental health service users on i npatient wards and put in place improvement programmes to respond to any harms or hazards identified. The indicator is based on the NHS Safety Thermometer and monitored by quarterly audits.
The numbers of falls resulting in harm has averaged 16 per month over the last seventeen months. However August 2016 saw a s harp increase in falls and a n exception report has been provided. For every fall the risk assessment will be reviewed and falls assessment updated.
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Allegation of physical violence towards staff from clients (by clients) (W8): August 2016 saw the continuation of an upward trend in numbers of violent incidents. A revised exception report has been provided.
All incidents of violence towards staff are reviewed by the Incident Governance Team. The nature and degree of harm and level of ongoing risk is reviewed and further information is sought either from the incident reporter or the manager who is responsible for managing the incident. A range of support and interventions can be provided by the Quality Governance Department. These include:-
• Confirmation that the staff who have been involved are being supported including physical health checks where required, access to staff counselling services, facilitated debrief, information and support with reporting the incident to the police where appropriate. • The trust Virtual Risk Team will offer support with reviewing and managing risk following an incident. In serious incidents this is offered directly from the Quality Governance department and can also be requested by teams themselves. This can also include input from the Management of Violence and aggression Lead, trust Security Lead and the Clinical Risk Modern Matron • The Quality Governance also offers support with facilitated debriefs and learning following incidents. • Incidents where staff have been physically assaulted or threatened and intimidated will be taken to the weekly SIGG meeting for review and discussion. Further information may be requested and a RCA level investigation may be initiated to identify further learning. • Where there have been a number of incidents reported in a specific area or the same patient or patient group are involved, this will be escalated to the Modern Matron and Operational Manager and also followed up by the VRT. • Continuing incidents and incidents of actual physical injury will be highlighted in the trust weekly Risk Intelligence report.
Effective Domain: Of the nine in-month metrics four are compliant (44.4%). The three non- compliant are:
Cluster accuracy/Quality (E2): Performance has improved slightly over the summer period to 86.7% following a long term deterioration but remains below target primarily
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due to high levels of expired or invalid clusters. An exception report was provided in May’s Board report and August position is in line with forecast.
The Mental Health Tariff Lead held a series of workshop in July 2016 and August with team managers. The aim was to provide training and s hare knowledge of cluster process. The following factors that impact on maintaining clustering performance were highlighted:
• Limited training available for clustering especially where there is high turn-over of staff - particularly in boroughs where there have been significant changes linked to service transformation and Section 75 changes. • High caseloads (as mentioned in the previous report, teams with lower caseloads have better performance in this metric e.g. Merton) • Issues specific to older adult services in relation to Clusters 18 and 19 which have been highlighted in previous reports and continue to be addressed.
The following actions were agreed in the team managers workshop: i. Team managers to use dashboard in team meetings ii. Supervision to include dashboard review of clustering iii. Protected time for practitioners to complete outcomes iv. Dashboard training to be arranged
% HONOS Assessed (Specialist Services) (E3): The performance has deteriorated and requires improvement.
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Twelve of the sixteen cases not HoNOS assessed are linked with Neuropsychiatry and Perinatal services. Breach cases will need audited and findings shared within the Specialist Services directorate.
Adult Acute length of stay (E4): Average length of stay has increased to 36.7 days (rolling 12 month metric) and position appears to be plateauing with an increase of only 0.5% over the last three months; a revised exception report was provided to the April Trust Board. Evaluation on l ength of stay has been pr ovided in key risks section.
Caring Domain: Four of the seven (57.1%) rag rate metrics were non-compliant in August in 2016. The non-compliant along with metrics new to reporting are included below:
Please note for metrics C2 – C5 (see below) there is no target threshold applied however exception reporting will be applied for cases that exceed the normal range – prone restraint being an example below. The metrics reported are all reported under the key metric heading of reducing of restrictive practice. Rapid tranquilisation and I ntensive Physical Intervention e.g. Nasogastric Feeding under restraint are new to Board reporting. There is limited data on rapid tranquilisation currently as months go by further trend analysis will be applied.
Rapid tranquilisation (C2): This is a new metric and as surance work is being undertaken by the restrictive practice group to ensure that incidents relating to this
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intervention are recorded correctly via the Trust Incident reporting system. There is a clear clinical protocol that all staff use following an i ncident of Rapid tranquillisation which includes debrief, physical observations and a review of the patients care plan. As alluded earlier in the exec summary this is audited monthly for quality assurances.
Intensive Physical Intervention e.g. Naso Gastric Feeding under restraint (C3): There has been a downward on reporting of Naso gastric feeding since March’s 2016 high point. The overall average for the period is 24 whilst average has dropped to 20.4 in 16/17. The peak in March/April was due t o the treatment of a client who required Naso Gastric feeding under restraint, the position on the ward has now changed as the client is now able to accept treatment.
Number of seclusions used (C4): Seventy episodes of seclusion were recorded in August 2016. It should be not ed that from June 2016 seclusion include incidents reported from Aquarius Ward which does not have a s eclusion room but does utilise “low stimulus time out” (where client is taken to a s afe environment away from other clients) for clinical safety reasons.
Prone Restraint (C5): Twenty three prone restraints were reported in August 2016 which is an increase of 7 and in excess of the expected range. An exception report has
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been provided. In future reports physical intervention metrics will be reported separately in Board in order to provide assurance on physical intervention levels and clinical practice.
The revised definition provided by the National Reporting Learning Service is that incidents of restraint that involve a service user being placed face down or chest down for any period (even if briefly prior to being turned over) should be de fined as prone restraint. Similarly, if a service user falls or places themselves in a face down or chest down position during a r estrictive intervention, this should be defined as a pr one restraint. All prone restraints are reviewed and f ollowed up by the Proactive Physical Intervention Lead. The increase in reported prone restraints is due to raising the awareness of restrictive practices and we have reviewed the reporting systems, there is still further work to be in order to refine the reporting process which is being progressed via Restrictive Practice Group chaired by the Deputy Director of Nursing. All prone restraints have been reviewed and were clinically necessary and done in the best interest of the patients.
Complaints responded to within 25 da ys (C8): The Trust increased target to 95% following agreements with commissioners. The Trust was 80% compliant in August 2016. The Trust incurred eight breaches in August which are summarised below.
Client Borough Ward/Team Breach reason 1 Kingston Kingston and Richmond Delay in receiving final sign off at Trust
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Assessment Team Head Quarters 2 Richmond Richmond Home Delay in receiving final sign off at Trust Treatment Team Head Quarters 3 Ellis Delay in service providing information 4 Carshalton and Delay in receiving final sign off at Trust Sutton Wallington Head Quarters 5 Ward 3 Delay in receiving final sign off at Trust Head Quarters 6 Wandsworth Rose Ward Delay in receiving final sign off at Trust Head Quarters 7 CAMHS Sutton CAMHS Delay in receiving information from service. 8 Specialist Avalon Service needed to re-review letter Services content which lead to slight delay (one day) in issue
Physical Health Assessments (C18): An exception report has been provided as performance has not improved.
Collaborative Crisis Plan (C19): The Trust is currently at 83% compliance against a year end 90% target for clients on CPA. Performance is on upward trend as shown in the following chart but is below trajectory requirement and rag rated amber currently.
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Responsiveness: Twelve of the fifteen year to date (78.5%) rag rated metrics are compliant in August 2016. The non-compliant are highlighted below.
% Urgent referrals to adult secondary care assessed within seven working days (R4): Position amber rated YTD but performance overall has improved over time. However in month position did deteriorate in August and a summary of breach cases is provided below.
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Client CCG Team Breach reason Progress notes indicate client was seen by Assessment Team 1 th on 7 day but this has not been booked or outcome. Appointment logged as urgent but appointment booked outside the 7 days. Assessment Team need to ensure such cases are 2 prioritised. If post screening appointments are deemed non urgent this needs to be amended on system prior to client being Merton Merton Assessment team seen. Attempt to engage within seven days – but contact unsuccessful – client subsequently contacted 3 who indicated they had improved mental state. Discharge to GP with advice given to client. Internal referral and seen in in junction with Traumatic Stress 4 Service. Team to review referral screening to ensure urgent tag is being appropriately applied. Attempt to contact client within seven day period for referral 5 East Wandsworth screening. Letter sent and client contacted team and client was subsequently assessed. Client contacted on day of referral and mental health and risk assessed – notes indicate that referral was non –urgent. Wandsworth Team to ensure appointment are Central Wandsworth and West booked and outcome as client 6 Battersea was contacted seen within seven day period; ensure referral urgency are reviewed post screening as this cannot be changed once client is seen.
% Urgent CAMHS Referrals seen within five working days (R9): Eight out of ten urgent referrals were seen within five working days. The two breach cases are highlighted below and both cases were consequently seen.
Client Borough Ward/Team Breach reason 1 Kingston Kingston CAMHS Tier 3 Client attended late for appointment which was inside 7 days and was unable to be seen – 2nd appointment also attended late. Client was subsequently seen on 9th working day. 2 Merton Merton CAMHS Liaison Client cancelled appointment seen on 7th working day.
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IAPT Recovery Rate (R15): IAPT recovery rate year to date is (47.1% which just 3% below target). Position does fluctuate month on month as demonstrated in the chart below with Wandsworth IAPT averaging 48% since April 2015 and Sutton Uplift at 44% since new service commenced in July 2015. An exception report has been provided
Well Led Domain: The Trust Board requested a further review on issues of non-compliance for the Well Led section. An update on the summary table is provided below.
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Indicator Indicator Target 2015/16 Year to Improvement Actions Code Date 16/17 The Trust received an elevated risk from CQC following the National Audit of Schizophrenia where Trust CQC monitoring of alcohol in-take Intelligent was below average. W1 Monitoring - 0 1 1
Elevated The Trust has implemented an Risks action plan to address. Only the CQC can lift the Elevated Risk. Action plan to mitigate is in place. As alluded to in key risks section the CQC provided the Trust with formal feedback of CQC its inspection in June 2016. Intelligent Five new requirement notices W2 Monitoring – 0 5 6 were issued (which gives the Requirement Trust a t otal of six). Notices Improvement plans to mitigate the requirements notices have been developed and progressed. Position compliant YTD – only one breach in target (February W3 % Sickness 4.6% 4.2% 4.1% 2016) reported in last two years. The Trust monitors reasons for leaving and encourages staff to complete an exit interview in order to understand the reasons behind staff leaving the organisation. The Trust is developing a Turnover W4 15.0% 16.7% 15.6% retention strategy which is due Rate to be launched in quarter 2 2016/17. A preceptorship programme for newly qualified nursing staff is in place in order to provide them with further support.
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Nursing recruitment campaign has been initiated.
Co-ordinated approach for recruitment i.e. nursing recruitment managed through Human Resources / assessment centres have W5 Vacancy rate 12.4% 19.6% 19.2% commenced and are now run three times per week
A new focus on Community vacancies has been launched. New recruitment and retention strategies were implemented in August 2016. Position improved over last to months to 86.0%.
In order to improve mandatory training compliance the following actions have been implemented:-
Additional classroom based courses providing a 25% increase in capacity for each course.
Where there is not enough internal capacity to deliver training this will be out sourced i.e. Safeguarding Children Mandatory Level 3 Training in 2016/17 is
and to be pr ovided by an external W6 95.00% 84.50% 86.0% Statutory provider.
Training Food Hygiene levels 2 and 3 is currently the biggest concern within MAST. T he e-learning package requires version 11 of internet explorer or Google Chrome to launch; neither are widely accessible in the Trust. IMT Department are testing compatibility with other key systems to address.
Service Directors with support from Human Resources Business Partners to develop action plans for areas of concern.
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Reporting commenced in July 2016 and the Trust achieved W7 Supervision 85% 86.8% th compliance on the 26 of September 2016. Financial Stability Strategy and Risk (FSSR) Higher deficit position than W9 – Calculated 2 4 2 planned impacted on the I&E in margin. accordance with TDA rules. The Trust operating plan for Earnings the year assumes a significant Before improvement in the run rate Interest Tax, from October onwards when 5.0 YTD Depreciation 14.7m the savings schemes are W10 Year end £3.5m and planned to be del ivered. In 14.3 Amortisation addition, mitigating action has (EBITDA) - been identified to address the £m shortfall against plan year to date
Currently slightly ahead o f 100% target but plan steps up Year end significantly from month 7. W11 Savings 64% 11%
(9% YTD) (Year end f orecast is 66% of
100% target to be met).
100% The Trust plans to spend the Capital. Year end capital budget in 2016/17 and W12 Spend as a 62% 12% will monitor progress on a % of plan (17%YTD) monthly basis. 13.6 Year 18.4 Cash will reduce by end of End W13 Cash - £m (target 17.6 year because of payments for
17.9) capital expenditure and PDC. 18.9 YTD
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Appendix 1: MONITOR PERFORMANCE
The Trust is compliant with all ten Monitor targets both in- month and YTD.
Seven Day Follow Up (M1): The Trust performance been above the national target of 95% for over two years. The consistent average level of performance is 96%.
% Annual CPA Review (M2):
NHS Digital (formally known as the HSCIC) adopted a revised methodology for this metric in the early part of 2016 and the Trust remains consistently above the target of 95% with an average performance of 98.7%. The Trust benchmarks amongst the best in the country.
However there remains a number of patients (on average about 30) who, at the end of each month, have been waiting longer than 12 months to receive a CPA review.
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The issue is routinely discussed at monthly Directorate Performance Review meetings and teams have been g iven enhanced dashboards to help them identify when CPA reviews are due. A summary of overdue CPA reviews in from June to August 2016 is shown below.
Borough Jun Jul Aug Total 34 23 29 Kingston 2 1 2 Merton 0 2 7 Richmond 4 8 6 Specialist Services 1 0 0 Sutton 23 8 8 Wandsworth 4 4 6
Learning Disabilities Monitor Standards (M7): The Trust is compliant against the six monitor standards:
• The Trust has a mechanism in place to identify and f lag patients with learning disabilities and protocols that ensure that pathways of care are reasonably adjusted to meet the health needs of these patients.
The RIO templates for recording learning disabilities and autism have been developed and currently being tested. The template is hyper linked to the Learning Disabilities and R easonable Adjustments form. The forms will be l ive on t he electronic care record system from 26th of September and will be accompanied by communication to teams. This coming quarter will see the development of Learning Disabilities Practice Standards.
• The Trust provides readily available and com prehensible information to patients with learning disabilities.
In the last quarter the focus has been on developing systems to enable us to comply with the Accessible Information Standard. The standard aims to make sure that people who have a disability, impairment or sensory loss are provided with 35
information that they can easily read or understand with support so they can communicate effectively with health and social care services.
• The Trust has pr otocols in place to provide suitable support for family carers who support patients with learning disabilities
The trust continues to obtain service user and carer feedback through RTF however this needs to be encouraged via the LD MH Governance group to ensure that consistent feedback is received from across all teams. Comments received in the last quarter are mostly positive. Through the recently appointed clinical lead, the Trust will continue to engage with carers as part of the wider LD transformation program ensuring that service changes are responsive to carer needs.
• The Trust has pr otocols in place to routinely include training on providing health care to patients with learning disabilities for all staff
The health needs of people will learning disabilities and autism continue to be highlighted in the Trust and in the last quarter this was done through the following:- • A one day event in July 2016 – “Skilling Up and not Dumping Down” (a service user led training in learning disabilities and autism). • A shortened version of Skilling Up and not Dumping Down for Trust leaders in September 2016. Trust Staff continues to be enc ouraged to undertake the learning disabilities e- learning and the Autism e-learning program provided via the London Borough of Sutton and open to all trust staff. Planning is progressing for the 2nd annual LD conference scheduled for the 19th of October.
• The Trust has protocols in place to encourage representation of people with learning disabilities and their family carers
The planned work to enhance the competencies of the LD champions will focus on engaging service users and carer’s to ensure a positive service user experience. By understanding the issues facing service users and their families, staff in local services, are able to reflect on their own and their team’s practice and implement adjustments to make this easier for both service users and carers.
This work will also be further enhanced through a 5 bor ough wide learning disabilities event planned for October 2016 as well as the imminent Green Light Toolkit re-audit.
• The Trust has pr otocols in place to regularly audit its practices for patients with learning disabilities and t o demonstrate the findings in routine public reports
Following the successful completion of the 2 year quality account and associated audits, the Green Light tool kit has now been incorporated into the Corporate Clinical Audit Programme as a yearly audit. Discussions are currently underway to agree the most appropriate NICE quality standards or guidance against which the LD MH services in the trust will be audited in 2016/17. This will ensure that the as well as auditing mainstream services, the LD MH services continue to work in line with best practice
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Delayed Transfer of Care (DTOC) (M8): The Trust continues to remain compliant and below the national target of 7.5% but there has been an upward trend since February 2016.
The increase relates to patients who are resident in Kingston and Richmond local authority as there is a lack of suitable housing/residential care within those London boroughs.
In week 24 there were 24 clients reported as a delayed transfer of care. The longest delays are subject to scrutiny at the weekly Executive Management Committee and the Chief Operating Officer provides senior management oversight on del ayed transfer of care.
LA Number of Total DTOC Days DTOC Range New patients DTOCS Kingston 3 81 6-38 1 Merton 2 232 41-191 0 Richmond 9 333 4-80 1 Sutton 1 31 31 0 Wandsworth 5 173 2-133 2
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Associate LA 1 24 24 0 Other LA 3(2) 340 102-136 0 Trust 24 1279 2-191 4
The Trust works collaboratively with commissioning groups and local authority colleagues to resolve delays relating to funding issue or the location of suitable placement/accommodation. This is further discussed under bed management section in the executive summary.
Referral to Treatment (M10): The Trust is compliant with the referral to treatment incomplete pathway Monitor target. (please see key risks section for fuller review).
Face to Face Gatekeeping (M12): The Trust performance remains above the 95% target with an average of 98%.
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APPENDIX 2: SAFE
The Trust is compliant in month on nine of the twelve (75.0%) safe domain metrics.
Incident Reporting (S1): There has been a continued increase in the reporting of incidents across the Trust since the successful implementation of electronic incident recording to support the adoption of a r eporting culture and performance remains well above target.
Number of lower level Patient Safety incidents (S2): Patient Safety data is published every 6 months by the National Reporting Learning System (NRLS). The Trust aims to be within the top 25% of Trust reporting as this indicates a good patient safety culture and has set a monthly target of 325 PSI’s per month in order to achieve this. The last published data shows the Trust as an “average” reporter. Whilst the number of incidents varies each month and the Trust consistently remains above target.
Number of lower level Patient Safety incidents (S3): The majority of patient safety incidents are of a low harm level with 340 out of 356 (94.7%) patient were recorded as no harm, near miss or low harm.
Number of low harm Patient Safety incidents (S4): In August there were 118 incidents of low harm patient safety incidents recorded.
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Number of moderate harm patient safety incidents (S5): In August there were 6 moderate patient safety incidents recorded; incidents types were linked to self-harm and falls.
Number of severe harm patient safety incidents (S6): In August there were six incidents of severe harm recorded; these cases were all linked to suspected suicide cases and subject to STEISS reporting.
Serious incidents average per month (inclusive of incidents not added to STEISS (S7); There were 89 incident reported YTD average is 46.3 per month – this is discussed in the executive summary section.
Serious Incidents (S8): In August 2016 thirteen serious incidents were reported on STEISS which is the highest number reported over the period April 2014 to August 2016. The average over the period is 5 per month.
The incidents that were reported in August are classified below.
STEIS Reported Incidents Number of Incidents % Unexpected / Potentially 9 69.2% Avoidable Death Unexpected / Potentially 2 15.4% Avoidable Injury* Other 2 15.4%
The reporting of deaths has increased, particularly in older peoples services, as a result of an increase in awareness of when a death should be reported.
The Governance Department will be provide a quarterly report to Board incorporating themes and learning from root cause analysis of serious incidents, complaints and real time feedback.
The Medical Director chairs the Mortality Committee where the data is reviewed and then shared with commissioners. The recent increase in unexpected deaths will be reviewed at the next Committee and any themes from incidents will reviewed and subsequently disseminated via the Integrated Governance Group.
40 The Trust benchmarks well nationally on both the numbers reported and timely completion of investigation of serious incident reports. The Trust is in the lowest quartile for the number of serious incidents reported (averaging 14 per 100,000 bed days (exc leave) plus face to face contacts) where national average is 26. Timeliness for completion of investigation has achieved 100% and is the best in London. The Trust is highlighted in red (T08) and other London Mental Health Trusts are green. It should be not ed that timeliness of serious incidents reporting has now moved to 60 days for all serious incidents.
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(Chart source NHS benchmarking).
Unexpected death - Suspected Suicide (S9): In August there were nine incidents of suspected suicide; these cases will be subject to STEISS and a root cause analysis investigation.
Unexpected death – natural causes (S10): There was unexpected death attributed to natural causes in August 2016.
Death of Clients within 6 m onths of discharge from services (reported month in arrears) (S11): In July there were 45 c ases against a monthly average of 45.8. The information is derived from notifications of death that have been recorded on the NHS National Spine and checked against any incidents reported and any relevant information on RiO. The Governance Department review each of these cases using a triage tool to check that appropriate clinical care was provided at the point of discharge from mental health services and/or death. It is the expectation that in nearly all cases death will be from natural causes but the review checks to ensure that there were no missed opportunities. The results of the review are scrutinised at the Mortality Committee and also by the Director of Nursing.
Falls resulting in harm (S12): See the Executive Summary section of this report as the number of reported falls in August was above the expected threshold.
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Self-harm incidents (S13): The monthly position was in line with the expected level of 40 although the mean remains slightly higher at just above at 42 per month. The outlier figure for June 2016 related to 2 in-patients who accounted for 44 low self-harm incidents and which was discussed in an exception report that was provided in The June Board report.
Self-Harm Incidents – low harm (S14): This is new to Board and in August there were 35 incidents recorded. Average position over last two years is 39.
Self-Harm Incidents – moderate harm (S15): In August there were four recorded incidents of self-harm resulting in a moderate level of harm. Three of the incidents related to an overdose of medication and resulted in the patients receiving treatment at A&E. Each service user was reviewed following the harm and appropriate plans put in place for follow up: one service user was admitted to an inpatient ward and two were followed up by an HTT. The fourth harm was an attempted suicide and is being investigated using RCA methodology and has been added t o STEIS. The average number of moderate harm incidents over the last two years is three per month.
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Self-Harm incidents – severe harm (S16): There were no incidents recorded.
Medication errors (S17): The number of reported errors was above the expected level and so is discussed in the Executive Summary section of this report.
Medication errors – low harm (S18): This is a new metric and six cases were reported in August
Medication errors moderate harm (S19): One case reported and discussed in the executive summary (see above).
Medication errors severe harm (S20): There have been zero cases reported this year.
Pressure Ulcers (S21): There was no pressure ulcers recorded in July or August 2016.
Number of Duty of Candour Breaches (22): There were zero duty of candour breaches reported in July and August 2016. .
Number of never events in month (S23): There have been no never events reported in July or August 2016.
Number of RIDDOR reports in month (S24): In August two RIDDOR incidents were reported which is in line with threshold of two.
Number of wards safely staffed (S25): No wards were unsafely staffed.
Risk assessment completed within 48 hours of admission (S26): The Trust is compliant on this metric at 95.0% having been under target in the previous two months.. A YTD summary reporting overall position and wards in breach is provided below. Reporting commenced in 16/17 and trend will start next from next month.
Allegations of physical violence towards staff from patients (S27): As above threshold reported in executive summary under the safe domain.
Allegations of physical violence towards patients from patients (S28): Position improved through the summer period with fewer incidents being recorded. The position is now below threshold.
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Allegations of physical violence towards patients from staff (S29): There were none reported in August. Future Board reports will show allegations by month.
Allegations of verbal abuse towards patients from staff (S30): There was 1 reported in August. Future Board reports will show allegations by month.
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APPENDIX 3: EFFECTIVE DOMAIN
The Trust is compliant in four of the nine (44.4%) effective domain metrics. . 30 Day Emergency readmissions (E1): The readmission rate fluctuates each month above and below the target level of 8.5%.
Cluster Accuracy and Quality (E2): Under target - see executive summary.
HoNOS at Assessment (Specialist Services only) (E3): As performance was under target reported in executive summary.
Average Length of stay and bed occupancy – adult acute (E4): Reported in in key risks section of executive summary.
CQUIN and Quality Account (E6-E8): Please see appendix 12.
Efficient Ward Staffing/Safe Staffing (E9): Actual hours used was within the 5% tolerance for August and position was compliant.
46 Planned Ward Actual Hours % Hours Halswell Ward 3307.86 5452.5 164.8% Wisteria (EDS Inpatient CAMHS) 2898.21 3803.75 131.2% Turner Ward 3708.76 4750.5 128.1% OCD/BDD NCG Inpatient & 2266.82 2698.9 119.1% Outpatients EDS National Service Inpatient 4453.09 5251.5 117.9% Ruby Ward 3327.73 3550 106.7% Crocus Ward 3606.36 3832.41 106.3% Aquarius Ward 3724.36 3944.52 105.9% Hume Ward 3327.21 3450.5 103.7% Ward 2 Acute 3442 3555 103.3% Ward 1 (13 Bed) PICU 6627.93 6804.12 102.7% Rose Ward 3715.69 3678.25 99.0% Laurel Ward 3274.11 3234.5 98.8% Lilacs Ward 3728.66 3637 97.5% Phoenix Ward 3141.76 2902.5 92.4% Jasmines Ward (Azaleas) 3342.33 3000.5 89.8% Jupiter Ward 3761.38 3345.75 89.0% Lavender Ward 3761.5 3344.21 88.9% Ward 3 3737.19 3299.5 88.3% Bluebell (Old Church) 3012.17 2648.25 87.9% Deaf Child Inpatient Corner House 1782.583 1477.08 82.9% All Wards 73947.7 77661.2 105.0%
Over performance against nursing hours is attributable to client acuity and increased levels of observation.
All Trust wards were safely staffed in August 2016.
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APPENDIX 4: CARING DOMAIN
In August 2016 the Trust was compliant against four out of the seven rag rated (57.1%) caring metrics.
Use of Physical Intervention – (C1): Reporting for physical is under review post changes to Ulysses reporting – reporting will be incorporated next month.
Prone restraint (C2): Reported in executive summary under restrictive practice metrics.
Seclusions use (C3): Reported in executive summary under restrictive practice metrics.
Complaints responded to within 25 days (C6): Reported in the executive summary as under target.
Complaints acknowledged within 3 days (C7): All complaints were acknowledged within the three day period in August 2016.
Compliments (C8): 182 compliments were received in August 2016 an 18.1% increase on previous month.
Number of PALS enquiries (C9): There were 74 concerns received in August 2016, an increase of thirty five on previous month.
Real Time Feedback – Inpatient responses (C10): The number of real time feedback response fell by 90 (16.8%) on previous month. Response levels are subject to month on month but have been on a downward trend since February 2016.
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Real time Feedback – General Satisfaction Community (C14): This metric no longer has a threshold following review by the Director of Nursing. The overall mean satisfaction score since April 2014 is 58.9 and in August the Trust score was 65.
The Patient Friends and Family Test (FFT) (C15): This has been national requirement for mental health Trusts since January 2015 and is collected at discharge on inpatient wards and at CPA review or discharge in the community. In August a total of 66 responses were received which is below the average of 85.6 per month.
Physical Health Assessments (C18): Reported in the executive summary and an exception report has been provided.
% CPA Client with collaborative crisis plan (C19): Reported in executive summary as under target.
Safeguarding Adults (C20): In August 2016 there were 69 safeguarding alerts reported.
% of Carers of Clients on C PA who have been offered a carers assessment (C21): The Trust is complaint with the trajectory target of (78.9%).
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The metric applies to boroughs where section 75 agreements with local authorities are in place. Currently this is Merton, and Kingston. The Trust has seen improvement in Kingston services that are now compliant with year-end 85% target (demonstrated above). Merton below is below trajectory and r equires improvement. Merton services are to write to carers either with no as sessment or with an of fer of assessment and ex pect to see an up ward trajectory on this metric over the coming months. Additionally a dashboard report will be made available to further assist services.
Quarter Q1 Q2 Q3 Q4 Carers Offered Assessment 75.8% 78.9% 82.0% 85.0% Trust Trajectory Performance in Quarter 63.3% 81.0% - -
Patient Led Assessments of the Care Environment: The official assessments were undertaken between February and June 2015. The dates for each site are allocated by the Health and Social Care Information Centre (HSCIC). The CQC are advised of our results and may use them as a tool to target areas when they do their own inspections. In addition Facilities Management also undertake an internal PLACE like assessments to ensure there is continual monitoring of the Trust’s environment throughout the year.
PLACE assessment findings and ac tion plans are fed back to the ward to progress and ensure completion. There is funding from Capital Projects for larger works that are identified during the assessments.
In terms of benchmarks the Trust is above the national and London average for cleanliness and privacy, dignity and w ell-being. However the scores for food and condition, appearance and maintenance are below both the national and London average.
Dementia is a new category and scores the environment on suitability for patients with dementia; this includes decoration, signage, flooring type. Trust benchmarks above national and London average here. Privacy, Dignity, Condition, Appearance, Cleanliness % Food % Dementia % Trust Wellbeing % Maintenance % 2014 2015 2014 2015 2014 2015 2014 2015 2015 SWLSTG 98.41 97.41 91.8 86.52 87.72 92.37 88.31 88.36 82.83 National Average 97.25 97.57 88.79 88.49 87.73 86.03 91.97 90.11 74.51 London Mental Health Trust NA 97.09 NA 89.45 NA 90.43 NA 89.09 81.47 average score
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APPENDIX 5: RESPONSIVENESS
The Trust is compliant in twelve of the fifteen (78.5%) year to date responsiveness domain metrics. Year to date is reported as the contract metrics are not reported in an in month format.
Zero Tolerance for 52 Week Breach (R1): No breaches were reported in August or YTD 2016/7.
Access to adult secondary care within 28 days (R2): Position complaint both in month and YTD.
Waiting times to access adult CMHT’s or assessment teams has on t he whole improved and has been above the average position (79%) in six of the last seven months.
CMHT Type CCG Target YTD August 2016 Adult CMHT Target 81.8% 85.0% Kingston 92.0% 91.7% Merton 79.0% 80.8% Adult CMHT 80% Richmond 91.2% 95.8% Sutton 83.8% 89.2% Wandsworth 72.9% 76.7%
% older adult patients assessed within 28 days (R3): There has been a consistent improvement in performance following an i ncrease of the target to 80% in April 2016. Currently all boroughs are meeting target in month and Richmond is just below target YTD but has met compliance in the last three months.
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CMHT Type CCG Target YTD August 2016 All OP Target 85.0% 90.6% Kingston 84.7% 100.0% Older People (inc 82.4% CMHT and Merton 85.3% Memory 80% 78.7% Assessment) Richmond 88.2% Sutton 85.5% 90.0% Wandsworth 87.1% 89.3%
% Adult Urgent Referrals within 7 D ays (r4): Under target - see executive summary section.
Local Contract Performance (R5): Cost and v olume plan has yet to be ag reed with commissioners.
NHS England Contract (R6): Specialist services are within 5% threshold for inpatient services.
% CAMHS Non-Urgent referrals seen within 8 weeks (R7): Performance remains consistently above target in all boroughs.
A summary of performance for August is provided below.
CCG Number seen Number Seen % within 8 weeks Kingston 17 20 85.0% Richmond 17 17 100.0% Sutton 8 9 88.9% Merton 17 18 94.4% Wandsworth 18 20 90.0% Total 77 84 91.7%
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The improvement in reported performance after October 2015 reflects the resolution of a technical issue which was preventing staff from recording relevant information on the CAMHS clinical system.
Urgent CAMHS Referrals (R8): As under target reported in executive summary.
EIS Clients treated within two weeks of referral (R9): The commencement of treatment for new EIS clients remains above target at 71% with and average performance of 66%.
Abscond - from escorted leave (R11): No absconds from escorted leave were recorded in August 2016
Abscond - failure to return from leave (R12): There was one incident recorded of failure to return from leave reported in August.
Absconded from the ward (R13): There was one incident recorded of failure to return from leave reported in August.
It should be noted that the abscond metrics have been subject to review by the Director of Nursing. The metrics now incorporate all wards with the exception of the rehabilitation wards and hospital hostels. The thresholds for absconds will need review and agreement and will be fully embedded in the coming months.
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DNA Rate all services (R14): The Trust is compliant although there has been an increase over the past 4 months.
Improved Access to Psychological Therapies Metrics (IAPT)
Access (R15): In July and August 2016 both Sutton Uplift and Wandsworth IAPT met their population access requirements, YTD position is below.
Numbers % Forecast Target Population IAPT Service entered Population Entering YTD Target Treatment YTD Treatment 1410 1502 Sutton Uplift 15% 16.0% (282 per month) (300 per month) 2310 26290 (524 per Wandsworth 12.6% 14.3% (462 per month) month)
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Recovery (R14): Both the Trust recent average performance and performance in August are below target – see the executive summary and exception report.
IAPT Referral to Treatment Waiting Times: (August 2016) (R15-R16)
55 Service Sutton IAPT Wandsworth IAPT % Seen within 6 weeks 96.8% 98.3% Target 75% 75% % Seen within 18 weeks 100.0% 99.5% Target 95% 95%
Trust IAPT services were compliant in month and also in year against the 6 week and 18 week national waiting times target.
56 APPENDIX 6: WELL LED
The Trust is compliant in four out of twelve (33.3%) year to date well led metrics.
Care Quality Commission Intelligent Monitoring – Number of elevated Risks (W1): Intelligent monitoring replaced the Care Quality Risk Profile in November 2014. The Trust has been i ssued with its first elevated risk. The elevated risk relates to the Trust Performance in the second round of the National Audit of Schizophrenia. The audit reported that the Trust performance for monitoring alcohol intake was considerably lower than the national average. Plans to mitigate are in place (see April 2015 exception report).
Care Quality Commission Requirement Notice (W2): There are currently 6 CQC requirement notices (5 from CIH inspection in March 2016, 1 from Avalon). At a meeting on 27th July 2016 the CQC agreed to attend and review the Avalon requirement notice, however they have not yet confirmed the date of attendance.
The following “must do’s” will be re-inspected on 27/28 September. See the executive summary for further information.
Community based mental health services for older people
The trust must ensure good medicines management practice, ensuring the safe transportation of medication between the team bases and patient homes and the keeping of a record of medicine stock levels.
The trust must ensure the Kingston team have effective administration support. This is to ensure all letters are sent to patients and GPs in a timely manner, and information needed to deliver care is stored securely and available to staff when they need it.
Wards for older people with mental health problems
The trust must ensure that staff on Crocus ward receive consistent 1:1 supervision.
Mental health crisis services and health based places of safety
The trust must ensure that an individual 1:1 supervision structure is embedded in the home treatment teams and that staff have access to regular individual supervision.
All incidents of violence towards staff are reviewed by the Incident Governance Team. The nature and degree of harm and level of ongoing risk is reviewed and further information is sought either from the incident reporter or the manager who is responsible for managing the incident. A range of support and interventions can be provided by the Quality Governance Department. These include:-
• Confirmation that the staff who have been involved are being supported including physical health checks where required, access to staff counselling services, facilitated debrief, information and support with reporting the incident to the police where appropriate. • The trust Virtual Risk Team will offer support with reviewing and managing risk following an incident. In serious incidents this is offered directly from the Quality Governance department and can also be requested by teams themselves. This can also include input from the Management of Violence and aggression Lead, trust Security Lead and the Clinical Risk Modern Matron • The Quality Governance also offers support with facilitated debriefs and learning following incidents. • Incidents where staff have been physically assaulted or threatened and intimidated will be taken to the weekly SIGG meeting for review and discussion. Further
57 information may be requested and a RCA level investigation may be initiated to identify further learning. • Where there have been a number of incidents reported in a specific area or the same patient or patient group are involved, this will be escalated to the Modern Matron and Operational Manager and also followed up by the VRT. • Continuing incidents and incidents of actual physical injury will be highlighted in the trust weekly Risk Intelligence report.
Support mechanisms for clients are in place (similar to above) however safeguarding adults processes would also apply. As a minimum, all incidents involving physical violence to patients are reviewed for Serious Incidents Governance Group by the safeguarding adults lead for the trust.
Turnover (W4): Staff turnover remains just above target at (14.9%) position has decreased by (0.27%) on previous month and is in line with mean position.
Vacancy Rate (W5): In August 2016 the Trust overall vacancy rate slightly decreased to 18.6%, position remains considerably above 12.4% target.
Sickness rate (W3): Sickness rate for July 2016 (reported month in arrears) is 4.0% - Trust average is 4.3% which is compliant and just below the 4.6% target.
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Mandatory Training (W6): Mandatory training compliance has increased to (87.3%) in August 2016.
Finance (W10-W14): Please see the separate Finance report.
Board Assurance Framework (W9): The Board Assurance Framework (BAF) is reported separately to Trust Board. The revised Quarterly BAF – now includes 3 Risks at red score (score 15 or above).
• A failure to provide consistent and responsive community services caused by an increase in demand, leadership vacancies and dependence on agency use resulting in not enabling recovery, escalation to crisis care and poor service user experience.
• A failure to achieve recurrent saving plans resulting in not meeting financial targets
• A failure to ensure regulatory compliance caused by inadequate review and monitoring processes resulting in regulatory action by the CQC and reputational damage
59 APPENDIX 7: BENCHMARKING
• Mental Health and Learning Disabilities Minimum Mental Health Data Set: The Trust benchmarks well when compared to other London Trusts on key mental health data set metrics. This is highlighted in the table below.
• NHS Benchmarks Adult Acute Beds per 100,000 – MH22 is the new Trust bench- marking code
The Trust has recently received some feedback from NHS benchmarks (for the 2016 period) this is currently being reviewed and will be incorporated into next Board report.
• National Reporting & Learning System: Nation Reporting of patient safety incidents.
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NHS Benchmarking (2014/15)- Violence Against Staff
The Trust benchmarks below average for reporting violent incidents against staff reporting 161 per 100,000 plus face to face contacts; national mean is 206.
CQC Community Teams: Patient Satisfaction Score
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The Trust satisfaction score of 73 is above the national average of 68.9%for client’s community team’s satisfaction rate and is the best in London.
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APPENDIX 8: Exception Reports
Performance Exception Report
Month August YTD 2016/17 Indicator Plan 2016 Plan Forecast S11 Falls Resulting in Harm 16 27 16
Executive Director Operational Lead Completed By Date Vanessa Ford Ian Higgins, Serious Theresa Pardey 23/09/2016 Incident Lead Investigator and Named Nurse
Reason for The indicator is based on the National NHS Safety Thermometer which is used to variation measure that and reduce harm caused by falls. It is a two year Quality Account target that commenced in 2014-15 which aims to drive behavioural change among staff to improve the physical health of mental health service users on inpatient wards and put in place improvement programmes to respond to any harms or hazards identified. The Trust is required to complete quarterly audits of fall incidents that occurred in the previous quarter as part of a two year strategy to improve the monitoring and treatment received.
In August levels of falls increased to 25 an increase of 11 (69%) increase on July position. Mean reporting for period April – August 2016 is in line with the threshold of 16 and is demonstrated in the chart above.
In August 19 of the 27 cases were recorded as low while six cases were recorded as moderate harm; this is highlighted in the table below.
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In order to provide assurance on client welfare further detail on moderate harm cases is provided below:-
Department Number of Moderate Comments on clients welfare and harm cases any remedial actions taken Laurel Ward 1 Client fell and received a cut their head, Was taken to the acute hospital for treatment post assessment by duty doctor. The Incident was shared with staff for future learning and the client levels of observation were increased. Ward 2 1 The client lost balance whilst climbing table and received a bang to head. Duty doctor assessed and client was ok. Client observed regularly for rest of the shift.
Impact Service User Outcomes Risk to patients health and wellbeing if the harm goes unmanaged. Financial Position n/a Regulator/Commissioner Requirements
Key Actions Action Date Due to be Taken • All falls reported that result in injury to be subject of a Post 31st October Incident review and discussed at weekly SIGG. and ongoing. • All incidents of falls to be reviewed for completion of Falls Risk assessment by the Ward Manager • All PIRs should consider whether a s afeguarding adults referral is indicated and Duty of Candour applies. • All reported falls to be reviewed with the ward by the trust Physical Health team. • Falls reported as incidents to be included as part of monthly Learning group reporting. Forecast By When Performance
64 December 19 February2016 16 Monitoring Falls Working Group/Monthly Learning Group
65 Performance Exception Report
Indicator Month August YTD Plan 201617 Plan 2016 Forecast S26 Physical Violence Against Staff 41 61 41 47
Executive Director Operational Lead Completed By Date Vanessa Ford Sharon Spain Theresa Pardey 20/09/16
Reason for Violence and Assault (both threatened and actual) is the top reporting incident theme variation and remains a concern for the Trust. This month sees a high proportion of assaults from Ward One (10 reported incidents involving 9 pat ients) Rose Ward (9 reported incidents involving 1 patient) Aquarius (8 reported incidents involving 4 patients).
Reporting has improved and needs to be further encouraged; however there is an ongoing view around the level of harm against each incident. The trust benchmarks just above average nationally for incidents of violence and assault towards staff. The issue of increasing violence has been raised by staff as part of the Listening into Action agenda.
Actual Harm Jun 16 Jul 16 Aug Total 16 over 3 months Not recorded 2 2 2 6 1-Near Miss 1 3 0 4 2-None(No Harm Occurred) 12 15 11 38
66 3-Low(Min. Harm-Patient Req. Extra Ob) 36 29 35 100 4-Moderate (Short Term Harm) 0 10 13 23
There have been 23 incidents of Moderate harm recorded over the last three months (0 in June) this is (13.4%) of all incidents (where n=171) reported over last three months. Further analysis below highlights increase in moderate harm reporting over last three months.
Impact Service User Outcomes N/a Financial Position None directly Regulator/Commissioner Requirements None Key Actions Action Date Due to be Taken • All incidents reported as moderate harm in this domain to be followed up by Ward Manager and Modern Matron
67 through a trust Post Incident Review. These will be discussed at the weekly SIGG and recommendations for further action or review will be agreed. • Higher reporting areas will be invited to contribute to weekly SIGG and develop a plan. • The Virtual Risk Team (VRT) can contribute to risk reviews in this domain and themes and actions shared at the Monthly Learning Group.
Where degree of harm is rated as moderate or above Head of Ongoing Security and l ocal borough management to provide support and 2016/17 advice. Low level harm or no harm incidents to be followed up by Ward or Team Manager. Following feedback via Listening into Action a task and finish group November 2016 has been s et up c haired by the Director of Nursing with aim to strengthen support to staff post incidents The Trust is reviewing lone working practices – this work stream is December 2016 being led by Health and Safety and Security. The director of nursing is chairing a task and finish group focused Dec 2016 on how we support staff post incident. The first meeting was held in sept and the minimum standards for support will be set with a full implementation plan to be monitored through the workforce and OD committee Forecast Performance Level By Month Target performance level (March 2017) 47 Monitoring To be monitored via monthly Incident Directorate Reports and DPR
68 Performance Exception Report
August YTD 2016/17 Indicator Target 2016 Plan Forecast C5 Number of prone restraints used No target – 23 - No target position outside normal range No target on reporting post review from the Director of Nursing exception required if performance is outside normal range.
Executive Director Operational Lead Completed By Date Vanessa Ford Sharon Spain Theresa Pardey/ 23/09/2016 Richard Hadfield
Reason for There are 23 i ncidents reported for August 2016 an ex ception report is required as variation position is outside the normal range (see chart below). The overall mean reporting is 8.6 per month however YTD average is increasing and is current at 19 prone restraints per month.
Authors have described de-escalation strategies as the primary method of intervention with the service user. Oral medication is described as a first and preferred option before the consideration of using Proactive Physical Intervention (PPI) as a last resort to support rapid tranquilisation. The managed incident outcomes have some constructive learning from teams revisiting the care plans, speaking to the author to gather more information of the incident, noting the need to revisit the incident with the service user if de-brief wasn’t appropriate for the service user at the time of the incident and praising all involved for their responses and well informed documentation of the incident.
All prone restraints are reviewed and f ollowed up by the Proactive Physical Intervention (PPI Lead) to offer assurance that the appropriate intervention was used, the incident reported identified observations, de brief and management guidance with learning outcomes for all involved
Nationally the NHS has identified a strategic target to eliminate prone restraint as a “primary method of restraint”.
69 Staff must not deliberately restrain people in a w ay that impacts on their airway, breathing or circulation, such as face down restraint on any surface, not just on t he floor. There must be no planned or intentional restraint of a person in a prone/face down. Incidents of restraint that involve a service user being placed face down or chest down for any period (even if briefly prior to being turned over), should be defined as prone restraint in line with national reporting guidance. Similarly if a service user falls or places themselves in a face down or chest down position during a r estrictive intervention, this should be defined as prone restraint. It is understood that a zero target of restraint was set on t he basis of reflecting this national target. This was approved as a target and was previously reinforced by the previous Executive Director of Nursing. It is possible that this has had an adverse impact on accurate reporting within clinical teams. This target will be reviewed by the new DON following the establishment of a reducing restrictive practice working group. In 2013 the Director of Nursing and M VA team met with MIND to look at prone restraints. In 2014 the positive and proactive care initiative was launched nationally. Changes were made to the Trust training on prone interventions to reinforce that it should not be a deliberate intervention, but still showed how to support a person on their front and reinforced the need for staff to report safer alternative positions as described in positive and proactive care guidance. This was confirmed with commissioners in November 2014 and the Trust also signed up to the restraint reduction network (supported by DON). In Mid 2015 NHS benchmarking updated the definition for prone restraint and changes were made to the Trust incident form to reflect this to capture data to support our involvement in the benchmarking exercise. Benchmarking data and best practice has been shared with ward teams. In all cases the prone restraint was unintentional and not a first level response. Wards had followed the Trust policy for a planned intervention of Communication, Risk Assessment, Communication, Review of the Care Plan and then intervention. It is recognised that as a r esult of work being undertaken to positively promote accurate reporting of such incidents that the overall level is likely to be higher in future months and that this is crucial to ensuring that staff fully understand the importance of safe practice. The potential to also highlight the length of time that any prone element of restraint occurs will also be considered. The 4th event of the National Benchmarking Network has now taken place and as yet a National Target for Prone restraint is yet to be set.
Restraints by Ward
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Rose ward. 1 patient recorded as six incidents of prone then the administration of rapid tranquilisation outcomes included: Note: Rose ward required a PICU bed but was unable to attain one for this person.
• Continue to monitor physical and mental state. Review with MDT. Update risk assessment. Debrief with staff.
Aquarius ward. 1 patient recorded as 9 incidents of prone and then administration of rapid tranquilisation outcomes included • staff and patient debrief risk assessment to be updated completed NHSE PPI form monitoring of physical health complete seclusion part on RiO
Jupiter ward. 1 patient recorded as 2 incidents of prone and then administration of rapid tranquilisation outcomes included • Evidence of attempts to verbally de-escalate oral prn offered although declined Physical observation assessed - high pulse in context to high arousal evidence of debrief with client attempted
Lilacs ward. 1 patient recorded as 2 incidents of prone and then administration of rapid tranquilisation outcomes included • Patient assessed, De-escalation techniques used Patient vital signs checked and documented on the NEWS chart. Progress notes and risk assessment updated Patient placed on level 2 observations On-call doctor informed of incident Incident form completed To be reviewed by MDT
Impact Service User Outcomes Potential impact is high however, all incidents have been reviewed in detail and no harm identified.
71 Financial Position None directly. Regulator/Commissioner Requirements None. Key Actions Action Date Due to be Taken 1) Review of individual cases by Senior PPI Trainer continues in 30/04/2016 - each month. Any learning identified is shared with the team ongoing and across the organisation through debrief.
2) Nursing Department and Training Department to monitor 30/04/2016 – National target attendance of 95% staff on the Mandatory PPI ongoing Training (Requirement for all In-patient staff to be trained in 3 day course Physical Proactive Interventions (PPI). This includes Basic Life support training which prioritises monitoring of vital signs of those in restraint. 3) 4) PPI training available for all Bank staff and bank Staff are September informed that this is Mandatory to be able to work on across 2016 our clinical services. All staff are required to have been appropriately trained prior to their involvement in any control and restraint intervention October 2016
5) For the Training Department to provide to the DDoN a monthly an update on PPI training data for both substantive and temporary staff.
6) Nursing & Training to implement and action plan where training falls below the 95% target.
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7) To continue to train staff on reporting Prone restraints using Ongoing Ulysses. Staff to refer to recent Podcast uploaded on inSite. 8) Patient Safety Manager to attend training to provide guidance on how to complete the electronic incident form. 9) Director of Nursing is commissioning a new working group to May2016 be established and chaired by the Deputy Director of Nursing to look at all forms of restrictive practices and the governance and practice standards around these in order to provide triangulated KPI reports. The first meeting has been held in May and this will report to IGG, and onwards to QSAC. The KPI for Prone restraint will be reviewed as part of this process. 10) All incidents of prone restraint will be reviewed by the medicine management team to check if medication administration was involved and if there were any other options for positioning the patient setting up a working group to further review rapid tranquilisation and the level of prone restraint recording 11) All staff must report via the Trust incident reporting system September incidents where a PICU bed was not available resulting in 2016 seclusions on a non PICU ward. Forecast By When Performance Monitoring Integrated Governance Group
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Performance Exception Report
August YTD 2016/17 Indicator Target 2016 Position Forecast C18 Ensuring Physical Health for Inpatients: 98% 94.7% 94.7% 97% All service users to have a Physical Health Assessment attempted within 48 hours of their admission.
Executive Director Operational Lead Completed By Date Dawn Chamberlain Mark Clenaghan Gwyn Davies 15/09/2016
It should be noted the Trust performs well on the whole on this metric and target has increased by 3% in 16/17 to 98% which means any breach is likely to impact on performance as denominator is low on t his metric. There is a need to ensure that wards do document the PHA when client does not consent to PHA. The “consent to physical assessment” being required to be completed.
The Trust is rag rated red against the PHA assessment offered within 48 hours. New target is difficult to attain as denominator in month is generally low and will only take a very small number of breach cases in order to miss target. Current performance is in line with the mean reporting position of 94%; there is month on month variance performance.
In general the Trust has improved performance on this metric as demonstrated in the chart below.
In order to meet compliance on this indicator two assessment forms need to be completed. The Physical Health Assessment form (usually completed by a doctor and the physical health monitoring form which is usually complete by the nursing staff. Both must be completed within 48 hours in order to count.
A summary of performance by ward for June is highlighted below. .
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Additional audit work has been undertaken to further review practice of PHA recording. A summary of the findings by ward is below.
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Audit issues highlighted:-
• PHA/PHM recording are not always documented on the forms and practice needs to be reinforced and position should be monitored daily. • Recording of BP SATS, PULSE temperature needs to be completed on PHM – it’s not enough to document this on PHA only; message needs to be reinforced especially to new Dr’s on rotation. • Consent recording on the forms needs to completed. There were cases consent was not provided but this was recorded on the PHA but not the PHM (and hence the trust incurs a breach). This is duplication (for busy clinical
75 staff) so an automated solution needs to be devised and implemented by the end of September.
Key Actions Action Date Due to be Taken Ward managers to ensure My Dashboard PHA report is monitored Ongoing daily in order to pick up new cases and review any breeches. Junior Dr’s to be further supported trained on PHA/PHM reporting September requirements – post rotation in August. 2016. Operations Manager for Sutton & Merton to reinforce practice and September monitoring with Ward Manager on Jupiter Ward. 2016
IMT to ensure that in cases where consent has not been given – September the report is applied to both forms to reduce duplication. In most 2016 cases consent is recorded on PHA. The message regarding recording of ‘refusals’ on RiO will be September reinforced. 2016 Forecast September 2016 95% December 2016 97% Monitoring Monitored at monthly directorate performance review
76 Performance Exception Report
Month YTD 2016/17 Indicator August 2016 Plan Plan Forecast r15 IAPT Recovery Rate 50% 47.5% 50% 50%
Executive Director Operational Lead Completed By Date Dawn Chamberlain Jeremy Walsh Jeremy Walsh/Gwyn 19/09/2016 Davies
Reason for • In 2016/17 50% of those clients commencing IAPT treatment should reach variation recovery by the end of treatment. • Recovery rates vary month on month so performance fluctuation is expected as demonstrated below. • Additionally the Trust has had difficulties with data updates from the system provider Mayden for a number weeks throughout the summer period. These issues were escalated via the Trusts Associate Director of Information Technology and Modernisation to senior management within Mayden and has now been rectified. • A summary of Sutton Uplift and Wandsworth IAPT Recovery Performance is provided below. • It should be noted that recovery rate is part now part of the Single Oversight Framework published by NHS improvement in September 2016. Reporting frequency will be quarterly.
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• Wandsworth IAPT do still carry some 5-7 cases who are more complex and therefore it is difficult for this cohort to move to recovery. The table below provides a breakdown for Wandsworth and shows that cluster 1 – 4 patients have a better recovery rate than those in cluster 5 or above and those without a cluster recorded (which may include patients who should be cluster 5 to 7): Cluster 5+ cluster clients are more complex cases and t herefore it is more difficult to achieve recovery for this cohort within the 10-12 week treatment period.
Service Cluster August 2016 Target
All 45.5% (n=321) Wandsworth IAPT 1-4 47.2% (n=267) 5+ 21.1% (n=19) 50% No cluster 45.7% (n=35) Sutton Uplift All 40.7% (n=182)
• It takes 4-5 months to move people through the pathway and therefore recovery rates take time to improve. • During the period of this exception Wandsworth IAPT was in midst of tender process the outcome of which will be known in October 2016
In Sutton, we have identified a few measures which we will be implementing over the next few months which we hope will lead to an improvement in the recovery rate: 1. Improving accuracy of mental health cluster allocation Sutton IAPT is commissioned to offer treatment to clients falling within mental health clusters 1-4. A recent preliminary analysis of twenty clients who were discharged non- recovered from the service in July indicated that 75% of them had been allocated to cluster 4. However, further training attended by two members of the IAPT Senior Management Team this week on mental health clustering indicated that we may have been clustering a number of clients as cluster 4 when in fact they should have been clustered as cluster 6 or cluster 7, and therefore not been offered treatment within the IAPT service. The scoring for the three clusters is very similar but clients falling within clusters 6 and 7 w ould present with enduring difficulties which are more difficult to treat due to strongly held beliefs. It would be significantly more difficult to move these clients to recovery within the short time-frames for treatment that we offer in IAPT (typically 8 sessions), and if we are seeing a significant number of cluster 6 and cluster 7 clients within the service currently, this could explain why we have found it challenging to meet the recovery target of 50% thus far. Whilst Sutton Uplift cannot be
78 clear about the number of clients who are potentially mis-clustered within the service and the impact it might have on the recovery rate if we were no longer to see them for therapy, believing it would be helpful to put in place a number of measures to try to ensure that the service is only offering treatment to those who can benefit from short- term therapy, i.e. clients who fall within clusters 1-4. These measures are: a) To ask the Step 2 clinicians who carry out the initial triage assessments from which a c luster is assigned, to bring to triage supervision a c ompleted clustering grid for any client whom they have clustered as a 4 so that this can be checked. b) To ensure that more effective discussions are had in triage supervision about any previous involvement with services, as this is one of the criteria that would distinguish between a cluster 4 and cluster 6 / 7 client, this question has been added to the triage supervision template. c) The two members of the Senior Management Team who attended the clustering training will provide further training to the rest of the team with an emphasis on di stinguishing between cluster 4 and c lusters 6 and 7. This training will take place in October 2016, as we will have a number of new team members starting then. d) If we start working with a client and it emerges through the course of therapy that they fall outside of clusters 1-4, then we could move them from Sutton IAPT to Non-IAPT on the IAPTUS electronic recording system so that they do not count toward the recovery statistics. This will however have an impact on access figures. e) If a client is referred to IAPT who has previously been clustered outside of cluster 1-4 in another service, they will be offered an assessment with a Step 3 clinician to determine if they do now fall within cluster 1-4 and henc e are appropriate to be s een in IAPT. Currently all clients undertake a t riage assessment first and are then booked for a Step 3 assessment, which means they contribute to our recovery rate even if we then subsequently cluster them outside of 1-4 and do not see them for treatment. f) Currently other services are querying our cluster allocations when we try to refer on to more specialist services. Some services have suggested that IAPT are sometimes allocating too high a c luster. The training attended this week suggested this is not the case and t o support our referrals going forward we will now include a copy of the clustering grid.
2. Reviewing all clients who are non-recovered following their treatment All clients who are about to complete a course of treatment and are non-recovered will be brought to supervision for discussion to consider whether there are any other options available within the service that might help move them towards recovery before we discharge them. This could include being offered another intervention at the same step, stepped up for a more intensive intervention or stepped down for a less intensive intervention. We have Trust imposed limits on the number of sessions that we can offer at each step so it is likely that any additional intervention offered would be at a different step.
3. Ensuring session-by-session symptom reviews The service introduced the concept of the symptom review in to the service a number of years ago but we feel it is important to revisit this to ensure it is being used consistently by every staff member with every client. The service is aware that some clients and c linicians are not paying as much attention to the weekly outcome measures as they should resulting possibly in an under-reporting symptom improvements by clients; the service having introduced a 10-minute symptom review at each session which focuses on the PHQ9 and GAD7 questionnaires that the client has completed. It aims to actively engage the client in tracking symptoms and noticing change, rather than them automatically ticking the same number on the questionnaire each week. The symptom review ensures that a treatment session is focused on the
79 client’s symptoms as listed in the measures. It thereby helps to generate an appropriately focused agenda for the session. The clinical leads for Step 2 and Step 3 will hold training sessions on c arrying out symptom reviews with all team members and their use will start to be monitored in supervision sessions.
4. Administrating of outcome questionnaires to spontaneous remitters A recent preliminary analysis of twenty clients who were discharged non-recovered from the service in July indicated that a few of them had been contacted by a clinician to commence treatment but had de clined as they felt much better. However, this improvement was not captured as no appointment took place and so the client would counted as non-recovered as their PHQ9 and GAD7 scores at their final appointment (usually an as sessment session) were non-recovered. To capture these improvements, we will ask clinicians in the team to check with clients who decline therapy because they have recovered whether they would be happy to quickly complete the questionnaires over the phone with the aim of capturing this recovery. This is likely to be small numbers of clients and some may also decline to complete the questionnaire as it can take quite some time.
5. Rolling-out of Silvercloud online CBT to enhance Step 2 capacity This month the IAPT service started offering online therapy at Step 2 v ia a ne w provider called Silvercloud. Going forward we will be able to offer this treatment option to 500 clients. Silvercloud is a new online CBT treatment system which allows clients to complete a course of CBT with limited therapist support. The integration of Silvercloud into our Step 2 provision will help to further improve the service’s clinical capacity by reducing the amount of clinical time per client by about 50%. Outcome studies assessing the effectiveness of Silvercloud have shown that it results in a recovery rate that is roughly equal to that obtained in traditional (guided) CBT treatment at Step 2 (i.e., slightly over 50%). Over the coming months we will aim to increase our Silvercloud provision and promote this to clients as a new alternative to guided CBT treatment.
6. Identification of factors resulting in client non-recovery A member of the IAPT Senior Management Team has been allocated some protected time to review non-recovered cases in the service going forward and we hope this will provide further suggestions for improving the recovery rate.
Key Actions Action Date Due to be Taken Review of number of sessions is being undertaken but any June and increase may require additional resource. ongoing 2016 Meetings with local community leaders have taken place in order to March 2015 co-produce group work sessions. These are aimed at members of communities that do not traditionally access IAPT Focus on Well Being staff working alongside IAPT staff in order April 2016 further improve patient outcomes. Waiting lists are being driven down and improved responsiveness May 2016 is another driver for improved recovery IAPT clinical lead to review all cases flagged for step 3 which September should improve consistency and potentially improve waiting and 2016 recovery. IAPT clinical lead to ensure staff discharge cases promptly to September ensure inclusion in reporting 2016 Roll-out of Silvercloud online CBT treatment September 2016
80 Reviewing non-recovered clients in supervision toward the end of September treatment 2016 Step 2 clinicians to bring clustering grids to triage supervision for September clients allocated to cluster 4 2016 Add previous therapy/service involvement to triage supervision September sheet 2016 To move clients to non-IAPT pathway on IAPTus should it emerge September during treatment that they are not cluster 1-4 2016 Previously higher clustered clients to be offered a Step 3 September assessment initially rather than a triage assessment 2016 To attach clustering grid to referrals to specialist services September 2016 Administration of PHQ9 and GAD7 questionnaires to spontaneous September remitters 2016 Further clustering training for team with a focus on distinguishing October 2016 between cluster 4 and clusters 6 and 7 clients Symptom reviews each treatment session following a further October 2016 training session with the team Ongoing analyses by Step 3 Lead to identify factors associated August 2016 - with client non-recovery ongoing To align with the Single Oversight Framework recovery rate October 2016 reporting will move to quarterly reporting. Forecast January 2017 48% (Wandsworth) 46% (Sutton) Monitoring Monthly Directorate Performance Review; Weekly Directorate performance review meetings;
81 APPENDIX 9: Explanation of Data Quality Assurance Scores Assurance of quality and performance indicators Explanation of data quality assurance scores and key principles 1. Background • Data and Information - The Trust has in place a comprehensive data and information assurance programme, which is developed and delivered by the Information Governance Group, chaired by the Senior Information Responsible Officer (SIRO). • Information sourcing should be automated where possible. Quality and performance data included on dashboards should: • Be sourced from a single database to ensure consistency and traceability.
• Be the primary source of data.
• Have documented definitions.
• Have documented workflows and business rules for production.
• A kite-mark will accompany the dashboard to provide visual assurance on quality of a performance indicator. • The kite-mark is a visual indicator that acknowledges the variability of data and makes an explicit assessment of the quality of evidence on which the performance measurement is based. • Each measure is assessed as ‘sufficient’, ‘insufficient’ or ‘not yet assessed’ on s even distinct elements. For each element a colour code shows the strength of assurance. Each measure has an equal weighting. An overall assessment is reported in the Quality and Performance Dashboard.
2. Elements of the kite-mark: • Timeliness – This is the time taken between the end o f the data period and w hen the information can be produced and reviewed. The acceptable data lag will be different for different performance indicators. Data should be c aptured as quickly as possible after the event or activity and must be available for the intended use within a reasonable time period. Data must be available quickly and f requently enough to support information needs and t o influence the appropriate level of service or management decisions. • Monitoring – This is the degree to which the trust can drill down into data in order to review and understand operational performance. The level to which the trust needs to drill down into the data will vary for different performance indicators. Some information should always be available at patient level for performance monitoring purposes. Whereas some information may be sufficient if it is available at speciality level for all specialties or even trust level for performance monitoring purposes. • Completeness – There are two aspects to completeness. This is the extent to which all of the expected attributes of the data are populated but also the extent to which all of the records for the relevant population are provided. • Validation – This is the extent to which the data has been validated to ensure it is accurate and in compliance with relevant requirements. For example, correct application of rules and definitions. The level of validation required will vary from indicator-to-indicator and will depend on the level of data quality risk. Final validation is classified as sufficient where validation has been completed and where the indicator has received final approval from responsible individuals.
82 • Audit – This is the extent to which the integrity of data (completeness, accuracy, validity, reliability, relevance, and timeliness) has been audited by someone independent of the KPI owner (for example, Internal Audit, External Audit, Clinical Audit or Peer Review) and the extent to which the assurance provided from the audit is positive. • Reliability – This is the extent to which the data is generated by a computerised system, with automated IT controls, or a manual process. It also relates to the degree of documentation outlining the data flow, i.e. documented process with controls and dat a flows mapped. Data should reflect stable and consistent data collection processes across collection points and over time, whether using manual or computer based systems or a combination. Managers and stakeholders should be confident that progress toward performance targets reflects real changes rather than variations in data collection approaches or methods. • Relevance – This is the extent to which the data is captured for the purposes for which it is used. This entails periodic review of the selection of key performance indicators to reflect changing needs, such as new strategic objectives. For example, is this indicator the right indicator by which to measure performance against a strategic objective?
3. Sufficient/Insufficient criteria Each indicator should be assessed as ‘sufficient’ ‘insufficient’ or ‘not yet assessed’. The assessment is based on a positive response to the criteria in the table below. Where an attribute is marked as ‘insufficient’ or ‘not yet assessed,’ the KPI owner should explain the issue, why it exists and the remedial action to be taken.
Attributes for each Sufficient Insufficient indicator Timeliness Where data is available daily for Where data is available daily for an indicator, up-to-date data can an indicator, up-to-date data can be produced, reviewed and be produced, reviewed and reported upon the next day. reported upon the next day. Where data is only available Where data is only available monthly, up-to-date data can be monthly, up-to-date data can be produced, reviewed and produced, reviewed and reported reported upon within one month. upon within one month. Where the data is only available Where the data is only available quarterly, up-to-date data can quarterly, up-to-date data can be be produced, reviewed and produced, reviewed and reported reported upon within three months. Where data is only available annually, data being produced, reviewed and reported upon is no more than 12 months old. Monitoring Where relevant, the trust is able The trust is either: to drill down into the data down 1.Not able to drill down into the to the right level (for example, data down to speciality or patient speciality or patient level) to level where required; or inform decision making on 2. able to drill down into the data operational performance. but the KPI owner cannot provide Additionally, where the trust is assurance that this information is able to drill down into the data to appropriately reviewed at different the right level, the KPI owner is levels. able to provide assurance that this information is reviewed on a regular basis at that level (i.e. board, sub-committees,
83 Attributes for each Sufficient Insufficient indicator divisions, service lines, consultants) Completeness Fewer than 3% blank or invalid More than 3% blank or invalid fields in expected data set. fields in expected data set This standard applies unless a Inadequate assurance or no different standard is explicitly assurance that effective controls stated for a KPI within are in place to ensure that 100% commissioner contracts or of records are included within the through national requirements. total population. Additionally, the KPI owner can provide assurance that effective controls are in place to ensure that 100% of records are included in population. In other words, no individual records are omitted from the population due to fraud or error. Validation The trust has agreed upon Either: procedures in place for the 1. No validation has taken place; validation of data for the KPI. or A sufficient amount of the data, 2. an insufficient amount of data proportionate to the risk, has has been validated as determined been validated by the trust to by the KPI owner; or ensure data is: 3. Validation has found that the • accurate; and KPI is not accurate or does not • in compliance with relevant comply with relevant rules and rules and definitions for the KPI. definitions. The KPI owner is responsible Commentary should be available for determining what a to indicate which of the above is ‘sufficient’ amount of data the case validation is. Audit The data quality of the KPI has 1. The data quality of the KPI has been audited in the last 3 years not been reviewed by audit in the and either: last 3 years; or • positive assurance was 2. the data quality of the KPI has received; or been reviewed by audit in the last • recommendations have been 3 years but: completed and successfully • negative assurance was followed up by audit. received; and • recommendations have not yet been followed up by audit. Commentary should be available to indicate which of the above is the case Reliability Mostly a computerised system, Mostly a manual system, with no with IT automated controls, and IT automated controls, and therefore less prone to human therefore more prone to human error. Automated controls may error. include field validation, system Process is not documented. interface reconciliations and Process has changed during the system configuration. last 12 months therefore there is Process is fully documented an increased risk that data is not with controls and data flows consistent between reporting mapped periods.
84 Attributes for each Sufficient Insufficient indicator Process is stable and consistent Where data is processed by a over the last 12 months. third party, the trust has not Where data is processed by a received assurance over the third party, the trust has processes and controls in place received assurance over the at the third party to ensure data processes and controls in place quality. at the third party to ensure data Commentary should be available quality. to indicate which of the above is the case. Relevance This indicator is relevant to the This indicator is no longer measurement of performance relevant to the measurement of against the: performance • Performance area against the: • Performance question • Performance area • Strategic objective • Performance question • Strategic objective
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APPENDIX 10: Summary of Assurance on Performance Indicators
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APPENDIX 11: Directorate Team Waiting Times
Waiting Times for Commencement of Treatment: July & August 2016
Waiting Times by Directorate, Service Type and Team
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96 Appendix 12: CQUIN and Quality Account
No. CQUIN 2016/17 Qrt Indicator August 2016 Update RAG Actions 1 Staff Wellbeing – Quarter 1 – Achieved Commence activities proposed Q2 Begin Implementation of action plan Wellbeing Initiatives Quarter 2- On track to achieve – no in strategy for Q1.
NB: National funding attached to target 2 Staff Wellbeing – No formal Q2 target Quarter 1 – Achieved No actions required Healthy Eating - Quarter 2- No Formal Target NB: National 3 Staff Wellbeing – Flu Submit cumulative data monthly on Quarter 1 – Achieved Develop a method of recording Q2 Vaccination (75% the ImForm website Quarter 2- No formal target or funding uptake and decide who will
Uptake) NB: National attached to Q2 however Trust has take overall responsibility for commenced actions towards Q3 entering data onto immForm Target NHS England.
Produced Patient Group Directive (PGD). Carry out risk assessments to include all health and safety Promotion materials revised and ordered issues and risks around the from NHS employers. Incentives, delivery of the programme. including drinks vouchers and hamper, Identify and ensure adequate arranged. supplies of sharps bins, plasters, consent forms, Flu Vaccination training held on the 30th alcohol hand gel, and August. emergency equipment.
Link created, accessible on InSite, so Flu vaccination training booked staff can easily record if they have for 4th Oct 2016. received the flu vaccination from their GP or pharmacy. Clinic rooms require booking and then advertised. Current workforce numbers identified.
Clinics booked at Leadership Events and Trust Inductions. Clinic timetable produced.
97 4 Urgent Care Pathway Quarter 1 – Achieved Q2 a. Produce a report demonstrating - Psychiatric Decision Quarter 2- On track to achieve a) outcome of 5 Borough engagements Unit (PDU) NB: Local and identify common themes and Independent Engagement lead has highlight areas for consideration when produced 5-borough engagement report. planning PDU pilot. Presented at Transformation Board b. Provide a full project plan for pilot of
Psychiatric Decision Unit, including Staffing mix agreed. Ward Manager engagement of relevant stakeholders appointed. Recruitment has commenced. e.g. Acute Trusts, GPs.
c. Provide a PDU Operational Policy Project manager has produced full clearly demonstrating patient project plan informed by PID. pathways; referral and discharge
routes and quality requirements Draft Service Specification produced by d. Agree structures, pathways and Head of Operations and currently under staffing/mix for PDU review from project group and e. Agree transportation and consent Transformation Board. Approved at arrangements for PDU September Transformation Board f. Agree monitoring and reporting excluding minor amendments. Agreed at arrangements relating to performance, July PDU project group for Service outcomes and activity. Specification to be submitted in Q2 and g. Review and confirm all subsequent the Operational Policy to be submitted in milestones and values in light of the October 2016. above
Workshop held on 23rd September for external stakeholders (Ambulance service, Metropolitan Police etc)
5 Quarter 1 – Under negotiation Develop sector-wide 2-phase Urgent Care Pathway Q2 a. Agreed monitoring and reporting Quarter 2- On track to achieve gatekeeping RiO form. Trial - Street Triage arrangements of paper version before NB: Local performance/outcomes/activity First draft for reporting and monitoring configuration of RiO form. - A&E Waiting times metric produced. To be discussed at st - S136 Assessments Transformation Board. Hub go-live 31 October.
- Admissions On track to integrate Contact Centre with Protocol for HTT night - Bed Days Acute Coordination Centre to provide visits/hub operating to be
98 single point of access. reviewed at Head of HTTS. - Patient/carer experience
b. Integrate Contact Centre with Acute First draft Operational Policy drafted by Sector-wide specification Care Coordination Centre to provide PICU Modern Matron. Operational policy currently under discussion OOH single point of access and will be used to inform sector-wide between the Trust and the decision making hub. specification. commissioners. c. Mobilisation of sector-wide
Integrated out of hours service First draft protocol for HTT night visits incorporating Crisis Assessment, produced and reviewed by project group Street Triage, medical rotas, Liaison
Psychiatry Pharmacy, ACC manager and project d. Produce and submit Sector-wide group SPR met to discuss pharmacy common Specification support protocol. Agreed to request e. Mobilisation of Operational Policy. endorsement of Patient Group Direction f. Provision of monitoring and (PGD), for particular medications reporting of performance/outcomes including zopiclone, from Drug and focused on Therapeutics Committee (DTC) g. Set up 24/7 Contact Centre Frist draft process map developed.
Kingston Street Triage mobilised at Kingston Hospital. Awaiting vetting from Kingston Police for Street Triage to be based at Police Station. 6 Recovery Café a. Go to tender and complete formal Quarter 1 – Achieved Q2 NB: Local procurement process Quarter 2- At risk of not achieving Q2
target b. Agree via Transformation Board
the basis upon which CCGs will be Business case was approved at the selected for initial two pilot sites September Board meeting. Tender (eg relative degrees of crisis; documents reviewed and agreed by population need; bed project group followed by Executive usage/increases) Management Committee on 20th c. Reference the results of the User September. Submitted for approval Engagement and submit full at Transformation Board in September. project plan for pilot of Recovery Cafes, including engagement of Project Manager has produced project relevant stakeholders
99 d. Provide a Recovery Cafe plan informed by PID. Operational Policy clearly demonstrating patient pathways; Monitoring and reporting arrangement referral and discharge routes and requirements included in Tender quality requirements specification. e. Agree structures, pathways and
staffing/mix for Recovery Cafes f. Agree monitoring and reporting arrangements relating to performance, outcomes and activity. g. Locations identified and confirmed h. KPIs agreed including basis upon which success will be confirmed i. Review and confirm all subsequent milestones and values in light of (b) above
100 7 Physical Health – Completed pathways in place and Quarter 1 – Achieved Q2 Cardio Metabolic disseminated to all clinical teams Quarter 2- On track to achieve Q2 Clinical Lead to attend
Assessment (CMA) (assessed locally by commissioners) target, risk associated with Q3/4 academic meeting in October NB: National targets to promote CMA and provide guidance for national audit in Care pathways identified, discussed at December 2016. August Physical Health Steering Group meeting, pathways actioned and Further advertisement on distributed. InSite.
Information Management Team has CMA training for community configured reporting from Physical nurses currently being Health RiO forms and data is now developed by Physical Health available on Dashboards will be Manager and CQUIN Lead. presented at DPR from October. Care Pathways to be finalised, Processes reviewed for community approved and disseminated to services and suggestions for CPA Policy clinical teams. submitted.
CMA training provided to new Junior Doctors.
Promotional posters for clinicians produced and printed and distributed. Advertised on InSite.
CQUIN Lead visiting teams to offer training including and monitoring. 8 Physical Health – Quarter 1 – No Target Produce audit report. Q2 Demonstrate that for 90% of patients Summaries of Care Quarter 2- On track to achieve in the audit sample an up-to-date NB: National summary of care (communicated via Sample provided by Information CPA Review Letters, Discharge Management. Summaries and other
correspondence) has been shared Junior Drs identified fo auditing. Audit with the GP and which sets out currently being conducted. Due to end on appropriate details of all of the
101 required elements 30th September.
Trust Quality Indicator June 2016 RAG Actions Priorities 2016/17 9 Coordinated Inpatient Q2 Quarter 1 – Achieved Indicator 1 Discharge Planning Quarter 2- On track to achieve CQUIN Lead to promote Distribute Discharge Draft Standards to Discharge Standards at Commissioners and GP Clinical Leads Discharge standards and Task Ward Managers Development for the boroughs. Management System have been added Day. Re-launch of updated Discharge as agenda items for the Purposeful Standards. Including promotion through admission project group to be reviewed; My shared pathway leaflet to local events and groups, promotional including configuration of RiO and Task be distributed to forensic materials and electronic publicity such Manager. service users for feedback. as the Trust Intranet and screensavers. Discharge Information for service users Indicator 2 Distribute and implement the usage of and carers utilising Older People the ‘my shared pathway’ element of services currently being coproduced. ward packs across forensic inpatient services and collect feedback from Revised discharge standards service users, friends, family and distributed and advertised. carers, and staff. Update ‘my shared pathway’ information based on feedback collected. Update adult discharge information for older peoples services coproduced with staff and service users. Indicator 3
102 Further development of the Task Management System to include: - Automatic copy of the email to the manager of the member of staff to whom the task is allocated - Automatic reminder to the staff member, their manager and the discharge coordinator when the task is overdue 10 Adult Autism a. Produce guidance for staff on how to Quarter 1 – Achieved Guidance to be produced. Q2 identify and record Quarter 2- On track to achieve Promote use of guidance Enhanced training materials b. Commence roll out of training Service User Open Day Event currently being sourced. package to appropriate clinical staff arranged. c. Audit number of appropriate staff trained at the end of Q2 Baseline number of staff trained d. Promote use of Skype focused obtained. specifically to target audience e. Hold Service User and Carer Open Trust LD Lead has met with potential Day trainer. Basic Training materials f. Submit Progress Report sourced and advertised. Clinicians currently completing basic awareness training developed by Sutton Council.
RiO configured but not currently available in live environment. Request made for data to be reportable and available on Dashboards. 11 Improving Safety Q2 a. Launch sign up to safety initiative Quarter 1 – Achieved Adult Safeguarding Lead to and promote staff involvement Quarter 2- On track to achieve approach service users to co- b. Coproduce ‘feeling Safe’ posters produce feeling safe posters. with service users and distribute to Sign up to Safety Campaign launched teams. by Associate Director of Governance, Adult Safeguarding Lead to c. Audit course objectives for Proactive Quality and Risk. update Ulysses guidance. Physical Intervention Training with regards to conflict resolution as part Ligature audit report produced.
103 London-wide reducing restrictive practice programme. Audit tool developed and distributed for d. Update guidance on recording proactive physical intervention training incidents on Ulysses. To include: audit. o Recommended recording practice for improved data Mock Inspections completed and report quality produced. o External reports to police, local authority and advocacy service o Recording service user views in de-brief e. Audit of ligature points in inpatients settings and produce plan for removal of ligature points based on environmental risk assessments. Where it is not possible to remove these staff to be made aware and mitigation plan implemented. f. Undertake Peer/Service User risk- focused walkabouts g. Peer Reviews
N Specialist Services Qrt Indicator June 2016 Update RAG Actions o. 2015/16 2 1 MH2 Recovery Q2 Commence actions from Q1 plan Quarter 1 – Achieved 2 Colleges for Medium Quarter 2- No formal target and Low Secure Patients Milestones and action plan for 2016/17 developed and submitted. Action plan commenced.
104 1 MH3 Reducing 1. Implementation of action plans, Quarter 1 – Achieved Working around linking Q2 3 Restrictive Practices including: engagement, training of Quarter 2- On track to achieve restrictive practice domains, within Adult Low and staff, adoption of policies, evaluation collating data for with Medium Secure plan. Appointed a clinical nurse specialist for SNOWMED and Turner is Services 2. Provision of training in accordance restrictive practice for October start date. going to pilot this. Which we with Positive and Proactive Workforce They have experience of implementing believe it will give us better (2015) to ensure staff are committed safe wards so will be able to lead on that quality data for each domain. to and have the necessary skills and element of the CQUIN. competencies to deliver change. Evaluation report for 3. Progress report on action plan. Restrictive Practice Policy reviewed, engagement process 4. Evaluation report of staff/patient local protocol signed off as interim required.. engagement process measure whilst policy is being approved.
Progress report produced. 1 MH4 Improving CAMHS Delivery of processes agreed against Quarter 1 – Achieved CQUIN report currently being Q2 4 Care Pathway the plan of improved outcomes for Q2 Quarter 2- On track to achieve produced. Journeys by Establishment of a validated survey of Enhancing the families or carers against which to All actions for Q2 achieved for Wisteria Experience of assess satisfaction. Ward and evidence provided. Family/Carer System for documenting information sharing developed. A draft version has been circulated to the consultant and ward manager for comments and discussed in the service development meeting. Final draft to be implemented. 1 MH5 Benchmarking 1. Analysis of indicators, aiming to Quarter 1 – Achieved Q2 5 Deaf CA & Adult MH finalise data collection and to conduct Quarter 2- On track to Achieve Services and Pilot data collection, involving the Developing Outcome following activities: Service staffing data - completed for Performance Plans and a. Liaison and feedback from SWLSTG. Standards external partners (e.g. Trust •outcome tool and Standards list – we IT/IG, commissioners) are working with other providers to b. Localised testing of data set finalise the standards list - to be c. Service user Workshop completed by 29/8/16. d. Collate information PRODUCT Data set determined for SWLSTG.
105 e. Refined draft set of indicators Currently being reviewed by Information with evidence of external Management. partner involvement, f. Update CRG Group meeting attended by Specialist g. Collected outcome tool data Service BSDM on 8th September in h. Trialling and collation of goal Birmingham. based outcome measures
1 Secure Service NHS England proposes using 0.75% Quarter 1 – Achieved Oct - Team operational Q2 6 Transformation and of the 2016-17 CQUIN allocation for Quarter 2 – On track to Achieve Repatriation of London mental health providers to deliver a January - 180 patients Secure Services Repatriation Programme for adult July - model for the Out of area team assessed by team secure inpatient services. This will be presented to the 3 Trusts. Skill mix 10 placements identified for used to agreed bringing back to local services • Fund the establishment and operation of a team of clinical August - Job Descriptions and posts April -10 placements back in S assessors drawn from provider advertised for new Out of Area team in London services organisations to assess OATS progress and identify patient cohorts • Identify opportunities to Sept – Recruitment underway repatriate/discharge patients • Fund the project management costs associated with delivery of the Repatriation Programme • Deliver a comprehensive needs assessment to inform the planned procurement programme • Scope a London Capacity Management System
106 Appendix 13: Draft CQC Intelligent Monitoring Report
The CQC Intelligent Monitoring Report currently shows one elevated risk (Trust has action in place) and one amber risk in relation to written complaints. The risk in relation to mental health learning disabilities minimum data set was been removed in the final version.
107 Appendix 14: CQC Compliance and Improvement Plan
Report title: CQC compliance and improvement Plan Update
Executive lead: Vanessa Ford, Executive Director of Nursing and Quality
Report author: Peter Hughes, Interim Head of Risk
Report discussed Directorate Quality and Performance meetings, EMC previously at:
Purpose and action required: This report provides a detailed summary of the progress and assurance against the CQC quality improvement plan. For approval X
QSAC is asked to: • Note the feedback received from the follow up visit by For discussion the CQC. • Scrutinise this report and assess if the level of assurance provided is adequate. • Commend the hard work and commitment of the staff To note and senior leaders in making the improvement to date, and continue with a high level of scrutiny and attention.
Key summary:
This report provides a monthly position with regard to the progress made and quality assurance position against the CQC Quality Improvement Plan:
1. The Quality improvement plan was approved at the July board and sent to the CQC.
2. The plan was developed by the leadership teams responsible within the directorates and/or corporate area of responsibility with front line engagement.
3. The plan sits in the Trust risk registers, so that they are integrated into the normal governance procedure. This process is strengthening the use and knowledge of both risk registers and the provision of quality evidence and robust assurance.
4. Since the last report a number of Quality Improvement reviews have been undertaken to assess improvement in individual teams. This included a full day of quality improvement peer reviews (Mock style CQC inspections) which evidenced significant improvements in the 3 key areas of focus for the re- inspection and also highlighted further areas for improvement.
5. A summary assurance position is provided in table 1 on page 9. This demonstrates the current level of assurance for the two key areas for the focused re-inspection at the end of September- supervision and administration, and an overall position.
6. Significant assurance can be provided in relation to the level of engagement
108 and commitment from staff at all levels in relation to the delivery of the plan.
7. Partial assurance is provided in relation to Kingston and Richmond. This is an improved position on last month, and therefore performance is being supported through the support and intervention framework and the direct support of the COO. The directorate leadership team attended and presented their quality improvement plan in full to EMC. The specific concerns relate to the management spans of control in the recovery teams and the cultural issues in relation to administration. Significant progress has been made in relation to administration and new team leadership spans of control will be in place from the first week in Oct 2016.
8. Significant Assurance is provided in relation to supervision. The new policy is now being implemented, the recording system is in place (as of the 31st July) and is now reported at a staff member, team, directorate and trust wide level. Teams have provided their organograms, however there are some teams with large spans of control and this is now being addressed through operations (2 teams in Wandsworth and 2 in Kingston and Richmond). There is strong ‘buy in’ from leaders and staff. As of the 23rd Sept performance hit the 85% of staff had received supervision that was recorded on the new system, however as supervision occurs on a six weekly schedule, it will take the full 6 weeks to demonstrate the true trust position. This metric is extremely sensitive. HTT, crocus ward and the community older peoples teams who are due to be re- inspected by the CQC were able to demonstrate 95% or above compliance and evidence of supervision consistently for the previous 3 months. A quality baseline survey was completed in the first 2 weeks of September and this will be repeated six monthly so that we have a quality position, alongside a performance position. The survey which was open to all staff was completed by 167 staff members of whom reported a 67% overall satisfaction with supervision. This report will provide a baseline for future quality reviews. The focus on supervision and the importance of the quality of the experience of this needs to remain a priority until fully embedded which it is anticipated will take a minimum of a further 6 months. The significant improvement trajectory that has been achieved demonstrates that supervision practices were in place across the organisation and a formalised policy and recording system has strengthened good practice. It is recommended that internal audit is asked to review supervision practice in 6 months to provide an external assurance assessment.
9. Partial assurance is provided in relation to administration. This is due to the consistent application of the new administration approach across the directorates, however this is a managed change programme with a clear project plan that is being managed to time. New administration leadership has been established and the COO is chairing the administration change programme. The administration changes in Harewood House provide significant assurance that the changes can and do work. Evidence provided to the CQC in relation to older peoples community services demonstrated over 95% compliance with discharge services within 7 days. Therefore significant assurance can be provided that key stakeholders communication through administration systems is improving, but further work is required to ensure complete consistency. The full voice recognition auto transcription has now been turned on and is being
109 piloted. There are some technical challenges as would be expected when managing a programme of change. The service directors are actively managing the administration processes to ensure timely communication for patients and stakeholders and that letters are stored in the correct place. Significant assurance is provided in relation to transportation of medication (lockable rucksacks) and stock list management in community services. Medicines code audits have been completed and safety briefing issued. This work will take further time to embed.
10. Partial assurance is provided in relation to restrictive interventions, rehabilitation and community services. The improvement plans are being implemented however as expected these actions will not be completed in advanced of the CQC focused re-inspection due to the depth and breadth of change required. The community services transformation presents the largest quality challenge to the organisation and a series of practice improvement meetings and community leaders chaired by the Director of Nursing have been established. A summary of the plan is included in the quality and performance report. QSAC will receive a full quality assurance report in November 2016. As clinical leaders are engaged in the design and implementation of the quality improvement actions it is becoming apparent that some of the timescales maybe overly ambitious to achieve the level of practice and cultural change and the directorates are reviewing all of the timescales to ensure achievability.
Care Quality Commission (CQC) update
The Board agreed on 1st September to proceed with the focused re-inspection. CQC completed their focused re inspection 27th & 28th September to visit Home Treatment Teams, Older People Community teams and Crocus Ward. The visit focused on supervision, medication management and administration. The CQC provided verbal feedback at the end of the inspection. They thanked the staff for their warm and professional approach and commended their hard work. They were impressed by the level of significant improvements made in all three areas and verbally confirmed that the trust had met its regulatory requirements and that in all three areas these would be updated. In terms of re rating the organisation given the verbal feedback and looking at the CQC matrix it indicates that the trust should be re rated as good. This needs to be confirmed through the CQC internal assurance processes and they will provided a written report and confirmation in the next 6 weeks
QSAC is asked to commend the hard work and commitment of the staff and senior leaders in making the improvement to date, and continue with a high level of scrutiny and attention.
Relationship to board assurance framework (risks) and/or Directorate Risk register? Are any existing risks in the board assurance Review of overall risk assessment relating to framework or directorate risk register affected? compliance. If yes, insert relevant risk reference: Range of existing risks included on risk register. Do you recommend a new entry to the board Yes as identified in section 7. assurance framework (i.e. Trust-wide level 1 risk) is made?
110 Relationship to Trust strategic objectives and our values of openness, respect, compassion, fairness and collaboration? 1. Improve Quality We will provide consistent, high quality, safe services that x and value represent value for money. 2. Improve We will develop stronger external partnerships and business Partnerships opportunities that improve access, responsiveness and service range. 3. Improve We will have reciprocal relationships which value service users, X Co-Production carers, staff and the community as co-producers of services. 4. Improve We will enable increased hope, control and opportunity for our X Recovery service users. 5. Improve We will become a leading innovative provider of health and Innovation social care services. 6: Improve ‘We will develop leadership and talent throughout the X Leadership and organisation. talent
Acronyms / terms used in the report CQC Care Quality Commission QSAC Quality and Safety Committee COO Chief Operating Officer
Supporting documents and/or further reading (e.g. Appendix 1 Quality Governance, Compliance and Quality Improvement report (February 2016) CQC Inspection Reports Trust Board report August 2016
111 Appendix 15: Acute Care Pathway Dashboard
Example of new Acute Care Pathway Dashboard which will allow clinicians to review local ward data over time and drill in to review outlying data.
112 SOUTH WEST LONDON ST GEORGE'S MENTAL HEALTH NHS TRUST BOARD OF DIRECTORS PERFORMANCE DASHBOARD AS AT AUGUST 2016
Month Year to Date Forecast Tolerances Data Quality Assurance Except. Key Metrics Measure Lead Previous Risk Current Commentary Action Independent Plan/ Threshold Actual Prev Year Plan Actual Prev Mth Trend Prev Year Plan Trend Prev Year Assurance On Target Of Concern Report Assurance month Mov'mnt Forecast Req Audit
MONITOR Community follow up within seven days post inpatient COO M1 Seven Day Follow Up 95.0% 96.1% 97.2% 96.5% 95.0% 96.1% 96.3% 96.0% 95.0% 96.0% 96.0% 4 >=95% <95% discharge % clients with a current up to date CPA Review - HSCIC COO M2 CPA review (snapshot position at end of month reported month in 95.0% 98.7% 97.6% 98.0% 95.0% 98.7% 97.6% 98.0% 95.0% 98.8% 98.5% 4 >=95% <95% arrears) M4 Early Intervention Number of Early intervention - New Cases YTD (153) COO 100.0% 241.0% 290.2% 192.9% 100.0% 241.0% 290.2% 192.9% 100.0% 241.0% 243.1% 4 >=100% <100% M5 % Data completeness – identifiers COO 97.0% 99.6% 99.6% 99.3% 97.0% 99.6% 99.6% 99.3% 97.0% 99.6% 99.6% 4 >=97% <97% Data completeness M6 Data completeness – outcomes COO 50.0% 93.2% 93.4% 93.1% 50.0% 93.2% 93.4% 93.1% 50.0% 93.2% 94.5% 4 >=50% <50% Compliance regarding access to health care for people with M7 Learning disability DnNQS 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100% 4 - - learning disabilities M8 Delayed transfers of care Delayed transfers of care COO 7.5% 5.9% 4.7% 4.5% 7.5% 5.6% 4.7% 3.9% 7.5% 4.7% 3.4% 4 <=7.5% >7.5%
Maximum time of 18 weeks from point of referral to M9 COO 90.0% - - - - 90.0% - 100.0% - 100.0% 90.0% - - 100.0% - >=90% <90% treatment in aggregate – admitted Referral to Treatment Maximum time of 18 weeks from point of referral to M10 treatment in aggregate – patients on an incomplete pathway COO 92.0% 96.8% 92.2% 96.4% 92.0% 93.6% 93.5% 98.2% 92.0% 95.5% 96.5% 2 >=92% <92% Y (waiting community pathway)
Number of Hospital acquired MRSA bacteraemia and M11 MRSA DoNQS 0 0 0 0 0 0 0 0 0 0 0 4 0 >0 Clostridium Difficile reported
% Admitted Clients (face to face ) Gate Kept by Home M12 Home Treatment Gate Keeping COO 95.0% 97.0% 99.0% 98.0% 95.0% 98.0% 99.0% 97.8% 95.0% 98.0% 99.0% 4 >=95% <95% Treatment pre admission SAFE
S1 Number of incidents reported DoNQS 580 769 776 627 580 792 798 688 580 735 719 4 >=580 <=552-579 <552
S2 Number of patient safety incidents DoNQS 325 356 360 301 325 396.2 406 359.2 325 376.4 >=325 309-324 <309
Number of Lower level patient safety incidents (Inc near miss s3 DoNQS - 340 338 - - - 376.4 385 - - - 243 ------No harm and low harm)
s4 low harm DoNQS - 118 121 - - - 130.4 133.5 - - - 130.4 ------
s5 moderate harm DoNQS - 5 11 - - - 11 - - - 11 ------
s6 severe harm DoNQS - 6 9 - - - 2 - - - 2 ------Serious incidents (average / month) (inclusive of incidents not s7 DoNQS - 89 65 - - - 46.3 41.5 - - - 41.5 ------addedd to STEISS) (reported month in arrears)
s8 Incidents reported to STEISS DoNQS - 13 8 - - - 9 9 - - - 10 - - - Feedback on themes to be incorporated Reporting commenced in August in quarterly Learning Report to Board - s9 Unexpected deaths - suspected suicide DoNQS - 9 - - - - 8 ------Board will require assurance on increases in SI's s10 Unexpected deaths - natural causes DoNQS - 1 - - - - 1 ------Reporting commenced in August Incidents Deaths of clients within 6 month of discharge from services s11 DoNQS - 46 45 - - 45.8 45.7 - - - 45.7 ------(reported month in arrers) Moderate harm cases narrative reported s12 Falls reported resulting in moderate harm or above DoNQS 16 25 14 11 16 17.8 14.5 15.7 16 19 14.5 4 in Board Safe Domain section. <=16 16-20 >=21 Y
s13 Self-harm incidents DoNQS 40 39 68 47 40 67 74 30.9 40 42 74 3 - - -
s14 Low harm DoNQS - 35 61 - 61 67.5 - 39 - - - - -
s15 Moderate harm DoNQS - 4 7 - 5 6.3 - 3 - - - - -
s16 Severe harm DoNQS - 0 0 - 0.2 0.3 - 2.4 - - - - -
s17 Medication errors DoNQS 5 7 8 7 5 6 5.8 . 5 5 4 2 <=5 5-7 >7
s18 Low harm DoNQS - 7 8 - - - 5.8 5.8 - . - 4 - - 4 -
s19 Moderate harm DoNQS - 0 0 - - - 0 0 - . - 0 - - 4 - - -
s20 Severe harm DoNQS - 0 0 - - - 0 3 - . - 0 - - Any case report by exception
s21 Pressure ulcers - Grades 3-4 DoNQS 4 0 0 0 4 1 1 1 4 1 1 4 Any case report by exception
s22 Duty of Candour Number of Duty of candour breaches DoNQS 0 0 0 0 0 0 0 0 0 0 0 4 0 1 or >
s23 NHS England Number of Never events in month DoNQS 0 0 0 0 0 0 0 0 0 0 0 4 0 1 or > Risks - Reporting of Injuries, Number of RIDDOR reports in month (YTD reported >2 per s24 Diseases and Dangerous DoNQS 2 2 2 0 10 9 7 2 24 22 - 4 <=2 per month cumulatively) month Occurrences Regulations s25 Safe Staffing Number of wards not safely staffed DoNQS 0 0 - 0 0 0 - 0 0 - 0 0 1 or > Risk Assessment completed within 48 hours of inpatient s26 Risk Assessment DoNQS 95% 95.0% 91.3% - 95% 93.0% 93.0% - 95% 93.0% - 4 >=95% <94.9% - >90% <95% admission As increase as exceeded mean position over last three months a revised Exception reported 3 months above s27 Allegations of physical violence towards staff from patients DoNQS 41 61 59 54 41 49.6 44 54.4 41 47 44 1 exception report has been provided. above mean or outside normal variation Y range
Exception reported 3 months above Allegations of physical violence towards patients from s28 DoNQS 30 28 41 40 30 33 50 33.2 30 33 50 4 above mean or outside normal variation patients Allegations of physical violence range Exception reported 3 months above s29 Allegations of physical violence towards patients from staff DoNQS - 0 3 - - - 2.4 4 - - 2.4 - - - above mean or outside normal variation range Exception reported 3 months above s30 Allegations of verbal abuse staff on client DoNQS - 1 0 - - - 0.2 0 - - 0.2 - - - above mean or outside normal variation range EFFECTIVE
E1 Emergency readmissions Emergency readmission within 30 days COO 8.5% 7.0% 15.0% 6.3% 8.50% 6.0% 6.0% 6.0% 8.50% 6.0% 6.0% 4 <=8.5% >8.5%
PBR lead to provide an updated exception in May's report. E2 Mental Health Tariff % clusters accuracy and quality MD 95.0% 86.7% 86.4% 86.8% 95.0% 86.7% 86.4% 86.8% 95.0% 86.7% 84.0% 3 >=95% <94.9% - >90% <95%
E3 HoNOS % HoNOS Assessed (Specialist Services only) MD 95.0% 81.2% 83.8% 95.0% 84.5% 84.8% 87.4% 95.0% 87.0% 88.9% 2 >=95% <94.9% - >90% <95% Reported in bed maangement narrative under key risks section ofexecutive E4 Average Length of Stay (Adult Acute exc leave - YTD) COO 28 36.7 35.6 30.0 28 36.7 36 29.0 28 36.7 29 2 <=28 29-30 >30 summary. Bed Management SOUTH WEST LONDON ST GEORGE'S MENTAL HEALTH NHS TRUST BOARD OF DIRECTORS PERFORMANCE DASHBOARD AS AT AUGUST 2016
Month Year to Date Forecast Tolerances Data Quality Assurance Except. Key Metrics Measure Lead Previous Risk Current Commentary Action Independent Plan/ Threshold Actual Prev Year Plan Actual Prev Mth Trend Prev Year Plan Trend Prev Year Assurance On Target Of Concern Report Assurance g month Mov'mnt Forecast Req Audit
E5 Bed Occupancy (Adult Acute Exc leave and ELFT & Non ELFT) COO 95.0% 95.7% 95.3% 89.0% 95.0% 95.3% 95.3% 90.0% 95.0% 96.0% 95.3% 2 <=95% >95%
E6 CQUIN - (% compliance on CQUIN indicators) DoNQS DoNQS CQUIN E7 Specialist CQUIN - (% compliance on CQUIN indicators) Please see Appendix 12.
DoNQS E8 Quality Account Quality Account (% compliance on Quality account indicators)
>=95.0% to >=95.0% to >=95.0% to E9 Inpatient Staffing Efficient ward staffing DoNQS 105.0% 104.2% 110.0% 104.6% 104.5% 113.5% 104.6% 111.2% 4 <=100% >105% - <110% >110% <=105.0% <=105.0% <=105.0% CARING
Data reconcillation on toal figures required post audit feedbsak on other C1 Total Physical Interventions DoNQS NA NA NA NA NA - NA NA - reducing restrictive practice metrics. <=36 37-39 >=40
Reporting commenced July 2016 Exception reported 3 months above C2 Rapid Tranquilisation DoNQS - 26 41 - - 33.5 41 - - - 33.5 41 - above mean or outside normal variation range Reducing Restrictive Practice Reporting commenced July 2016 Exception reported 3 months above Intensive Physical Intervention e.g. Naso Gastric Feeding C3 DoNQS - 1 6 - - 20.4 6 - - - 24 6 - above mean or outside normal variation under restraint. range Exception reported 3 months above C4 Seclusions DoNQS - 17 7 - 0 - 16 - 2.6 - 8.6 - - above mean or outside normal variation range Exception reported 3 months above C5 Prone Restraint DoNQS - 23 17 - 8 - 19 - 7.8 - 8.6 - - above mean or outside normal variation range C6 Safe Staffing Number of wards with shift fill rate less than 95% DoNQS 7 7 - 7 7 - 7 - - - - C7 Number of wards with shift fill rate more than 105% DoNQS 8 8 - 8 8 - 8 - - - -
C8 % Complaints responded to within 25 days DoNQS 95.0% 80.0% 81.3% 94.0% 95.0% 83.0% 84.0% 95.0% 95.0% 79.0% 83.0% 2 <95% Complaints >=95% C9 % received complaints acknowledged within 3 days DoNQS 100.0% 100.0% 90.0% 98.0% 100.0% 86.0% 85.0% 98.0% 100.0% 86.0% 85.0% 4 100.0% 95.0% - 99.9% <95%
C10 Compliments Number of compliments DoNQS - 182 149 - 77 174.6 172.8 - 71.2 148.4 - - - - -
C11 PALS Enquiries Number of PALS enquiries DoNQS - 74 39 - 15 37 28 - 14.4 37 - -
C12 Real Time Feedback - Responses (inpatients) DoNQS - 446 536 - 400 - 504 518.0 - 447 - 644 - - - - -
Real Time Feedback C13 Real Time Feedback - General satisfaction score - Inpatient DoNQS - 65 58 - 60.0 - 58.0 56.0 - 59.0 - 58.9 - - - - -
C14 Real Time Feedback - General Satisfaction score - Community DoNQS - 79 87 - 76 84.0 86.0 - 77 79.0 - - - - - C15 Friends and Family Friends and Family Responses (via Real Time Feedback) DoNQS - 66 103 - 85.6 90.5 - 124 - - - - - COO 84.0% C16 % in Settled Accommodation (18-69 yrs, CPA only) 61.0% 85.6% 85.3% 61.0% 85.6% 85.6% 85.1% 61.0% 86.0% 84.4% 4 >=61% <61% Social Inclusion C17 % Employed (18-69 yrs, CPA only) COO 7.1% 9.6% 9.3% 9.4% 7.1% 9.4% 9.3% 9.7% 7.1% 9.2% 9.6% 4 >=7.1% <7.1% % clients whom have had a physical Health Assessment Rag rating amber due withih 5% of C18 Physical Health Assessments COO 98.0% 95.0% 97.0% 94.0% 98.0% 95.0% 95.0% 95.2% 98.0% 88.0% 96.0% 2 >=98% >=93% - >98% <93% Y completed within 48 hours of admission trajectory target C19 Crisis Plan % CPA clients with a Collaborative Crisis plan recording COO 85.2% 83.2% 82.3% - 85.2% 83.2% 82.4% - 90.0% 92.0% - 4 >=90% <90% C20 Safeguarding adults Average number of Safeguarding adult alerts per month DoNQS - 69 86 - 64 - 69.2 69.3 - 55 - 69.3 - 49.3 N/a - - % of Carers of Clients on CPA who have been offered a carers Target on trajectory 85% year end. C21 Carers Assessment COO 78.9% 81.0% 71.3% - 78.9% 81.0% 71.3% - 85% 85.0% 62.3% 3 >=78.9% <=78.9% assessment RESPONSIVENESS R1 Wait for Treatment 52 Week waits (reported a month in arrears) COO 0 0 0 0 0 0 0 0 0 0 1 4 0 >0 R2 % patients assessed within 28 days - adult COO 80.0% 85.0% 85.6% 75.0% 80.0% 82.0% 81.3% 74.1% 80.0% 79.0% 70% 4 >=80% 75%-79% <75% R3 % patients assessed within 28 days - OP COO 80.0% 90.6% 85.4% 97.6% 80.0% 85.0% 83.6% 81.2% 80.0% 86.1% 74% 4 >=80% 75%-79% <75%
Community Mental Health Teams % urgent referrals to adult secondary care assessed within 7 R4 COO 90.0% 85.3% 97.1% - 90.0% 86.4% 86.9% - 90.0% 86.0% - 3 >=90% 85.0%- 89.9% <85% (CMHT) days
% urgent referrals to Older People's Services assessed within Denominator is low (n=3) in August 2016. R5 COO 90.0% 100.0% 100.0% - 90.0% 90.9% 87.5% - 90.0% 90.9% 83% 4 >=90% 85%-89.9% <85% 7 days Cost and activity plan not yet agreed - position will be reported next month. >+-5% - R6 % Variance from local CCG contract plan DoFP As per YTD +-5.0% TBC TBC - 2.8% +-5.0% TBC - -1.4% TBC +-5% >+-10% <+-10% Contract >+-5% - R7 % Variance NHS England DoFP As per YTD +-5.0% -4.2% -3.7% -1.1% +-5.0% -4.2% -0.9% 4 +-5% >+-10% <+-10% R8 % Clients assessed within 8 weeks COO 80% 91.6% 86.2% - 80% 90.1% 89.9% - 80% 78.0% 1 4 >=80% 75% - 79.9% <75% CAMHS R9 % Urgent CAMHS referrals seen within 5 Working days COO 95% 80.0% 100.0% 75.0% 95% 89.6% 91.0% 92.0% 95% 91.0% 88.3% 2 4 breach cases reported in August 2016. >=95% <94.9% - >90% <90% R10 EIS % Client's treated with NICE approved care package within tw COO 50.0% 64.0% 86.0% - 50.0% 68.0% 80.0% - 50.0% 66.0% 86.0% 4 >=50% <50% R11 Absconded Greater than 12 hours - Escorted Leave (in month & DoNQS - 0 - - - 0 - - 0 - - - - Abscond reporting has been redefined Absconsion - applies to all MHA R12 Failure to return from leave Greater than 12 hours (in month & DoNQS - 1 - - - 1 - - 1 - post review by Director of Nursing. - - - patients Target will be reviewed for next report. R13 Abscond from ward Greater than 12 hours (in month & month DoNQS - 1 - - - 1 - - 1 - - - - R14 DNA's DNA Rate all services DoNQS 15.0% 12.0% 12.0% 11.0% 15.0% 12.0% 12.0% 11.0% 15.0% 12.0% 11.0% 4 <=15% 16%-17% >17% R15 % Recovery Rate (all HoNoS clusters) COO 50.0% 43.8% 47.3% 47.8% 50.0% 47.1% 48.1% 45.8% 50.0% 46.0% 46.4% 2 >=50% < 50% Y
% expected population need met by IAPT Wandsworth IAPT Not R16 COO 5.25% 6.0% 4.9% Not compliant 5.25% 6.0% 4.9% 12.6% 14.3% 12.9% 4 r >=5.25 r <=5.25 compliant
IAPT % expected population need met by IAPT Sutton Uplift Not R17 COO 6.25% 6.7% 5.4% Not compliant 6.25% 6.7% 5.4% 15.0% 16.0% 15.2% 4 r >=6.25 r <=625 compliant
R18 % clients commenced treatment within 6 weeks COO 75.0% 99.0% 96.4% 97.3% 75.0% 96.5% 96.4% 97.2% 75.0% 97.0% 96.4% 4 <=75.0% >75%
R19 % clients commenced treatment within 18 weeks COO 95.0% 99.8% 100.0% 99.8% 95.0% 99.5% 99.8% 99.8% 95.0% 99.8% 99.8% 4 <=95% >95%
WELL LED W1 CQC Intelligent Monitoring - Number of elevated risks DoNQS 0 1 1 0 1 1 0 1 1 0 >0
Care Quality Commission W2 CQC requirement notices DoNQS 0 6 6 0 6 6 0 6 5 0 >0
W3 % Sickness Rate (reported month in arrears) DoHR 4.6% 4.0% 4.6% 3.6% 4.6% 4.1% 4.1% 4.1% 4.6% 4.3% 4.3% 4 <=4.6% >4.6% SOUTH WEST LONDON ST GEORGE'S MENTAL HEALTH NHS TRUST BOARD OF DIRECTORS PERFORMANCE DASHBOARD AS AT AUGUST 2016
Month Year to Date Forecast Tolerances Data Quality Assurance Except. Key Metrics Measure Lead Previous Risk Current Commentary Action Independent Plan/ Threshold Actual Prev Year Plan Actual Prev Mth Trend Prev Year Plan Trend Prev Year Assurance On Target Of Concern Report Assurance month Mov'mnt Forecast Req Audit W4 % Turnover rate DoHR 15.0% 14.7% 15.2% 16.1% 15.0% 15.6% 15.8% 16.0% 15.0% 15.0% 16.0% 4 <=15% 15.1% - (17%) >17% Workforce W5 % Vacancy rate DoHR 12.4% 18.6% 18.6% 18.9% 12.4% 19.2% 19.3% 14.6% 12.4% 18.6% 19.0% 3 <12.4% 12.5%- 14.5% >14.5%
W6 Mandatory training % mandatory training compliance DoHR 95% 87.3% 86.0% 71.5% 95% 87.3% 84.9% 89.0% 95% 85.9% 84.9% 3 >=95% 90.0% -94.9% <90% It shouod be noted that at the time of reporting (end of Septmber) the Trust W7 Supervision % had a supervision with line maanager within last six weeks DoNQS 85% 86.8% - - 85% 86.8% - 85% 86.8% - 4 had achieved target - please see executive summary.
W8 Board Assurance Framework Number of High Risks on BAF DoNQS 3 1 3 1 3 1 - -
W9 FSRR Calculated in accordance with TDA rules DoFP As per YTD 3 2 2 4 4 4 4 3 4.00 <4 <4
W10 EBITDA £m DoFP 1.1 0.6 0.9 1.2 5.0 3.5 2.9 4.8 14.3 14.3 14.7 2 Act. = Plan Var >2.5% Var>5%
W11 Savings % achievement against external plan before mitigation DoFP 3.0% 3% 2% 5% 9.0% 11.0% 7.0% 26.0% 100.0% 100.0% 64.0% 2 100% <90% <90%
W12 Capital Expenditure Capital Spend as % of plan DoFP 4.0% 3% 4% 7% 17.0% 12.0% 9.0% 20.0% 100.0% 100.0% 62.0% 3 100% <75% <75%
W13 Cash £m DoFP As per YTD 18.9 17.6 17.0 15.1 14.6 14.6 18.4 3 Act.=Plan Act. <£10.0m Act. <£9.0m
Risk Movement and Trend Forecast Assurance Exception Reports Data Quality Assurance
Improvement in performance and within plan Deterioration in performance but still within plan Performance continuing on plan 1 No Plan in Place Blank not required Sufficient assurance provided to the exec owner and Head of
Improvement in performance but still slightly off plan Deterioration in performance and slightly off plan Performance continuing, still slightly off plan 2 Plan in place but progress insufficient N Required but not available Head of Perf and Info / independent audit of assurance criteria
Improvement in performance but still off plan Deterioration in performance and off plan Performance continuing, still off plan 3 Plan in place and progress satisfactory Y Required and attached Insufficient assurance (see appendix for details) Not yet assessed against all criteria
Independent assurance through external audit
Minutes of the meeting of the Finance and Investment Committee Held on 20 July 2016
Present: Jonathan Thompson Non-Executive Director (Chair) Barbara Greenway Non-Executive Director David Bradley Chief Executive Officer
In attendance: Suzanne Marsello Director of Strategy and Planning Emma Whicher Medical Director Dawn Chamberlain Chief Operating Officer Jayne Halford Interim Deputy Director of HR Philip Warner Head of Financial Planning Matthew Neal Director of Estates Modernisation Programme Sarah Hewison Head of Office of the CEO and Chairman (Minutes) Deborah Parry Property Lawyer (external guest)
75-15/16 Apologies for Absence 75.1. Apologies were received from Clive Field, Interim Director of Finance, and Debbie Hollinghurst, Interim Deputy Director of Finance.
76-15/16 Minutes of the Meeting held on 25th June 2016 (FC(16-17) 4A 76.1. The minutes were approved as an accurate record of the meeting.
77-15/16 Recovery House Business Case (FC(16-17) 26 77.1. The Chair began the meeting with item 9 on the agenda.
77.2. The Chief Operating Officer presented the business case which incorporates the Wandsworth Rehabilitation Pathway and Crisis Recovery House, the intention of which is to modernise and improve the Wandsworth pathway.
77.3. The Committee discussed the options presented in part B of the meeting.
78-15/16 Agency Spend Update FC(16-17) 23 78.1. The Interim Deputy Director of HR outlined the plans to reduce agency use, including governance around approval with an agency approval panel, and an unfreezing of recruitment in community and administration posts where agency use is high. There will be efforts to move agency staff to the bank, and more focus on succession planning, as well as an increase on notice periods to allow better planning. The Chief Executive asked for clarity on targets and the Chair expressed concern that there was not enough focus on holding managers to account and that the panel must have authority.
79-15/16 Estates Modernisation Programme Update FC(16-17) 25 79.1. The Director of Estates Modernisation provided an update on the progress of the project plan bring the Committee’s attention to a number of key items in the report.
The Committee approved the paper
SWLSTG minutes of the Finance and Investment Committee, 20 July 2015 (Part A) Page 1
80-15/16 Commercial Report FC (16-17) 28 80.1. The quarter 1 Commercial Report has already been to the board and was included for completeness.
81-15/16 Commercial Report FC (16-17) 27 81.1. The Director of Strategy and Commercial Development updated the Committee on activity since the last meeting including the submission of the Wales Tier 4 tender and the need to submit and interest for Richmond OBC in advance of the next F&I Committee. The Committee agreed for EMC to agree the submission.
The Committee noted the paper.
82-15/16 Financial Report FC(16-17) 21 & 22 82.1. The Head of Financial Planning presented the report and confirmed that the new format would be used going forward. He highlighted that the current position is adverse against plan and that the forecast remains on target.
The Committee approved the paper.
83-15/16 Reference Costs 2015/16 Submission FC(16-17) 24 83.1. This paper was noted. It has been submitted and represents an improvement in terms of benchmarking form last year but is above the national average.
Sarah Hewison Jonathan Thompson Head of the office of the Chair of the Finance and Investment CEO and Chairman Committee
SWLSTG minutes of the Finance and Investment Committee, 20 July 2015 (Part A) Page 2
Trust Board Meeting
6 October 2016
Paper Reference: TB(16-17) 98
Report Title: Finance Report Month 5 2016/17
Executive Summary: • The Trust is forecasting a £2.1m surplus before impairments for the year. This is in line with the agreed control total at the start of the year of £1.1m, plus the £1.0m adjustment for the Sustainability and Transformation Fund. • The Trust has planned impairments for the year of £0.2m, which will result in a net surplus of £1.9m. • After five months, the Trust is reporting a £1.6m deficit, which is £1.5m adverse compared to budget. • The cash balance at the end of the month was £17.6m, £1.3m short of plan. • The Trust is working to deliver £12.2m of new savings over 2016/17 and 2017/18 with £1m per month being delivered from October. Schemes for £10.9m have been identified and the Trust is finalising implementation plans. • The Trust is currently budgeting for £159.8m of income during the year compared to the £163.2m provided for in the operating plan submitted to the NHS Improvement Agency (movement of £3.4m). The Trust budget reflects the agreed contracts with local commissioners and the NSHE and the STP funding. • The Trust is reporting a £1.5m adverse position against expenditure this is principally within pay. This reflects the under achievement of savings on the Admin and Clerical review, and high agency spend. • The Trust has spent £7.1m on agency staffing which is £2.7m higher than the target spend required by the NHSI. The Trust is reviewing all non-front line agency and further tightening the use and governance of agency spend. Action Required: The Board is asked to note the report.
Link to Strategic Objectives: Support existing services to provide consistent, high quality, safe services that represent value for money (Quality & Value strategic objective)
Risks: Achievement of Financial Duties Failure to deliver CiP target Failure to deliver agency target
Quality Impact: Not impact assessed except C iP schemes that have quality impact assessments
Resource Implications: Impact on Capital Resource Allocation Impact on Surplus position Legal/Regulatory Implications: None
Equalities Impact: Not impact assessed
Groups Consulted: None
Author: Debbie Hollinghurst, Acting Deputy Director of Finance Owner: Clive Field, Interim Director of Finance & Performance
Page 2 of 2
Clive Field, Interim Director of Finance and Performance
9th September 2016 Contents
• Summary I&E Position • Financial Duties and KPIs • Income Position • Pay Position • Non Pay • Savings • Capital • Statement of Financial Position • Cash
2 Summary – I & E Position
Financial Reports 2016/2017 YTD month 5 12 Mths to 31 March 2017 • The Trust is forecasting £2.1m surplus (Adv)/ (Adv)/ Budget Actual Budget F/Cast after £0.9m STP and before Fav'ble Fav'ble
impairments which is in line with plan E Income 66.6 66.6 (0.0) In 159.8 159.7 (0.0) • Forecast assumes 66% achievement of Pay (48.5) (49.6) (1.1) E (115.9) (118.0) (2.1) the CIP target giving a £2.1m shortfall. Non Pay (13.1) (13.5) (0.4) (29.6) (27.5) 2.1 The majority of CIP plans are phased in EBITDA 5.0 3.5 (1.5) 14.3 14.3 0.0 M7 to M12. Post EBITDA (5.1) (5.1) (0.0) (12.2) (12.2) 0.0 • The YTD position is (£1.6m) deficit, Underlying Surplus / (Deficit) (0.1) (1.6) (1.5) 2.1 2.1 0.0
which is (£1.5m) worse than plan Impairment 0.0 0.0 0.0 (0.2) (0.2) 0.0
Net Surplus / (Deficit) (0.1) (1.6) (1.5) 1.9 1.9 0.0
2.5 Revised Operating Plan Budgetted Surplus Trust Income and expenditure budget is Forecast Surplus 1.5 Actual Surplus £4.7m less than in the operating plan submitted to NHSI
0.5 • Urgent care pathway £2.4m, £m
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar • Local QIPP requirements £0.8m -0.5 • NHSE QIPP £0.6m
Best Forecast Outturn • Other £0.9m. -1.5 Most Likely Forecast Outturn Worst Forecast Outturn This also impacts on the monthly profiling of the budget. -2.5
3 Part A Financial Duties and KPIs
Revised Control Total of £2.1m surplus New Metric before Impairments Cost of Capital Absorption Duty The Trust has been informed that Better Payments Practice Code from October the agency ceiling metric will be included as a full FSRR of 4 metric, and not in shadow form as External Financing Limit (cash target) was originally intended. The Trust is Capital Resource Limit not forecasting to achieve this metric.
Key Month YTD Forecast Previous Risk Prev Prev Metrics Measure Plan Actual Plan Actual Trend Plan Actual Prev Year Assurance Month Movem't Year Year FSRR Calculated in accordance with TDA rules As per YTD 3 2 4 4 4 4 2
EBITDA £m 1.1 0.6 0.9 1.2 5.0 3.5 4.8 14.3 14.3 14.7 2 Savings % achievement against external plan before mitigation 3% 3% 2% 5% 9% 11% 26% 100% 66% 64% 2
CapEx Capital Spend as % of plan 4% 3% 4% 7% 17% 12% 20% 100% 100% 62% 3
Cash £m As per YTD 18.9 17.6 15.1 14.6 14.6 18.4 3
Risk movement and trend Assurances Improvement in performance and within plan Deterioration in perfomance but still within plan Performance continuing on plan 1 No plan in place Improvement in performance but still slightly off plan Deterioration in perfomance and slightly off plan Performance continuing but still slightly off plan 2 Plan in place but progress insufficient Improvement in performance but still off plan Deterioration in performance and off plan Performance continuing but still off plan 3 Plan in place & progress satisfactory
4 Part A Income Position
The Trust is forecasting to achieve £159.7m of income in line with budget.
Year to date is break even compared to plan. One-off non-clinical income is offset by reduced non-contractual activity and shortfalls in cost and volume contracts. Financial Reports 2016/2017 YTD month 5 12 Mths to 31 March 2017 (Adv)/ (Adv)/ Budget Actual Budget F/Cast Fav'ble Fav'ble
EbLocal Contracts 44.3 44.4 0.1 In 106.2 106.4 0.3 Nhs England 11.5 11.5 (0.0) 28.3 28.2 (0.1) Npsa Income 2.5 1.9 (0.6) 6.0 5.3 (0.7) Other Nhs Clinical Income 1.4 1.4 0.0 3.2 3.2 (0.0) Nhs Clinical Income 59.7 59.2 (0.5) 143.7 143.2 (0.5)
Education & Training 2.7 2.7 0.0 In 6.5 6.5 0.0 Other Non Clinical Income 1.7 2.0 0.3 In 3.8 4.3 0.4 Merit Award Income 0.1 0.1 (0.0) In 0.1 0.1 0.0 Non Clinical Income 4.4 4.8 0.3 10.5 10.9 0.4
Non Nhs Clinical Income 2.5 2.6 0.1 In 5.6 5.6 0.0 Non Nhs Clinical Income 2.5 2.6 0.1 5.6 5.6 0.0
Income 66.6 66.6 (0.0) 159.8 159.7 (0.0)
5 Part A Pay Position
• The Trust is forecasting to spend £118.0m on pay during 2016/17 compared to budget of £115.9m, an overspend of £2.1m.
Financial Reports 2016/2017 Current Month YTD month 5 12 Mths to 31 March 2017 Pay T ype (Adv)/ (Adv)/ (Adv)/ Budget Actual Budget Actual Budget F/Cast Fav'ble Fav'ble Fav'ble E Permanent Staffing 8.5 8.0 0.5 41.5 39.7 1.8 In 100.9 96.1 4.7 Bank 0.5 0.6 (0.1) 2.5 2.7 (0.2) E 6.0 8.5 (2.5) Agency 0.7 1.4 (0.8) 4.4 7.1 (2.7) 9.0 13.4 (4.4) Total Pay 9.7 10.0 (0.3) 48.5 49.6 (1.1) 115.9 118.0 (2.1)
• The cumulative adverse position on non clinical staff reflects the under achievement of savings on the Admin and Clerical review, high levels of agency spend particularly within the Programme Management Office, Contracts and HR. • The Trust continues to incur high agency costs on nursing particularly in community services. • The Trust is reviewing all non front line agency staff and introducing further agency controls in order to reduce spend going forward. • Trust is also exploring options to employ all agency staff permanently or via our bank. Financial Reports 2016/2017 Current Month YTD month 5 12 Mths to 31 March 2017 Staff Type (Adv)/ (Adv)/ (Adv)/ Budget Actual Budget Actual Budget F/Cast Fav'ble Fav'ble Fav'ble EBMedical N 1.9 1.9 (0.0) 9.3 9.1 0.2 In 22.1 21.6 0.5 Nursing N 4.0 4.3 (0.2) 20.1 20.7 (0.6) E 48.0 49.2 (1.1) Other Clinical N 1.9 1.9 0.0 9.4 9.5 (0.0) 22.7 22.3 0.4 Non Clinical N 1.9 2.0 (0.1) 9.7 10.3 (0.6) 23.1 24.9 (1.8) Total Pay 9.7 10.0 (0.3) 48.5 49.6 (1.1) 115.9 118.0 (2.1)
6 Part A Non Pay
• The Trust spent £2.6m on non pay in August which was (£0.1m) adverse to plan. • Forecast is currently £27.5m which is below plan. Reserves and contingencies are budgeted as part of non pay but are likely to be used to offset overspends in pay. • Although lower than in previous months, demand for acute care beds exceeded the number of beds available, resulting in the Trust purchasing alternative provision for three patients in addition to the additional contracted ELFT beds. From September onwards the ELFT and additional beds are no longer expected to be needed. Financial Reports 2016/2017 Current Month YTD month 5 12 Mths to 31 March 2017 (Adv)/ (Adv)/ (Adv)/ Budget Actual Budget Actual Budget F/Cast Fav'ble Fav'ble Fav'ble EB Drug Costs N (0.2) (0.2) 0.0 (1.1) (1.0) 0.0 In (2.5) (2.5) (0.0) Secondary Commisioning Costs N (0.2) (0.2) (0.0) (1.1) (1.3) (0.2) E (1.9) (2.2) (0.3) Clinical Supplies & Servs Cost N (0.1) (0.1) (0.0) (0.3) (0.3) (0.1) (0.6) (0.7) (0.1) Other Costs N (2.1) (2.1) (0.0) (10.6) (10.8) (0.2) (23.8) (22.0) 1.7 Contingency N 0.0 0.0 0.0 0.0 0.0 0.0 (0.8) 0.0 0.8 Total Non Pay (2.5) (2.6) (0.1) (13.1) (13.5) (0.4) (29.6) (27.5) 2.1 • The costs of capital are currently forecast to be in line with plan. Financial Reports 2016/2017 Current Month YTD month 5 12 Mths to 31 March 2017 (Adv)/ (Adv)/ (Adv)/ Budget Actual Budget Actual Budget F/Cast Fav'ble Fav'ble Fav'ble EB Cap Charges - Depreciation N (0.5) (0.5) (0.0) (2.3) (2.3) (0.0) In (5.5) (5.5) 0.0 Cap Charges - Pdc Dividend N (0.6) (0.6) (0.0) (2.8) (2.8) (0.0) E (6.7) (6.7) 0.0 Impairment N 0.0 0.0 0.0 0.0 0.0 0.0 (0.2) (0.2) 0.0 Interest Receivable N 0.0 0.0 (0.0) 0.0 0.0 (0.0) 0.1 0.1 0.0 Post EBITDA Total (1.0) (1.0) (0.0) (5.1) (5.1) (0.0) (12.3) (12.3) 0.0 7 Part A Savings
• £10.9m of schemes identified – 89% • Identified schemes increased by £0.1m compared to last month • High levels of red and amber classification (combined total 73%) • Key delivery areas remain HR, Operations, Finance, Estates, with major focus on agency Scheme Classification Aug 16 Sept 16 Move £m's £m's £m's • Month 5 delivery of £189k of Identified 10.8 10.9 0.1 savings, operating plan = £178k Unidentified 1.4 1.3 -0.1 • Cumulative performance is £91k better than plan. • Plan phased to increase from October
8 Part A Capital
Actual £m Budget £m • The capital expenditure budget for Estates Schemes Maintenance 0.2 2.5 the year is £17.2m. Wards Refurbishment 0.0 3.8 Other Refurbishments 0.5 1.7 ECR Electronic Care Record System 0.3 1.1 • The Trust plan allows for the EMP 0.8 5.6 disposal of South Place and Roseland sites for £3.9m during Total Estates Schemes 1.8 14.6 IM&T the year. IT Block Capital 0.2 2.6 Total IM&T 0.2 2.6 Total Capital Expenditure 2.0 17.2
• The CRL for the year has been EFL CRL Plan £m Plan £m confirmed as £13.4m in line with the Capital Expenditure 17.2 Trust plan. The Trust is planning to Planned Depreciation 5.5 achieve this target. PDC Movement in working capital (5.7) Disposal 3.9 (3.9) • The Trust EFL is £3.6m which the Retained Earnings 0.9 Trust is planning to achieve. This is Total EFL/CRL 4.6 13.4 the original plan of £4.6m adjusted for the STP fund.
9 Part A Statement of Financial Position
Statement of Financial Position as at 31 Actual Actual Actual Forecast 31 March Previous Current 31 March August 2016 (£m) 2016 Month Month 2017 NON CURRENT ASSET: Opening PPE £199.4m Intangible assets 3.8 3.4 3.4 4.3 Plant, Property and Equipment 195.6 195.7 195.7 207.7 Depreciation (£5.5) Total Non-Current Assets 199.4 199.1 199.1 212.1 Capital Expenditure £17.2 Non Current Asset Held for sale 3.9 3.9 3.9 0.0 Valuation Impact £1.0 Total Non-Current Assets Held for sale 3.9 3.9 3.9 0.0 CURRENT ASSETS: Closing PPE £212.1m Inventories 0.1 0.1 0.1 0.2 Receivables (due in less than 1 year): NHS Trade Receivables 5.4 2.4 1.4 5.7 Non-Nhs Trade Receivables 1.3 1.7 1.4 1.3 The overall debt position at the end of Other Receivables 1.1 1.0 0.7 0.4 Other Financial Assets (Accrued Income) 0.0 3.2 4.0 0.0 August was £2.8m of which £0.8m Prepayments 0.4 0.6 1.1 0.6 relate to prior financial years. This Total Receivables - due in less than 1 year 8.3 8.8 8.7 8.0 Cash and Cash Equivalents 18.4 17.9 17.6 14.8 mainly relates to NHS invoices and Total Current Assets 26.8 26.9 26.4 22.9 only £0.2m is non NHS. CURRENT LIABILITIES Trade Payables (3.9) (0.3) (0.3) (4.5) Other Payables (4.1) (4.2) (4.4) (4.2) PDC Dividend Payable 0.0 (2.0) (2.6) (0.9) Cash - see next page Capital Payables (2.1) (1.4) (1.4) (1.8) Provisions (1.5) (1.4) (1.3) (0.5) Other Financial Liabilities (Accruals) (5.9) (7.7) (7.6) (8.3) Deferred Revenue (0.6) (1.6) (1.2) (1.0) Provisions – assumes redundancy Total amounts falling due within one year (18.0) (18.6) (18.8) (21.2) provision is used up by the year end. NET CURRENT ASSETS/(LIABILITIES) 12.6 12.1 11.4 1.7 The Trust is reviewing the annual TOTAL ASSETS LESS CURRENT LIABILITIES 212.0 211.3 210.5 213.8 Provision for Liabilities and Charges (0.1) (0.1) (0.1) (0.1) leave provision to determine whether TOTAL ASSETS EMPLOYED 211.9 211.2 210.4 213.7 a non recurrent benefit can be FINANCED BY TAXPAYERS EQUITY: Public dividend capital 127.1 127.1 127.1 127.1 reported in the I&E. Retained Earnings (accumulated losses) 9.3 11.3 11.3 11.3 Retained Surplus(Deficit) in year 2.0 (0.8) (1.6) (6.1) Donated asset reserve 0.0 0.0 0.0 0.0 Revaluation Reserve 73.5 73.5 73.5 81.3 Other Reserves 0.0 0.0 0.0 0.0 TOTAL TAXPAYERS EQUITY 211.9 211.2 210.4 213.7
10 Part A Cash
• The planned cash flow shows an increasing cash balance in the first and second half of the year due to the build up of cash resources to meet the payment of PDC in September and March. • The Trust continues to build planned cash reserves which are required in future years in order to partly fund the Estates Modernisation Programme. • The cash balance at the end of the month was £17.6m compared with the plan of £18.9m; this is shortfall is principally due to the I&E deficit position. • The plan is to have a closing balance of £14.8m at the end of the financial year.
(A) Early receipt of Q1 SLA from Health Education England (B) Gradual build up of cash for PDC payment due in September (C) Payment of £3.4m PDC (D) Higher Payment runs to clear Q3 invoices including NHS properties (E) Receipt from disposal of South Place and Roseland sites totalling £3.8m (F) Payment of £3.3m PDC and other year end invoices (G) On target at year end
11 Part A
Trust Board Meeting
6 October 2016
Paper Reference: TB(16-17) 99
Report Title: Single Oversight Framework – new Financial Metrics
Executive Summary: This report summarises the new Single Oversight Framework (SOF) which was published by NHS Improvement on 13th September 2016 with the intention that it should be implemented wef 1st October. The SOF consolidates the current range of Performance Frameworks, including the Continuity of Services Risk Rating (CoSRR) currently used to assess financial performance. The SOF includes a metric to assess Agency Spend – based on the Trust’s current very high use of agency staff the Trust would be capped at a score of 3 (1 is the best; 4 is the worst and could result in the Trust being placed in Special Measures). Action Required: For discussion.
Link to Strategic Objectives: We will provide consistent, high quality, safe services that represent value for money Risks: None Quality Impact: Maintain / Improve quality of external audit Resource Implications: None Legal/Regulatory Implications: Statutory requirement – Single Oversight Framework Equalities Impact: None Groups Consulted: None Author: Debbie Hollinghurst, Acting Deputy Director of Finance Owner: Clive Field, Interim Director of Finance and Performance
Clive Field, Interim Director of Finance and Performance
20th September 2016 Current Financial Metrics
• The Trust’s financial performance is currently monitored by NHSi against the Financial Sustainability Risk Rating (FSRR), introduced in September 2015 to reflect revisions in Monitor’s Risk Assessment Framework.
• The FSRR retained the liquidity ratio and the capital servicing capacity used in the previous rating system (CoSRR) which had been designed to assess financial sustainability by reviewing the Trust’s ability to service its debts and its business continuity.
• The FSRR also incorporated I&E Margin and I&E Margin variance from plan to focus additional attention on the measurement of operating performance.
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Single Oversight Framework
• The NHSi published its Single Oversight Framework (SOF) on 13 September.
• The SOF sets out how the NHSi will oversee NHS trusts and NHS foundation Trusts, covering five themes including finance and use of resources.
• Following a period of consultation and feedback NHSi plan to introduce the framework from 1 October.
• Full details of the Single Oversight Framework can be found attached – see section 5.2 re-Finance & Use of Resources
3 New Financial Metrics - Scoring
• The SOF measures Trusts’ performances against 5 metrics with a score of 1 (best) to 4 against each metric. – Capital Service Capacity – Liquidity Days – I&E Margin – Distance from Finance Plan (I&E) – Agency spend • A use of resources score will be derived by averaging the scores across all metrics. • Having an overall mean score of either 3 or 4 will trigger a concern. • Scoring a 4 on any one metric will mean that the overall rating is at least a 3 triggering a concern.
4 New Financial Metrics - Detail
5 Forecast against Financial Metrics
• Based on the current plan and forecast the Trust would achieve a score of 1 or 2 for all metrics with the exception of Agency spend.
• There is significant risk attached to the score against the I&E Margin (currently <1%) and Distance from Financial Plan (currently ~1% of T/O from plan).
• Agency Target - it is unclear whether the Trust will be monitored against the full year agency target of £9.0m or just from October. If against the full year target :- • Score 4 if agency spend greater than £13.6m (Trust target=£13.4m). • Score 3 if agency spend is £11.3m - £13.5m. (This would give an overall mean score = 2 if plan is achieved for the other metrics). • Score 2 if agency spend is greater than target but less than £11.3m
Significant Risk – There is a significant risk of scoring a 4 on the agency metric which will mean that the overall rating is at least a 3 triggering a concern that could lead to the Trust receiving mandated support.
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Single Oversight Framework
September 2016
About NHS Improvement NHS Improvement is responsible for overseeing NHS foundation trusts, NHS trusts and independent providers. We offer the support NHS trusts and NHS foundation trusts need to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. By holding providers to account and, where necessary, intervening, we help the NHS to meet its short-term challenges and secure its future.
NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.
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Contents
1. Introduction ...... 4
2. The Single Oversight Framework ...... 6
3. Summary of our approach ...... 8 3.1. Other considerations ...... 10
4. Monitoring providers ...... 10
5. Identifying potential support needs ...... 13 5.1. Quality of care (safe, effective, caring and responsive) ...... 13 5.2. Finance and use of resources ...... 14 5.3. Operational performance ...... 16 5.4. Strategic change ...... 17 5.5. Leadership and improvement capability (well-led) ...... 18
6. Segmentation ...... 19 6.1. Segmentation process ...... 19
7. Support activities ...... 20
Appendix 1: Summary of information used and triggers ...... 22
Appendix 2: Quality of care (safe, effective, caring, responsive) monitoring metrics ...... 24
Appendix 3: Operational performance metrics...... 27
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1. Introduction
In recent years, the NHS has achieved improvements in care and delivered efficiencies during a time of increasing financial pressure caused by slowing growth in the NHS budget and rising demand. The need to respond effectively to this continuing increase in demand during a period of limited funding growth was the key impetus for the NHS Five Year Forward View (5YFV).
NHS Improvement
Part of the national response to the ambitious and stretching tasks highlighted in the 5YFV was the creation of NHS Improvement, reflecting the similar challenges faced by both NHS trusts and NHS foundation trusts. On 1 April 2016, NHS Improvement became the operational name that brings together Monitor, the NHS Trust Development Authority (TDA), Patient Safety, the Advancing Change Team and Intensive Support Teams. The specific legal duties and powers of Monitor and TDA persist.1 As NHS Improvement we will build on the best of what these organisations did but with a change of emphasis in relation to NHS trusts and NHS foundation trusts to one primarily focused on helping them to improve.
We will provide strategic leadership, oversight and practical support for the trust sector. We will support NHS trusts and NHS foundation trusts2 to give patients consistently safe, effective, compassionate care within local health systems that are financially and clinically sustainable. We will work alongside providers, building deep and lasting relationships, harnessing and spreading good practice, connecting people, and enabling sector-led improvement and innovation. We will stimulate an improvement movement in the provider sector, helping providers build improvement capability, so they are equipped and empowered to help themselves and, crucially, each other. The Single Oversight Framework does not give a performance assessment in its own right, nor is it intended to predict the ratings given by the Care Quality Commission (CQC). Our aim, however, is to help providers attain, and maintain, CQC ratings of ‘Good’ or ‘Outstanding’.
The challenges facing the system require a joined-up approach and increased partnership between national bodies. We are committed to working more closely with CQC, NHS England and other partners, at national, regional and local levels.
1 NHS Improvement is clear which duties and powers of Monitor and the TDA it is exercising at board and executive level. Non-executive positions are joint and the executive decision-making structure accommodates appropriately constituted committees to enable the exercise of respective functions. 2 For the purposes of this document and our framework, we use the term ‘provider’ to mean NHS trusts and NHS foundation trusts. This document does not apply to independent sector providers: Risk assessment framework for independent sector providers of NHS services (available at www.gov.uk/government/publications/risk-assessment-framework-independent-sector-providers-of- nhs-services) covers our statutory duty to assess financial risk at those organisations where they provide commissioner requested services (CRS).
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The five themes of the Single Oversight Framework
In carrying out our role we will work across five themes:
Quality of care (safe, effective, caring, responsive): we will use CQC’s most recent assessments of whether a provider’s care is safe, effective, caring and responsive, in combination with in-year information where available. We will also include delivery of the four priority standards for 7-day hospital services. Finance and use of resources: we will oversee a provider’s financial efficiency and progress in meeting its financial control total, reflecting the approach taken in Strengthening financial performance and accountability.3 We are co-developing this approach with CQC. Operational performance: we will support providers in improving and sustaining performance against NHS Constitution standards and other, including A&E waiting times, referral to treatment times, cancer treatment times, ambulance response times, and access to mental health services. These NHS Constitution standards may relate to one or more facets of quality (ie safe, effective, caring and/or responsive). Strategic change: working with system partners we will consider how well providers are delivering the strategic changes set out in the 5YFV, with a particular focus on their contribution to sustainability and transformation plans (STPs), new care models, and, where relevant, implementation of devolution. Leadership and improvement capability (well-led): building on the joint CQC and NHS Improvement well-led framework, we will develop a shared system view with CQC of what good governance and leadership look like, including organisations’ ability to learn and improve. By focusing on these five themes we will support providers to improve to attain and/or maintain a CQC ‘good’ or ‘outstanding’ rating. Quality of care, finance and use of resources, and operational performance relate directly to sector outcomes. Strategic change recognises that organisational accountability and system-wide collaboration are mutually supportive. Leadership and improvement capability are crucial in ensuring that providers can deliver sustainable improvement. These five themes are also reflected in NHS Improvement’s 2020 Objectives.4 The Single Oversight Framework will support the delivery of NHS Improvement’s 2020 objectives, including helping more providers achieve CQC ‘good’ or ‘outstanding’
3 Published in July 2016 and available at https://improvement.nhs.uk/uploads/documents/Strengthening_financial_performance_and_accou ntability_in_2016-17_-_Final_2.pdf 4 Available at https://improvement.nhs.uk/uploads/documents/NHSI_2020_Objectives_13july.pdf
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ratings, reducing numbers of trusts in special measures and achieving aggregate financial balance from 2017/18 as well as meeting NHS Constitution standards.
2. The Single Oversight Framework
This document sets out NHS Improvement’s approach to overseeing both NHS trusts and NHS foundation trusts and shaping the support we provide. Section 3 Summary of our approach: sets out a high level description of the framework Section 4 Monitoring providers: describes how we will collect the information we require from providers Section 5 Identifying potential support needs: sets out how we will identify potential support needs across each of the five themes described above Section 6 Segmentation: outlines how we will segment the provider sector according to the level of support each provider needs. The purpose of the framework is to identify where providers may benefit from, or require, improvement support across a range of areas (see below). This will inform the way we work with each provider. This framework does not set out in detail the improvement support we will provide in each case as this will be tailored to individual provider needs.
The Single Oversight Framework replaces Monitor’s Risk Assessment Framework and TDA’s Accountability Framework. It applies to both NHS trusts and NHS foundation trusts. As far as possible, we have combined and built on the previous approaches of Monitor and TDA, adapting them to reflect and enable our primary improvement role. Any changes from these frameworks are intended as far as possible to be incremental. The changes we are making are intended to reflect the challenges providers face and initiatives to support them. All other related policies and statements, unless indicated, remain and should be read in the light of this document.
Ongoing statutory roles of Monitor and the NHS Trust Development Authority
The Single Oversight Framework works within the continuing statutory duties and powers of Monitor with respect to NHS foundation trusts and of TDA with respect to NHS trusts (whereby the TDA exercises functions via directions from the Secretary of State).
Alignment with the Care Quality Commission
CQC sets out what good and outstanding care looks like, asking five key questions of all care services: Are they safe, are they effective, are they caring, are they responsive to people’s needs, and are they well-led? These questions will be
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supplemented by a forthcoming assessment of the use of resources being jointly developed by CQC and NHS Improvement.
While our five themes are linked to CQC’s key questions, they are not identical. This is because CQC’s questions do not yet incorporate use of resources; because we have a particular role in supporting improvement in performance against the NHS Constitution standards for patients; and because our approach to improvement incorporates the strategic changes within local health systems that will be needed to assure the delivery of high quality services by providers in the longer term.
We will continue to work with CQC to align approaches more fully as we move towards a single combined assessment of quality and use of resources. We will work with CQC to develop the well-led framework, to help identify support needs for leadership and improvement capability. We will work together to share data and develop common data sets where possible. We will also continue to develop close operational working, for example aligning the way we and CQC work together in engaging with individual providers.
Alignment with recommendations from the Carter review
Lord Carter’s review, Operational productivity and performance in English NHS acute hospitals: Unwarranted variations,5 recommended the development of an integrated performance framework to ensure there is a single set of metrics and approach to reporting, reducing the reporting burden in order to allow providers to focus on improving quality and efficiency. In line with this recommendation, we are working with the CQC, NHS England and the provider sector to ensure that we draw on a single, shared set of metrics both to review performance and to decide where to target support or oversight.
Links between the Single Oversight Framework and the Model Hospital
The Carter review also recommended the creation of a ‘model hospital’ – a nationally available online information system, with a series of themed compartments which present key performance metrics for different areas across the hospital, and best practice guidance. We will ensure that the metrics used in the Single Oversight Framework are included in the Model Hospital. This will enable providers to access them easily, compare performance against their peers and national benchmarks, and identify areas where they need to improve. The prototype Model Hospital online portal is already live to users in acute providers, and is being populated in stages with data and metrics across a hospital’s work.
5 Available at www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productiv ity_A.pdf
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3. Summary of our approach
NHS Improvement’s Single Oversight Framework: provides one framework for overseeing providers, irrespective of their legal form
helps us identify potential support needs, by theme, as they emerge
allows us to tailor our support packages to the specific needs of providers in the context of their local health systems, drawing on expertise from across the sector as well as within NHS Improvement
is based on the principle of earned autonomy.
We will be flexible in how it carries out its role. For example, we may need to respond quickly and proactively to unexpected issues in individual providers or sets of providers, or to national policy changes. We may, therefore, from time to time, adjust the approach set out in this document, for example: add/remove some metrics from our oversight of providers
increase the frequency of our data collection
act sooner than the general threshold set in the framework.
We will segment the provider sector according to the scale of issues faced by individual providers. This segmentation will be informed by data monitoring and, importantly, judgement based on an understanding of providers’ circumstances (see Figure 1).
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Figure 1: Summary of our approach
The segment a provider is in determines the level of the support we provide but not the precise support package. We have identified three levels of support – universal offers, targeted offers and mandated – which will link to the segments (see section 7).
NHS Improvement teams will work with providers to determine the appropriate, tailored, support package for each support need identified, including directly provided support and support facilitated by, for example, other parts of the sector.
The legal basis for actions in relation to NHS trusts and NHS foundation trusts remains unchanged. This means that, for example, a foundation trust will only be in segments 3 or 4 where it has been found to have been in breach or suspected breach of its licence. Mandated support for NHS foundation trusts6 continues to follow existing policy set out in the Enforcement guidance.7
6 Based on s.105, s.106 or s.111 of the Health and Social Care Act 2012 7 Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/284474/ToPublishEnforce mentGuidance28March13_0.pdf
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3.1. Other considerations
The NHS provider licence
The statutory obligations of Monitor and TDA continue within NHS Improvement. Therefore, NHS Improvement must ensure the operation of a licensing regime. The NHS provider licence8 forms the legal basis for Monitor’s oversight of NHS foundation trusts and can be found here. While NHS trusts are exempt from the requirement to apply for and hold the licence, directions from the Secretary of State require TDA to ensure that NHS trusts comply with conditions equivalent to the licence as it deems appropriate. This includes giving directions to an NHS trust where necessary to ensure compliance.
The Single Oversight Framework applies equally to NHS foundation trusts and NHS trusts. We aim to treat all providers in comparable circumstances similarly unless there is sound reason not to. We will therefore base our oversight, using the Single Oversight Framework, of all NHS trusts and NHS foundation trusts on the conditions of the NHS provider licence.9
4. Monitoring providers
We use information from our data monitoring processes and insights gathered though our work with providers, to identify where providers have a potential support need under one or more of the five themes (which indicates they are not in segment 1). We will also use judgement, based on consistent principles, to determine whether or not providers are in breach of licence – or the equivalent for NHS trusts – and to determine, as part of that judgement, if providers should go into special measures (segment 4).
We collect information on providers (see Figure 2) either directly or from third parties. We seek to ensure that the collection burden is proportionate and, where possible, we use nationally available information.10 Examples of information collected include: regular financial and operational information
annual plans
8 www.gov.uk/government/publications/the-nhs-provider-licence 9 For the most part, this is likely to entail holding trusts to account against the standards in condition FT4 – the NHS foundation trust governance condition, but other conditions such as those relating to continuity of services and integrated care could be engaged too. Our scope extends to the entire NHS provider licence (see www.gov.uk/government/publications/the-nhs-provider-licence). For completeness it should be noted that NHS Improvement has functions and powers in addition to those stemming from the Monitor provider licence in relation to both NHS trusts (through directions from the Secretary of State) and NHS foundation trusts (through statute). The Single Oversight Framework does not cover these additional matters. 10 Eg assessing performance against national targets and standards
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third-party information
any ad-hoc or exceptional information that can be used to oversee providers according to the five themes.
We will work with partners – including NHS England and CQC – to ensure, as much as possible, a shared dataset across the various oversight organisations.
Figure 2: Summary of information required for monitoring
Collection is:
in-year: following a regular in-year monitoring cycle (see Figure 3), using monthly, quarterly or lower frequency collections as appropriate. In extreme circumstances (eg where a provider is displaying critical problems) we will consider more frequent information
annual: using annual provider submissions (eg annual plans, annual statements on quality) or other annually published data (eg staff surveys)
ad-hoc/by exception: NHS Improvement aims to be as agile as possible in responding to issues identified at providers. Where material events occur, or we receive information that triggers our concern outside the regular monitoring
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cycle, we will take these into account when considering whether there are potential support needs at the provider.
For providers in segment 1, although some data will be collected monthly and reviewed as for providers in other segments, we will – in line with the principle of earned autonomy – generally review the segmentation of the provider on a quarterly basis, unless there is information giving cause for concern.
Figure 3: NHS Improvement’s oversight cycle
During 2016/17, we will use the existing Monitor and TDA oversight templates to collect information. We will give notice of changes to the collection as we develop our processes to gather information from providers.
Rather than require providers to make bespoke data submissions, wherever possible we will use nationally collected and evaluated datasets, in particular for operational performance. Appendix 3 lists the metrics we will use and the frequency of their collection across acute, mental health, ambulance and community trusts. We may revise this list – introducing new metrics or varying the collection frequency – as necessary and appropriate, particularly as the Model Hospital work develops.
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In line with Lord Carter’s recommendations, we are also working with NHS England, the Department of Health, CQC and NHS Digital to rationalise the reporting requirements on providers, aiming to demonstrate a clear reduction in burdens over time.
5. Identifying potential support needs
We will use the information we collect on provider performance to identify where providers need support across the five themes.
Our approach in each theme is set out below and the triggers are summarised in Appendix 1. Where providers have a potential support need, based on the triggers, we will consider the circumstances to determine the level of support required. Practically, we will consider:
the extent to which the provider is triggering a Single Oversight Framework measure under one, or more, of the five themes
any associated circumstances the provider is facing
the degree to which the provider understands what is driving the issue
the provider’s capability and the credibility of plans it has developed to address the issue
the extent to which the provider is delivering against a recovery trajectory.
We will engage with providers on an ongoing basis. When providers have a potential support need, we will consider whether the level of interaction needs to change to monitor the issue and the provider’s response to it. How we will identify potential support needs against each theme is set out below.
5.1. Quality of care (safe, effective, caring and responsive)
Where CQC’s assessment identifies a provider as ‘inadequate’ or ‘requires improvement’ against any of the safe, effective, caring or responsive key questions, this will represent a potential support need.
We will supplement CQC’s inspection findings with other relevant information such as warning notices, any civil or criminal actions or changes to registration conditions to ensure that we use the most up-to-date CQC views of quality and also that we incorporate their views on quality at providers yet to be inspected. We will also use extra in-year quality-related metrics to identify emerging issues and/or scope for improvement at providers (see Appendix 2). If necessary, we will use this information to identify any improvement and support needs. We will also work with CQC as it develops its new insight tool around the use of data and information and its relationship with quality of care.
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In addition we will oversee delivery of 7-day hospital services across providers to identify where organisations need support. This will include assessing whether providers are delivering against an agreed trajectory to meet the four priority standards for 7-day hospital services. We may, in time, extend this to monitoring other 7-day services standards and metrics where appropriate. We will work closely with NHS England to co-ordinate our respective support offers and oversight.
5.2. Finance and use of resources
We will oversee and support providers in improving financial sustainability, efficiency and compliance with sector controls such as agency staffing and capital expenditure. We are also, with CQC, co-developing a shared approach to assessing and rating how well trusts use their resources. This will build and expand on the metrics used in the Single Oversight Framework, and be consulted on separately if needed.
The finance and use of resources score
We will use a few financial metrics to assess financial performance (see Table 1) by:
scoring providers 1 (best) to 4 against each metric (see Figure 4) averaging individual providers’ scores across all the metrics to derive a use of resources score for the provider.11 Where providers have a score of 4 or 3 in the financial and use of resources theme, this will identify a potential support need under this theme, as will providers scoring a 4 (ie significant underperformance) against any of the individual metrics.12 Providers in financial special measures will score a 4 on this theme.
11 Scores are rounded to the nearest whole number. Where a trust’s score is exactly between two whole numbers, it is rounded to the lower whole number (eg both 2.2 and 2.5 are rounded down to 2). This follows Monitor’s method in assessing best performance where financial scores were rounded positively, ie towards the ‘best’ score for trusts. 12 The best overall finance and use of resources score that a provider scoring 4 on any individual metric can obtain is a 3.
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Table 1: Finance and use of resources metrics
Note: brackets indicate negative numbers 1 Scoring a ‘4’ on any metric will mean that the overall rating is at least a 3 (ie either a 3 or a 4), triggering a concern.
Broader value-for-money considerations
In addition to using the metrics above, we may consider whether there is, more broadly, any evidence that suggests a provider is failing to operate effective systems and/or processes for financial management and control, and not operating economically, efficiently and effectively.
Such evidence would come from, for example, national benchmarking, including the Model Hospital work. We may also consider other factors linked to whether a provider is delivering good value for money, such as management consultancy spend. We may also look at, for example, paybill growth, consolidation of back office and pathology services, and the extent to which providers are addressing unsustainable services through consolidation, and change or transfer to a neighbouring provider.
The Carter review
Lord Carter’s review Operational productivity and performance in English NHS acute hospitals: Unwarranted variations described methodologies to improve productivity at NHS providers. Work to implement the various recommendations – including the Model Hospital – is underway. During 2016/17 NHS Improvement will, as part of this effort, consider change in cost per weighted activity unit as part of this.
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Finance and use of resources metrics and weighting
The overall finance and use of resources score is a mean average of the scores of the individual metrics under this theme, subject to any support needs being identified in value for money – except that:
if a provider scores 4 on any individual finance and use of resources metric, their overall use of resources score is at least a 3 – ie cannot be a 1 or 2 – triggering a potential support need if a provider has not agreed a control total: o where they are planning a deficit their use of resources score will be at least 3 (ie it will be 3 or 4) o where they are planning a surplus their use of resources score will be at least 2 (ie it will be 2, 3 or 4).
As we continue to develop a shared approach to use of resources with CQC we may seek to revise the finance and use of resources metrics used in the Single Oversight Framework. If we do so, we will consult as needed.
Phasing in the new finance and use of resources metrics We are currently considering two other metrics – change in cost per weighted activity unit and capital controls. We will share specifics as we develop them. We would introduce them in ‘shadow’ form in 2016/17, to assess how best to use them thereafter. As a result, we will not use this information to identify any concerns or consequent support needs at providers in 2016/17. We can then consider how best to introduce them formally, with detailed definitions and thresholds if appropriate, in 2017/18. For 2016/17 our oversight for identifying a potential financial support need will be based on the metrics in Figure 4.
5.3. Operational performance
NHS providers must strive to meet key national access standards, including those in the NHS Constitution. We will track providers’ performance against, and support improvements in, a number of NHS standards. Rather than require providers to make bespoke data submissions, wherever possible we will use nationally collected and evaluated datasets. Appendix 3 lists the metrics we will use and how frequently they are collected across acute, mental health, ambulance and community providers. We may revise this list – introducing new metrics or varying the collection frequency – as necessary and appropriate, particularly as the Model Hospital work develops. We will consider whether there is a potential support need:
for a provider with one or more agreed Sustainability and Transformation Fund trajectories against any of the metrics in Appendix 3: it fails to meet any trajectory for at least two consecutive months
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for a provider with no agreed Sustainability and Transformation Fund trajectory against any metrics: it fails to meet a relevant target or standard in Appendix 3 for at least two consecutive months
where other factors (eg a significant deterioration in a single month, or multiple potential support needs across other standards and/or other themes) indicate we need to get involved before two months have elapsed.
We will then consider the issues, use this to identify the appropriate segment for the provider (see section 6) and develop the support offer.
5.4. Strategic change
The 5YFV sets out the agenda for the change necessary to support a sustainable NHS. We will consider the extent to which providers are working with local partners to address local challenges and improve services for patients.
We will develop our approach to identifying support needs under this theme. In the interim, we will consider providers’ contribution to developing, agreeing and delivering sustainability and transformation plans (STPs) − including providers’ relationships with local partners, the plans, and how far these plans have been implemented − as well as, in some cases, the implementation of new care models and implementation of devolution.
We have produced guidance on how we expect well-led providers to work with partners and collaborate locally to improve the quality and sustainability of services for patients.13 In this guidance we set out the expectation that providers should engage constructively with local partners to:
build a shared understanding of local challenges and patient needs
design and agree solutions
implement improvements.
It will be important in our oversight and our support offer to acknowledge the interplay between individual provider outcomes and delivery of aggregate outcomes across a local health system.
13 Available at www.improvement.nhs.uk/uploads/documents/Guidance_on_good_governance_in_ a_LHE_context_final.pdf
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5.5. Leadership and improvement capability (well-led)
Similar standards of governance were set out in the NHS foundation trust governance condition (FT4), the TDA Accountability Framework and the TDA general objective. Governance issues can provide early warnings of problems that have yet to manifest themselves in, for example, quality issues or financial underperformance. We expect providers to demonstrate three main characteristics – effective boards and governance, continuous improvement capability and effective use of data − as part of this theme.
1. Effective boards and governance: We will use several information sources to oversee provider leadership as used previously by Monitor and TDA, including:
information from third parties
staff/patient surveys
organisational metrics
information on agency spend
delivering Workforce Race Equality Standards (WRES)
CQC ‘well-led’ assessments.
We will also draw on the existing well-led framework and associated tools to identify any potential support needs concerning the governance and leadership of a provider. Many providers have already used this framework to assess their governance.
2. Continuous improvement capability: We are working with CQC to consider how the current shared well-led framework needs to evolve to better reflect continuous improvement capability.
3. Use of data: Effective use of information is an important element of good governance. Well-led providers should collect, use and, where required, submit robust data. Where we have reason to believe this is not the case, we will consider the degree to which providers need support in this area.
As we develop the well-led framework we will build on this approach to identifying support needs under all aspects of this theme, including potentially culture and engagement, particularly through working with CQC. We will look to incorporate the principles and findings of the National Leadership Development and Improvement Board.
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6. Segmentation
Segmentation helps NHS Improvement determine the level of support required (see section 7). It does not give a performance assessment in its own right, nor is it intended to predict the ratings given by CQC. It also does not determine the specifics of the support package needed − this is tailored by teams working with the provider in question. We are segmenting the sector into four, depending on the extent of support needs identified through the oversight process.
Figure 5: Segmenting the provider sector
6.1. Segmentation process
The segment a provider is placed in will reflect our judgement of the seriousness and complexity of the issues it faces. We will base our decision on:
considering all available information on providers – both obtained directly and from third parties
identifying providers with a potential support need in one or more themes
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using our judgement, based on relationship knowledge and/or the findings of formal or informal investigations, or analysis, consideration of the scale of the issues faced by a provider and whether it is in breach or suspected breach of licence conditions.
Providers will then be placed in a segment as per Table 2 below:
Table 2: Segment description
Segment Description
1 Providers with maximum autonomy − no potential support needs identified across our five themes – lowest level of oversight and expectation that provider will support providers in other segments 2 Providers offered targeted support − potential support needed in one or more of the five themes, but not in breach of licence (or equivalent for NHS trusts) and/or formal action is not needed 3 Providers receiving mandated support for significant concerns – the provider is in actual/suspected breach of the licence (or equivalent for NHS trusts) 4 Special measures − the provider is in actual/suspected breach of its licence (or equivalent for NHS trusts) with very serious/complex issues that mean that they are in special measures
Segmentation needs to be as timely and rigorous as possible, without becoming over bureaucratic or complex. Where our in-year, annual or ad-hoc monitoring of a provider flags a potential support need, we will review the provider’s situation and consider whether we need to change its allocated segment.
In parallel with the development of the framework, we will consider the incentives for providers to be in segment 1. While some conditions are fixed across the sector (eg control totals), others could vary from segment to segment in accordance with the principle of earned autonomy.
7. Support activities
Our teams will co-ordinate and oversee tailored support for providers to support sustainable improvement. Under the Single Oversight Framework, we may identify support needs in more than one theme where there is a shared underlying cause in more than one theme. In these cases, we will not ‘double count’ identified support needs and will ensure that the support activity is appropriate to the underlying cause.
Individual support packages will be provider-specific, and tailored to the support needs identified, but comprise one or more of three levels of support:
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Universal support offer: tools that providers can draw on if they wish to improve specific aspects of performance – its use is voluntary.
Targeted support offer: support to help providers with specific areas – eg intensive support teams to help in emergency care or agency spend. Programmes of targeted support will be agreed with providers. This support is offered to providers – its use is voluntary.
Mandated support: where a provider has complex issues, we may introduce a mandated series of improvement actions, eg appoint an improvement director, or agree a recovery trajectory and support providers to deliver this. In these serious cases, providers are required to comply with NHS Improvement’s actions/expectations.
Table 3 below outlines how these types of support link to the segment a provider is in.
Table 3: Support offer by segment
Segment Levels of support
Universal support 1 eg tools, guidance, benchmark information made available for providers to access Universal support (as for segment 1) Targeted support as agreed with the provider 2 to address issues and help move the provider to segment 1 either offered to provider (and accepted voluntarily) or requested by provider Universal support (as for segment 1) Targeted support as agreed with the provider (as for segment 2) 3 Mandated support as determined by NHS Improvement to address specific issues, help move the provider to segment 2 or 1 compliance required Universal support (as for segment 1) Targeted support as agreed with the provider (as for segment 2) 4 Mandated support as determined by NHS Improvement to help minimise the time the provider is in segment 4 compliance required
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Appendix 1: Summary of information used and triggers
Theme Information used Triggers
Quality of CQC information CQC ‘inadequate’ or ‘requires care improvement’ assessment in one or Other quality more of: information to inform - ‘safe’ our view of a provider - ‘effective’ (see Appendix 2) - ‘caring’ - ‘responsive’ 7-day services CQC warning notices
Any other material concerns identified through, or relevant to, CQC’s monitoring process, eg civil or criminal cases raised, whistleblower information, etc
Concerns arising from trends in our quality indicators (Appendix 2)
Delivering against an agreed trajectory for the four priority standards for 7-day hospital services Finance Sustainability Poor levels of overall financial o Capital service performance (average score of 3 or 4) cover o Liquidity Very poor performance (score of 4) in any Efficiency individual metric o I&E 14 margin Controls Potential value for money concerns o Performance against plan o Agency spend
Value for money information
14 Income and expenditure, or surplus/deficit margin
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Theme Information used Triggers
Operational NHS Constitution For providers with Sustainability and performance standards Transformation Fund (STF) trajectories in any metric: failure to meet the trajectory for Other national targets this metric in more than two consecutive and standards months (quarterly for quarterly metrics)
For providers without STF trajectories: failure to meet any standard in more than two consecutive months
Strategic Review of sustainability Material concerns with a provider’s change and transformation plans delivery against the transformation and other relevant agenda, including new care models and matters devolution Leadership Findings of governance Material concerns and or well-led review improvement undertaken against the CQC ‘inadequate’ or ‘requires capability current well-led improvement’ assessment against ‘well- framework led’.
Third party information, eg Healthwatch, MPs, whistleblowers, coroners’ reports
Organisational health indicators
Operational efficiency metrics
CQC well-led assessments
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Appendix 2: Quality of care (safe, effective, caring, responsive) monitoring metrics
NHS Improvement will use the 39 indicators below to supplement CQC information in order to identify where providers may need support under the theme of quality.
Quality indicators Measure Type Frequency Source Organisational health indicators – all providers NHS Digital Organisational Staff sickness Monthly/quarterly (publicly health available) NHS Digital Organisational Staff turnover Monthly/quarterly (publicly health available) Organisational Executive team turnover Monthly Provider return health Organisational CQC (publicly NHS Staff Survey Annual health available) Organisational Proportion of temporary staff Quarterly Provider return health Organisational Aggressive cost reduction plans Quarterly Provider return health NHS Digital Written complaints - rate Caring Quarterly (publicly available) Staff Friends and Family Test % NHSE (publicly Caring Quarterly recommended - care available) NHS Improvement Occurrence of any Never Event Safe Monthly (publicly available) NHS NHS England/NHS Improvement Improvement Safe Monthly Patient Safety Alerts outstanding (publicly available)
Acute providers Mixed sex accommodation NHSE (publicly Caring Monthly breaches available) Inpatient scores from Friends NHSE (publicly Caring Monthly and Family Test − % positive available) A&E scores from Friends and NHSE (publicly Caring Monthly Family Test − % positive available) Emergency c-section rate Safe Monthly HES
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Measure Type Frequency Source CQC inpatient/MH and Organisational CQC (publicly Annual community survey health available) Maternity scores from Friends NHSE (publicly Caring Monthly and Family Test − % positive available) NHSE (publicly VTE Risk Assessment Safe Quarterly available) Clostridium Difficile - variance PHE (publicly Safe Monthly from plan available) Clostridium Difficile - infection PHE (publicly Safe Monthly rate available) PHE (publicly MRSA bacteraemias Safe Monthly available) Hospital Standardised Mortality Effective Quarterly DFI Ratio (DFI) Hospital Standardised Mortality Effective Quarterly DFI Ratio - Weekend (DFI) NHS Digital Summary Hospital Mortality Effective Quarterly (publicly Indicator available) Potential under-reporting of NHS England Safe Monthly patient safety incidents15 (dashboard) Emergency re-admissions within 30 days following an elective or Effective Monthly HES emergency spell at the provider
Community providers Organisational CQC (publicly CQC Community Survey Annual health available) Community scores from Friends NHSE (publicly Caring Monthly and Family Test - % positive available)
Mental health providers CQC inpatient/mental health and Organisational CQC (publicly Annual community survey Health available) Mental health scores from NHSE (publicly Friends and Family Test - % Caring Monthly available) positive Admissions to adult facilities of NHS Digital patients who are under 16 years Safe Monthly (publicly old available)
15 NHS England dashboards have monthly provisional data. This indicator is valid only at the level of extreme outliers for under reporting as per CQC IM methodology and only in non-specialist acute trusts.
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Measure Type Frequency Source Care programme approach (CPA) follow up - proportion of NHS Digital discharges from hospital Effective Monthly (publicly followed up within 7 days - available) MHMDS NHS Digital % clients in settled Effective Monthly (publicly accommodation available) NHS Digital % clients in employment Effective Monthly (publicly available) Potential under-reporting of NHS England Safe Monthly patient safety incidents16 (dashboard)
Ambulance providers Ambulance see and treat from NHSE (publicly Friends and Family Test - % Caring Monthly available) positive Return of Spontaneous NHSE (publicly Circulation (ROSC) in Utstein Effective Monthly available) group NHSE (publicly Stroke 60 minutes Effective Monthly available) NHSE (publicly Stroke care Effective Monthly available) ST Segment elevation NHSE (publicly myocardial infarction (STeMI) Effective Monthly available) 150 minutes
16 NHS England dashboards have monthly provisional data. This indicator is valid only at the level of extreme outliers for under reporting as per CQC IM methodology.
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Appendix 3: Operational performance metrics
Standard Frequency Standard17
Acute and specialist providers18
A&E maximum waiting time of 4 hours from arrival to Monthly 95% admission/transfer/discharge Maximum time of 18 weeks from point of referral to Monthly 92% treatment (RTT) in aggregate − patients on an incomplete pathway All cancers – maximum 62-day wait for first treatment Monthly from: - urgent GP referral for suspected cancer 85% - NHS cancer screening service referral 90% Maximum 6-week wait for diagnostic procedures Monthly 99% Ambulance providers19 Maximum 8-minute response for Red 1 calls Monthly 75% Maximum 8-minute response for Red 2 calls Monthly 75% Maximum 19-minute response for all Category A calls Monthly 95% Mental health providers20 Patients requiring acute care who received a Quarterly 95% gatekeeping assessment by a crisis resolution and
17 Minimum % of patients for whom standard must be met 18 NHS Improvement is following the development of indicators assessing the expansion of liaison mental health services in acute hospitals, including routine analysis of (i) numbers of presentations at A&E of people of all ages with a mental health condition or dementia and liaison mental health service response times; (ii) numbers of emergency admissions of people of all ages with a mental health condition or dementia; (iii) length of stay for people of all ages admitted with a mental health condition or dementia; (iv) delayed transfers of care for people of all ages with a mental health condition or dementia. These may be incorporated in future iterations of this framework. 19 We will balance this oversight with the impact of dispatch on disposition and other pilots affecting performance reporting currently underway across ambulance trusts 20 In addition to the MH indicators, NHS Improvement is following the development of metrics to assess: (i) access and waiting times for children and young people eating disorder services in line with evidence-based treatment guidelines (ii) providers’ collection of data on waiting times for acute care (decision to admit to time of admission, decision to home-treat to time of home-treatment start), delayed transfers of care and out of area placements (OAPS) and (iii) systems to measure, analyse and improve response times for urgent and emergency mental health care for people of all ages. These may be incorporated in future iterations of this framework.
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Standard Frequency Standard17
home treatment team in line with best practice standards (UNIFY2 and MHSDS)21 People with a first episode of psychosis begin Quarterly 50% treatment with a NICE-recommended package of care within 2 weeks of referral (UNIFY2 and MHSDS)22 Ensure that cardio-metabolic assessment and Quarterly treatment for people with psychosis is delivered routinely in the following service areas: 90% a) inpatient wards 90% b) early intervention in psychosis services 65%
21 In line with the recommendation of the 5YFV for mental health, providers should be working with commissioners to ensure that crisis resolution home treatment teams are delivering care in line with best practice standards (www.ucl.ac.uk/core-resource-pack/fidelity-scale). For 2016/17, commissioners have been asked to focus on the following key components of CRHTT care: rapid response to new referrals provision of a 24/7 gatekeeping function, assessing all people face-to-face within four hours of referral adequate staffing with caseloads in line with recommended practice provision of intensive home treatment in line with recommended practice (For example, by routinely visiting people at least twice a day for the first three days of home treatment, providing twice daily visits when required thereafter, and routinely offering visits that allow enough time to prioritise therapeutic relationships and help with social and practical problems) routine collection and monitoring of clinician and patient reported outcomes, as well as feedback from people who use the service. These are reflected in NHS England’s CCG Improvement and Assessment Framework mental health indicators. 22 This standard applies to anyone with a suspected first episode of psychosis aged 14-65.Exclusions must not be made of people aged >35 who may historically not have had access to specialist EIP services. Technical guidance is available at: www.england.nhs.uk/mentalhealth/wp- content/uploads/sites/29/2016/02/tech-cyped-eip.pdf. Provider boards must be fully assured that RTT data submitted is complete, accurate and in line with published guidance. Both ‘strands’ of the standard must be delivered. performance against the RTT waiting time element of the standard is being measured via MHSDS and UNIFY2 data submissions. performance against the NICE concordance element of the standard is to be measured via: - a quality assessment and improvement network being hosted by CCQI at the Royal College of Psychiatrists. All providers will be expected to take part in this network and submit self- assessment data which will be validated and performance scored on a 4-point scale at the end of the year. This assessment will provide a baseline of performance and will be used to inform the development of performance expectations for 17/18 and beyond. - submission of intervention and outcomes data using SNOMED-CT codes in line with published guidance. Provider boards must be fully assured that intervention and outcomes data submitted are complete and accurate. Further information can be found in the implementation guidance published by NHS England here: www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/04/eip-guidance.pdf
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Standard Frequency Standard17
c) community mental health services (people on Care Programme Approach) 23
Complete and valid submissions of metrics in the monthly Mental Health Services Data Set submissions to NHS Digital: identifier metrics24 Monthly 95% priority metrics25 Monthly 85%
Improving Access to Psychological Therapies (IAPT)/talking therapies proportion of people completing treatment who Quarterly 50% move to recovery (from IAPT minimum dataset) waiting time to begin treatment (from IAPT minimum data set) - within 6 weeks Quarterly 75% - within 18 weeks Quarterly 95%
Community providers Any relevant mental health or acute metrics above
23 Board declaration but can be triangulated with results of CQUIN audit which will be for a sample of patients in each service area). People with psychosis should receive: a completed assessment for each of the cardio-metabolic parameters with results documented in the patient’s records a record of interventions offered where indicated, for patients who are identified as at risk as per the red zone of the Lester Tool. The cardio metabolic parameters based on the Lester Tool are as follows: smoking status lifestyle (including exercise, diet, alcohol and drug use) body mass index blood pressure glucose regulation (HbA1c or fasting glucose or random glucose as appropriate) blood lipids. Information on the Lester Tool and the recommended key interventions and treatments can be found at: www.england.nhs.uk/2014/06/lester-tool/ This indicator aligns with the national CQUIN scheme for 2016/17: www.england.nhs.uk/nhs- standard-contract/cquin/cquin-16-17/ 24 Comprising: NHS number, date of birth, postcode, current gender, registered GP org code, commissioner org code 25 For achievement by 2016/17 year-end. Comprising: ethnicity, employment status (for adults only), school attendance (for CYP only), accommodation status (for adults only), ICD10 coding. Note: ICD10 for CYP may be supplanted by capture of a problem descriptor, rather than a formal medical diagnosis.
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30 © NHS Improvement (September 2016) Publication code: C 05/16
Trust Board Meeting
6 October 2016
Paper Reference: D03638 CF Moller – VAR TB(16-17) 100
Report Title: Estate Modernisation Programme (EMP) Purchase Order
Executive Summary: The Trust’s design team under CF Moller have nearly concluded Stage 3 of the Design process and are about to commence Stage 4 work. A fee proposal for this Stage 4 work has been submitted and is in line with the previously agreed overall fee proposal. The CF Moller appointment was subject to a European procurement process in September 2011.
The Stage 4 fee is £2,973,366; a monthly fee drawdown schedule is associated with C. F. Møller’s work. The F&IC approved the raising of a purchase order to CF Moller (attached) on 26 September 2016 and recommended that it was taken to the next Trust Board for approval, due to the size of the contract.
This purchase order is already contained within the EMP budget and is in line with our forecast.
Action Required: The Trust Board is being asked to approve the attached purchase order for £2,973,366.
Link to Strategic The purchase order links to the following strategic objectives: Objectives: • We will provide consistent, high quality, safe services that represent value for money. • We will develop stronger external partnerships and business opportunities that improve, access responsiveness and service range. • We will become a leading innovative provider of health and social care services.
Risks: The Estates Modernisation Programme (EMP) is linked to Board Assurance Framework Risk SO1-01 – Failure to modernise will impact on quality and safety and the scheme may not be affordable within the construction period.
All risks are linked to the departmental risk register. The EMP team also has its own risk register for the programme and OBC.
Quality Impact: The Quality Impact Assessment (QIA) for the EMP was approved by QSAC on 26th March 2015.
Resource Implications: The overall capital investment is £159.5m at Q2 2014, of which this purchase order is part of.
Legal/Regulatory This purchase order is in line with the European procurement process. Implications: Equalities Impact: An EIA has been completed.
Groups Consulted: Capital Programme Board and the Finance and Investment Committee.
Author: Matthew Neal, Estate Modernisation Programme Director Owner: Clive Field, Senior Responsible Owner
Page 2 of 2
DRAFT AC(15-16) 1A
Minutes of the meeting of the Audit Committee Held on Tuesday 25 May 2016
Present: Richard Flatman Non-Executive Director (Chair) Mr Jonathan Thompson Non-Executive Director and Chair of the Finance and Investment Committee Prof Andy Kent Non-Executive Director Board Members in attendance:
Mr David Bradley Chief Executive Ms Dawn Chamberlain Chief Operating Officer Mr Clive Field Interim Director of Finance Ms Barbara Greenway Non-Executive Director Dr Ali Hasan Non-Executive Director Ms Suzanne Marsello Director of Strategy and Commercial Development Dr Emma Whicher Medical Director Others in attendance: Bosede Babalola Head of Financial Services (except for items 10- 18) Ms Patricia Hymas Associate Director of Quality, Governance and Risk Mr Stephen Guile Interim Head of Corporate Governance Debbie Hollinghurst Head of Management Accounts (except for items 10-18) Mr Ranjeet Kaile Head of Communications and Stakeholder Engagement Mrs Frances Smith Deputy Director of Finance
Mr Paul Grady Grant Thornton Ian Merrington Grant Thornton Mr Marcus Ward Grant Thornton Mr Grant Bezuidenhout TIAA (except for items 5-18) Mr Ashley Norman TIAA
The Chair confirmed that all Board members had been invited to attend for the review and approval of the Annual Report and Accounts and associated items under delegated authority by the Board.
1 –16/17 Apologies for Absence Apologies were received from: 1.1 Ms Jean Daintith, Non-Executive Director; SWLSTG minutes of the Audit Committee, 25 May 2016 Page 1
Ms Vanessa Ford, Director of Nursing and Quality; Peter Molyneux, Trust Chair; Michael Parr, Director of Finance and Performance, and Kevin Limn of TIAA.
2-16/17 Minutes of the Meeting held on 24 March 2016 AC (15-16) 5A The minutes of the meeting held on 24 March 2016 were confirmed as a true 2.1 record of the meeting.
3-16/17 Action Tracker/Matters Arising AC (15-16) 5Ai The Committee reviewed the action tracker on pr ogress in implementing 3.1 actions agreed at the Audit Committee
3.1.1 Health and S afety Annual Report (Mins. 75.1): The H & S Annual Report was due t o go to QSAC on 5 J uly 2016. Action: Director of Nursing and Quality.
3.1.2 Deep Dive: Programme Management Methodology and Capacity (Mins. 76.1): the committee recognised the importance of this and this is likely to be the next deep dive, linked to the delivery of CIPs. Action: Interim Director of Finance.
3.1.3 Review of Governance Organisations and Systems and Committees/Groups (Mins. 76.2): The Interim Director of Finance advised that some work had been undertaken and would be taken to EMC and then to the Committee. Action: Interim Director of Finance/ Interim Head of Corporate Governance.
3.1.4 Internal Audit review of Facilities Management (Mins. 78.2) TIAA confirmed that this will be completed as part of the annual follow up process, after the new Facilities Management IT system had been implemented. Action TIAA.
3.1.5 Recommendation Tracker (Mins. 79.1) The Tracker had been r eviewed by EMC on 17/ 05/2016 and would be reviewed regularly, prior to each Audit Committee meeting.
Action closed.
3.1.6 Information Governance Toolkit (Mins. 80.1): TIAA was awaiting the management response to the mandatory review of the Information Governance Toolkit. Action: Interim Director of Finance.
3.1.7 Controls on use o f Agency Spend (Mins 81.1): A summary of the new controls wold be pr esented to the Audit Committee at its next meeting and after a period of three months, internal audit would review their effectiveness. There were limits in respect of individual agency appointments, against which the Trust had to report to NHS Improvement, and limits of spending for the trust as a whole. Action: Interim Director of Finance.
3.1.8 Quality Account (Mins. 81.1): Further consideration would be g iven to a quarter 3 progress review, prior to completion of the Quality Account for the
SWLSTG minutes of the Audit Committee, 25 May 2016 Page 2
year. Action: Director of Nursing and Quality.
3.1.9 Tender Waivers (Mins. 86): The Interim Director of Finance said that the report on Governance breaches would be brought to the Committee’s next meeting. Action: Interim Director of Finance.
3.1.10 Register of Seals (Mins. 88): Next Report on Seals will be at the next meeting. A process was being put in place to verify appropriate authority for the underlying transaction for which a request to sign or seal a document is received. Action: Interim Head of Corporate Governance.
3.1.11 Register of Gifts, Hospitality and External Sponsorship Policy. (Mins. 90.1): A report was due to be brought to next meeting. Action: Interim Head of Corporate Governance.
3.1.12 Counter Fraud Progress Report: Patients’ Monies (Mins 93.4): Internal Audit was reviewing cashiers (Patients Monies). The audit started on 19 April 2016. Action: TIAA
4-16/17 Counter Fraud Annual Report AC(16-1) 1
4.1 Mr Grant Bezuidenhout of TIAA presented the report.
The Committee noted the activity undertaken during the year, amounting to 180 days spent. The interim Director of Finance said that he would wish to see measures that demonstrated the value of the outcomes and Mr Bezuidenhout undertook to respond. Action: TIAA
The Chair noted that the Trust was required to complete the Self Review Tool for NHS Protect by 31 May 2016. He would have wanted the Committee to review the self-assessment before submission. This would be s igned off by the Interim Director of Finance but in future would be t imetabled for the Committee to review. Action: TIAA . 5-16/17 Going Concern Conclusion AC(16-17) 2
5.1 In presenting his report, the Interim Director of Finance said that the Board was responsible for preparation of the Trust’s Annual Accounts and must satisfy itself that the Trust was a going concern. He advised that the Trust had sufficient cash for its activity and had a t rack record of generating revenue surpluses. The Trust had achieved a Financial Risk Rating of 4. The Annual Report and Accounts would be amended to explain why the Trust had such a substantial amount of cash: the need for funding for the Estates Modernisation Programme (EMP). The Committee noted that the Trust had received Department of Health and Treasury approvals of its EMP Outline Business case.
5.2 The Committee confirmed the conclusions as to the Trust being a going concern.
SWLSTG minutes of the Audit Committee, 25 May 2016 Page 3
6-16/17 External Auditors Reports AC(16-17) 3
6.1 Mr Ward presented Grant Thornton’s Audit Committee Progress Report which included emerging issues and developments. The report set up the processes adopted for the 2015/16 audit.
Mr Ward advised that Grant Thornton’s report on the Quality Account would follow when the Trust’s final draft Quality Account, including stakeholder responses, was provided. The report on the Quality Account would be presented to QSAC 's meeting on 31 May and to the Board at its meeting on 2 June 2016, at which the Quality Account would be approved.
The Chair noted with some disappointment that the audited work on the Quality Account had not yet been completed because the period for seeking stakeholder feedback had finished too late and that as a result the Audit Report was not available. He said that he expected better planning for 2016/17.
6.2 The Committee noted that the report set out the obligations of the Trust in relation to the procurement and appointment of an external auditor, including the setting up of an auditor panel to advise on the selection and appointment of an auditor. The committee noted that Grant Thornton had been appointed for 2016/17 but that the Trust would need to have the appointment of an auditor for 2017/18, completed by 31st of December 2016. Action: Interim Director of Finance to consider options and provide recommendation in terms of process.
6.3 Mr Grady confirmed that the financial statements’ audit was substantially completed. There were no significant adjustments to report. The Trust’s accounting policies have been appropriate and had been appropriately applied. Grant Thornton had been satisfied that with the quality of the accounts and with the control environment and would be issuing an unqualified opinion. There had been a new audit team and there would be further work with the Trust to refine the process. Mr Grady thanked the Trust’s staff for their help and support during the audit.
The Chair asked whether Grant Thornton would now be removing the caveats "subject to the satisfactory resolution..." which appeared in pages 10 to 12 of the report. Mr Grady confirmed that these caveats would be removed from the final version of the report to be presented to the Trust Board at its meeting on 2 June,
6.4 The report also set out the basis on which Grant Thornton would reach its value for money conclusion. The Committee noted that the Audit Code, established by the Audit Commission, required auditors to satisfy themselves that the Trust "had made proper arrangements for securing economy, efficiency and effectiveness in its use of resources". The criterion was whether "in all significant respects, the Trust had proper arrangements to ensure that it took properly informed decisions and deployed resources to achieve planned unsustainable outcomes for text payers and local people."
SWLSTG minutes of the Audit Committee, 25 May 2016 Page 4
Mr Merrington presented the value for money findings. He noted that the Trust had achieved its planned surplus. He explained the processes that have been carried out in order to conclude that the Trust had proper arrangements in all significant respects to ensure that it delivered value for money from the use of resources. Key areas of investigation were: • Strategic vision and governance • Transformation • financial Sustainability • delivering sustainable cost improvement programmes
The Committee noted Grant Thornton’s recommendations in respect of its value for money work, which would be given further consideration by management and the report would be provided to the next committee meeting. Action: Interim Director of Finance. A key area for focus was coordination of programme management and ensuring that related risks were recorded and managed actively. In response to a question from Mr Thompson, Mr Merrington agreed that it was important to recognise the needs of internal and external stakeholders.
Summing up, the Chair said that the Committee noted: • the "Clean" audit opinion in relation both to the Annual Report and Accounts and the value for money assessment. • the findings in respect of internal control • the findings in respect of value for money and asked that management undertake a more detailed review of the findings and recommendations • the declining trend in the delivery of CIPs and that an improved programme for delivery was essential and the recommendations in respect of the Project Management Office (PMO) • that the auditors would be issuing their final reports with no reservations.
The Committee would review project and capital management in a deep dive at the Committee’s next meeting. Action: Interim Director of Finance.
The Interim Director of Finance said that the audit was being completed later in the process than planned. It would be helpful to learn from the process internally and with our auditors. Action: Interim Director of Finance.
7-16/17 Annual Accounts 2015/16 AC(16-17) 4
7.1 The Committee noted the draft annual accounts and agreed that further amendments of detail may be made between the Trust and Grant Thornton. The completed accounts would be submitted to the Department of Health by 2 June. The Chair noted that the Committee had approved the statement on going concern, that the annual accounts had received a clean audit from Grant Thornton and therefore that the accounts were ready for approval by the Committee.
7.2 The Committee approved the Annual Accounts for 2015/16, Subject to final minor amendments agreed between the Trust and Grant Thornton, for SWLSTG minutes of the Audit Committee, 25 May 2016 Page 5
signature and submission to the Department of Health by 2 June 2016
8-16/17 Letter of Representation AC(16-17) 5
8.1 The Committee noted the draft letter of representation. In response to a question from the Chair, the Auditors confirmed that the letter contained only standard representation and that nothing was included in the letter as a result of matters arising during the audit. Mr Thompson noted that each Board member had been asked to sign a statement that they had brought any necessary matters to the auditor’s attention and asked what type of matters it was in envisaged ought to be reported.
Grant Thornton commented that the matters that would need to be reported would be items that significantly affected the governance of the Trust or would be likely to impact on future transactions.
In response to a question from the Chair, the Interim Director of Finance said that he was not aware of any matters that needed to be brought to the attention of the auditors that had not been brought to their attention.
The Committee approved the letter of representation to Grant Thornton, to be signed by the Chief Executive, Chair of the Committee and the Interim Director of Finance.
9-16/17 Annual Governance Statement including Head of Internal Audit Summary Internal Audit Opinion AC(16-17) 6
9.1 The Interim Head of Corporate Governance introduced the Annual Governance Statement, which was a key part the Trust’s Annual Report. The draft AGS had previously been submitted, as required, to the Department of Health (who had made no comments upon it) and to the auditors, by the due date of 22 of April. Grant Thornton confirmed that they had reviewed the AGS and that their comments had been taken account of.
The Committee noted that the Head of Internal Audit Opinion summarised the work that internal audit had conducted and gave a conclusion of reasonable assurance. The Committee noted that the summary Head of Internal Audit opinion was included in the Annual Governance Statement, which would a public document. The Committee received assurance from the internal auditors that they were satisfied with the Annual Governance Statement.
9.2 The Committee approved the Annual Governance Statement, subject to an amendment to reflect the fact that the external auditor was expected to give an unqualified opinion on the Trust’s Quality Account.
10-16/17 Annual Report 2015/16 AC(16-17) 7 The Committee reviewed the 2015/16 Annual Report. Grant Thornton 10.1 confirmed that they had reviewed the document and given feedback to the Trust.
SWLSTG minutes of the Audit Committee, 25 May 2016 Page 6
The Committee approved the 2015/16 Annual Report subject to final proof checking, corrections, formatting and reconciliations, correction of the priority in relation to suicide prevention and the addition of the Statement of Accounting Officer’s Responsibilities. 11-16/17 Quality Account 2015/16 AC(16-17) 8
11.1 The Committee noted that it was asked to review the draft Quality Account 2015/16, before it was presented to QSAC and then for approval at the 2 June 2016 Board meeting.
The external auditors reported that they had been provided with a draft of the Quality Account but that this was as not yet complete. They would complete their review when the completed document, including stakeholder feedback, was provided.
The Committee noted some amendments that would be made and some checking, for example with the draft Chief Inspector of Hospitals Report.
The Committee recommended the Quality Account for approval to the Trust Board subject to assurance being provided by the external auditors following their final review.
12-16/17 Internal Audit Progress Report AC(16-17) 9
12.1 The Committee noted the update on progress, and in particular the findings in relation to the following completed reports, full copes of which were also provide under agenda item 14:
• Risk management • Governance • Payroll Analytics
The Committee noted the management actions and t hat these would be reported to the Committee in Recommendations’ Tracker and by Internal Audit follow-up reviews.
The Committee noted that all internal audit reports came to the Committee and that, additionally, those reports with quality implications were reviewed by QSAC.
13-16/17 Internal Audit Annual Report 2015/16 AC(16-17) 10
13.1 The Committee noted the Annual Report, including the Annual Opinion- which was of a Reasonable Level of Assurance. Mr Norman confirmed that this was the second highest level- Substantial Assurance was not normally given.
14-16/17 Internal Audit Final Reports TIAA AC(16-17) 11
14.1 The Committee noted the full reports whose findings and management responses were included within agenda item 12. above • Risk management
SWLSTG minutes of the Audit Committee, 25 May 2016 Page 7
• Governance • Payroll Analytics
15-16/17 Internal Audit Recommendation Tracker TIAA AC(16-17) 12
16.1 The Committee noted progress in implementing agreed actions in response to Internal Audit findings and recommendations. A further update on the one outstanding action- in relation to North Kingston CMHT, meant that there were now none outstanding. Actions form the newly completed reports would now be added.
16-16/17 Board Assurance Framework and Risk Register 16.1 The Committee noted the quarterly review of the Board Assurance Framework and Risk Register, with a report to the Board on 2 June to follow.
The following were highlighted: • Workforce/Community teams • There were a large number of transformational projects, whose co- ordination was vital.
17-16/17 Governance Breaches AC(16-17) 7
The Interim Director of Finance said that the report on Governance breaches 17.1 would be brought to the Committee’s next meeting. Action: Interim Director of Finance.
18-16/17 Quality and Safety Assurance Committee Report and Minutes of Part A and Part B of the QSAC meeting held on 1 March 2016 and 5 April 2016 18.1 The Committee received the 1 March and 5 April 2016 minutes of QSAC and an oral report from the Committee Chair, who highlighted Bed occupancy, Breaches’ in A&E and Vacancy rates for nurses, whilst noting recent success in recruitment.
19-16/17 Any Other Business
None Time and date of next meeting: It was agreed to rearrange the date of the next meeting from 27 July 2016. Action: Interim Head of Corporate Governance. Specific Items identified for the next meeting: Internal audit reviews: • Information Governance Toolkit review • e-roster, bank and agency • cashiers/patients’ monies • mobile phones Appointment of external auditors (Interim DoF) : • 2016/17 • Process for appointment for 2017/18 onwards Controls on use of Agency Spend (Interim DoF)
SWLSTG minutes of the Audit Committee, 25 May 2016 Page 8
Richard Flatman Chair of the Audit Committee June 2016
SWLSTG minutes of the Audit Committee, 25 May 2016 Page 9
Trust Board meeting
6 October 2016
Paper Reference: TB (16-17) 103
Report Title: Annual Safeguarding Report - Adults
Executive Summary: The CQC inspection in March 2016 found that staff across the trust had a good knowledge of safeguarding and this was well managed across the services.
Changes in Leadership and Governance structure will increase accountability and improve effectiveness of service.
Policy and practice is being aligned with latest statute, guidance and best practices. This includes co-production of a ‘Making Safeguarding Personal’ project that will inform service developments (see - appendix 3).
Organisational learning from audit and individual cases is being embedded in governance systems.
Changes in inter-agency working arrangements have provided opportunities for review and streamlining on working relationships.
Data on reporting levels suggest better screening and categorisation of incidents.
Workforce Development is keeping pace with the widening scope of safeguarding issues.
Plans for 2016/17 take account of organisational changes within the Trust and in external NHS and Safeguarding Board structures.
Action Required: For noting
Link to Strategic Objectives: Safe - Making services safe for service users is fundamental to the provision of high-quality health services
Effective – Executive Safeguarding Committee will aim to improve the effectiveness of our safeguarding services
Well led - The Executive leadership will develop and implement operational and strategic plans through a quarterly Executive Safeguarding Committee.
Risks: Service user groups include adults at risk of abuse and neglect. Risk of significant harm to service users, carers and others. Reputational risk when allegations made against staff and organisation.
Quality Impact: Trust will remain focussed on enhancing the quality of its safeguarding services. It is a top priority as part of a quality improvement process.
Resource Implications: Corporate Services Review 2 in progress.
Legal/Regulatory Care Act places duty on Trust to cooperate with Implications: safeguarding boards.
NHS executives should lead and promote the development of initiatives to improve the prevention, identification and response to abuse and neglect.
Statutory requirement to pay due regard to risk of terrorism.
Equalities Impact: The Trust Equality Strategy (2014-17) aims to remove or minimize disadvantages suffered by people due to their protected characteristics.
Groups Consulted: Safeguarding Adults Quality & Compliance Group (now defunct). Making Safeguarding Personal Group.
Author: Patrick Bull – Safeguarding Adults Lead
Owner: Vanessa Ford – Executive Director of Nursing and Quality.
M:\Trust Sec\Board & Cttees\Bd Mtgs\BM 2016-17\6. October 2016\Part A\12.1 ANNUAL ADULT SAFEGUARDING REPORT 2 2016 - v2.docx
Safeguarding Adults - Annual Report 2015/16
Date: 27.09.2016 Status: First draft Current Version: 0.2 Transparency : Public Restricted to: Reason: Commissioned Executive Lead – Director of Nursing and Quality by:
Distribution & approvals history
Version Distributed to Date Action required / taken V 0.1 Director of Nursing and Quality 27.09.20 For review 16 Safeguarding Adult Lead Doctor V 0.2 Director of Nursing and Quality 28.09.20 Final approval Safeguarding Adult Lead Doctor 16
M:\Trust Sec\Board & Cttees\Bd Mtgs\BM 2016-17\6. October 2016\Part A\12.1 ANNUAL ADULT SAFEGUARDING REPORT 3 2016 - v2.docx
1. Executive summary • The CQC inspection in March 2016 found that staff across the trust had a good knowledge of safeguarding and this was well managed across the services.
• Changes in Leadership and Governance structure will increase accountability and improve effectiveness of service.
• Policy and practice is being aligned with latest statute, guidance and best practices.
• The co-production of a ‘Making Safeguarding Personal’ (MSP) project that will inform service developments (see - appendix 3).
• Organisational learning from audit and individual cases is being embedded in governance systems.
• Changes in inter-agency working arrangements have provided opportunities for review and streamlining on working relationships.
• Data on reporting levels (safeguarding alerts decreased by 14%) suggest better screening and categorisation of incidents.
• Workforce Development is keeping pace with the widening scope of safeguarding issues.
• Plans for 2016/17 take account of organisational changes within the Trust and in external NHS and Safeguarding Board structures.
• Areas for development include: re-defining key roles; executive management of commitment to external agencies; maintenance of focus on quality improvement targets; implementation of MSP recommendations.
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Safeguarding Adults - Annual Report 2015/16
2. Foreword The Trust has continued to promote best practice in adult safeguarding throughout the year. There was consolidation of many aspects of good governance, including a change in executive leadership, and reshaping of corporate governance. Making services safe for service users is fundamental to the provision of high-quality health services and the Trust will remain focussed on enhancing the quality of its safeguarding services. The Trust has made this a top priority as part of a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against statutory, national, and local guidance, policy and standards.
3. Changes in legislation From April 2015, the No Secrets 2000 guidance was replaced by Section 42-46 of the Care Act 2014. The Care Act defines safeguarding as "protecting and adult's right to live in safety, free from abuse and neglect". The principle of promoting wellbeing is the driving force behind the legislation. Wellbeing has a broad definition, including personal dignity, physical health, mental health, protection from abuse and neglect and control over day to day life, as well as participation in work, education or training. This principle applies equally to carers and those with care needs. The Care Act also places Safeguarding Adults within a legal framework and all local authorities are required to have a Safeguarding Adults Board.
3.1 The Trust should always promote the adult’s wellbeing in their safeguarding arrangements. People have complex lives and being safe may be only one of the things they want for themselves. Professionals should work with the adult to establish what being safe means to them and how that can be best achieved. And the Trust has arrangements in place which set out clearly the processes and the principles for sharing information with other agencies.
3.2 In response the Care Act, and other organisational pressures, The Trust and the local authorities have made a number of changes to their respective inter-agency arrangements. These changes have provided excellent opportunity to review and streamline our procedures and protocols.
4. Challenges In March 2016, the Trust welcomed a team of inspectors from the Care Quality Commission (CQC), and they completed a detailed week-long inspection of our services. They were assessing and judging how well the Trust puts the quality of care and the interests of patients at the centre of what the Trust does. To get a full and thorough understanding of how well our services work, the inspectors interviewed staff about their work, talked to patients about the care they receive, and monitored the care being given to make sure the right systems and processes are in place.
4.1 The CQC rated three of the ten services that they inspected as ‘requires improvement’ and seven as ‘good’. So the overall rating for the Trust was ‘requires improvement’. The CQC will be returning in September for a focussed re-inspection of the areas that need improvement, and consider the improvements we have already made.
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4.2 The CQC report noted that Trust had safeguarding processes in place, with local variations based on the individual boroughs. And that all five boroughs had signed up to the pan-London safeguarding agreement with a Trust safeguarding lead for each borough and leads in wards and teams. The Trust service director attended the safeguarding board in each borough and the Trust executive lead, at that time, was the medical director, with reports on adult and children’s safeguarding routinely presented to the Trust board.
4.3 The inspection found that staff across the trust had a good knowledge of safeguarding and this was well managed across the services. Staff were confident about reporting incidents and there was a user friendly patient information booklet produced by the Trust on safeguarding adults. The safeguarding leads felt that they had made good progress in raising staff awareness and encouraging staff to ‘think family’ when considering safeguarding concerns.
5. Executive Leadership The Executive leadership for safeguarding adults and children is now with the Director of Nursing and Quality. They will lead and promote the development of initiatives to improve the prevention, identification and response to abuse and neglect. They will make sure the Trust responds to national developments and assure themselves that Trust systems and practices are effective in recognising and preventing abuse and neglect. They will also directly supervise the safeguarding leads.
5.1 The Executive leadership will develop and implement operational and strategic plans through a quarterly Executive Safeguarding Committee that combines Child and Adult safeguarding. This committee will oversee safeguarding activity across all services and will be directly accountable to the Quality and Safety Assurance Committee.
5.2 The actions identified by the Executive Committee will be followed up, and acted on, by the bi-monthly Safeguarding Working Group. This will aim to improve the effectiveness of our safeguarding services (see appendix 1).
5.3 There are key leadership roles, including the Safeguarding Adults Lead Doctor and the Trustwide Safeguarding Adults Lead. The requirements of these roles are currently under review by the Executive Safeguarding Committee and will be updated in line with recent policy guidance and best practice.
5.4 The Executive Safeguarding Committee is also developing guidance for the Trust Directors (or equivalent) who are members of the local Safeguarding Boards, with emphasis on the statutory and policy requirements of SAB membership. Other guidance on the requirements of Trust representation at the SAB sub-groups is also in development.
5.5 The Directorate Lead roles for each borough will remain central to the management of the working relationship with local authorities and other key agencies. The requirements of the role have changed with the new inter-agency working arrangements and the proposed Service Line Management changes. New guidance and role descriptions are in development.
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6. Policy reviews The Safeguarding Adults policy was reviewed and updated to align with the Care Act and associated statutory guidance. The policy describes the leadership and governance arrangements in place to maintain the highest standards of practice and performance. The governance of adult safeguarding is achieved through clearly defined roles with responsibilities for the oversight of governance and operations of adult safeguarding, including line management accountability and reporting lines. The safeguarding governance system is also mapped out in terms of the responsible internal groups and committees.
6.1 The Care Programme Approach policy was reviewed and updated in April 2016. Active service user involvement and engagement is at the heart of the approach, and it will focus on reducing distress and promoting social inclusion and recovery. It is based on a thorough assessment of the service users’ individual circumstances. Care plans are developed with full collaboration of the service user and focus on the service user’s strengths and seek to promote their recovery. Care plans recognise the diverse needs and preferences of service users, reflecting their cultural and ethnic background as well as their gender and sexuality. Note - This policy is currently subject to further review.
Achievements
7. Making Safeguarding Personal In 2014/15 the Safeguarding Adults leadership team initiated a monthly ‘Making Safeguarding Personal’ group. It followed on from, and built on, Quality Account projects in previous years. The service user group engaged in a dialogue with the Trust on abuse, neglect and safeguarding. The group met monthly with terms of reference firmly based on the principles of co-production. The members of the group wanted to learn from past experiences to prevent the abuse and neglect of service users in future. The group reviewed existing safeguarding adult policy and practices, and made a number of recommendations that have been presented to the Safeguarding Adults Executive (see Appendix 3). The MSP group project was presented to the Board as a ‘Patient Story’.
7.1 The MSP group report will be central to safeguarding service developments in 2016/17 and two of the SABs have invited representatives from the MSP Group to join the SAB service user representation sub-groups.
7.2 Recommendations for mental health services include: • Learn from what happened • Promote ‘Zero Tolerance’ everywhere • Promote social justice • Uphold rights • Uphold dignity • Show respect • Challenge discrimination
8. Lampard Report The Trustwide Workforce Development team have led on the embedding of the Lampard Report into practice. The report summarised the findings of the NHS investigations into 7
allegations of abuse by Savile at a number of NHS hospital sites, and identified themes and lessons to be drawn by the NHS as a whole. All actions are complete, with the exception of the following:
• Actions 9(a) and 9(b): Review the Policies and Processes governing the Trust’s Charitable Funds, with specific reference to the management of the Trust’s brand and reputation and association with any future major donors and celebrities. Develop formal relationships with the Leagues of Friends to enable a shared understanding of the Trust’s priorities and needs: Legal advice has been sought from Trust’s solicitors, who have recommended agreeing a Memorandum of Understanding with the League of Friends. A letter has been sent to the League of Friends proposing a Board to Board meeting to progress this, though the League has currently suspended its activity as a results of constitutional issues, pending discussions with the Charities Commission.
Inter-agency working arrangements
9. Kingston and Richmond Areas for improved working have been highlighted by the SAB chairs of both Kingston and Richmond. The Director of Nursing and Quality has engaged proactively with the boards in order to establish improved relationships and focus. This will be closely monitored through the Executive Safeguarding Committee.
9.1 The section 75 agreement with Kingston is under review. And an inter-agency Operational Leads meeting has been initiated by the Clinical Commissioning Group to oversee performance, practice and governance systems and structures. The close working relationship with Kingston Borough will continue under the leadership of Dr Martin Humphrey, who will be representing the Trust at the Kingston Safeguarding Adult Board.
9.2 The Trust’s section 75 agreement with Richmond was discontinued in July 2016 and a new inter-agency protocol is in place. The close working relationship with Richmond Borough will continue under the leadership of Dr Martin Humphrey, who will be representing the Trust at the Richmond Safeguarding Adult Board.
10. Wandsworth The section 75 agreement with Wandsworth was discontinued in December 2015. The effectiveness of inter-agency protocol with Wandsworth has been closely monitored through ongoing inter-agency meetings.
11. Sutton and Merton The Trust leadership in both Sutton and Merton remains unchanged, with additional local authority-led Operational Leads meetings being put in place to support existing Memoranda of Understanding.
12. Prevent & Channel Reports on all Prevent/Channel activity is submitted quarterly to NHSE and to the CCGs. The Prevent Lead attends NHSE Quarterly Network meetings and is directly supervised by the Executive Lead for Safeguarding. The Prevent Lead is panel member for Wandsworth
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Channel and attends other Channel panels when required. The Trust maintains a network of key Prevent professional contacts across the five boroughs the Trust covers. All staff are able to report Prevent concerns directly on incident reporting system and can discuss cases with Prevent Lead where needed.
13. Other It should be noted that the Trust is unusual in that it relates to five SABs, as well as five LSCBs, each with a number of sub-groups. A mapping and scoping exercise is underway to consider how the Trust can work with the chairs of the SABs to rationalise attendance whilst maintaining its focus and commitment
The Trust plays key role in a number of multi-agency risk panels. A mapping exercise (shown in appendix 2) was under taken to make sure Trust representation is in place.
14. Learning The Integrated Learning Group has ensured that appropriate structures, and support processes are in place to identify learning through the review of data and information from Safeguarding Incidents and Safeguarding Adult Reviews - SAR (formerly known as Serious Case Review - SCR). The introduction of the Safeguarding Adults Review process provides an opportunity for greater levels of scrutiny of the most challenging cases and to learn from the outcomes. The Quality Governance team have developed system for monitoring the progress of SARs, SCRs and DHRs to help support directorates with the tracking and monitoring of the progress of these investigations.
15. Organisational Audit The Safeguarding Adults at Risk Audit Tool has been developed by the London Chairs of Safeguarding Adults Boards (SABs) network and NHS England - London. It reflects statutory guidance and best practice. It provides a consistent framework to assess monitor and/or improve the Trust Safeguarding Adults arrangements. In turn this supports the SABs in ensuring effective safeguarding practice across the organisation.
15.1 The Trust completes these audits annually and submits them to SAB ‘Challenge and Support’ events. In 2015/16 the audit highlighted good practices: • Staff at all levels have responsibilities to safeguard adults at risk • Listening Into Action – a staff engagement project • Virtual Risk Team – access to support for risk management • Independent audit rated 93% cases as good/adequate • MSP Group (see appendix 3)
16. Audit - Patient on patient incidents This audit is part of a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria. The Trust needs to learn from incidents where there has been a potential, or actual, harm to a person using Trust services.
16.1 The threshold for meeting external reporting requirements is unclear. Staff and managers generally manage the immediate response to these incidents well, with evidence of some good practices. Staff and managers will be provided with clear guidance on how to
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respond to these incidents and when they should be reported externally to local authority and police.
16.2 The recommendations from this audit are also included in the targets for the Trust Quality Priorities. The Trust will: • Coproduce ‘feeling Safe’ posters with service users and distribute to teams. • Update guidance on recording incidents on Ulysses. To include: o Recommended recording practice for improved data quality o External reports to police, local authority and advocacy service o Recording service user views in de-brief
17. SCR - Community The complexity of multi-service issues arising and the circumstances of service user’s death, were deemed to meet the criteria for a Serious Case Review. The SCR Overview report concluded that there was no guarantee that any amount of strategies, contingencies or resources would have been able to mitigate risks associated with the service user’s choices and volatile behaviour while in the community. It was therefore not possible to say that her death was preventable. The Coroner recorded a verdict of death by natural causes. The Service Director arranged a Learning Event and Team de-brief.
18. Prevent case The Trust facilitated a Multi-agency de-brief for a service user known to ‘Prevent’ who had been an in-patient and was care coordinated by a community team. The Care coordinator made every effort to maintain optimal care and treatment with support of the team manager. The team made timely contact with Trust Prevent and they engaged with police and Multi- Agency Public Protection Arrangements. The service user was convicted under Terrorism legislation and the Chief Executive commended staff for the professionalism of their actions throughout trial process.
19. SAR - Inpatient The Police and related investigations are on-going and the cause of death and related factors are still being established. Assurances were given to the local authority that the Trust had taken actions regarding any immediate practice concerns. The Care Quality Commission are fully involved given their new Health and Safety Investigative duty. The Richmond SAB/SAR Sub Group will act as overseer and coordinator of investigations.
20. Community Drug and Alcohol Team Between June 2013 and December 2013 there were seven deaths of people using Community Drug and Alcohol Team services. The investigation was completed in June 2015. The full report went to the Safeguarding Adults Board for the consideration of its Serious Case Review Group. The resulting action plan was reviewed and implemented through Public Health Commissioning. A comprehensive briefing was provided to Care Quality Reference Group in July 2015.
21. In-patient service A series of meetings were called because a number of allegations were raised regarding the quality of care provided to patients on in-patient service. The concerns were anonymous 10
and were circulated to the Police, Care Quality Commission (CQC) and Wandsworth Clinical Commissioning Group. The meetings shared all relevant information on the allegations and oversaw a comprehensive investigation. The allegations of abuse and neglect were not substantiated.
22. Safeguarding in numbers It is important to note that the National figures provided by the Health and Social Care Information Centre (2015) relate to referrals made to local authorities. The Trust figures shown below, indicate the number of safeguarding alerts or concerns that have been raised. The alerts/concerns may have been managed locally and not referred to the local authority. Some may have been referred to the local authority and the referral was then declined.
22.1 The Trust will work to continually improve inter-agency systems and governance structures to increase the quality of information sharing at all stages of the safeguarding process. One of the key targets for the Trust in 2016-17 is to negotiate agreements with the five SABs on exchanging data on safeguarding activity, and most importantly, recording the outcomes of all referrals.
Type of abuse 2015/16 2014/15 2013/14 % number % number % number Discriminatory 1 7 1 10 1 4
Domestic Violence 8 51 n/a n/a n/a n/a
Financial or material 13 87 13 100 17 78
Institutional >1 2 2 14 2 7
Modern Slavery 1 4 n/a n/a n/a n/a
Neglect and Acts of Omission 10 69 9 74 7 33
Organisational 31 21 n/a n/a n/a n/a
Physical 35 236 46 366 47 210
Psychological 13 87 18 140 15 66
Prevent >1 6 n/a n/a n/a n/a
Historic Abuse >1 3 n/a n/a n/a n/a
Self-Neglect 6 39 n/a n/a n/a n/a
Sexual 9 63 11 87 11 50
Total (n) 675 791 448
Note: figures may not tally due to rounding
22.2 This year, the number of incidents being reported in the safeguarding adults category has decreased (approx.15%) and in other categories the number of incident has increased (approx. 13%). This suggests there has been better categorisation of incidents by line managers. There has also been increased oversight of the whole reporting system through the Quality Governance team, and this has also improved accuracy of categorisation of incidents.
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22.3 There has also been a decrease in the proportion of allegations of physical abuse (35%), and this is closer to the national figure (27%) than in previous years.
22.4 The highest category in national referrals is neglect and acts of omission (32%). This category has been a consistently low proportion of Trust alerts. The Safeguarding Executive Committee will be responsible for further investigation in to the reasons for this.
22.5 The new categories defined in the Care Act statutory guidance and Pan-London policy are included in the reporting system. It is expected that levels of reporting in these categories will increase in 2016-17 as levels of awareness will increase through the Workforce Development programme.
23. Demographics The tables below show demographic data on those who were allegedly abused or neglected.
Age 2015-16 2014-15 Reports of alleged Service user Those subject of Service user abuse population – total allegations population – total 18 to 65 81% 67% n/r n/r Over 65 19% 33% n/r n/r
This is the first year that the Trust has reported demographic data on the age of adults who have allegedly been abused. There is a low proportion of alerts (19%) being raised in the over 65 group compared to the national figure (HSCIC 2015) for safeguarding referrals (63%), though this included all service user groups. This will be monitored through the Safeguarding Executive Committee throughout 2016-17. Further analysis of the reporting levels across services will be undertaken to make sure services are meeting their reporting requirements.
Gender 2015-16 2014-15 Reports of alleged Service user Those subject of Service user abuse population – total allegations population – total Male 42% 45% 47% 47% Female 58% 55% 53% 53% 23.1 There is slight increase in the proportion of females reported to have been subject to abuse within the Trust. The figures are comparable to the national figure (HSCIC 2015) for safeguarding referrals (60%), though this included all service user groups.
Ethnicity 2015-16 2014-15 Reports of Service user Reports of Service user alleged abuse population alleged abuse population White 66% 69% 63% 70% Mixed/multiple 3% 3% 2% 3% Asian/Asian British 8% 7% 7% 8% Black/African/Caribbean/Black British 18% 8% 17% 10% Unknown >1% 7% 9% 4% Other 4% 6% 2% 5% 23.2 There is evidence that the service users from BME groups are over-represented as ‘victims’ of alleged abuse. The growing diversity in the demographic characteristics of the population of South West London present challenges to the Trust and its partners, in the commissioning and delivery of mental health services that meet local needs. The Trust Equality Strategy (2014-17) aims to remove or minimize disadvantages suffered by people due to their protected characteristics. All patients irrespective of their protected characteristics should have equitable access to services and receive treatment that delivers similar mental health outcomes.
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24. Workforce Development All staff that come into contact with adults at risk have a responsibility to safeguard and promote their welfare and should be aware of the actions to take if they have concerns about safeguarding issues. To fulfil these responsibilities, it is the duty of this Trust to ensure that all health staff have access to the appropriate safeguarding training, learning opportunities and support to facilitate their understanding of the clinical aspects of adults welfare and information sharing.
24.1 All new staff are required to attend introductory sessions on safeguarding adults and Prevent at Induction. Subsequently they are required to complete Safeguarding Adults level 1 (e-learning). Compliance has been monitored throughout 2015/16 and currently stands at 91.1% compliance. All staff undertaking work with adults have access to a source of additional advice and guidance particularly in complex and contentious situations.
24.2 Local Authority provide training at higher levels (2 to 5) and it is accessible to senior staff and managers. Trust representatives attend their respective SAB training sub-groups (or their equivalent) to make sure adequate training is available
24.3 The roll-out of the Prevent Workforce Development plan is being implemented and is expected to meet NHSE targets. ‘Basic Prevent Training - BPT’ is now part of all Trust Inductions, and Workshops to Raise Awareness of Prevent (WRAP) have been offered across all Trust sites.
24.4 There have been twenty WRAP sessions attended by 146 staff and 380 have been provided BPT. A second WRAP trainer is being registered with the Home Office and will start to deliver WRAP sessions in October 2016.
25. Future Plans - Objectives for 2016/17 Objective 2016/17 Action and resource required Timescale Further strengthen governance Develop terms of reference and schedule September 2016 arrangements with Executive meetings accordingly Safeguarding Committee To develop a robust inter-agency Trust SAB Leads to negotiate inter-agency December 2016 information sharing procedure to make protocol and/or memorandum of sure the Trust is made aware of the understanding and embed this requirement outcome of all safeguarding alerts. in to practice
Policy review to align content with Pan- Safeguarding Executive Committee to November 2016 London policy - SCIE 2015 oversee completion of review and update.
Implementation of the 2016/17 Safeguarding Executive Committee to April 2017 Workforce Development plan. ensure robust monitoring system is developed in partnership with Workforce Development team. To establish a process through a Trust SAB Leads to get agreement from January 2017 standard operating procedure to receive SAB/SAR sub-groups feedback from Safeguarding Adults Partnership Boards on the completion of SAR's.
Meet Quality Account Indicators for Trust Lead to provide guidance on action October 2016 2016/17 through reducing patient on required to Service Leads patient, and staff on patient incidents.
Fully implement the work co produced Develop detailed action plan based on MSP April 2017 by the Making Safeguarding Personal group recommendations.
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group… Executive Safeguarding Committee to oversee implementation of action plan
Support MSP group to improve access to SABs. Acknowledge and commend the work of Executive Safeguarding Committee to April 2017 our front line staff in supporting provide regular bulletins on good practice safeguarding policy and practice
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Appendix 1 Corporate Structure SWLSTG NHS Trust Board
Quality and Safety Assurance Committee
Executive Safeguarding Committee Chair - Executive Lead Membership – Service Leads
Safeguarding Working Group Chair - Head of Social Work Membership – Operational/Clinical Leads
Key Corporate post-holders
Executive Lead - Director of Nursing Vanessa Ford
Safeguarding Adults Lead Doctor Dr Ben Nereli
Safeguarding Adults Lead Patrick Bull
Directorate roles and inter-agency arrangments Directorates
Kingston and Richmond Sutton and Merton Wandsworth Specialist Services Kingston - s75 Richmond - Inter- Sutton - Merton - Inter-agency Inter-agency agreement with agency protocol Memorandum of Memorandum of protocol in place protocol in place local authority in place Understanding in Understanding in with host authority currently under place place (Wandsworth). review
SAB Member – SAB Member – SAB Member – SAB Member – SAB Member – SAB membership Consultant, Dr Consultant, Dr Service Director, Gill Service Director, Service Director, not required Martin Humphrey Martin Humphrey Moore Gill Moore Jeremy Walsh
Service Lead – Service Lead – Service Lead – Service Lead – Service Lead – Service Lead – ADSW, Iain Band 7 tbc Social Worker, Chris ADSW, Henrietta Operational Head of Social Richmond Allen Brown Manager, Martin Work, Chris Morris Merchant
Multi-agency risk Multi-agency risk Multi-agency risk Multi-agency risk Multi-agency risk Multi-agency risk forum: forum: forum: forum: forum: forum:
Multi Agency Multi Agency Domestic Abuse Multi Agency Multi Agency Multi Agency Public Protection Public Protection Strategic Group Public Protection Public Protection Public Protection Arrangements Arrangements Arrangements Arrangements Arrangements (MAPPA) (MAPPA) Safer Sutton (MAPPA) (MAPPA) (MAPPA) Partnership Multi Agency Risk Multi Agency Board Multi Agency Risk Multi Agency Risk Multi Agency Risk Assessment Risk Assessment Assessment Assessment Assessment Conference Conference Multi Agency Conference Conference Conference (MARAC) (MARAC) Public Protection (MARAC) (MARAC) (MARAC) Arrangements Community (MAPPA) Community Multi- MARAC Agency Risk Multi Agency Assessment Domestic Abuse Risk Assessment Panel (CMARAP) Strategic Group Conference (MARAC) Safer Kingston Partnership Board Community MARAC
Local Authority – key roles and structure Safeguarding Adult Board (SAB)
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Kingston Richmond Sutton Merton Wandsworth
SAB Chair – Sian SAB Chair – Brian SAB Chair – Deborah SAB Chair – Simon SAB Chair – Nicky Walker Parrott Klee Williams (until Pace September 2016)
SAB sub-groups: SAB sub-groups: SAB sub-groups: SAB sub-groups: SAB sub-groups: Training Training Quality Assurance Performance Workforce and Performance Development and Quality and Performance Management Communication Performance Human Resources and Communications Quality Safeguarding Safeguarding Training – Assurance Adults Review Adults Review Safeguarding Workforce (SAR) (SAR) Adults Review Development Workforce (SAR) Development Communication and Community Safeguarding Engagement Adults Review (SAR) Safeguarding Adults Review (SAR)
Appendix 2
Objectives for 2015/16 – update on progress and completion
Objective 2015/16 Action and resource required Timescale Progress Policy review SAQG to oversee policy review June 2015 Completed
Ratification of policy by Integrated Governance Group. June 2015 Completed
Update policy and embed Pan London policy December 2015 (tbc) Carried over to 2016/17 Care Act impact Service Directors to work with December 2015 Completed SABs on changes in performance measures required.
Nominated Care Act leads to continue to support all staff with April 2015 Ongoing changes in practice required. MCA/DoLs Cheshire West – Nominated MCA leads will provide April 2015 and monthly impact SAQG with update on statutory developments Mental Health Act Code of Nominated MCA leads will provide April 2015 and monthly Completed Practice: update MHA policies SAQG with update on statutory to ensure compliance. developments
Fully integrated incident Identify System supervisor and July 2015 Completed reporting system system administrator.
Develop issues log for Ulysses, Completed IM&T and administrators. Audit programme Audit leads to register audit April 2015 Completed programme requirements.
SAQG to monitor audit application Monthly Completed of programme Embedding of MSP principles Initiate MSP service user group. July 2015 Completed in to services. Develop recommendations for Increase Recovery College presentation to SABs. December 2015 Completed Service User awareness. Develop education programme for Recovery college March 2016 Carried over HR engagement in SGA Nominate a HR safeguarding July 2015 Completed adults lead.
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Training to level 1 will be provided September 2015 Completed to all HR staff.
Reviewing processes and March 2016 Carried over to 2016/17 procedures to ensure compliance Freedom to Speak Up report.
Implementing the Equality Delivery System (EDS2) over 2015/16. March 2016 Carried over to 2016/17
Promote awareness through Review and update Trust website December 2015 In progress new technology and social and InSite pages media.
Advocacy – monitor access SAQG to receive reports on Monthly In progress referrals to advocacy
Appendix 3 The ‘Making Safeguarding Personal’ Group A Co-Production Project - 2015/16
Executive summary • Aim This report describes a co-production project that reviewed existing safeguarding adult policy and practices. It follows on from, and builds on, Quality Account projects in previous years. The report makes a number of recommendations on how disclosures of abuse and neglect should be dealt with. The members of the group wanted to learn from past experiences to prevent the abuse and neglect of service users in future. • Method A service user group engaged in a dialogue with the Trust on abuse, neglect and safeguarding. The group met with the Trust safeguarding adults lead monthly with terms of reference firmly based on the principles of co-production. Chairing and administrative support was provided by a voluntary sector organisation. • Strengths There was consistent commitment from all those involved. The group felt it was important that abuse and neglect were being taken seriously. The recommendations are wide-ranging and practicable. Other service user groups were consulted on the project. Professional advice and support was offered where needed. • Areas for improvement There could have been wider consultations, and greater representation from other boroughs. • Recommendations Safeguarding should not just be a professional process, it needs a culture change. Recommendations cover what actions services should take when the service itself is alleged to have been abusive and how safeguarding should be embedded in to professional practice. It is important that existing statutory guidance is followed. And it is essential that service users are at the forefront of service developments and are represented at highest organisational levels. There is also need to increase
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awareness of safeguarding amongst the service user population, and for service users to know how to safeguard themselves.
• The key messages. Mental health services should: o Learn from what happened o Promote ‘Zero Tolerance’ everywhere o Promote social justice o Uphold rights o Uphold dignity o Show respect o Challenge discrimination
MSP report 2015 16 final with exec summa
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The ‘Making Safeguarding Personal’ Group A Co-Production Project - 2015/16
Executive summary • Aim This report describes a co-production project that reviewed existing safeguarding adult policy and practices. It follows on from, and builds on, Quality Account projects in previous years. The report makes a number of recommendations on how disclosures of abuse and neglect should be dealt with. The members of the group wanted to learn from past experiences to prevent the abuse and neglect of service users in future. • Method A service user group engaged in a dialogue with the Trust on abuse, neglect and safeguarding. The group met with the Trust safeguarding adults lead monthly with terms of reference firmly based on the principles of co-production. Chairing and administrative support was provided by a voluntary sector organisation. • Strengths There was consistent commitment from all those involved. The group felt it was important that abuse and neglect were being taken seriously. The recommendations are wide-ranging and practicable. Other service user groups were consulted on the project. Professional advice and support was offered where needed. • Areas for improvement There could have been wider consultations, and greater representation from other boroughs. • Recommendations Safeguarding should not just be a professional process, it needs a culture change. Recommendations cover what actions services should take when the service itself is alleged to have been abusive and how safeguarding should be embedded in to professional practice. It is important that existing statutory guidance is followed. And it is essential that service users are at the forefront of service developments and are represented at highest organisational levels. There is also need to increase awareness of safeguarding amongst the service user population, and for service users to know how to safeguard themselves.
• The key messages. Mental health services should: o Learn from what happened o Promote ‘Zero Tolerance’ everywhere o Promote social justice o Uphold rights o Uphold dignity o Show respect o Challenge discrimination
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The ‘Making Safeguarding Personal’ Group A Co-Production Project - 2015/16
Co-Production Partners Sutton 1 in 4 network Making Safeguarding Personal (MSP) Group South West London & St Georges Mental Health NHS Trust
With thanks for contributions from: Hilcrombe House York Road Brunel House Belmont Connect Signpost Sutton Mental Health Foundation Sutton & Merton User Reference Group
Introduction The publication of reports in to cases of historic abuse, both locally and nationally, increased the level of awareness of how services should be responding to disclosures of abuse or neglect. As a result, the members of a Service User Reference Panel were seeking information on how the SWLSTG NHS Trust responds to disclosures of abuse and were wanting to know how safeguarding adults’ services work.
Sutton and Merton Adult Service User Reference Panel - Purpose
• To provide a forum for the Sutton & Merton Directorate to discuss service delivery issues and models and collaborate with local service user representatives. • To provide a forum for service users to influence the service delivery model, both current and future for the benefit of service users. • To agree a programme of key issues that service users and the Sutton & Merton Directorate will work collaboratively on.
The Trust Safeguarding Adults lead was invited to attend the panel meeting and presented some of the issues arising from the Quality Accounts (see appendix 1) and gave an overview of the principles of ‘Making Safeguarding Personal’.
Making Safeguarding Personal: ‘…is about person centred and outcome focussed practice. It is how professionals are assured by adults at risk that they have made a difference to people by taking action on what matters to people, and is personal and meaningful to them’.
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(Pan-London Policy SCIE - 2015)
‘…engages the person in a conversation about how best to respond to their safeguarding situation in a way that enhances involvement, choice and control as well as improving quality of life, wellbeing and safety’ (Dept. of Health 2014).
It was clear that the service users wanted to engage in a dialogue with the Trust on this topic and both sides made a commitment to do so. A number of service users volunteered to be part of a co-production project and it was agreed that the service users and the Trust safeguarding lead would arrange to meet to consider how to start to address the issues of abuse and neglect experienced by people who use mental health services.
Making Safeguarding Personal (MSP) Group The venue for the meeting was agreed and the first meeting was held in June 2015. It was agreed that the meeting should be based on co-production principles. These were set out in the group’s terms of reference and were based on the Sutton User Involvement & Partnership Framework and the SWLSTG NHS Trust Service Users and Carer Involvement Policy. There was oversight from the Trust Safeguarding Adult’s Quality & Compliance Group and also reference made to the Local Government Association guidance, Care Act statutory guidance and the Pan-London policy (see appendix 2). The members of the group called themselves the ‘Making Safeguarding Personal’ group (MSP Group).
MSP Group – terms of reference • Sutton User Involvement & Co-production Framework • SWLSTG NHS Trust Service Users and Carer Involvement Policy • Local Government Association guidance • Monthly meetings: June to November 2015 • Chaired by Sutton 1 in 4 Network • Venue Salvation Army
The meetings were chaired by Sutton 1 in 4 Network, and they also provided administrative support, with the minutes of the meetings being uploaded to the Sutton 1 in 4 website. The monthly meetings were consistently attended by up to eight mental health service users and a Trust representative. Throughout the period the MSP Group met, there were consultations with other mental health service user groups in the area. The feedback from service users from Hilcrombe House, York Road, Brunel House, Belmont Connect, Signpost Sutton, Mental Health Foundation, and the Sutton & Merton User Reference Group was invaluable.
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The members of MSP group were able to share their personal and collective experiences of abuse and neglect in a supportive setting. There was particular focus on the ‘day to day’ inequalities and the ‘culture’ of services that allowed abuse to happen. The group members wanted to use their experiences of some deeply distressing events to try to prevent other service users having to suffer in the same way. The considerable emotional efforts required should not be underestimated, and group members supported each other to cope with their recollections of abusive situations. Professional advice and support was also offered where needed. The members were engaged with the MSP group in the expectation that the project would have real impact on how people were safeguarded from abuse and neglect in future.
“Over ten years ago I was raped and sexually assaulted. It was reported to the police and it was investigated. They agreed that it had happened. All I got was an apology. I was on medication that made be less inhibited. Two staff saw what happened and were egging on the patient assaulting me. I was very high. I had no control. There should have been segregation”
It was decided early on that it would not be appropriate to engage carers in the group meetings as they may have conflicting priorities to the service user population.
Key Issues The MSP group first set out some of the more general issues they had identified. Some of these are already part of policy guidance, while others echo, and support, the existing policies. There were concerns that abuse is often hidden – sexual abuse, institutional abuse, harassment and bullying could be happening every day. The group members all felt it was important that finally abuse and neglect were being taken seriously. There was a need to emphasise that action should be taken, and just stating there will be ‘zero tolerance’ of abuse is not enough. It should not just be a professional process – it needs a culture change.
“A man in supported accommodation, he had a history of mental health problems and self- harm. Every year the residents of the home contribute towards the cost of the Christmas meal, in order that they have all the trimmings, etc. A large turkey was purchased and cooked and the residents wanted to use the leftovers for sandwiches only to find that the turkey remnants had been taken away by staff and consumed”
There was also a question about the language of safeguarding. Describing the person who has been abused as the ‘victim’ can be seen as a judgemental term: it is a person who has been affected by abuse or neglect; it’s not their fault. It is about the person’s experience of
4 feeling abused. It is not about meeting a ‘threshold’, if someone feels they have been abused or neglected, there needs to be a response.
Key Issues • ‘Victim’ is a judgemental term – it is a person who has been affected by abuse or neglect. It’s not their fault. • Important that abuse and neglect is taken seriously • It is about the person’s experience of feeling abused, it is not about meeting a ‘threshold’. • Everyone’s rights must be upheld. • Abuse is often hidden - sexual, institutional abuse, harassment and bullying could be happening every day.
The discussions moved on to more specific consideration of how abuse and neglect changes people’s lives. The impact of abuse must be recognised both at the time of the incident and later on.
“I was terrified. No one listened. No one understood me. I was not taken seriously. I was contacted to give a statement, but they believed someone else. I never knew the outcome”
In the first instance, there should be a check on the person’s feelings with immediate support being available from the agencies involved. In some cases it may be appropriate for support to come from peer networks or peers or a trusted person.
Sutton ‘1 in 4’ run a Circle of Support group for inpatients on an Acute Psychiatric Ward and runs every fortnight.
Those involved in safeguarding should see whole person and write down what the person actually says. Within mental health services allegations of abuse may be dismissed as delusional. The professional view is not enough, what is the abused person’s view? Abuse is not always a major, single incident. There can be a build-up of ‘little’ indignities that can feel abusive too.
“One of the other patients left the hot water boiler's tap open in the night - they may well have done this over several nights and this could well have been deliberate. The staff response was to lock up the boiler all day and all night while providing brief periods in the day where water was doled out to people wanting tea or coffee. Regrettably, it did seem that the member of staff managing the distribution of the water enjoyed this arrangement
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rather too much - it appeared that he took pleasure in telling us we couldn't have a hot drink outside the appointed times as we "couldn't be trusted". I also remember being surprised at a lack of professionalism when I was told to "enjoy my lukewarm coffee"
Decisions on what happens should be with the abused person; the process should follow the person, not vice versa. There must be feedback on what is happening at the time, and what will happen next.
Support for the abused - 1 • Give immediate support • Do not dismiss it as ‘delusional’ • See the ‘whole’ person • Record exactly what is being said • Use peer support if safe to do so • Say what happens next
Secondly, there may be a lifelong effect on a person’s wellbeing. Access to counselling and emotional support should be fast-tracked. And it must be remembered that disclosing a past abuse can feel like re-living the abuse and must be handled sensitively. There should be consideration of the need for post-incident trauma counselling.
Support for the abused - 2 • Abuse can cause trauma • Impact of abuse must be recognised • Disclosing abuse can feel like re-living the abuse • Disclosure must be handled sensitively • Post-incident trauma counselling must be considered
Organisations/services The MSP Group went on to develop recommendations on how services should be delivered, and how the response to safeguarding concerns should be undertaken. Abuse and neglect can change peoples’ perception of services. It can lead to mistrust of service providers and other agencies. There was consideration of how service providers can improve delivery of safeguarding services. For example, there must be greater effort to look after people’s physical health needs and to keep a check on the impact of low income and benefit changes.
“I thought I must be in hell. I asked myself, what have I done wrong. It was like a prison. The door was locked. My own judgement was taken away. I was treated like a child”
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Existing statutory guidance needs to be followed. There should be access to advocacy to help people navigate through the process and to make sure their rights are upheld. The service users who were consulted, were not aware of their right to access advocacy services if they have ‘substantial difficulty’ with the safeguarding process.
Service providers should: • Support staff whistleblowers • Not scapegoat people who complain. • Ensure crisis/help lines have higher level of awareness of safeguarding issues. • Support service user organisations (e.g. 1 in 4 network) to signpost • Provide access to immediate support • Provide access to advocacy
There were other specific recommendations about what actions services should take when the service itself is alleged to have been abusive.
Services should: • Ensure management investigations are independent. • Where possible, services should not investigate themselves. • Identify service leads to guide other staff on all safeguarding issues. • Take responsibility for actions of staff and be held accountable for them. • Provide staff with de-brief after interventions too, as they can get ‘pumped up’
The actions and interventions taken by professionals are not always effective. When the alleged abuse relates to a service provider, then it is suggested there should be assertive actions taken. The MSP Group’s made suggestions about what actions may help.
Suggested actions • After acts of violence and aggression people must be separated. • The perpetrator should be moved, not the victim • Mediation can make matters worse, especially in community • There needs to be risk assessment of the impact of safeguarding process • Discrimination and ‘hate crime’ may be an underlying cause
Underlying the recommendations are questions about the culture of service provision. Service providers have commitment to be open and transparent in the way they respond to concerns. This needs to be central to the way safeguarding is embedded in to practice.
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Abuse is not always a major, single incident. There can be a build-up of ‘little’ indignities that can feel abusive too.
Organisations must: • Offer reconciliation • Acknowledge abuse has taken place • Accept it is not just a process – needs a culture change • Acknowledge any build-up of ‘little’ indignities are an abuse • Emphasise actions and consequences, zero tolerance alone is not enough • Not allow perpetrators to get away unscathed to repeat abuses
“If you want to make safeguarding personal, then you have to make the services people use feel safe”
Service user involvement There were also clear messages on service user involvement. Service users at all levels must be at the forefront of service development. It needs the involvement of service users who have had experience of abuse and/or neglect. Service users have to stay in foreground. Service users have to keep coming back and should be in advisory positions at service provider’s executive level. And policies and procedures should not be written by professionals alone. They should be co-produced, reviewed annually and treated as living documents. Service users are seeking representation at highest organisational levels.
Service user presence • Service users at all levels must be at the forefront of service development. • It needs the involvement of service users who have had experience of abuse and/or neglect. • Service users have to stay in foreground. • Service users have to keep coming back. • Service users should be in advisory position at service provider’s executive level.
The MSP Group are seeking representation of service users on: – Safeguarding Adult Boards (SAB) to shape and develop services – Mental Health Trust service development projects – Nominated (SAB) Board member to support MSP group
Policies and procedures
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– Should not be written by professionals alone. – Should be co-produced and reviewed annually. – Should be a living documents
Training • Service user involvement in delivery of sessions • Train the trainer sessions for service users. • Service user organisations to receive training • Content of sessions to include MSP Group recommendations
It was noted that there is already service user representation at the Trust Quality Safety and Assurance Committee (QSAC) and Patient Quality Forum (PQF).
Education for Service Users Overall, there is a need to increase awareness of safeguarding amongst the service user population. It is important people know about the types of abuse and recognise them for what they are. They can then start to learn how to keep themselves safe and learn how to assess the risks themselves.
The MSP Group understood very clearly what abuse is, but there was very limited understanding of what can be done about it. People who use services need to know what ‘safeguarding adults’ policy means to them. The service user population need to be provided advice, support and information on how to uphold their right to lead a life free from abuse and neglect. If someone is feeling abused or neglected, who should they contact? What rights do they have? Can they access local support? People who use services should be made more fully aware of their rights. Human rights are for all and must be upheld (see appendix 3).
“A young woman whom recently had been discharged from hospital was befriended by her neighbour and started to act as her carer. This individual manipulated her to get hold of her benefits and access to her bank account. The person felt confused and angry and was not certain as to what to do. On the one hand they could see that they were being financially abused but on the other hand, they wanted someone to support and care for them. They were not certain how to report this incident and felt embarrassed that they could not protect themselves”
Service users should be encouraged to write their own safeguarding plan in their own language. It should show what their own responsibilities are. They need to be a part of an
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honest discussion about risk and what makes them feel safe and complete a ‘self-risk assessment’. It should not just be a ‘one-off’ but part of care plans which include safety plans and advance directives.
Service users should have access to education on how to: • Develop an awareness of safeguarding • Learn how they can keep themselves safe • Understand what is abuse – what are the types of abuse • Understand the Mental Capacity Act • Complete a ‘Self risk assessment’ • Know who you can contact if you need help • Understand what their rights are. • Know how to access local support – e.g. ‘Circle of Support’.
Conclusion In conclusion, there is a need for service providers and service users to support the development of a community-wide ‘learning culture’ to prevent abuse. This report provides opportunity for mental health service providers, in all sectors, to review their current policy, procedures and practices, and consider what actions are needed to make their services more responsive to disclosures of abuse and neglect. They should also embed these recommendations into both their training sessions.
The issues outlined in this report should be presented to the local Safeguarding Adults Board and the Trust Executive. The Trust’s Recovery College will also have a key role in supporting the development of an educational package for people who use mental health services and their carers.
All mental health services should: • Learn from what happened • Promote ‘Zero Tolerance’ everywhere • Promote social justice • Uphold rights • Uphold dignity • Show respect • Challenge discrimination
Service user feedback on MSP Group This feedback is taken directly from the service users who are members of the MSP group. They agreed it could be shared with the Trust staff
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It’s been useful. It’s the best co-production I’ve been involved in. Our report shows how co- production can work. Shows that people can work together.
We’ve worked well together.
We disagreed and had conflicts, but we’ve always found a consensus.
I’ve learnt a lot. I’ve been on a steep learning curve. It’s been educational.
Because we’ve been taken seriously, it’s increased my confidence in the mental health system.
I feel the group has made us as service users, be more influential. We’ve all put in a lot of energy, time and commitment. And the group’s work doesn’t end here. The written report is just the beginning.
In the 1:1 meeting it was very hard to deal with the issues. And I was upset remembering what had happened. But it was good to get it off my chest and talk about it.
We’ve dealt with some very sensitive, complex, and confidential matters.
The scope of the conversation was much wider than I expected. Safeguarding is not just about the big issues, it’s the little things too.
It gave me the confidence to go in to a meeting with the Safeguarding Adults Board. I knew where I was coming form. I was comfortable representing the service users’ group knowing the MSP Group was behind me.
I used to say I was talking in the wind, and what I was saying was getting lost. This has been a model of how to work together. The staff should take the praise. Now people want us, as service users, at the table. They wanted us to be there.
There is a bigger message. This is shows how co-production can work. This report gives the evidence that we can work together.
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APPENDICES
Appendix 1 - Quality Accounts In 2011 the Trust had a well-established governance structure to promote and oversee practice improvement and performance in all its Safeguarding Adults work. However, it became evident in 2010/11 that while this has enabled some improvements in practice and performance reporting, it needed to be revised and augmented in order for the Trust to be sure it is delivering its obligations and promoting the safety of people we work with.
To start to address this, a full time Safeguarding Adults lead post was established to work Trust wide on both practice improvement and performance reporting and analysis. The Trust actively sought feedback from service users, carers, families and friends to build on service improvements already made.
To incentivise improvements in both compliance with safeguarding process timescales and to test whether we can gain useful qualitative feedback from service users we used the Quality Accounts in 2012/13 to focus our efforts. The Quality Accounts are annual reports to the public from providers of NHS healthcare about the quality of the services they deliver.
The Safeguarding Adults Quality Account aimed to: • Review services, decide and show areas that are doing well, but also where improvements are required. • Demonstrate what improvements the Trust plans to make • Provide information on the quality of the services provided
In 2012/13 a project group developed a centralised reporting system to record the key issues raised by Safeguarding Adult service users through telephone and face to face at interviews. In 2013/14, additional feedback about people’s experiences of the safeguarding adult process was sought through the distribution of questionnaires.
Sample of service evaluation comments. • Only a minority consciously ‘felt’ or ‘knew’ they (or their family member) were better protected after the safeguarding process. • The language of ‘safeguarding’ was generally experienced as quite alienating and not easy to understand. • Feeling ‘steam-rolled’ into a process by one member of staff. • Not feeling supported to be directly involved - ‘a meeting happened without me. I should have been there’.
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The issues identified in the feedback were in keeping with the guidance on ‘Making Safeguarding Personal’.
In 2014/15, the SAQG used the qualitative feedback from the Quality Account project and considered how this could be used to inform practice. It was agreed that the Safeguarding Adults leadership should be consulting with service users and carers to support self- management and self-protection for service users and families.
Appendix 2 – Terms of Reference
Sutton User Involvement & Partnership Framework This Framework is the product of consultation with individual service users from a range of different settings and circumstances across Sutton. It aims to provide a clear framework upon which all future user involvement and partnership activity will be based and should be seen in the context of developing a unified user involvement and partnership action plan as part of a mental health commissioning strategy for the borough. (Sutton 1 in 4 Network 2014)
Service Users and Carer Involvement Policy The Trust seeks to involve service users and carers and learn from their experiences in how we evaluate, deliver, plan and develop services. We aim to improve service users’ recovery through opportunities to engage in meaningful activities. (SWLSTG NHS Trust 2014)
Making safeguarding personal: A toolkit for responses The objective of this toolkit is to provide a resource that encourages councils and their partners to develop a portfolio of responses they can offer to people who have experienced harm and abuse so that they are empowered and their outcomes are improved. (Local Government Association 2010)
Safeguarding Adults Quality and Compliance Group (SAQG) This group drives and monitors compliance with the Trust’s adult safeguarding policy and procedures and its obligations towards five local Safeguarding Adults Boards.
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Appendix 3 – Human Rights
What rights does the Human Rights Act protect? • The right to life – protects your life, by law. The state is required to investigate suspicious deaths and deaths in custody; • The prohibition of torture and inhuman treatment – you should never be tortured or treated in an inhuman or degrading way, no matter what the situation; • Protection against slavery and forced labour – you should not be treated like a slave or subjected to forced labour; • The right to liberty and freedom – you have the right to be free and the state can only imprison you with very good reason – for example, if you are convicted of a crime; • The right to a fair trial and no punishment without law - you are innocent until proven guilty. If accused of a crime, you have the right to hear the evidence against you, in a court of law; • Respect for privacy and family life and the right to marry – protects against unnecessary surveillance or intrusion into your life. You have the right to marry and raise a family; • Freedom of thought, religion and belief – you can believe what you like and practise your religion or beliefs; • Free speech and peaceful protest – you have a right to speak freely and join with others peacefully, to express your views; • No discrimination – everyone’s rights are equal. You should not be treated unfairly – because, for example, of your gender, race, sexuality, religion or age; • Protection of property, the right to an education and the right to free elections – protects against state interference with your possessions; means that no child can be denied an education and that elections must be free and fair.
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Trust Board Meeting
6 October 2016
Paper Reference: TB(16-17) 104
Report Title: Annual Safeguarding Children Report
Executive Summary: The CQC inspection in March 2016 found that staff across the Trust had a g ood knowledge of safeguarding and this was well managed across the services.
Changes in Leadership and Governance structure will increase accountability and improve effectiveness of service.
Safeguarding Children responsibilities to continue to be highlighted and embedded in all clinical services.
The increased vulnerability of families with parental mental illness to form part of all assessments
Organisational learning from Serious Case Reviews and multi-agency audits to continue to be embedded in governance systems.
Plans for 2016/17 take account of organisational changes within the Trust and in external NHS and Safeguarding Board structures.
Action Required: For noting.
Link to Strategic Safe - Making services safe for service users is Objectives: fundamental to the provision of high-quality health services
Effective – Executive Safeguarding Committee will aim to improve the effectiveness of our safeguarding
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services
Well led - The Executive leadership will develop and implement operational and strategic plans through a quarterly Executive Safeguarding Committee.
Risks: Service user groups include children and adults at risk of abuse and neglect.
Risk of significant harm to service users, carers and others.
Reputational risk when allegations made against staff and organisation.
Quality Impact: Reducing incidents where parental mental illness, Domestic Abuse and substance misuse are primary features.
Resource Implications: Corporate Services Review and Service Line Reporting in progress
Legal/Regulatory This report is based on t he key principles and Implications: guidance detailed in H.M. Government document Working Together to Safeguard Children (March 2013).
Equalities Impact: The Trust Equality Strategy (2014-17) aims to remove or minimize disadvantages suffered by people due to their protected characteristics.
Groups Consulted: Author: Ian Higgins, Named Nurse for Safeguarding Children
Owner: Vanessa Ford – Executive Director of Nursing and Quality.
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Safeguarding Children and Adolescents at Risk Annual Report 2015/16
Document Information This report provides an ann ual overview on the safeguarding children activity and governance within South West London and St George’s Mental Health NHS Trust in 2015/16
Date: 2.09.2016 Current Version: Draft V1.0 Transparency level: Internal Restricted to: Reason: Author: Ian Higgins, Named Nurse for Safeguarding Children Owner: Quality and Safety Assurance Committee (QSAC) Commissioned by: Director of Nursing File location:
Distribution & approvals history
Version Distributed to Date Action required / taken V 1.0 Director of Nursing and Named Doctor 27.09.2016 For review V 1.0 Quality and Safety Assurance Committee 04.10.2016 For review
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Executive Summary
• The CQC inspection in March 2016 found that staff across the Trust had a good knowledge of safeguarding and this was well managed across the services.
• Changes in Service Line reporting and Governance structures will increase accountability and i mprove effectiveness of the safeguarding children and vulnerable families interventions both internally and w ith the multi-agency network.
• Policy, practice and training is aligned with latest statute, guidance and best practices.
• Organisational learning from internal and multi-agency audits, Serious Case Reviews and individual cases is being embedded in governance systems.
• Safeguarding children and vulnerable families is embedded in Trust incident reporting and review of serious incidents, with the Named Nurse sitting on the Serious Incident Governance Group.
• Plans for 2016/17 take account of organisational changes within the Trust and in external NHS and Safeguarding Board structures.
• Areas for development include: re-defining and s trengthening key roles; executive leadership of the Trust Safeguarding Committee; strengthening the knowledge and r esponsiveness of clinical staff; increased contribution to shared multi-agency initiatives and developments.
1. Introduction
1.1 This Annual Report details the work and practice in Safeguarding Children and Adolescents of the South West London & St Georges (SWLSTG) Mental Health Trust between April 2015 and September 2016.
1.2 This report is based on the key principles and g uidance detailed in H.M. Government document Working Together to Safeguard Children (March 2013). The guidance states that effective safeguarding arrangements should be underpinned by two key principles:
• safeguarding is everyone’s responsibility: for services to be e ffective each professional and organisation should play their full part; and
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• a child-centred approach: for services to be effective they should be based on a clear understanding of the needs and views of children.as: “The process of protecting children from abuse or neglect, preventing impairment of their health and development and ensuring that they are growing up i n circumstances consistent with the provision of safe and effective care which is undertaken so as to enable children to have optimum life chances and enter adulthood successfully.”
2. National Guidance
The Children Act (1989) provides the core legislative framework for safeguarding children and is supported by the statutory duty on agencies to cooperate in making arrangements to safeguard and promote the welfare of children under section 11 of the Children Act (2004).
Key legislation, guidance and reports to inform practice are:
• Children Acts 1989 and 2004 • The London Child Protection Procedures (4th Edition, 2010) and other London Safeguarding Board associated guidance • Working Together to Safeguard Children (2013) • The Lampard Review (February 2015). Themes and lessons learnt from the NHS investigations into matters relating to Jimmy Savile • The revised Intercollegiate Document (March 2014) Safeguarding children and young people: roles and competences for health care staff. • Multi-Agency Working and Information Sharing.
3. Training and Development
The Trust provides statutory safeguarding children training at Levels 1, 2 and 3.
All Trust staff receive Level 1 s afeguarding children training as part of mandatory induction. Level 2 training is provided to all clinicians working directly with patients and is an e-learning package. The Trust Level 3 training is aimed at all staff working within CAMHS services and also for Safeguarding Children Leads within teams and borough leads. Child Sexual Exploitation and FGM specific presentations have also been developed for these trainings. There is also specific bespoke training for teams following incidents or SCR’s.
Safeguarding courses are also being developed for Service Users and Carers at the Trust Recovery College to improve access to safeguarding knowledge and understanding.
In addition, training is provided internally by the 5 par tner Local Safeguarding Children Boards to staff who work predominantly with children, young people and parents.
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The Trust percentage training completion as at September 2016:-
• 93% of eligible staff are up to date with Level 1 training • 92% of eligible staff are up to date with Level 2 training • 86% of eligible staff are up to date with Level 3 training
4. Safeguarding Children Supervision (See Appendix 1)
During 2016, the Trust has reviewed and strengthened the clinical supervision policy to ensure regular, consistent and recorded supervision for all clinical staff. Safeguarding children supervision is further embedded within this revised policy supported by access to more specialist supervision from the Trust Named professionals and the CCG Designated Safeguarding Children nurses.
The Trust Named professionals and the CAMHS Modern Matron also provide case supervision, consultation and advice as requested to teams and practitioners. The Trust Named Nurse receives supervision internally from the Director of Nursing and Quality and both Named Professionals also access safeguarding children supervision from a Designated Doctor and Nurse based in one of the CCG’s.
5. Governance
During 2015/16, the Trust’s current safeguarding children arrangements have been reviewed and audited through a number of forums, external audits and LSCB and Trust inspections.
These audits have identified that there is good knowledge and awareness in adult mental health services for the need to include children and adolescents of adults being seen in services as part of assessments, review and risk management. Audits and serious case reviews have also highlighted that there is a need t o further develop this knowledge. This is required to ensure that the ability and awareness of adult mental health patients to protect and support the welfare of children is assessed and reviewed.
Annual LSCB Section 11 Audits These have been completed for each of the 5 LSCBs and have included challenge meetings and follow up reviews. Areas identified for further review and development include:-
• Increased reporting of child safeguarding and welfare concerns form adult mental health services. • Attendance of Trust staff at Child in Need and Child Protection meetings. • Improve links with local schools and colleges with regards to adolescent mental health and well being
6
LSCB Multi‐Agency Audits The Trust contributes to case audits and shared learning linked to specific themes across the 5 LSCB’s, including:-
• Identification of child neglect. • Children who repeatedly go missing. • Looked after Children who have multiple placements and moves. • Identifying the combined risks of Domestic Violence, drug and alcohol misuse and Parental Mental Illness.
CQC Inspection March 2016 The report highlighted that safeguarding procedures were robust and that staff across the Trust had a good knowledge of safeguarding and this was well managed across the services.
Local Authority/Ofsted Inspections The Wandsworth inspection report (February 2016) highlighted:-
• The benefits of the new Access service, delivered through a partnership between SWLSTG and the local authority. This has improved: pathways to services; consistency in the application of thresholds; and waiting times for services. • A dedicated mental health worker appointed to work exclusively with care leavers, starting in January 2016.
6. Policy and Procedure
The Trust Safeguarding Children policy was reviewed, amended and s igned off in April 2015 and has been shared with the 5 LSCB’s
The Trust Clinical Disengagement (DNA) policy was reviewed and amended to include a specific section on potential risks for children when parents do not engage with services or bring children to appointments. This policy was signed off in February 2016.
7. Safeguarding Children Governance Structure (See Appendix 2)
Following the transformation of Trust CAMHS in late 2014, the Trust governance processes for safeguarding children were reviewed. The Clinical leads for safeguarding children are the Consultant Psychiatrists for the 5 CAMHS Community services supported by the CAMHS Team Managers. The Trust Named Doctor and Named Nurse also contribute to various LSCB meetings with a f ocus on Serious Case Reviews and multi-agency audit and learning.
The Trust is represented at the LSCB board meetings and a variety of sub groups of the LSCB. It should be noted that the Trust is unusual in that it relates to 5 safeguarding children boards and all of the numerous sub committees. A piece of
7
focused work is underway to consider how the Trust can work with the chairs of the safeguarding boards to rationalise Trust attendance whilst prioritising the meetings that require Trust contribution and commitment.
The new executive led Safeguarding Children and Adults meeting will report directly to the Trust QSAC
Areas for improved collaborative working have been highlighted by the chairs of the LSCB’s and t he Director of nursing and t he Trust Named Professionals have engaged proactively with the boards in order to establish improved relationships and focus. This will be c losely monitored through the revised executive led Trust Safeguarding Committee (Children and Adults).
8. Serious Case Reviews April 2015- September 2016
This section of the report details by borough completed SCR reports that have been completed and published during the period.
• Sutton - Child E This was a case of a Looked after Child who had significant care and social problems leading self-harm from an early age and s ignificant alcohol and substance misuse. Child E was placed in various out of area placements including secure accommodation. In May 2015 he was discharged from a Specialist Hospital provision to a s upported community home where he tragically died from an accidental drug overdose.
The main finding related to the Trust was regarding commissioning and who is responsible for providing CAMHS services and mental health assessments for a Looked after Child placed out of borough. The Trust has developed an out of area protocol that has been agreed with LSCB’s.
• Richmond - Child H This case has not been published due to concerns regarding the potential impacts on Child H of publication. The child had been seen under local CAMHS and the high standard of interventions was highlighted in the report. The learning was primarily multi-agency in nature and particularly regarding children who go missing and the risk of exploitation. There were no CAMHS specific recommendations and the Trust has contributed to local practitioner multi-agency learning events.
• Kingston - Child B This was a case that did not directly involve Trust services but support for the process was provided by the CAMHS Team Manager. The final SCR report, however, highlighted concerns regarding CAMHS resources nationally and rapid access to services. The Trust through the Named Nurse and Medical Director, raised concerns with the LSCB Chair and the report author as the report could read as raising concerns regarding local CAMHS, which had not been involved in the case.
8
The Trust concerns were acknowledged following a m eeting with the Chair and author.
• Merton - Child C This SCR is ongoing and is due to be concluded by November 2016. Trust learning has been identified with regards to the impacts of parental mental illness and discharge from adult mental health services.
9. Future Plans - Objectives for 2016/17
Action and Resource Objective 2016/17 Timescale Required Further strengthen the Trust Terms of Reference for adult November 2016 safeguarding governance and child safeguarding arrangement with executive aspects revised and agreed. led committee Lines of reporting to be established. To review and revise the New job description to be January 2017 Named Nurse role, ratified and post advertised responsibilities and job following outcome of description. Governance and Service Line review Develop with the 5 LSCBs Meetings with the LSCB February 2017 criteria for attendance and Chairs/deputy. Formulate at contribution to LSCB board Trust Safeguarding and sub committees. Committee.
Review Safeguarding Children Develop with the revised January to April training and delivery and Named Nurse Role and Trust 2017 improve attendance at LSCB Training Group (MAST) led training.
9
Appendix 1
Safeguarding Children Supervision Structure
Trust Named Designated Local Authority Doctor and Trust Professionals Named Nurse
• Safeguarding Children Borough Lead • Level 4 Training and Supervision with Named Nurse for Trust • Contribute to Borough LSCB • Links to Designated Professional
• Identified Safeguarding Lead in Team • Level 3 Intercollegiate Trained • Provide advice, guidance and links to Borough Leads and Other Agencies
• Case Load Review • 1:1 Supervision – Professional, Managerial, Clinical. 4-6 Weekly • Safeguarding Children integrated in Supervision Policy
Safeguarding children embedded in: • CPA’s / Care Plan Reviews / Discharge Summaries / Risk Assessments • Team Supervision / Discussion – MDT Range of Disciplines • Zoning Review – Minimum weekly including Safeguarding Status • Recording of Dependent Children
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Appendix 2 SAFEGUARDING CHILDREN’S STRUCTURE
11
Trust Board Meeting
6 October 2016
Paper Reference: TB (16-17) 105
Report Title: Annual Business Plan Requirements for 2017-19
Executive Summary: The report to the Trust Board provides a summary of the 2- year NHS national planning guidance for 2017-2019, including an overview of the submissions that the Trust is required to make, and timescales.
Action Required: The report is presented to Trust Board for information. Trust Board is asked to consider and approve the proposed internal governance process in support of the required submission and timescales.
Link to Strategic Objectives: Links to all strategic objectives
Risks: Links to all BAF risks
Quality Impact: None identified
Resource Implications: N/A Legal/Regulatory Implications: N/A
Equalities Impact: None identified Groups Consulted: Executive Management Committee
Author: Suzanne Marsello, Director of Strategy and Commercial Development
Owner: Suzanne Marsello, Director of Strategy and Commercial Development
Introduction
Page 1 of 3
The NHS is required to plan for a 2 year period 2017-19, with three core aims: • Implement the Forward View • Restore and maintain financial balance • Deliver core access and quality standards
These are the same as for 2016/17; the nine key “must dos” also remain the same as for 2016/17. A summary of the key points and requirements from the planning guidance is provided for the Trust Board in the accompanying paper.
The key headlines from the planning guidance are: • Funding to shore up NHS deficits will continue to 2019 (although in 2016/17 none of this was made available to mental health trusts) • There will be STP-wide system controls related to both financial control totals and performance • Where contract negotiations cannot be finalised dispute resolution will be straight to the CEOs of NHSE and NHSI • GP services will be required to expand to evenings and weekends • CCGs will be expected to explore merging leadership and governance
What are the Implications for SWLSTG as an Organisation? There are a number of key risks and issues for the Board to note:
Timescales and Board Approval Process Timescales are significantly reduced with all contracts due to be finalised and signed by 23rd December 2016. This will require a significant amount of organisational effort for the next three months. The key milestones are outlined in Slide 4 of the supporting paper. The key dates for submission approval within the organisation are:
Milestone Date Trust Process Provider response to commissioner offers 11th November Part B Board 3rd November EMC 8th November Submission of full draft plans 24th November EMC 15th November FIC 21st November Board review 1st December Submission of final operational plans 23rd December EMC 13th December including signed contracts FIC 19th December
The milestones mean that it is not possible for the Trust Board to consider the final operational plan prior to submission within its existing meeting schedule. It is therefore proposed that the Board considers the full draft submission in its December meeting, and identifies any key areas of concern that need to be resolved prior to final submission on 23rd December. It is proposed that the FIC meeting on 19th December then considers and approves the final submission on behalf of the Board.
Links to SWL Sustainability and Transformation Plan (STP) The guidance clearly sets out the expectation that each organisation will be accountable for delivering both its individual financial control total, and also the overall control total across the STP. (These will be confirmed by 30th September.) It is not clear how this will be enforced across the system, but this represents a significant risk to the organisation due to the financial positon of all acute physical healthcare providers in SWL, as well as a number of CCGs.
Page 2 of 3 The Trust is expected to demonstrate in its detailed activity and workforce submissions how these relate to the STP planning assumptions. However, the SWL STP focus has been on acute physical healthcare and primary care activity changes and so this will be a challenge for the organisation. There will need to be close working with key STP team members to agree how this requirement can best be satisfied.
The planning guidance confirms that the FYFV for Mental Health Implementation Plan is expected to be a core part of the commissioner and provider plans for 2017-19, which represents an opportunity for SWLSTG to ensure that appropriate investment is secured. There has been early discussion at Trust Board that development of community services is the next key priority for the organisation, which fits with both the FYFV and SWL STP priorities.
Trust Business Planning Process Slides 9-13 provide information about the business planning process that will operate and how this will enable key strategic planning requirements to be met.
Action for Trust Board: Trust Board is asked to consider and approve the proposed internal governance process in support of the required operating plan submission and timescales.
Page 3 of 3 NHS Operational Planning Guidance
Suzanne Marsello Director of Strategy and Commercial Development 23rd September 2016 Contents Slide:
Summary 3
Planning Timetable 4
2017-19 Must Dos 5
Mental Health Must Dos 6
Finance and Contracting 7
Core STP Metrics 8
Operating Plan Submission Requirements 9
SWLSTG Business Planning Process 10
Business Planning Development Summary 11
Corporate Strategy Implementation Plans 12
Operating Plan Submission Requirements 13
2 Summary The 2017-19 NHS Operational Planning and Contracting Guidance was issued on 22nd September 2016. This sets out three core aims:
• Implement the Five Year Forward View (FYFV)
• Restore and maintain financial balance
• Deliver core access and quality standards
As expected, a key focus of the guidance is that each STP will have a financial control total that equates to the sum of the individual organisations control totals. All organisations will be accountable for delivering both their individual control total and the overall system control total. It is not clear at present how this will be enforced, but this represents a significant risk for SWLSTG, with all four acute provider organisations and three CCGs in SWL in financial deficit, and both Croydon University Hospital and Croydon CCG in special measures.
There is a specific annex to the Guidance for Mental Health Transformation Planning Requirements: this is a repeat of the key priorities in the FYFV for MH Implementation Plan (summary presented to Trust Board in September 2016). The Guidance clearly states “CCGs should commit to sharing and assuring financial plans with local Healthwatch, mental health providers and local authorities. Details of deliverables and actions are summarised below but areas should make reference to fuller guidance set out in “Implementing the Five Year Forward View for Mental Health””.
The key requirement for contracts to be signed by 23rd December 2016 is going to require significant organisational effort and focus over the next 3 months.
3 Planning Timetable
Milestone Date Trust Approval Process STF guidance issued to providers 30th September
Commissioner allocations, provider control totals and STF 21st October allocations published Submission of STP plans 21st October
Final CCG and specialised services CQUIN scheme guidance 31st October issued Commissioners to issue initial contract offers that form reasonable 4th November basis for negotiations to providers Final NHS Standard Contract published 4th November
Provider response to commissioner offers 11th November Part B Board 3 November EMC 8 November Submission of full draft 2017-19 operational plans by providers 24th November EMC 15 November NB: Templates issued on 1st November FIC 21 November Trust Board 1st December If contract signature deadline 23rd December at risk local decisions 5th December to enter mediation Contract mediation 5th – 23rd December Final national tariff published 20th December
National deadline for signing contracts, submission of final 23rd December EMC 13 December approved operational plans (aligned with contracts) FIC 19 December 4 Urgent and Emergency Care (UEC): The “Must Dos” for 2017-19 • A&E 4 hour standard These remain the same as for 2016/17 • 7 day services • Implement UEC review: 24/7 integrated care STPs: service for physical and mental health by March • Implement the milestones and agreed trajectories 2020 in each STP • Cross-system approach to prepare for waiting time standard for urgent care for those in MH Finance: crisis • Deliver control total (STP wide and as organisation) • Implement STP plans to moderate demand RTT and Elective Care: • Implement demand reduction measures: redesign • 92% seen in 18 weeks for non-emergency urgent & emergency care; support self-care and prevention; progress new care models; MCP; • Deliver patient choice of first OP appointment and medicines optimisation 100% use of e-referrals by April 2018 – in line with CQUIN and payment changes from October 2018 • Provider efficiency measures: pathology and back office rationalisation; procurement and estates transformation plans; improve job planning and Cancer rostering to reduce agency spend and increase • No key deliverables fro mental health clinical productivity; more integrated primary and
community services Mental Health: • See separate slide Primary Care:
• Implement the GP Forward View • Workforce and workload issues: includes further People with Learning Disabilities: expansion of IAPT into GP practices • Deliver Transforming Care partnership plans • Support expansion of MCP/PACS Improve Quality in Organisations: • Implement plans 5
Mental Health Must Dos
These are the priorities outlined in the FYFV for Mental Health Implementation Plan:
• Children and Young People’s Mental Health
• Perinatal Mental Health
• Adult Mental Health: Common Mental Health Problems (IAPT)
• Adult Mental Health: Community, Acute and Crisis Care
• Adult Mental Health: Secure Care Pathway
• Health and Justice
• Suicide Prevention
• Sustaining Transformation: A Healthy NHS Workforce
• Sustaining Transformation: Infrastructure and Hard-Wiring
• Standards and Implementation Support
See the paper presented to Trust Board in September 2016 for more detail.
6 Finance and Contracting CQUINs: Payment: • The full 2.5% will continue to be available to • Efficiency deflator 2% across both years providers • National tariff uplift 2.1% in both years i.e. net 0.1% uplift • 1.5% of this will be linked to delivery of • HEE will not introduce changes to the education and training nationally identified indicators – for mental tariff before April 2019 health these are: • Staff health and wellbeing Sustainability and Transformation Funding (STF): • Crisis liaison • £1.8bn will again be available in 2017/18 • Physical health for people with SMI • Individual providers have been allocated an indicative share • Transition for CYP with MH needs which will be notified on 30th December: in 2016/17 this went • Preventing ill health from risky to acute hospital providers only. behaviours
Contracting Specific Contract Requirements: • Minimal changes to Standard Contract • Letters to GPs following clinical attendance: • Currently 14 days • Resorting to arbitration will be seen as a failure of • 10 days from 1st April 2017 collaboration and good governance. • 7 days from 1st April 2018 • Escalation for arbitration will be straight to the CEOs for • All clinical letters to be electronic with NHSE and NHSI standardised clinical headings by 1st • The 2 year contracts will reflect the 2 year activity, workforce October 2018 and performance assumptions • Mandatory data sharing agreements for • Expected to include how risks have been jointly identified and UEC by April 2017 mitigated • NHS Digital guidance to require daily submission of electronic SUS from April Risk Reserve: 2018 • CCGs to ensure 1% of allocation spent non-recurrently • NHSE will add £200m to this 7 • 0.5% of local CCG CQUIN to be held in risk reserve - £270m Core Baseline STP Metrics Implications for SWLSTG: • The implementation of the FYFV for MH is clearly The proposed metrics against which the whole STP embedded in the annual planning guidance giving it systems will be measured are: high profile for commissioners • Risk from the move to a whole STP system being Finance: held collectively accountable for delivering a financial control total when most organisations in • Performance against system control totals SWL are in deficit position: SWLSTG could be asked to make a higher contribution to CIP delivery/ control Quality: total • Operational performance • Provider plans for finance, activity and workforce • A&E performance have to be consistent with the STP financial plan (to st • RTT performance be submitted on 21 October) : this will be a challenge as the SWL plans have focussed on acute
physical healthcare and primary care with very little Health Outcomes and Care Redesign: detail for mental health. Could be considered an • Progress against cancer taskforce plan opportunity as well as a risk. • Progress against MH FYFV Implementation Plan • If any of the activity, workforce and finance data is • Progress against GP Forward View not correct we are tied into the contract for 2 years • Hospital bed days per 1,000 population at the wrong level - and the reduced timescale means there is less time for quality assurance and • Emergency hospital admissions per 1,000 potentially more opportunity for error population
Mitigation: Direct leadership by Director of Finance and STPs are expected to agree trajectories against these Performance and Director of HR to drive the work that areas for 2017-19 8 will be required from their teams to deliver this
The Operating Plan Submission:
Plans are required to demonstrate:
Area Lead Director
How the nine Must-Dos will be delivered Director of Strategy and Commercial Development
How they will support delivery of the local STP DoSCD
How they intend to reconcile finace with activity and Director of Finance and Performance workforce to deliver their agreed contribution to the relevant STP control total Robust, stretching and deliverable activity plans DoFP which are directly derived from the STP How local independent sector capacity is factored into COO capacity planning and local providers engaged The planned contribution to savings DoFP
How risks have been jointly identified and mitigated DoSCD and DoFP through an agreed contingency plan Impact of new care models, including how contracts DoFP with secondary care providers will be adjusted to take account of the introduction of new commissioning arrangements e.g. for SWLSTG Forensics collaboration, Richmond Outcomes Based Commissioning 9 SWLSTG Business Planning Process
The key business planning meetings have been reconvened: Business Planning Steering Group (BPSG) and Business Planning Forum (BPF).
October – December 2016:
The focus needs to be on delivery of the 23rd December which will be led by the DoFP (activity, finance and workforce – with input from Director of HR); the accompanying narrative re delivery of FYFV and STP priorities will be led by the DoSCD.
The contracting negotiations (including agreeing service developments with commissioners and developing business cases to support these) will be jointly led by the DoFP and COO as for last year.
This work will form the basis of the Board-level corporate objectives for 2017/18
January – March 2016:
The focus will be the development of the 1 year delivery plan for each corporate strategy, led by the relevant lead director; and from this of the Directorate level business plans that will inform the core workload of both the clinical and corporate directorates in 2017-19.
The 1 year delivery plan for each corporate strategy will need to be approved by the relevant Board sub-committee/ EMC before the end of March, in lien with the agreed process.
10
Business Planning Development Process
Trust Strategy Supporting Strategies and Implementation Plans: Strategic - Quality - Clinical Context - Workforce - Commercial - ICT - Estates - Service User Experience - Communications
Clinical Clinical Clinical Clinical Annual Directorate Directorate Directorate Directorate Plans Business Business Business Business Plan Plan Plan Plan
Annual Capacity Plan
Annual Corporate Plans: Supporting delivery of the Divisional business plans Estates Information ICT Finance HR Corporate Office 11 Corporate Nursing Communications Strategy and Commercial Corporate Strategy 1 Year Implementation Plans: Approval Process
Strategy Approval Lead Director
Clinical (servcie developments) Board Medical Director/ COO
Quality QSAC Director of Nursing and Quality Standards
Commercial FIC Director of Strategy and Commercial Development
HR/OD Workforce Director of HR
Estates FIC Director of Finance and Performance
IMT EMC DoFP
Service User Experience/Involvement QSAC DoNQS
Comms and Engagement EMC Director of Communications
Membership EMC DoComms
12 Operational Plan Submission Requirements
• Contract tracker returns: updated and submitted throughout the contracting timetable in accordance with the weekly submission schedule detailed in Annex G (DoFP) • Finance return (DoFP) • Activity return through the Portal (for draft plan and final plan): NHS mental health, community and ambulance trusts do not need to submit activity returns (DoFP to confirm with NHSI) • Workforce return (DoHR) • Triangulation return: detailing the required triangulation checks between finance, activity and workforce plans (DoFP and DoHR) • Review of alignment between financial plan revenue and contract revenue (DoFP) • Operational plan narrative (maximum 16 pages), which should take forward the local health and care system’s STP and outline the provider’s approach to activity, quality, workforce and financial planning for 2017/18 to 2018/19. (DoSCD with input from all directors to relevant sections): • Activity planning: DoFP • Quality planning: DoNQS • Workforce planning: DoHR • Finance: DoFP
NB: finance and workforce templates to be published on 1st November 2016- first draft plans due for submission 24th November
13
Trust Board Meeting
6 October 2016
Paper Reference: TB(16-17) 106
Report Title: Mental Health Law and Associate Hospital Managers’ Annual Report 2015/16
Executive Summary: This Report provides an annual review of the use in the Trust of the Mental Health Act 1983 (amended 2007), Mental Capacity Act and Deprivation of Liberty Safeguards. It summarises the activities of Associate Hospital Managers in 2015/16 and provides assurance to the Board with regard to legal compliance with the Code of Practice and good governance. This is to provide the Trust Board with the assurance it is complying with its statutory requirements under the Mental health Act 1983 and the Mental Capacity Act.
The report highlights that there are 37 Associate Hospital Managers currently acting on behalf of the Board in reviewing detentions under the MHA. They undertook 233 hearings in 2015/16 in addition to 292 mental health tribunals that were held in the Trust during the same period.
The report describes the role and t he activities of the Mental Health Law Governance Group and London -wide forums in which the Trust takes part.
In relation to the use of the MHA, there has been a 7% decrease in the total use of the MHA on the previous year bringing the Trust back to pre-2014 levels of overall detention and a lower number of CTOs. The apparent decrease in the number of new CTOs is observed mainly in Kingston and Richmond, where these numbers had been disproportionately high in the past and indicate a positive trend towards a more appropriate and balanced use of the Act.
There were 26 authorisation requested under the Deprivation of Liberty Safeguards, ten of which were granted.
There is the apparent ongoing overrepresentation of certain black and certain minority ethnic groups in detention, and in the more restrictive and criminal sections of the MHA particularly. In 2015/16, 20% of detained patients across the Trust were black, which is consistent with the previous year.
Detention rates were particularly high for Black African (2.2 times higher than would be expected from the population), black Caribbean (4.2 times higher), other black (6.6 times higher) and other ethnic minority groups (2.1 times higher). There were 10 epi sodes of unlawful detention, one of which, due to its serious nature, was investigated through a R oot Cause Analysis.
The report shows that the Responsible Authority (i.e. the Trust Board) is on any given day responsible for up to 280 detained patients and up to 158 CTOs.
Action Required: For discussion and approval
Link to Strategic Objectives: We will provide consistent, high quality, safe services that represent value for money. We will enable increased hope, control and opportunity for our service users.
Risks: Patients’ rights may be breached with regard to their right of appeal to the Mental Health Tribunal and Associate Hospital Managers.
There may be formal complaints, directions and formal summonses issued by the Tribunal to the Trust professionals, including the CEO and the Medical Director (as was the case in April 2015).
Legal detention papers left unchecked may lead to unlawful detention and unlawful medication as well as law suits against the organisation including claims for compensation. Professionals may not receive reminders and notifications about important legal deadlines such as section expiries and consent to treatment reminders, which may cause the Trust to break the law and, as a consequence, pay out compensation.
Quality Impact: Resource Implications: None
Legal/Regulatory Implications: Potential liability to disadvantaged service users under the MHA.
Equalities Impact: Successfully addressing the issues raised in this report would improve equality in the Trust’s delivery of services.
Groups Consulted: IGG
Author: Tom Lelmezh, MHA Manager
Owner: Dr Emma Whicher, Medical Director Vanessa Ford, Director of Nursing and Quality
South West London and St Georges Mental Health NHS Trust
MENTAL HEALTH LAW AND ASSOCIATE HOSPITAL MANAGERS’ ANNUAL REPORT April 2015 to March 2016
Document information This Report provides an annual review of the Mental Health Act 1983 (amended 2007), related legislation and the activities of Associate Hospital Managers in 2015/16, and to provide assurance to the Board with regard to legal compliance, adherence to the Code of Practice and good governance.
Date: September 2016 Status: Final Report
Transparency Public level: Restricted to: Reason: Annual report Author: Tom Lelmezh, MHA Manager Owners: Vanessa Ford, Director of Nursing and Quality Emma Whicher, Medical Director Commissioned by: QSAC
File location:
Distribution & approvals history
Version Distributed to Date 0.1 IGG Sept 2016 For approval 0.2 QSAC Sept 2016 For approval
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South West London and St Georges Mental Health NHS Trust
1. Introduction
1.1 This report is intended to provide information and assurance to the Board on the use of the Mental Health Act (MHA) within its services. The Trust Board is the detaining Authority and carries ultimate responsibility for the operation of MHA. Although it delegates the vast majority of day-to-day duties to employed officers, it needs a clear line of sight in order to be assured that its patients and service users who are subject to compulsion, are treated lawfully and have their rights upheld. This report includes a summary of all known instances of unlawful detention or treatment within our services.
1.2 The Mental Capacity Act (MCA) is intended to provide wider safeguards for people over the age of 16 who have been assessed as lacking capacity to make specific decisions for themselves. It is used on a daily basis within the Trust in both inpatient and community settings, sometimes alongside the MHA for the treatment of physical conditions. It is a trust requirement that all clinical staff should have a good working knowledge of this legislation appropriate to their professional competencies. The use of MCA powers is now recorded on RiO and, if appropriate, reported through the Mental Health Law Governance Group (MHLGG).
1.3 The Deprivation of Liberty Safeguards (DoLS) are an extension of the MCA and are applicable to people over the age of 18 who have a mental disorder and are assessed as lacking capacity to decide on their care and treatment. DoLS are particularly applicable in our services for people with cognitive impairment or dementia but can occasionally be used in other inpatient settings. This report sets out actions taken one year on from the landmark Cheshire West judgment in the Supreme Court in 2014.
2. Associate Hospital Managers (AHMs):
2.1 This group of community representatives acts on behalf of non-executive directors of the Board. It exists to ensure that where required, patients subject to unrestricted MHA sections have their detention reviewed by a panel of at least three persons who are not trust employees but have authority under the MHA to discharge a detained patient or Community Treatment Order (CTO) patient where three of them agree. These panels can include NEDs but the AHM power of discharge is the only MHA duty that cannot be delegated by the Board to trust employees. The AHM Annual and Quarterly Meetings are chaired by Jean Daintith, NED. The AHM Steering Group is chaired by Kate Allan, Lead AHM, supported by Marion Down as a Vice-Lead.
2.2 There were two quarterly and one annual meeting of AHMs in 2015/16. The meetings were held on 15 April 2015, 15 July 2015 (Annual), and 7 October 2015. Each meeting was followed by a training session in the afternoon. Members were briefed on the developments within the Trust and had talks and training on the following subjects:
• “Feedback from AHM Hearings” by Dr Stephenson and Dr Guest • “Writing-up Skills: focus on AHM Control Forms” led by experienced AHMs • “Transformation Programme Update” by Glynn Dodd
In addition, a number of AHMs, whose appointment was up for a renewal, underwent an individual reflection and appraisal process, which included:
(1) being observed at a hearing, followed by a verbal and written feedback; (2) completing a self-appraisal questionnaire; and
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South West London and St Georges Mental Health NHS Trust
(3) attending an interview with the MHA Manager and the Lead AHMs to assess their performance and knowledge of the MHA Code of Practice.
A written summary of their performance, skills and development needs was sent to each AHM together with a letter of reappointment.
2.3 Throughout the year, AHMs have been undertaking pre-arranged ward visits across the Trust in pairs or small groups. On average, there was one AHM ward visit conducted every month. Such visits are designed primarily to educate AHMs about the services we provide and increase their understanding of service user experience, but AHMs are also asked to share their positive and negative impressions from ward visits in a structured report. AHMs send their feedback to the MHA Manager, who forwards it on to the relevant ward manager or a service director, if appropriate. There are plans to report AHM’s feedback to the Mental Health Law Governance Group and then to IGG on a regular basis to ensure that no issue of concern raised by AHMs goes unaddressed or unanswered.
2.4 Some of the concerns raised by AHMs during the ward visits in 2015-16 included: qualified nurse staffing levels, environmental concerns and some reported delays in discharge arrangements. It has been agreed that these visits are beneficial to the organisation as they provide an opportunity for ordinary members of our local communities to have an insight into inpatient areas and to report candidly. In all their reports, AHMs commented positively on the leadership of the wards visited and the interactions they witnessed between staff and patients. Some AHMs participated in a number of 15 step visits during the year and there are plans to involve them in future visits.
3. AHM Hearings and Tribunals
3.1 There are currently 37 fully-trained Associate Hospital Managers active within the Trust, where they undertook 233 hearings during 2015-16 in total, 113 of which were paper reviews. AHMs made no discharges in 2015/16 compared to 2 discharges in 2014/15 and 7 in 2013/14. Discussion with other London Mental Health Trusts reflect a low level of discharge is characteristic of AHM, where AHM panels appear equally guarded when it comes to exercising their right to discharge patients under section 23 of the MHA, however there is no official benchmarking currently.
3.2 First-tier Tribunals:
3.2.1 Mental Health Tribunals are part of the Health, Education and Social Care Chamber, one of seven chambers of the First-tier Tribunal which settles legal disputes and is structured around particular areas of law. It is an external judicial service responsible for handling applications for the discharge of patients detained in psychiatric hospitals. Tribunals also handle applications to change CTOs and the conditions placed on a ‘conditional discharge’ from hospital.
3.2.2 During the reported period, there were 292 tribunals hearings held at the three main sites resulting in 19 discharges and 5 deferred conditional discharges for restricted patients. These figures do not include numerous cases where the patient was either discharged, transferred or withdrew prior to their hearing.
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South West London and St Georges Mental Health NHS Trust
4. Mental Health Law Governance Group
4.1 Since April 2015, the Mental Health Law Governance Group, established for the purpose of improving our compliance with both MHA and MCA, has reported to IGG instead of QSAC. During the reported period, the membership included the Director of Social Work, Social Work Leads, Medical Director’s representative, Senior Nursing representative, Trust Safeguarding Lead, Lead AHM, Vice-Lead AHM and MHA Manager.
4.2 A number of actions have been underway during 2015/16 such as targeted training for clinical staff on MCA and DoLS for all clinical staff and senior clinicians. An MCA/DoLS e- Learning package was made available to all staff on the Compass training website alongside the existing e-Learning courses on the MHA and the Code of Practice.
4.3 During the reporting period, an extensive MHA/MCA training programme was delivered to clinical staff in all areas of the organisation: in total 577 staff, including consultants, attended training on the Mental Capacity Act and the Deprivation of Liberty Safeguards. In addition, seven training session were provided on the new MHA Code of Practice, which were attended by 127 clinical staff. And there were 7 bespoke training sessions on the MHA/MCA provided to the nursing staff on the wards, which were attended by 37 members of staff. The training programme was complemented by four presentations on the MHA/MCA delivered at the Junior Doctors’ Induction and there was regular MHA/MCA training as part of the bi-monthly Corporate Induction for all new clinical staff.
4.4 The Group supervised the on-going Authorised Officer training aimed at our ward staff. There are currently 187 trained Authorised Officers who can scrutinize and accept section papers on behalf of the Hospital Managers, i.e. the Board. A comprehensive programme of training on the new MHA Code of Practice, which came into force in April 2015, was provided to all relevant staff throughout the year by Ruth Allen and Tom Lelmezh, MHA Manager.
4.5 This Group also oversaw a raft of electronic RiO forms including the Brief and Full Mental Capacity Assessment Forms, Section 17 Leave Form, s.62 and s.64 Forms being developed and implemented. MHLGG received TIAA audit reports and other papers to establish the best practice around recording s.132 rights, consent to treatment and other aspects of MHA practice. The Group has updated the Trust’s MHA Scheme of Delegation, which shows how the duties imposed by statute on the Hospital Managers, i.e. the Board, are delegated within the organisation, bringing it in line with the new Code. The Group also approved a policy and procedure for AHM paper hearings.
4.6 The Group received regular updates on Pharmacy’s audit of compliance with consent to treatment regulations and briefings on CQC ward visits. The annual KP90 Korner returns were submitted to the Department of Health by the Group on behalf of the Trust. In preparation for the CIH Inspection in March 2016, the Group led on a number of initiatives to further minimise the risk of patients being unlawfully detained or unlawfully medicated.
5. Unlawful Detentions during 2015/16 and subsequent actions
5.1 There were 10 episodes of unlawful detention, leading to 1 RCA review:
• In February 2016, it was discovered that a patient had spent 6 months at the Shaftesbury Clinic without statutory authority, having been mistakenly brought back from court to hospital instead of prison to which he had been sentenced.
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• In the other nine cases, sections had to be discharged by the RC due to fundamentally defective section papers.
5.2 All affected patients were properly informed and, where appropriate, apology was offered.
5.3 The MHA Office is actively working to reduce the likelihood of avoidable unlawful detentions while seeking to provide an efficient service for the service users whose treatment is provided within legal frameworks. The MHA Office notifies the Mental Health Law Governance Group of all such incidents and reports back on the action taken and the learning.
5.4 Each episode of unlawful detention is also reported on Ulysses as a formal incident, investigated and used as a learning opportunity to improve our services. The Root Couse Analyses are conducted into more serious incidents of this nature, producing robust action plans and recommendation for learning and embedding best practice.
5.5 For example, the learning from the incident in which the nursing staff had mistakenly brought a patient from court back to hospital after he was sentenced to prison, included follow-up meetings with the Shaftesbury Clinic nursing and admin staff where the errors were discussed and the staff were reminded that all section papers and any relevant court paperwork should be forwarded immediately to the MHA Office after a court hearing. In terms of embedding best practice, a regular MHA training slot has been added to the Ward Mangers’ Monthly meeting. This will allow training and reminders to be provided for clinical staff who are required to care for forensic patients and undertake escorts to and from court to ensure they understand the process for patients/offenders sentenced to prison. The MHA Office now also reports all instances of unlawful or unwarranted detention via the Trust’s Ulysses system.
6. London Mental Health Act Network
6.1 This Network has been in existence since the early 2000s providing opportunities for sharing best practice across London Mental Health Trusts and some of their neighbouring organisations. The Trust has been represented at their quarterly meetings by Kate Allan, Lead AHM, and Tom Lelmezh, MHA Manager.
6.2 The Trust has contributed to the work of this committee in devising standards for Hospital Managers (known as either MHA Managers or Associate Hospital Managers in different organisations) particularly around hearings and are also involved in devising training programmes to assist them in their role.
7. London Mental Health Law Managers’ Group
7.1 This group comprises Heads of Mental Health Law across the 10 London Mental Health Trusts and has authority from the London MH Trust CEOs’ meeting to agree and share actions, protocols and best practice in relation to both MHA/MCA. Their quarterly meetings have taken place immediately after the London MHA Network and have been regularly attended by the MHA Manager.
7.2 The group also shares information about problems with the arrangement of Mental Health Tribunals, the practical administration of the MHA and the use of MCA in their respective settings. During the year we have shared a range of information (including our
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South West London and St Georges Mental Health NHS Trust
policies and locally designed AHM control forms) and collectively sought formal advice from the CQC on some requirements of the Code of Practice.
8. The Use of the MHA during 2015/16
8.1 The Board will wish to note that all uses of the MHA must statutorily be recorded and reported. It is widely acknowledged nationally that where powers are exercised outside the hospital by or with the police (sections 135 & 136) there has historically been significant underreporting due to loss of documentation which may partly explain the reduction during the current reporting period. A number of successful s.136 triage pilots may also account for the number of s.136 admissions decreasing.
8.2 Table 1 below provides information on the use of the MHA at the point of admission and – unlike a KP90 report – includes patients who were already detained, transferred in or out of our Trust. Full statistical breakdown and analysis by borough, gender, ethnicity and other parameters is available in The MHA Performance Report: Annual Summary 2015/16.
Table 1. Detentions under the MHA 1983 by section for the SWLSTG Trust: 2015/16 compared to 2014/15, 2013/14 and 2012/13 Whole Trust - use of MHA up to the last full year 2012/2013 2013/2014 2014/2015 2015/2016 Trends Row Labels S2 S2 711 763 870 832 S3 S3 534 547 616 585 Emergency S4-5 S4 23 19 13 11 S5(2) 234 225 217 229 S5(4) 22 21 14 22 CTOs S17A CTO 267 207 200 118 S17E recall 59 54 37 44 Part III S35 1 7 4 1 S36 0 0 0 2 S37/41 12 13 8 16 S37H 16 18 22 12 S38 5 6 1 6 S42 CD 13 9 10 12 S47 0 1 0 0 S47/49 6 4 4 5 S48 0 0 0 0 S48/49 11 12 12 16 Police S135 14 8 24 24 S136 488 542 653 579 Grand Total 2417 2458 2705 2514 Source: Pulse
8.3 The Comparison of 2015/16 & 2014/15:
8.3.1 Overall, there has been a 7% decrease in the total use of the MHA on the previous year bringing the Trust back to pre-2014 levels of overall detention and a lower number of
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South West London and St Georges Mental Health NHS Trust
CTOs. The apparent decrease in the number of new CTOs (118 compared to 200 in the previous year) is observed mainly in Kingston and Richmond, where these numbers had been disproportionately high in the past and may indicate a positive trend towards a more appropriate and balanced use of the MHA.
8.3.2 According to the Pulse data, there was an 11% increase in the total use of the MHA from 2013/14 to 2014/15. All boroughs, apart from the Richmond borough, saw a decrease in the overall use of the MHA compared to the previous year. In 2015/16, 16% of all detained patients were from out-of-area boroughs. The year before, 18% of all detained patients were from out-of-area boroughs.
8.4 The Snapshot of legal status as at midnight on 31 March 2016: Table 2 shows the status of all our patients including those on leave and those under compulsion in the community under a CTO.
Table 2. Legal Status on 31 March 2016 Male Female Detained 155 125 Informal 57 69 Total in-patients 212 175 CTO patients 119 39 Total All categories 331 233
The table above shows that the Responsible Authority (i.e. the Trust Board) is on any given day responsible for up to 280 detained patients and up to 158 CTOs.
8.5 The Use of CTOs: Table 3 shows the number of CTOs made during the year, the number of recalls to hospital and revocations. There has been a slight increase in the number of recalls and revocations compared to the previous year.
Table 3. Uses of Community Treatment Orders during 2015/16 Male Female New CTO made 78 40 Number of recalls to 28 16 hospital Number of revocations 25 16 Number of discharges 34 from CTO (total)
8.6 The Use of Section 136:
8.6.1 Section 136 gives the Police the power to detain a person appearing to be in need of care and control in a public place to remove them to a place of safety.
8.6.2 During the year, there were 579 recorded uses of section 136 across the Trust. This is an 11% decrease from last year where the power was used on 653 occasions. Several successful Street Triage pilots in the Boroughs may account for the reduction in the number of admission under this section. The chart below shows the outcomes of the section 136 uses.
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South West London and St Georges Mental Health NHS Trust
Section 3 Transferred Already Section 136 Outcomes 2% 1% on CTO 0% Section 2 13% Admitted informally 3% Discharged 81%
8.7 The gender of patients subject to the MHA:
In 2015/16, Trust-wide, 45% of detentions were female patients and 55% were male (cf. 43% female and 57% male in 2014/15), compared to 33% female patients nationally. This may reflect the nature of the beds provided in the Trust. The local proportion of women detained has increased year on year over the last four years while the gender split of the bed base has not significantly changed. This needs to be understood also at Borough/Directorate level as patterns of admissions of men and women vary across each area, and they also vary by month and quarter (as monitored each quarter in the MHLGG).
Table 4. Detention under MHA 1983 by gender: April 2015 – March 2016 120%
100%
80% 32% 52% 45% 50% 55% 60% 54% 57% 55% 60% 77% 81% 75% 75% 100%100% 100%100% Male 40% 68% Female 48% 55% 50% 20% 45% 40% 46% 43% 45% 23% 19% 25% 25% 0%
8.8 The ethnicity of patients subject to the MHA
8.8.1 The available data on different types of detention and use of CTOs by ethnicity is regularly reported to the MHLGG, which explores different ways of understanding the apparent ongoing overrepresentation of certain black and minority ethnic groups in detention, and in the more restrictive and criminal sections of the MHA particularly. Nationally, detention rates were particularly high for Black African (2.2 times higher than
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South West London and St Georges Mental Health NHS Trust
would be expected from the population), black Caribbean (4.2 times higher), other black (6.6 times higher) and other ethnic minority groups (2.1 times higher).
8.8.2 The CQC and other national sources accept that the reasons for differential detention for different ethnic groups is contested and that the reasons do not necessarily lie within secondary mental health services’ practices (i.e. are not necessarily related to discriminatory practices within secondary services, although this is not ruled out) but lie in wider issues of appropriate care pathways and models of support, and access to services, as well as in wider societal factors.
8.9 The 2015/16 ethnicity data:
8.9.1 In 2015/16, 20% of detained patients across the Trust were Black, which is consistent with the previous year. The Wandsworth borough continues to have the highest over representation of Black patients overall and the Sutton borough has the largest over representation of Asian patients.
8.9.2 The Richmond Borough saw a noticeable increase in the number of Black and Asian detained patients compared to the previous year, where there were 3.5 times more Asian and twice as many Black patients in 2015/16 than in 2014/15. In Merton, there was a 43% increase in the number of detained Asian patients. By contrast, Sutton saw a 46% decrease in the number of detained black patients on the previous year. The Kingston and Wandsworth boroughs detained a relatively consistent number of BME patients compared to the year before.
8.9.3 In May 2015, Dr Sean Whyte, presented a detailed report to the Board entitled Equality in the Trust’s service delivery and use of the Mental Health Act. The report analyses the data found through an audit of RiO and MHA Office records from 2009 until March 2015. In response to the recommendations of this report it was agreed at the Equality and Diversity Steering group to share the report with stakeholders for their feedback and develop an action plan around the findings in the report.
Presentations to the BME Mental Health Forum, Healing our Broken Village and Allied Health Manager’s Annual General Meeting provided an opportunity for the Trust to present its findings, plans (in relation to national directives) and engage community stakeholders in the developing action plan. It was acknowledged by the various groups that it will take time to see the changes, however the Trust was commended for raising the awareness and taking action to address the findings.
Table 5. Ethnicities of detained Patients across the Trust: April 2015 – March 2016
Asian Black
Mixed Other
White
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South West London and St Georges Mental Health NHS Trust
Table 6. Number of patients detained under the MHA 1983 by ethnicity: April 2015 – March 2016 compared to 2011 London Census Ethnicity Wandsworth Merton Richmond Kingston Sutton
Under Local Under Local Under Local Under Local Under Local the populat. the populat. the populat. the populat. the populat. MHA MHA MHA MHA MHA
White 54% 71% 56% 64% 84% 85% 78% 74% 83% 77%
Asian 6% 8.5% 14% 15% 3% 5% 9% 14% 13% 5%
Black 38% 9% 27% 10% 2.5 1.5% 8% 2% 7% 3.5% %
Other 5% 2% 5% 1% 9% 1% 6% 2% 3% 1%
Other - 2% 5% 3% 3% 3% 3% 3% 1% 1% 3% Mixed
9. Mental Capacity Act and Deprivation of Liberty Safeguards
9.1 The 2014 Supreme Court ‘Cheshire West’ Judgment continues to focus the attention of all mental health organisations on whether they are now potentially depriving patients of their liberty in mental health wards. As a result of this case, a great deal of effort has been made to train and support staff around MCA and DoLS.
9.2 Significant attention has been paid to the MHA Code of Practice requirements surrounding assessment and documentation of capacity to consent to treatment 3 months into detention. There has been a renewed focus, following criticism on some CQC visits, on the need to consider and document capacity on or shortly after admission to our services for all patients whether informal or detained.
9.3 To address these issues, two electronic forms have been created on RiO to capture mental capacity and best interest assessments. The MHA Office pro-actively monitors the use of these new forms. The staff’s compliance with completing these forms is consistently good.
9.4 Deprivation of Liberty Safeguards: During the reported period, 26 authorisations – urgent and standard simultaneously – were requested by ward staff under MCA/DoLS, of which 1 was refused, 10 granted and the rest cancelled due to discharge from hospital or the patient’s death (in two cases). The following wards made DoLS applications during the year: Crocus, Jasmines, Jupiter, Ward 2, Lilacs, Bluebell and Fuchsias.
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South West London and St Georges Mental Health NHS Trust
10. CCQ Visit Reports
There were 19 CQC MHA-related ward visits made across the Trust in 2015/16. The Trust’s responses were coordinated by the Quality Governance Department. The key concerns which are being addressed across the Trust are:
• Section 132 rights for detained patients, especially representation • Documentation of capacity and need to assess on/shortly after admission • Minimal recording of patients’ views in care plans • Missing Approved MH Professional reports following detention • Staffing and environmental issues
11. Summary of priorities addressed in 2015/16
Summary issue Achievements 1 Mental Capacity MHLGG has reviewed and produced guidance on assessment assessesment forms of capacity prior to informal admission and created electronic on RiO tools for capturing it on RiO.
2 New MHA Code of The Trust has implemented the new MHA Code of Practice by Practice updating its policies, extensive training and embedding best practice throughout the organisation.
3 CIH Inspection MHLGG and the MHA Office worked hard to minimize the risk of unlawful detention and unlawful medication within the organisation by reviewing policies, strengthening existing systems and introducing new ways of working to ensure the Trust’s full compliance with MHA and MCA.
12. Potential Risks
It is important to note that there are inherent risks for the Trust if the Metal Health Act, Mental Capacity Act and other relevant legislation is poorly understood and misapplied by the members of staff. A well trained workforce and an expert MHA Office are key to achieving full compliance in this important area of practice. This is particularly relevant at a time of organisational change and restructure the Trust is going through. The potential risks are as follows:
• Patients’ rights may be breached with regard to their right of appeal to the Mental Health Tribunal and Associate Hospital Managers.
• There may be formal complaints, directions and formal summonses issued by the Tribunal to the Trust professionals, including the CEO and the Medical Director (as was the case in April 2015).
• Legal detention papers left unchecked may lead to unlawful detention and unlawful medication as well as law suits against the organisation including claims for compensation. Professionals may not receive reminders and notifications about important legal deadlines such as section expiries and consent to treatment reminders, which may cause the Trust to break the law and, as a consequence, pay out compensation.
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South West London and St Georges Mental Health NHS Trust
13. Next Steps
As the rest of the country, the Trust is expecting to see major changes in the legal process around the Deprivation of Liberty Safeguards (MCA/DoLS), which will affect our service users who are detained under that legal regime. The Law Commission, whose role is to make recommendations to Parliament about amending various laws, is currently reviewing the entire system of DoLS as set out in the Mental Capacity Act. There are proposals, for instance, to create a role similar to that of the AMHP, who would make decisions with regards to deprivation of liberty under the MCA. These proposals are likely to be published and adopted in 2017.
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