Board of Directors 25 November 2015

www.sussexpartnership.nhs.uk

BOARD OF DIRECTORS MEETING IN PUBLIC

To be held on 25 November 2015 at 10.00 Training Centre, Trust HQ, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP AGENDA

TBP49 /15 INTRODUCTION

1000 TBP49 .1/15 Chair’s Welcome and Introduction Verbal

1000 TBP49 .2/15 Apologies for Absence & Declaration of Interests Verbal

Minutes of the Board of Directors meeting held 28 October 2015 1001 TBP49 .3/15 A & Action Points (not covered on the agenda)

1002 TBP49 .4/15 Questions from Members of the Public Verbal

TBP50 /15 QUALITY & PERFORMANCE

Chief Executive Report 1005 TBP50 .1/15 (Colm Donaghy, Chief Executive) B

1015 TPB50 .2/15 Patient Story video

To receive a report on the last meeting of the Quality Committee C (Gordon Ferns, Non-Executive Director)

1025 TBP50 .3/15 Update on the Quality Improvement Plan and CQC Compliance D Notices Action Plans (Helen Greatorex, Executive Director of Nursing & Quality

To receive the Quality & Performance Report (Sally Flint, Executive Director of Finance & Performance; Helen 1035 TBP50 .4/15 E Greatorex, Executive Director of Nursing & Quality; Managing Directors)

To receive a report on the last meeting of the Finance and F Investment Committee

(Richard Bayley, Non-Executive Director) 1105 TBP50 .5/15 Financial Performance (Sally Flint, Executive Director of Finance & Performance) G

To receive a report on the last meeting of the People Committee H (Diana Marsland, Non-Executive Director) 1115 TBP50 .6/15 To receive the People Report I (Sue Morris, Executive Director of Corporate Services

To receive an update on Safe Staffing 1125 TBP50 .7/15 J (Helen Greatorex, Executive Director of Nursing and Quality)

To receive a report on the last meeting of the Mental Health Act 1130 TBP50 .8/15 Committee K (Caroline Armitage, Chair)

TBP51 /15 GOVERNANCE

Board Assurance Framework 1135 TBP51 .1/15 L (Helen Greatorex, Executive Director of Nursing and Quality)

To receive a report on the last meeting of the Audit Committee 1145 TBP51 .2/15 M (Tim Masters, Non-Executive Director)

1150 TBP52/15 ANY OTHER BUSINESS

Date and Venue for Next Meeting: 27 January 2016 Training Centre, Swandean 85 Arundel Road, Worthing West Sussex, BN13 3EP To adopt the motion:

“That representatives of the press and other members of the public be excluded from the remainder of this meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest ” (Section 1(2) Public Bodies (Admission to Meetings) Act 1960)

NB Those present at the meeting should be aware that their name will be issued in the notes of this meeting which may be released to members of the public on request

Sussex Partnership NHS Foundation Trust Board of Directors: 25 November 2015 - Public Agenda Item TBP49 .3/15 Attachment: A For: Decision By: Rebecca Huth, Corporate Governance Administrator

SUSSEX PARTNERSHIP NHS FOUNDATION TRUST

Minutes of the Board of Directors meeting held in public on Wednesday 28 October 2015 at 13.30 in Meeting Room A, Hellingly Centre, Woodside Annex, The Drive, Hellingly, Hailsham, East Sussex, BN27 4EP

Present: Caroline Armitage, Chair Colm Donaghy, Chief Executive Diana Marsland, Non-Executive Director Tim Masters, Non-Executive Director Sally Flint, Executive Director of Finance and Performance Richard Bayley, Non-Executive Director Dr Tim Ojo, Executive Medical Director Professor Gordon Ferns, Non-Executive Director (arrived at item TBP31.5/15) Simone Button, Interim Managing Director of Specialist Services Sue Morris, Executive Director of Corporate Services Lorraine Reid, Managing Director of Adult Services

In Attendance: Peter Lee, Head of Corporate Governance Sue Esser, People Director Rebecca Huth, Corporate Governance Administrator (minutes)

Observers Neil Waterhouse, SPFT staff member Claire Newman, SPFT staff member Katharine Pearson, SPFT staff member Scott Hunt, SPFT Public Governor Paul Gresham, Member of public

ITEM NO ITEM

TBP44 .1/15 Chair’s Welcome and Introduction

1 Caroline Armitage welcomed all members and attendees to the meeting, adding her delight to being in Hellingly, East Sussex. Caroline wished to especially welcome Scott Hunt, Public Governor of Sussex Partnership.

TBP44 .2/15 Apologies for Absence

2 Caroline Armitage noted apologies from; 3 Helen Greatorex, Executive Director of Nursing and Quality Kay Macdonald, Clinical Academic Director Vincent Badu, Strategic Director of Social Care and Partnerships

Sam Allen, Director of Strategy and Improvement.

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4 Caroline wished to note that Elizabeth Hall, Service User Governor, has attended every Board of Directors meeting as the Council of Governors representative for the last three years since joining the Council. Caroline added that Elizabeth is not

present today due to ill health of her husband, adding that of behalf of the Board we wish them both the best. 5 There were no additional declarations of interest.

TBP44 .3/15 Minutes and Action Points from 30 September 2015

6 Minutes of the Board of Directors held on 30 September 2015 were approved as an accurate record.

7 Peter Lee advised that all Action Points are either complete or are on today’s agenda.

TBP44 .4/15 Questions from members of the public

8 There were no questions from members of the public.

TBP45 .1/15 Eliminating Mixed Sex Accommodation/Maintaining Safety Privacy and Dignity

9 Caroline Armitage introduced this item, noting its importance. 10 Tim Ojo advised that the NHS Framework asks Foundation Trusts to commit to eliminating mixed sex accommodation and to have a same sex accommodation action plan in place, with an impact analysis document. Included in the documents available today, is an overview setting out the commitment for us to eliminate same sex accommodation.

11 Tim Masters queried why, if these regulations have been around for some time, has it taken so long for us to start this work. Tim Ojo advised that we’re not the only Trust in this situation, as the policy and guidance have evolved. We have always

taken into account the dignity of our patients and because we do not have entirely separated wards, it doesn’t mean we don’t take this in to account on our wards. Sue Morris advised that the main issues are around Dementia wards and we need support and to engage with our commissioners. 12 Colm Donaghy advised that this issue was picked up during our CQC Wave Inspection. Colm added that he’s recently spoken with our lead inspector from CQC, who asked to be informed if we will not meet the deadline for any action, especially

those that aren’t completely within our gift to resolve, alone. 13 Richard Bayley advised that he is a bit disappointed with the paper as at the previous Board meeting he asked for the capital expenditure to be included as an

appendix, so when making this policy decision we can clearly see the financial implication, risks and whether it is deliverable. Tim Ojo apologised for this omission and advised that it’s not about the cost of mitigating single sex accommodation. The policy states ‘where possible’ we should eliminate mixed sex accommodation, and if this is not possible, we need a rational as to why. Richard Bayley reinforced his

concern about the risks in relation to resource and sustainability and suggested a need to RAG-rate the mitigation of risk. 14 Caroline Armitage summarised Richard’s comments, stating the point he is trying to make is that the policy needs to be more clearly articulated, however there is a general acceptance that the clinical detail is correct. Caroline added that an additional piece of work is required around the implementation of the policy, although does not stop the Board approving the policy, in principle.

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Decision – the Board approved the policy in principle.

15 Action: Implementation plan of Eliminating Mixed Sex Accommodation Policy to be added to January 2016 Board Agenda, as part of CDS planning.

16 Lorraine Reid advised that she supports Board approval of this policy, and would like to revisit the narrative of the RAG rating. Caroline Armitage advised that the Quality

Committee should review the RAG rating and narrative of the policy and bring an update to the Board in due course. 17 Action: Quality Committee to review the RAG rating and narrative of the policy and update the Board.

TBP46 .1/15 Chief Executives Report

18 Colm Donaghy introduced his report, advising that it is a short update this month. Colm noted updates in the report including the development of our Care Delivery

Services (CDSs) and a CQC update, adding that the CQC will be back next year to re-inspect our services. 19 Colm advised in relation to Monitor’s KPIs for 7 Day Follow-up that we met the target for this month, and we are implementing a 3 Day Follow-up procedure to ensure no more targets are missed, and patients are not waiting more than a week for a follow up after discharge. Colm added that these follow-ups are vital as they have been linked to the reduction of suicides following discharge. 20 Caroline Armitage wished to note the Adult Services Update, as Neil Waterhouse, East Sussex Service Director, who is here with us today, has been nominated for a Sussex Police East Sussex Divisional Award for his efforts and achievements above

and beyond the call of duty.

21 Diana Marsland wished to ask Colm a question which is not in relation to his report today; following the breach of information Talk Talk has recently encountered, what policies or actions do we have in place to avoid this? Sue Morris advised that our Public website has no back system, so no private information is held in any way on the website. Our information is stored on a very secure system, which is approved by Health and Social Care Information Centre; it is one of the highest secured specifications in the world. Sue added that we have our own IT Security Manager who has recently started work on Cyber Awareness. Diana Marsland was content with this answer.

TPB46 .2/15 Patient Story

(video played) 22 Caroline Armitage started off comments by stating her interest of the service user in the video stating that ‘service user’ was more stigmatising than ‘patient’. Tim Ojo added on this shows how easily complaints can be generated by using the wrong

term, and we should agree with individuals what they would like to be called. 23 Caroline Armitage welcomed members of the public in attendance to comment; Scott Hunt, Public Governor for Sussex Partnership, advised that he thought the video was very positive, and noted that the argument over ‘patient’ or ‘service user’

will continue to go on. Another member of the public wished to note the importance of psychological therapies and the great impact it can make to some people. 24 Colm Donaghy was pleased of the perseverance of the individual to continue with her psychological therapy, even though for 2 months she felt that it did not make a difference to her.

25 Caroline Armitage advised that she would be grateful for any ideas from members of Page 3 of 8

the public in ways we can promote the patient voice at Board meetings.

TBP46 .3/15 To receive the Annual Patient Experience Report

26 Tim Ojo introduced this report noting that he would present and take questions on behalf of Vincent Badu, adding that Vincent had asked him to note as a key highlight, that we have done much better than before with Crisis Care.

27 Tim advised that our problems with comparisons between years occur when survey questions change, however we need to increase our scores across the board. Tim added that it’s important to show what we’re doing with the feedback as much as it is

to show why we ask for this feedback.

28 Diana Marsland advised that the report is very useful, however was unsure of the portion of our service users and carers contribute to our survey and feedback, and whether this relates to our 2020 Vision. 29 Lorraine Reid advised that she was a little disappointed with the way the improvement work has been listed. Lorraine added that she’s interested in identifying the highest impact changes that can be put in place, however some areas

had longer lists than others and she was unsure of whether the report really highlights all the work that’s on-going. Lorraine queried whether it would be helpful to establish a reference group of service users for each CDS to review themes of complaints. 30 Tim Masters agreed with Lorraine and finds it difficult to relate this report to the 28% increase in complaints. He feels that the board needs sight on the top few risks identified rather than the general detail provided, to help the board take note of

things that will really make a difference to patient care. 31 Caroline Armitage advised that the message she’s hearing from the Board is that this report includes lots of useful information, but nothing that helps us deliver better care.

32 Colm Donaghy advised that this information includes improvements; however, it would be helpful to see what we’re going to do differently in future.

33 Tim Ojo acknowledged the points made and a need to match what we’ve found and what we’re going to do.

34 Colm Donaghy stated that we need to feature patient experience in our performance reports to measure what we’ve done to ensure we’re engaging with our patients and carers. 35 Sue Morris highlighted that in the Q2 Friends and Family Test, our staff members are less likely to recommend our Trust than our patients are, which is an interesting correlation. 36 Caroline Armitage wished to acknowledge the overall good work being done to engage with patients and carers.

37 Action: Quality Committee to consider this feedback and to review Patient Experience and update the Board accordingly.

TBP46 .4/15 To receive an update on CQC Action Plans

38 Caroline Armitage asked about some of the detail missing from this paper. Lorraine Reid advised that there is much detail that sit behind this and would circulate the full report.

39 Action: Lorraine Reid to circulate the full CQC Action Plan report.

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40 Richard Bayley advised that there appear to be four or five areas that have slipped, looking at appendix 1, and it would be helpful to know what actions there are to

ensure these are delivered. 41 Simone Button advised in relation to the ligature risks at Chalkhill, this work will be completed by November, and she was confident that the rest will be delivered.

42 Caroline Armitage advised that these action plans were agreed in June and have been monitored at an operational level since, however the Board Assurance

Framework is not as rigorous as we would like it to be. Gordon Ferns agreed that the Board Assurance Framework needs to be more rigorous. 43 Colm Donaghy advised that if any actions are slipping, we’ve agreed to share this with the CQC to be open and honest. Colm added that it may be useful to share with

the Board the same areas as the CQC and our plans around the actions. 44 Lorraine Reid advised that training is a significant risk and that’s not clearly identified here.

TBP46 .5/15 To receive the Quality & Performance Report

45 Sally Flint advised that this is the last report in this format. The heat map will also be going into the public domain soon, which shows the RAG ratings across our services.

46 Sally noted the following highlights;

Areas of concern

 Pleased to report that bed pressures have been managed really well with a clinical approach. There has been a fantastic improvement made with ECR’s with only two since the beginning of August. The clinical approach is being moved to delayed transfer of care, where at the moment we have 40 delayed patients. We aim to have no more than 25-30 at one time.

 Temporary staffing is still a large concern and has gained a high interest from Monitor.

Emerging concerns  Sickness rate

 Serious Incidences (SI) – the SI review group are looking at any themes, hotspots and trends throughout the organisation. 47 Gordon Ferns noted that every meeting the vacancy rate and impact on costs of staff are particularly high for some wards, and there seems to be little improvement. Caroline Armitage advised that there are strategic issues around this, not

operational issues, however we need a policy and plan in place to address this. 48 Sue Morris advised that there is a big piece of work Sue Esser is leading on with services to implement new roles which will be piloted in Langley Green Hospital soon. We’re also putting funding in place to support staff and their training. Sue

added that in the last month our turnover has been high, with 77 new starters and approximately 48 staff leaving. 49 Caroline Armitage queried whether it would be helpful to arrange an interview for new starters after 6 months, as most staff tend to leave in the first year. Diana Marsland advised that a large amount of staff that have left, have said they do not feel valued by the trust.

50 Sue Esser advised that there’s much work underway to make progress with this, and reminded members about the paper the board received recently on the workforce

strategy. Sue agreed to prepare an update on this for the Board in January, covering Page 5 of 8

the seven work streams we’re working on with the CDSs.

51 Action: Paper to Board in January updating on the workforce strategy. 52 On a different note, Diana Marsland queried whether themes can be included in the Complaints section of this report. Peter Lee confirmed that this has already been worked on and will be included in next month’s report.

TBP46 .5/15 To receive an update on Safe Staffing

53 Sue Morris provided an update on Helen Greatorex’s behalf, highlighting that looking at fill rates, issues seem to be particularly during the night shifts. Dementia wards are struggling with recruitment.

TBP46 .5/15 To receive the performance against Business Objectives

54 Sally Flint outlined the progress to date on Business Objectives, advising that some need to be reflected in the Board Assurance Framework. The Board asked that the gaps in assurance need to be included in the BAF (coming to Board in November).

55 Action: Gaps in Assurance for business objectives to be reflected in the BAF 56 A discussion was held around Objective 4.2 relating to staff appraisals, which is currently rated red. Sue Morris advised that the next stage of MyLearning is now available online, which makes it much easier for staff to upload their appraisals.

TBP46 .5/15 To receive an update on Sign up to Safety

57 Gordon Ferns queried why mandatory training is receiving such a poor uptake. Diana Marsland advised that we’ve brought in additional trainers to help, however

staff find it difficult to uptake full day training as everyone’s working extremely hard to cover shortages of staff. Sue Morris reiterated that mandatory training is extremely important and is very respectful to our patients.

58 Colm Donaghy advised that although Kay Macdonald is in charge of reviewing training and its implementation, it’s not up to Kay to ensure training is complete. Colm added that we should reiterate this to service leads to the line of accountability is clear. Colm stated that we can provide e-training to improve accessibility.

59 Tim Masters noted that there are two compliance actions from the CQC regarding mandatory training, which need to be completed by November.

TBP46 .6/15 To receive a report on the last meeting of the Finance and Investment Committee

60 Richard Bayley discussed the highlights in the report, including areas of scrutiny and the progress in Adult Services, Community Services and Corporate Services. Richard reiterated to the Board that these challenges are within our control and we

need pace and traction. At the November Finance and Investment Committee, Corporate Services will be looked at in great detail. 61 Colm Donaghy advised that Corporate Services savings are within our control; however we have not been holding all vacancies and this will be subject to greater scrutiny. 62 Sally Flint ran through the best case, mid case and worst case that will be submitted to Monitor.

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TBP46 .6/15 Financial Performance (Quality & Performance Report)

63 No further questions.

TBP46 .7/15 To receive the People Report

64 Diana Marsland advised that good progress has been made with agency staffing and it have decreased in three areas. A new dashboard has been created for the People Committee, which includes staff retention, turnover rate and sickness which

is divided by each Care Delivery Service (CDS). th 65 Sue Morris advised that the NHS Staff Survey is taking place now and as of 26 October 2015 our response rate was 24.5%; our goal is over 50%. We’re working hard to ensure staff understand that their feedback will help to make a difference.

66 Sue Morris added that in relation to Non-Framework agencies, we’re now compliant with 70% of framework agencies and we have submitted exception requests to Monitor for 6 agencies, due to delivery, and we’re waiting on the decision. There have been some framework agencies that are charging more and we are tracking this carefully.

TBP47 .1/15 To agree the Q2 in-year Governance Statement to Monitor / Update on changes to Monitor’s Risk Assessment Framework

67 Peter Lee advised that in previous years we’ve always been confident of a Monitor (finance) rating of 3. This year, Monitor has changed their rating criteria and as a consequence we are at greater risk of not achieving at least a 3. Peter advised that

we will achieve a rating of 3 with our current forecast, and so recommends that the Board confirms this statement. 68 Peter Lee advised that we’re not able to confirm Monitor’s compliance targets due to missing the delayed transfer of care target last quarter and not having confidence for Q3. The return should therefore reflect this and, as set out in the quality and

performance report, explain the steps we are taking to improve DToC. 69 The Board of Directors approved the statement to Monitor, as recommended.

TBP47 .2/15 To receive the quarterly notification of Sealed Documents

70 Peter Lee advised that the report is for information. 71 Sue Morris advised that in relation to the lease for Pepperville House, this is something we’ve been working on for quite some time in order to make necessary environmental improvements there. Sue added that this is a really good achievement made.

TBP47 .3/15 Board Members Action Points following the Council of Governors meeting held on 19 October 2015

72 Caroline Armitage advised that there are four actions on the log which have no updates, and asked Peter Lee to liaise with those appropriate, however noted that

the meeting was only last week. 73 Sally Flint advised that an interesting discussion took place at the meeting regarding our Internal Auditors testing the activity of Occupational Therapies on wards. Sally added that following discussions with our Internal Auditors, they believe this could be a really interesting piece of work and have gone away to come back next week with ideas for this work.

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74 Tim Masters advised that we do need to determine something that is actually measurable.

TBP48 /15 Any Other Business

75 Caroline Armitage closed the meeting at 15:35.

Date and Venue of next Board of Directors Meeting Wednesday 25 November 2015 1000 – 1200 Training Centre, Trust Headquarters, Swandean Arundel Road, Worthing, West Sussex, BN13 3EP

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Sussex Partnership NHS Foundation Trust Board of Directors: 25 November 2015 - Public Agenda Item TBP49 .3/15 Attachment: A For: Decision By: Rebecca Huth, Corporate Governance Administrator

MATTERS ARISING: ACTION POINTS FROM THE BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON 28 OCTOBER 2015

Action Minute Action Points Lead Action Required Date Referen ce 28.10.2015 TBP45 .1/15 Implementation plan of Eliminating Mixed Sex Peter Lee/ Tim Ojo Complete: Added to Accommodation Policy to be added to January 2016 Board forward look

Agenda, as part of CDS planning.

28.10.2015 TBP45 .1/15 Quality Committee to review the RAG rating and narrative of Tim Ojo the policy and update the Board.

28.10.2015 TBP46 .3/15 Quality Committee to consider this feedback and to review Vincent Badu Patient Experience and update the Board accordingly.

28.10.2015 TBP46 .4/15 Lorraine Reid to circulate the full CQC Action Plan report. Lorraine Reid

28.10.2015 TBP46 .5/15 Paper to Board in January updating on the workforce Sue Morris Complete: Added to strategy. forward look

28.10.2015 TBP46 .5/15 Gaps in Assurance for business objectives to be reflected in Helen Greatorex the BAF.

Page 1 of 1 Board of Directors: 25 November 2015 – Public Agenda Item:TBP50.1/15 Attachment: B For information and discussion By: Colm Donaghy, Chief Executive CHIEF EXECUTIVE REPORT 1. Introduction In this month’s report I will highlight a number of areas including:  Delayed Transfers of Care ( DTOCs )  Statutory/Mandatory training  Data Quality and  Social Care  Specialist Services 2. Context Delayed Transfers of Care I am pleased to report that DOTCs are on a downward trend. In October the Trust reported 7.7% against a target of 7.5% and in November so far we are at 6.9%. If this trend continues the Trust should meet the Monitor KPI at the end of this quarter. This reduction has been the result of sustained effort in operational services.

Statutory/Mandatory Training At our last Board meeting we agreed that delivering our 75% compliance rate should be the responsibility of operational services as well as the Trust’s Education and Learning Department. The Executive Team have therefore commissioned plans from each of the Care Delivery Services (CDS) and Corporate Support Services as to how they propose to improve compliance rates to meet the Trust’s 2015/16 target of 75%. Education and Learning will remain responsible for identifying and providing the tools and capacity to enable staff to complete the necessary training. The plans will be shared with the Trust Board at our next meeting in January 2016.

Data Quality Trust commissioners and Monitor have signalled that they will be measuring Trust performance in future through the Mental Health Data Sets on our electronic information systems. Increasingly commissioners are requesting data sets as opposed to information reports, which raises concerns given existing Trust data quality levels. Currently the Trust supplements electronic information with manual validation and update. With the roll out of Care Notes, the Trust’s new electronic patient information system, and the increasing need to have reliable electronic data the Executive Team have commissioned a plan from the Finance and Performance Directorate to meet the required data quality improvements. The plan will be considered by the Service Delivery Board in January 2016.

Social Care Trust Board members will be aware that there has been much national debate about reductions in Local Authority funding the subsequent potential reduction in funding for social care services and its potential impact on the delivery of health services. The Trust will be responding to Local Authority consultation highlighting our concerns where we believe reductions in social care funding will adversely impact service delivery.

Specialist Services Update Neither Hampshire nor Kent and Medway CAMHs are achieving their waiting time target for Page 1 of 2

assessment and treatment. As the Board is aware this is as a result of significant continuing high demand and an on-going lack of capacity to address in both services.

In Hampshire ahead of commencing the new 5 year contract in April 2016 when the service will be implementing a new service model, additional non recurring resource has been made available by commissioners to clear the existing waiting list and reduce waits to 4 weeks for assessment and 18 weeks for treatment by end March 2016. The detailed plan to reduce the waiting lists, which has been agreed with commissioners is to use a combination of new staff (assistant psychologists on 6 month contracts); support from No Limits, a third sector provider concentrating on the Tier 2 work; existing staff working extended hours, and agency staff where required.

In Kent and Medway, the service is working closely with commissioners and have been able to provide assurance that the Trust is utilising all resources to best effect towards achieving the specified waiting times. With the existing funding and continuing high demand, although progress is being made, it is proving challenging to improve that position in all areas. Some additional resource has been promised from one CCG but this is not expected to be released until January 2016.

Crawley Road, our secure rehab unit which has previously been part of the Recovery and Rehabilitation Partnership, a joint venture company we previously ran with Care UK until earlier this year, will come into the Trust formally from 1st December and become part of the Secure and Forensic Service (S&F). We welcome all of those staff who are joining us.

Our Secure and Forensic Service have canvassed staff about renaming their CDS to reflect the breadth of services they provide which include, Secure, Prison Healthcare and Police Court Liaison and Diversion Teams. The name they have chosen is Secure Healthcare and from 1st January 2016 this will be the name their CDS will be known as. 3. Recommendations Board members are invited to note the contents of this report, comment and ask questions.

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Sussex Partnership NHS Foundation Trust Board of Directors: 25 November 2015 - Public Agenda Item: TBP50.3/15 Attachment: C For: Information By: Gordon Ferns Non-Executive Director

QUALITY COMMITTEE SUMMARY REPORT

1.0 EXECUTIVE SUMMARY

The Committee met on Thursday 19 November 2015. Non-Executive Director Gordon Ferns chaired the meeting. Minutes of the meeting will shortly be available to all board members on board pad. The meeting’s agenda is attached to this summary for ease of reference.

2.0 Items for the Board to note:

 Care Quality Commission Action Plan Update Clinical Directors updated the committee on progress on closing the remaining actions. It was noted that the two Performance Contract (all day) meetings in the previous week had considered in detail, progress in relation to the action plans all of which had been shared with local teams. CDSs were clear about the priorities, and of the importance of preparing for re- inspection. A checklist to support preparation had been developed and shared, prompting the user to consider key items including statutory and mandatory training, medicines management, hygiene and cleanliness and ensuring that patients’ views are reflected in care plans. The overarching Trust action plan had been populated in partnership with the Care Delivery Services (CDSs) and the content approved by the Managing Directors and Executive Director of Nursing and Quality. The committee noted that it was to be presented to the public part of the next board meeting.

 Learning From Serious Incidents (SIs) The Trust had held its first annual Learning From SIs event since the last committee meeting, with over two hundred staff drawn from across the Trust in attendance. Work to revise and improve the SI investigation policy and process is nearing completion led by the Executive Medical Director. The time taken to close final reports had improved but the committee was advised that there is still work to do to ensure that every report is completed, closed and shared with Clinical Commissioning Groups on time. Clinical Directors undertook to ensure that systems in their CDS support this aim and the chair tasked them with improving performance and reporting back in February.

 Mitigating Risks to Quality – Cost Improvement Plans The committee agreed that for the forthcoming financial year, each CDS will explicitly capture in its Cost Improvement Plan proposals, any potential risk to quality and the proposed mitigation. These will be shared with the Quality Committee.

 Changes to the Committee The committee chair, Executive Director of Nursing and Quality and Executive Medical Director had started discussions on how the committee’s form and function could be further strengthened. It was agreed that a proposed way forward would be presented to the February meeting.

 Terms of Reference Approved ToR for the Serious Incident Review Group were approved (attached for information)

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AGENDA

Date: 19 November 2015

Time: 1400 - 1630

Duration: 2.5 hours

Subject: Quality Committee

Venue: Main Meeting Room, Mill View Hospital

Chair: Professor Gordon Ferns, Non-Executive Director

1. Welcome, Introductions: Apologies received from: Dr Alison Wallis, Sally Flint, Vincent Badu, Verbal Gordon Ferns 1400 Giles Adams,

2. Declaration of Interests Verbal All 1405

3. Minutes from Quality Committee 7 May 2015 Paper Gordon Ferns

4. Matters Arising 1410

All Action Points from last Quality Committee Paper

QUALITY & EFFECTIVENESS 5 Quality & Patient Safety Report – Q2 Jul - Sept 2015  Safeguarding Adults – revision of reporting mechanisms Paper  Complaints Analysis Emma Wadey 1415  Duty of Candour Performance Update Report  Next of kin data

6. Annual Patient Experience Report Paper Bryan Lynch 1440

7. Data Quality Update Paper Dave West 1445

8 Quality and performance metrics Paper  Data Quality and IG Group update Dave West 1450 9 Clinical Academic Groups Paper Kay Macdonald 1500

10 Clinical Audit Assurance Framework:  Clinical Audit Plan Progress Update by Care Group Verbal CDs 1510  Observation Audit Q1 & Q2

11 Sign up to Safety Q2 Review Paper Helen 1525 Greatorex

2 of 5 12 CQC Compliance Actions Update Paper  CDS Updates CDs  Learning from SIs 1530

 CQC Compliance Action Exceptions

13 Cost Improvement Programme – Mitigating Risks to Quality Discussion All 1545

SAFETY 14 Serious Incidents  Serious Incidents Update 01 – 31 October 2015 Paper  Suicide & Homicide Review Group – Update Tim Ojo 1550  Suicide Rates – National Average

15 Incident Report Briefing  Update on closure of outstanding final SI reports Verbal Emma Wadey 1600 16 SI Review Group Helen Paper  ToR for ratification Greatorex/ Verbal 1605 Emma Wadey  SI Audit Verbal

Terms of Reference Helen 17 Paper 1615 Attached for Review. Greatorex

18 AOB Verbal All 1625

Date, Time & Venue of Next Meeting:

Thursday, 4 February 2016, 19 All 1625 1000 - 1230, Venue: Seminar Room 2, SEC

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Serious Incident Review Group

TERMS OF REFERENCE July 2015

1. Constitution The Serious Incident Review Group is a sub committee of and accountable to the Quality Committee. It will provide assurance to the Quality meeting and receive the work of the new Suicide and Homicide Review Group.

Establishing a quarterly over-arching group, reporting to the Executive Assurance Committee will create a triangulation and monitoring meeting at a high level, which could serve to ensure the required improvements for identifying and applying learning were highlighted and reinforce the new model.

2. Membership

Helen Greatorex, Executive Director of Nursing & Quality (Chair) Vincent Badu, Strategic Director of Social Care & Partnerships Tim Ojo, Executive Medical Director Kay Macdonald, Clinical Academic Director John Rosser, Programme Director Emma Wadey, Director of Nursing Standards & Safety Michael Mergler, Deputy Managing Director, Adult Services Clinical Commissioning Group Quality Lead Programme of invitations to Clinical Directors for specific purposes

3. Quorum At least three members of the group

4. Authority The group is authorised by the Quality Committee to undertake any activity in relation to the review, learning from and improvements as a result of Serious Incidents

5. Duties

Meeting quarterly the group will

 Ensure that there are robust systems in place at every level of the Trust, to identify share and change practice as a result of learning from Serious Incidents and near misses.

 Identify emerging themes, trends and hot spots, taking remedial action to address them

 Consider actions required and to test the sharing of learning across the trust through the commissioning of audit and review processes

 Ensure that the SI policy, process and sign off points work as effectively and efficiently as possible, meeting all required standards and timescales

 Ensure Directorates have in place robust systems to ensure delivery of action plans and audit of compliance on a continuing basis.

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6. Reporting

To the Quality Committee which meets quarterly.

7. Communication

The Minutes of the meeting will be provided to the Quality Committee. Wider communication to be via the Report & Learn Bulletin.

8. Review

Terms of Reference to be reviewed in December 2016.

Date agreed by group/committee.

Date agreed by sponsoring group/committee.

5 of 5

Board of Directors: 25 November 2015 - Public Agenda Item: TBP50.3/15 Attachment: D For Information By: Helen Greatorex, Executive Director of Nursing & Quality

CARE QUALITY COMMISSION COMPLIANCE ACTION UPDATE

SUMMARY & PURPOSE

The Trust continues to ensure that the actions required following the Care Quality Commission’s inspection in January are completed, where possible, by the end of November. The summary (Appendix 1) provides a summary to date, which was reviewed by the Quality Committee on 19 November. The Governance Support Team and Care Delivery Services all hold the detail relating to each specific item and action, these are closely monitored and any variance to plan addressed.

The Executive Assurance Committee (EAC) considered progress at its November meeting and suggested additional steps to seek assurance, including:

 Asking the Director of Nursing Standards to re-inspect the services subject to compliance notices and sharing the outcomes with EAC.  Arranging board visits so that directors cover each service in order to seek assurance that the plans reflect what is happening on the ground and to establish with staff whether any barriers exist that the board can support them with.

Some excellent progress has been made with the Quality Improvement Plan and an update in each of the themes across the five domains is due to be published on our website during the w/c 23 November 2015. The main area to highlight to the Board where there remains concern in meeting the improvement trajectory agreed is statutory and mandatory training compliance. This is being monitored through the People Committee and Care Delivery Services and Corporate Services are establishing alternative plans to meet the target.

The second area to highlight to the Board is the improvement required in our dementia inpatient units in East and West Sussex. The East Sussex plan is progressing well and a full business case will be brought to the Board in Q4 of 2015/16 for approval of funding for the preferred option. A SOC for the West Sussex reconfiguration is in development and the case for change has been shared with Commissioners.

LINK TO OUR 2020 VISION

The provision of Safe, Effective, Quality Patient Care.

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to note the progress to date, the issues arising, and the steps suggested by the Executive Assurance Committee.

CQC Must Do Actions Status Report 19th November 2015

Must Do Status (Red or green) Trust wide Suicide prevention strategy completed

Trust wide Suicide Prevention Action Plan completed Local plans are in place

All staff are in date for Statutory Mandatory Training Trajectory not yet met

Policy and standards are adhered to in all areas for Medicines Management

The trust must comply with standards of hygiene and cleanliness in all Good progress made evidenced by audit. areas.

Trust must meet the Fit and Proper persons test

The trust must improve the recording and analysis of incidents and Incident reporting improved, new governance structures support continued complaints, and how lessons are learnt from this. improvement. The trust and the local service must improve the effectiveness of the CDS transition in progress. links between the corporate and local governance processes.

This is the Trust Wide narrative by CDS.

Must Do Status (Red or green) Trust wide Suicide prevention strategy completed

Trust wide Suicide Prevention Action Plan completed Brighton involved in public health led strategy. Brighton CDS action plan involves working with Grassroots and made an application to become a suicide safer community. East Sussex are developing an action with public health for ratification with CDS Dec 2016. NWSx developing a local suicide prevention plan based on themes and learning from SIs. Coastal has local leads and is working with Emma Wadey to develop local plans. There will be an overarching plan for WSx linked in with local public health lead. All staff are in date for Statutory Mandatory Training See below

Policy and standards are adhered to in all areas for Medicines Green for CDSs Management Brighton confident that policies and standards are being adhered to. In East Sussex this is completed. Completed in NWSx evidence from audit, community pharmacist starting in Jan2016, review of CRHT medication management currently underway. Coastal is confident, ward audits evidence progress. The trust must comply with standards of hygiene and cleanliness in all Brighton – audits show this is much improved. Query management of cleaners areas. should transfer to Matrons. E Sussex is checking performance. NWSx audits show improvement, regular meetings with estates and facilities. Coastal has ongoing difficulties with made worse by the refurbishment at Meadowfield –query transfer of cleaners to Matrons to enable more local control. Estates and facilities are doing a daily walk round with Matron. Trust must meet the Fit and Proper persons test Achieved

The trust must improve the recording and analysis of incidents and Brighton services have SI forum, newsletter to promote learning from incidents, complaints, and how lessons are learnt from this. process for complaints and SIs is less well embedded in the community. Cluster team configuration is helping and community governance team is being recruited to. East Sussex have robust quality and governance arrangements to review all incidents SIs Complaints and positive feedback and triangulate at a CDS and team level. NWSx CDS governance process is in place, governance team have agreed the process for disseminating learning. Benchmarking of incidents across the trust. Coastal – mixed picture on reporting incidents with good reporting in rehab and slow reporting on inpatient wards. The CDS has good governance arrangements in place for learning from SIs and complaints. DLT and local forums are in place and there are regular opportunities to look at learning.

The trust and the local service must improve the effectiveness of the Local BPs are embedded within CDS. Discussions about how CDSs provide links between the corporate and local governance processes. central assurance during the transition to the CDS model. Performance contract meeting oversees performance and quality on a monthly basis, heatmaps have been introduced, CDS accreditation process assesses governance.

Service / Team Specific

Substance Misuse

Ward Must DO Status Dove 1. All staff to have appraisals Will be completed by November 2015

2. All staff to be compliant with Statutory mandatory training Plans in place but team not likely to be compliant before end of November 2015. 3. All staff to have been on Induction

4. All staff to have regular supervision

5. Evidence Resuscitation equipment has been checked

6. All staff know how to check Resuscitation equipment

7. Accessible Ligature cutters

Wards for Older people

All Older Must Do Status people wards 1. All ligature risks have been identified as part of the annual ligature Brighton is double checking everything is in date ‐ audit. East Sussex ‐ St Gabriel ligature audit has been put on hold due to pending move. Beechwood completed

NWSx – Green on Opal ward.

Coastal ‐ Green 2. Staff know how to manage identified ligature risks Brighton is double checking East Sx St Gabriel staff are aware of risks and this is identified in risk assessments and level of observation – St Gabs is closing Beechwood completed NWSx and Coastal – are green

3. Mandatory training completed Brighton ‐Each service has an action plan and booked time, a trajectory of improvement has been developed. East Sussex ‐All staff have booked or have been allocated e learning time to complete, some training has not been completed due to lack of training days such as immediate life support.

ILS also a problem at Beechwood; Also gaps in on‐line training; Discussed at staff’s last performance management supervision‐ for review this month as staff now have admin time allocated for notes and for training purposes New recruits have had problems accessing 5 day PMVA due to cancellations, as have contracted staff with 3 day updates

NWSx have action plans and trajectories.

Coastal – all teams have plans around mandatory training and local training on risk has been provided in relation to SI training. Bite size skills based training has been introduced (non mandatory training)

Accessibility to ILS and PMVA is problematic.

4. All staff have completed DOLs and MCA training Starts in December 2015 Planned in with mandatory training in all areas. 5. Ensure staff now how to complete Mental capacity assessments Starts in December 2015 Planned in with mandatory training in all areas. Some training around MCA was provided in the summer (Ellen Lim) 6. All staff have had an appraisal Brighton – plan and trajectory in place East Sussex ‐ Grid in managers office to evidence this, trained staff can identify regular supervision; less regular for untrained staff; reminders made frequently in trained nurses supervision; supervision tree to be revisited due to changes in staff and supervisors to try and promote this. NWSx plan in place monitoring through My Learning. Coastal – all teams report that they are on target.

7. All staff have regular supervision Brighton – plan and trajectory in place NWSx – community teams have good uptake and compliance, audit planned. Acute have actions which is being monitored closely – temporary staff is the challenge, permanent staff are compliant. Coastal – every team has supervision tree and audit is in place to evidence that supervision is taking place. 8. All informal patients are aware of their rights Brighton, East Sussex NWSx, Coastal self assess as Green ‐ evidenced by CQC MHA visits and local audit – green

9. Wards are compliant with DOH Gender Separation requirement s Brighton ‐ Brunswick is not currently compliant, needs convert the cinema room to a female only lounge, staff need greater awareness of how the risk can be managed through greater scrutiny and care planning. The issue is access to the bathrooms. Brunswick rooms do not include showers. East Sussex ‐ St Gabriel plan to relocate Beechwood ‐ Compliant with trustwide policy –but amber because there is mitigation in place. NWSx is compliant and rooms are self contained, staff are better aware. Coastal has issues with HK and Burrows both are technically compliant with mitigations in place therefore the rating is Amber. Meadowfield – In Maple compliance has not been consistent and ward staff are being supported to improve their adherence to policy 10. All wards practice Safe medicines management Brighton – amber, work continues East Sussex – self assess Green, Trained staff wear a red tabard which says do not disturb when doing medication , this has decreased the number of drug errors, all trained staff are up to date with meds management Trial of red apron has been extended to Beechwood Staff are encouraged use clinic room as this is a quiet space, medication is easily accessible. NWSx regularly audit, some administration errors, self assess ‐ Amber Coastal self assess ‐ green 11. That wards do not routinely prescribe medications on admission No evidence of this in Brighton, NWSx or East Sussex. Resolved at Meadowfield. 12. Patients have a safe opportunity to be off ward AWOL safety collaborative is addressing this in Brighton. Changes made in East Sussex to enable garden access, St Gabs is closing. NWSx – green, access to café and gardens. Coastal – green. At HK supervision is required in the garden area.

Community Based Mental Health Services for Older Age Adults

No Must dos were identified for this service

Learning Disability Services Inpatient.

Area Must Do Status Seldon 1. Remove Blanket restrictions

2. Address gender segregation fully

3. Ensure segregation room is fit for purpose

4. Ensure correct paperwork for completion of capacity paperwork 5. Capacity assessments must be completed which are time and choice specific.

Community Mental health services for people with Learning Disability or Autism

No Must dos were identified for this service Long Stay Rehab

Area Must Do Status Rutland Gardens 1. Ensure good standards of Cleanliness and Hygiene Infection Control Audit 99%

2. Care plans must be person cantered and reflect person’s CQC commented on marked improvement current needs Amberstone 3. All staff must complete Stat man training, including 95% staff basic/intermediate life supports, DOLS, medicines Plans in place but team not likely to be compliant before end of management November 2015. Hanover 4. All staff must complete the required statutory and Closed Crescent mandatory training including: risk assessment, PMVA breakaway training, basic or intermediate life support, Mental Health Act and Mental Capacity Act/Deprivation of Liberty Safeguards. All trained nurses must complete medicines management training. 5. Ensure good standards of Cleanliness and Hygiene Closed

6. Individual risk assessments must be comprehensive and Closed reflect shared input from the individual, the referrer and staff. 7. The service needs clarity and a clear sense of operational Closed purpose and recommendations, to make sure that it can safely meet the needs of people. There are serious concerns about the safety and suitability of the building, risk assessment processes and current staffing arrangements.

Mental health Crisis Services and Places of Safety

No Must Dos identified for this service

Community Based Mental Health Services for Working Age adults

No Must Dos were identified for this Service

Acute wards for Working Age Adults and Psychiatric Intensive Care Wards

Team Must Do Status All wards 1. Ensure medicine management is always conducted in All report compliance accordance with the trust’s policies or best practice guidance. 2. Ensure all wards comply with the Department of Health gender All areas are technically compliant – separation requirements.  All mixed wards have in place mitigation plans written by Matrons.  Strategy endorsed by the board.

Meadowfield 3. Ensure ward staff have received supervision, appraisals or Resolved undertaken reflective practice in line with the trust’s policy. Maple 4. Ensure patients are not routinely prescribed intra‐muscular Resolved injections on admission to be given when required regardless of their individual needs or presentation. Oaklands 5. Ensure patients’ prescription only drugs are held securely Resolved 6. Ensure ward staff have received supervision, appraisals or Supervision is monitored through records on each ward and undertaken reflective practice in line with the trust’s policy audited. Includes introduction of reflective practice for staff ‐ green. 7. Ensure patients, who are not detained, are not prevented from All compliant ‐ Signs on all doors are in place (as per policy) and leaving the ward staff are regularly re advised on policy. Langley Green 8. The service must improve the recording and analysis of Governance processes are tighter and all actions following from Hospital incidents and complaints, and how lessons are learnt from this. the CQC recommendations are completed. Amber/ Green?

Child and Adolescent Mental Health Wards

Area Must Do Status Chalkhill 1. Ensure there is adequate Qualified Nursing cover at all times on the unit. 2. Ensure appropriate action has been taken to mitigate risk of ligatures. 3. Ensure staff have received physical health training. Planned for December 2015

4. Ensure staff have completed their Stat Mandatory training. Underway and planned to complete Dec 15

Community Based Mental health Services for Child and Adolescents.

Area Must Do Status All Areas 1. Staffing levels did not ensure that young people in need of Demand and capacity work in place in all 3 services – CAMHS received a timely service for their needs, which discussions with commissioners through transformation could put young people at risk. planning and provision of Tier 1&2 services to reduce inappropriate demand on Tier 3 underway 2. The waiting times for assessment and treatment across all As above the CAMHS services were significantly high which meant Co‐designed information for families produced that young people did not receive a timely service and could be at risk of harm to themselves or others. 3. The risks to young people on the waiting list were not always monitored, which put young people at risk of harm to themselves or others. 4. The assessments of young people did not include a developmental history, which meant that important information was not routinely captured and assessed. 5. The physical health of young people receiving psychotropic medications was not always monitored. 6. Staff did not always receive regular mandatory training Plans in place but team not likely to be compliant before end of updates. November 2015. 7. Risk assessments were not always up‐to‐date. They were not easily accessible to staff due to a transition between paper and electronic records.

Forensic Inpatient/ Secure Services

No Must dos were identified for this service

Board of Directors: 25 November 2015 - Public Aggenda Item: TBP50.4/15 Attachment: E For Information By: Sally Flint, Executive Director of Finance & Performance Specialist Services section, Simone Button, Managing Director Specialist Services Adult Service Section, Lorraine Reid, Managing Director Adult Services

Trust Quality and Performance Report – October 2015

SUMMARY & PURPOSE

The Trust Performance report, attached, provides a summary of Trust performance against an agreed set of performance indicators related to Quality, People, Finance, and those set by Monitor and CCG Commissioners. The Executive Summary, at the front of the report highlights the current key risks and emerging issues.

The Trust Board is asked to:  Review the performance of the organisation as reported.

LINK TO ANNUAL PLAN

The Annual Plan areas this paper relates to –

1. Quality and Experience of patients 2. Finance Information and Performance 3. People

ACTION REQUIRED BY BOARD MEMBERS

The Trust Board is asked to:  Review the performance of the organisation as reported and consider / test the actions in place to address the concerns raised.

1.0 Introduction

The Trust Performance report is attached to this paper. This report is published in one revised format this month, which is laid out as follows.

1. A Trust-wide heat map at the front of the report, which details the performance of each Care Delivery Unit against the key quality and performance indicators. The heat map describes the rolling quarter’s performance against the key indicators at a glance. The key to the left of the heat map describes which CQC domain the indicator relates to and whether targets have been set whether they are local, national or Monitor targets. The heat map shows a financial rating and quality rating for each area. Please note that the quality rating calculated based on the performance against the key non finance indicators in the list. The appropriateness of the algorithm used for each Care Delivery Unit is in development and hence the rating should be taken as draft at this stage.

2. The Trust wide section details the key areas of achievement, key issues, and emerging issues impacting on the Trusts performance. This section also covers any Trust wide issues which are not covered in the Adult and Specialist sections of the report.

3. Adult and Specialist performance is described in the following sections of the report. Narrative within these reports is organised around the Care Quality Commission domains of Responsive, Well lead, Safety and Caring.

2.0 Report

The Trust has achieved the following indicators at the end of October 2015/16: Care Programme Approach reviews in the last 12 months, 7 day follow ups, Early Intervention new cases of psychosis, Gate-keeping of Inpatient Admissions, Access to Healthcare for people with a Learning Disability, Mental Health Minimum Dataset (completeness) and Mental Health Minimum Dataset (Outcomes).

The Trust has not achieved the Delayed Transfers of Care indicator in October; however progress is being made, and is reporting 7.7% against the target of 7.5%. Adult services are reporting 9.4% delays. 41 patients were delayed at the end of October.

3.0 Recommendation/Action Required

The Trust Board is asked to:

Review the performance of the organisation as reported and consider / test the actions in place to address the concerns raised.

4.0 Next Steps

The performance of the organisation is reviewed each month in Adult and Specialist Services performance contact meetings, which review key areas of Finance, Performance, quality and people issues.

Performance Dashboard

October 2015

www.sussexpartnership.nhs.uk Sussex Partnership Domain Heat Map October 2015 August ‐ October 2015

CDS

CDS TOTAL

PERIOD

Pathways

Sussex &

TOTAL Sussex

CDS

SERVICES Hove

CDS INDICATOR Forensic Care & Disabilities

Care CDS

West

& SERVICES TOTAL

West

Sussex YTD) TOTAL

REPORTING =

Wellbeing Primary ADULT Complex CAMHS Total SPECIALIST TOTAL CDS Learning CDS East Brighton CDS North Coastal Secure TRUST QUALITY RATING SCORE 9117607 52337 9 quarter;

(Q FINANCE RISK RATING INDICATOR 2a 1 2b 2a 4 3 4 4 4 Waiting times: 28 days to routine

KPI Q 97.7% 94.3% 91.3% 98.3% n/a 96.7% 60.2% 61.0% 87.0% n/a 62.0% 80.1% assessment

Delayed Transfers of Care Q 15.8% 10.4% 18.1% 2.0% n/a 11.0% 1.8% n/a 5.5% 0.8% 1.1% 8.9% MON RESPONSIVE ‐ Gatekeeping of Admissions to Inpatient Q 99.4% 98.8% 100% 100% n/a 99.7% n/a n/a n/a n/a n/a 99.7% MON Units

EFFICIENT ECRs: External Bed Days Purchased Q 21 35 12 26 n/a 94 0 n/a 000 94 INFO

Sickness Absence Rate (a month in

KPI Q 5.6% 5.9% 3.7% 5.2% 2.2% 4.8% 2.6% 1.4% 3.2% 6.5% 3.5% 4.1% arrears) LED

Temporary Costs as Proportion of

KPI Q 14% 21% 13% 15% 2% 15% 10% 2% 13% 14% 11% 13%

WELL Paybill ‐

KPI Agency Costs as Proportion of Paybill Q 5% 13% 5% 4% 0% 6% 7% 0% 5% 2% 6% 6% MONEY

FOR

KPI Performance YTD against I&E Budget Y 1% 18% 9% 3% ‐329% 5% ‐3% ‐13% ‐4% ‐2% ‐3% 1% VALUE 15% 0% 19% 11% n/a 11% 59% 82% 49% 86% 67% 36% KPI CIP YTD Actual against Plan Y

7 Day Follow‐Ups Q 94.9% 89.3% 95.4% 96.4% n/a 94.8% n/a n/a n/a n/a n/a 94.8% MON

Serious Incidents reported in period: Q 7541102780031138 INFO

SAFETY Level 1 ‐ Serious Incidents reported in period: Q 654702210023 25 INFO Level 2 & 3 QUALITY Serious Incidents Reports completed Q 40% 29% 64% 69% 0% 54% 64% n/a 0% 67% 58% 55% INFO and submitted within 60 working days *

Friends & Family Test ‐ Patient Q 89% 85% 84% 91% 95% 89% 83% 86% 75% 77% 82% 86% INFO Experience

CPA reviews in 12 months Y 95.4% 95.4% 97.9% 95.5% 100% 96.1% 94.7% n/a n/a n/a 94.7% 95.9% MON CARING ‐

KPI Payment by Results Re‐assessments Y 83.2% 62.9% 82.3% 85.0% n/a 81.0% 76.2% n/a n/a n/a 76.2% 80.9%

QUALITY Complaints Received in month Q 35 29 22 37 1 124 53 1 9 7 71 197 INFO

Complaints responded to in agreed

KPI Q 83.3% 77.8% 86.4% 90.3% 100% 85.7% 85.7% n/a 83.3% 100% 86.7% 85.6% timeframe

Data Completeness: MHLDDS Identifiers Q 99.8% 99.7% 99.5% 99.8% 100% 99.8% 99.5% 99.8% 99.9% 98.7% 99.6% 99.7% MON QUALITY

Data Completeness: MHLDDS Outcomes Q 92.1% 92.4% 94.8% 93.7% n/a 93.2% 90.6% n/a n/a n/a 90.6% 93.0% MON DATA

* SIs received since April 2015 must be investigated and a report submitted to the Commissioners within 60 working days of the incident. This timeframe does not necessarily coincide with SIs received in the current time period and may reflect ones reported earlier. October 2015 Sussex Partnership

Trust-wide Performance NHS Foundation Trust

TRUST WIDE - KEY ACHIEVEMENTS IN THE MONTH

The number of external contractual placements in the month has reduced significantly with none being reported in September and 2 bed nights in October.

TRUST WIDE - AREAS OF CONCERN

Temporary staff costs as a proportion of pay: Temporary staff costs accounted for 12.97% of the pay bill in October. Of this, agency costs accounted for 6.2% of the pay bill. NHS Employers have suggested that temporary staff spend should be less than 11% and agency spend less than 2 to 3% of the total pay bill.

The Cost Improvement Plan achieved at Month 7 (year to date) was £2,463k against a target of £6,846k, and is therefore reporting a shortfall of £4,383k.

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

Year to Date at Month 7 Total Target £k Actual £k Variance £k

Corporate 109 59 -50 Estates and Site Rationalisation 536 516 -20

Strategic Pay 1,365 329 -1,036

Operational Services 4,580 1,559 -3,020 Procurement and Non Pay 256 - -256

Total 6,846 2,463 -4,383

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

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

Finance, Financial performance: October has resulted in a deficit of £54K, against a break even target. The year to date variance is £940k. The main underlying issues continue to relate to the shortfall of cost improvement targets within pay and non-pay, overspending inpatient wards, and high agency usage. There were minimal levels of ECR usage in the month, for the second month in a row. The value of non-recurrent savings at the end of October is £3,463k, which has increased by £454k in the month.

October 2015 1 Trust-wide Performance October 2015 Sussex Partnership

Trust-wide Performance NHS Foundation Trust

TRUSTWIDE - EMERGING ISSUES

Patient Experience, Complaints: In October 87% of complaints were responded to within the Trust’s target of 25 working days or other mutually agreed timeframe.

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

People, Sickness Absence: The Trust sickness absence rates are 4.2% compared to 3.9% for the same period last year against a target of 3.5%

In response to an increase in sickness absence, and in line with our strategy to empower local services, HR advisors are working pro-collaboratively with Care Delivery Services (CDS) to improve attendance. This continues the actions reported in prior months.

Serious Incidents: All Serious Incidents (SIs) are reviewed by the Trust in accordance with the severity of the incident. Level 1 reviews relate to moderate harm, Level 2 incidents relate to serious harm which involves a death. Level 3 incidents involve a homicide event. Final SI reports should be shared with Commissioners within 60 working days of the SI being reported.

Analysis of trends, themes and hotspots as well as benchmarking of the number SIs is carried out by the Director of Nursing Standards and Safety. Information regarding SIs is also presented to each locality divisional leadership team to ensure that data is triangulated with other performance information to identify and act on any emerging areas of concern. The outliers identified are given further review by each operational area in partnership with the Director of Nursing Standards and Safety.

A significant number of Serious Incidents related to Information Governance Issues has been noticed in CAMHS services over the past 6 months. ( 5 in June, 1 in July and 2 in August and 2 in September, none in October). These have been reviewed in detail by the service and an action plan has been developed to ensure lessons are learnt.

October 2015 2 Trust-wide Performance

Adult Services

Performance Dashboard

October 2015

www.sussexpartnership.nhs.uk Sussex Partnership October 2015 Adult Services Dashboard NHS Foundation Trust

Page RESPONSIVE

Routine Assessments within 4 weeks of referral - target 95% CONTRACTUAL TARGET 1

IAPT Waiting Times to treatment - target 75% in 6 weeks 95% in 18 weeks MONITOR TARGET 1

Delayed Transfers of Care - Timely discharge of patients - less than 7.5% MONITOR TARGET 1

Crisis Team Gate-keeping - Avoiding unnecessary admissions - target 95% MONITOR TARGET 1

Extra Contractual Referrals (ECRs) No Target 2

Responsive narrative 2 WELL LED

Sickness absence - 3.5% or less TRUST-ONLY TARGET 4

Temporary and Agency costs - 11% or less TRUST-ONLY TARGET 4

Income/Expenditure performance against budget TRUST-ONLY TARGET 4

Cost Improvement Plan (CIP) performance against target TRUST-ONLY TARGET 4

Well led narrative 5 SAFETY

7 Day Follow-up - Acute inpatient discharges followed up <7 Days - 95% threshold MONITOR TARGET 6

Serious Incidents - Reporting on and demonstrating learning No Target 6

Safety narrative 6 CARING

Reporting Patient Experience Feedback - Friends and Family Test No Target 7

CPA Patients having a Formal Review at least every 12 months - target 95% MONITOR TARGET 7

PbR - Reassessment frequency in accordance with patient needs - target 95% TRUST-ONLY TARGET 7

Complaints resolved within 25 working days - target 85% CONTRACTUAL TARGET 8

Caring narrative 8

performance meets or exceeds target

performance is within 10% of target

performance is 10% or more below target

October 2015 2 Index October 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

4 week waiting time to assessment 100% Adult Services (Local indicator) 95% Month: October 2015 Target: 95% 90% Month YTD 85% Number of Assessments 973 6,448 % assessments <4 Weeks 95.6% 95.6% 80%

Average Wait Days 16.6 16.5 75% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Indicator covers AMHS (exc MAS). % assessments <4 weeks Target Average Wait Days = average wait time from receipt of Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 referral to assessment. ADULT 96.6% 96.8% 97.7% 97.1% 96.9% 98.4% 94.5% 93.8% 93.0% 97.6% 97.6% 96.9% 95.6% TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

IAPT Waiting Time to Treatment 100.0% Adult Service (New MONITOR Indicator) 80.0%

Month: October 2015 60.0% Month Quarter Target % treated in 6 weeks 59.0% 59.0% 75.0% 40.0%

% treated in 18 weeks 95.0% 95.0% 95.0% 20.0%

0.0% New MONITOR indicator to be reported from Q3. % treated in 6 weeks % treated in 18 weeks % treated Target treated in 6 weeks Target treated in 18 weeks

Responsive

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

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

% Delayed (Adult) 9.8% 9.8% 11.2% 5% % Delayed (TRUST) 7.9% 7.9% 9.3%

0% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Non-acute adult patients aged 18 and over from AMHS % delays Target (inc Dementia). Reported to MONITOR quarterly. TRUST Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 figure (for MONITOR) includes numbers from S&F. ADULT 5.3% 4.4% 4.4% 5.0% 10.0% 11.5% 12.6% 11.3% 11.7% 10.6% 12.1% 10.9% 9.8% TARGET 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5%

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

95% Month: October 2015 Target: 95%

Month Quarter YTD 90% No. of Admissions 193 193 1,340 85% No. Gate-kept 191 191 1,335

% Gate-kept 99.0% 99.0% 99.6% 80% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15

% gatekept Target

AMHS patients under 65 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 TRUST 100.0% 98.9% 100.0% 100.0% 100.0% 99.5% 99.4% 100.0% 99.0% 100.0% 100.0% 100.0% 99.0% TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

October 2015 1 Adult Services October 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

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

350 Month: October 2015 300

Month YTD 250

Number of Bed Nights 2 1,388 200

150

100 Extra Contractual Referrals (ECRs) relate to Trust patients who are receiving care in inpatient units outside of the Trust. These 50 0 referrals are made in situations where the Trust has no available Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

beds to accommodate new patients. ECRs

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 ADULT 239 250 414 391 92 0 2 00000

Waiting times for assessment in 4 weeks: 95.6% of patients were assessed within 4 weeks in Sussex. 92.9% of patients in Brighton & Hove were assessed in this timeframe. The division has an action plan in place to improve this performance which is regularly reviewed with the Brighton & Hove Clinical Commis- sioning Group. The performance is under target in Crawley (90.2%), a plan is in place and has been agreed with Commissioners.

IAPT Waiting times, Monitor Indicator: By March 2016, 75% of people referred to the IAPT programme should begin treatment within 6 weeks of referral, and 95% should begin treatment within 18 weeks of referral. The Trust is required to report against this indicator to Monitor from Q3 this year.

Responsive In October, 59% of patients met the 6 week target from referral to treatment and 95% of patients were treated in 18 weeks.

This is a key target for CCGs as well as a Monitor target for the Trust. As a consequence, the Primary Men- tal Health Care Delivery Unit has been working closely with East Sussex CCGs to identify the resources that would be required to meet the standard by the end of the financial year. The estimated cost to achieve this was £800k. The CCGs identified funding of £417k and wrote a bid to NHSE for the remaining amount from a central national fund that was not successful.

As a consequence, the CCGs have reached a decision that they will be unable to achieve the target set. The £417k will still be invested in Health in Mind and the service has forecast that they will achieve the target by the end of July 2016, assuming demand remains constant and that recruitment to key posts is successful.

Of course the CCGs deciding that they cannot give us the funding to meet the target means that we as a Trust won’t meet the target. We have considered the option of whether we should be escalating this with CCGs. However, on balance we feel that this course of action would not be advisable because of the following reasons: 1. The CCGs don’t have the money. They have already identified £417k and any additional money taken would be better used in our secondary care services 2. Up till this point, there has been a strong collaborative approach taken in trying to achieve the funding required and good relationships maintained 3. There is no pressure from CCGs to meet the target given that NHSE funding hasn’t been forthcoming 4. A great many other services are unlikely to meet the monitor target given the lack of central funds available to address it 5. Even if the Trust got the funding, there is no practical way we could achieve the target in the timescales remaining given recruitment challenges and a lack of available agency staff 6. A more gradual and graded approach to the clearing of the waiting list is more realistic clinically and will help us to ensure governance and quality standards that we could not guarantee if we tried to clear the waiting list more quickly with staff we have no accountability over.

October 2015 2 Adult Services October 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

Delayed Transfers of Care (DTC)

The Trust has not achieved the Delayed Transfers of Care indicator in October, however progress is being made, and is reporting 7.9% against the target of 7.5%. Adult services are reporting 9.8% delays. 41 patients were delayed at the end of October, the main challenges are in the Dementia wards and Rehab in West Sussex. Consistent criteria is being applied to all delays reported across the trust.

There is a clear focus on timely transfer from acute care arising in the context of the plan to manage acute bed pressures.

A weekly Trust wide review of all DTCs is in place where planning and discharge dates are reviewed for all patients.

The Trust is also engaging with Commissioners and the wider Healthcare Community through the Systems Resilience Groups to ensure that system wide issues are addressed and anticipating that winter pressures could further impact on the availability of placements for people with Dementia.

Of those patients who were delayed at the end of October.

2 were awaiting public funding 2 were awaiting further NHS Care 8 were awaiting residential home placements 14 were awaiting nursing home placements 1 was awaiting a package of care in their own home 5 were due to family choice issues 7 were awaiting housing Responsive 2 were due to disputes

Extra Contractual Payments / Bed Pressures.

The number of external contractual placements in the month has reduced significantly with none being reported in September and 2 bed days October.

The pressures on the acute care pathway are likely to continue over the winter months. The current clinically led approach has stabilised the situation. Clinical audits and routine reporting have shown that patients with psychosis have a longer length of stay than our average or target length of stay. Development of the clinical pathway for psychosis is being prioritised to improve clinical outcomes for patients with this diagnosis and ensure a more consistent approach across the trust. This will include a more focused approach to medication compliance and post-discharge follow up. It should bring added value in terms of patient satisfaction particularly in relation to information about medication.

October 2015 3 Adult Services October 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

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

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

Month Year 4.5% Trust absence rate 4.19% 4.03% 4.0% 3.5% Adult Services absence rate 4.86% 4.85% 3.0%

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

Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 TRUST 3.85% 4.10% 4.39% 4.99% 5.30% 5.10% 4.98% 4.10% 3.90% 3.95% 4.10% 3.95% 4.19% ADULT 3.95% 4.23% 4.26% 5.09% 6.24% 5.63% 5.63% 4.60% 4.80% 5.04% 5.25% 4.56% 4.86%

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

Month YTD 10% Temporary Spend 13.84% 14.03% Agency Spend 5.96% 5.17% 5%

0% Agency and temporary staff spend as a proportion of the total Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 pay bill. Target is to maintain this below 11%. Temporary Costs - Adult Agency Spend - Adult Target

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16

ADULT 13.55% 13.15% 13.20% 14.81% 15.37% 14.38% 13.84% 0.00% 0.00% 0.00% 0.00% 0.00% Well Led AGENCY 4.92% 3.56% 4.81% 6.54% 5.83% 5.65% 5.96%

Income/Expenditure Budget £3,000 TRUST-WIDE (Local indicator)

£2,000 Month: October 2015 £K Month YTD (000s) (000s) £1,000

Income/Expenditure Variance 282 2,702 £0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

YTD Variance against I&E Budget - Adult YTD Variance against I&E Budget - Trust

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 Any positive variance against budget is an overspend ADULT 498 1,008 1,726 1,920 2,324 2,418 2,702 00000

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

80% Month: October 2015 YTD 60%

(000s) 40%

CIP Target 2,952 20% CIP Achieved 324 0% CIP % Achieved 11.0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 CIP Recurring/Non-recurring - Adult Target

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 Recurring and non-recurring actual costs YTD against plan ADULT 0.00% 8.78% 9.57% 10.85% 10.91% 10.95% 10.98% 0.00% 0.00% 0.00% 0.00% 0.00% TARGET 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

October 2015 4 Adult Services October 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

Sickness Absence. Sickness absence in Adult Services is 4.9% in September (reported 1 month in arrears). East Sussex 5.2%; Brighton & Hove 3.4%; North West Sussex 6.5%; Coastal West 5.8%; and Primary Care and Wellbeing 1.9%.

Temporary Costs as a proportion of Pay: The Temporary costs as a proportion of pay is 13.8% in Adult Services, 6.0% for agency staff. A rolling programme of recruitment is in place to fill the identified vacancies. HR is supporting services to reduce the rate of staff turnover. The performance in each area is as follows:-

Temporary Costs as Agency cost as a pro- a proportion of pay portion of pay

North West Sussex 21.5% 12.7% Coastal West Sussex 12.5% 5.3%

Brighton & Hove 12.9% 6.3% East Sussex. 15.0% 4.4%

Primary Mental Health Care and 1.9% 0.1% Wellbeing Total 13.8% 6.0%

Income / Expenditure Budget:

Well Led Reducing Inpatient Spend

The Trust has a cumulative £997k variance related to ECR spent and inpatient cost reduction. Work is continuing to ensure that wards understand and meet their revised budgets, which were increased to reflect improved staffing ratios and the three shift system, at the start of the financial year.

There is a detailed plan for reducing overspending wards, further to the increase in budget to ensure safer staffing. This has taken a clinically-led approach led by Helen Greatorex and Dr Shakil Malik with the Matrons sharing best practice and developing plans for their services that address the central themes. Clinical Deliv- ery Services (CDS) are using mid year performance reviews to ensure that Matrons and Ward Manager’s objectives are closely aligned to Trust objectives. Attention is being given to the use of non-framework agencies and we are working closely with framework agencies to improve fill rates. Good progress has been made in securing consistent agency staff in areas such as West Sussex Dementia wards.

CDSs are adopting a look and see approach, with managers and clinicians spending regular time on the wards, identifying and helping staff to resolve local issues.

October 2015 5 Adult Services October 2015 Sussex Partnership

Key Indicators - Safety NHS Foundation Trust

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

95% Month: October 2015 Target: 95%

Month Quarter YTD 90% Discharged 246 246 1,803 85% Followed-up 234 234 1,736

% Followed-up 95.1% 95.1% 96.3% 80% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15

% followed-up Target

All adults aged over 18 discharged from Adult Mental Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 TRUST 98.2% 99.2% 98.1% 96.3% 96.2% 94.7% 95.5% 98.7% 97.5% 97.5% 94.6% 95.1% 95.1% Health inpatient units TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

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

Month: October 2015 16

All Serious Incidents Level 1 Level 2 Level 3 8

Adult Services 4

Sussex 12 7 0 0 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Sussex SIs (Adult) - Level 1 Sussex SIs (Adult) - Level 2 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Level 182212103815511412

Level 2545438106137697 Safety

7 day follow ups: The Trust has achieved the target for patients to be followed up within 7 days of discharge from an acute ward in October. 234 of the 246 (95.1%) patients were followed up in this timeframe. Work continues to promote follow up contact by day 3.

Serious Incidents: In addition to the standard process for reviewing and learning from these incidents, the Clinical Delivery Services (CDS) carry out initial reviews of each incident in the month that they occur to identify any patterns. These incidents form part of the monthly reporting from each Care Delivery Unit. Pro- cesses are in place within the governance arrangements for the CDSs to share the learning from Serious In- cidents.

October 2015 6 Adult Services October 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

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

Month: October 2015 60% Month Quarter YTD 40% Friends & Family Test 128 128 714

% Positive 82.0% 82.0% 88.3% 20%

% Extremely Likely 57.0% 57.0% 57.1% 0% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 % Negative 8.6% 8.6% 4.3% % Positive Feedback

% Extremely Unlikely 3.1% 3.1% 1.4% Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 ADULT 88.1% 83.8% 85.8% 92.9% 85.4% 87.7% 87.7% 87.0% 93.0% 85.2% 92.1% 92.3% 82.0% Figures reported from September 2014 onwards TARGET 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

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

Current Month: October 2015 Target: 95% 60% Month 40% Adults on CPA at end of month 2,485 Last Review within 12 months 2,387 20%

% adults with review <12 months 96.1% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

% <12 month Review Target This indicator shows a snapshot position as at the end of Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 the month and is submitted to MONITOR quarterly ADULT 88.2% 90.8% 97.9% 96.5% 95.9% 97.3% 96.1% 0.0% 0.0% 0.0% 0.0% 0.0%

TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Caring

Payment by Results (PbR) 100% Adult Services (Local indicator)

90% Month: October 2015 Target: 95%

Under 65 65 & over TOTAL 80% With a Cluster 11,347 11,923 23,270 70% With a valid Cluster 8,227 10,593 18,820

% valid Cluster 72.5% 88.8% 80.9% 60% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Each cluster has a review period and the cluster is valid if % valid cluster Target the patient's needs are reassessed before the end of the Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 respective review period and the patient is re-clustered. TRUST 81.0% 81.1% 80.2% 80.6% 81.4% 80.3% 80.7% 81.1% 81.3% 80.5% 80.3% 80.4% 80.9% TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

October 2015 7 Adult Services October 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

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

Month: October 2015 Target: 85% 60% Resolved within 25 working days or agreed timeframe 40% Complaints resolved this month 27 Resolved within the agreed timeframe 21 20%

% resolved within agreed timeframe 77.8% 0% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Average number of days to resolution 26.0 TRUST - resolved within timeframe Adult Services - resolved within timeframe Target

Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 TRUST 90.0% 96.1% 86.2% 87.9% 85.1% 82.5% 70.5% 70.0% 86.9% 83.1% 84.5% 85.7% 87.0% Complaints received (as at month end) 44 ADULT 92.0% 93.8% 91.2% 87.2% 83.9% 77.8% 71.8% 61.8% 85.7% 78.4% 80.0% 94.6% 77.8%

100 Total Number of complaints received

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

Adult new complaints

Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 ADULT32375339425429344330473644

Caring

Complaints

44 new complaints were received in October in Adult services. 77.8% of complaints responded to in the month were responded to in the agreed timeframe. In response Clinical Delivery Services plan to set a bench- mark based on best performing mental health trusts and work towards achieving this, reduce the number of concerns escalated to complaint and resolve issues locally. They are considering the key themes and focusing on trends and patterns linking this data with their service visiting programmes.

October 2015 8 Adult Services October 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

CPA 12 month Formal Review

The Trust has achieved the indicator which measures whether patients have had a review under the Care Programme Approach (CPA) in the last 12 months. 96.1% of patients on CPA have had a review in the last 12 month at the end of October.

Patient Experience Feedback

82% of patients have responded favourably to the friends and family questionnaire, 57% extremely positively in Adult Services. The Trust is setting internal targets based on the number of patient seen in each service to improve the response rates to these questionnaires which will produce a richer source of qualitative feedback which can be used to support service improvement activities.

Payment by Results

The Trust is working closely with local Mental Health Commissioners to develop a comprehensive work programme to drive the development of payment by results, both as contracting currency, and as a tool to drive service improvement and better outcomes for patients. This will be one of the Trusts CQUIN schemes in 2015/16.

Adults Care Delivery Services have developed action plans, East Sussex have made good progress and have shared their approach. Performance is expected to improve significantly by the end of the financial year in all areas.

Caring Discharge Summaries: The Trust has recently undertaken an audit of the timeliness of communication of discharge summaries to GPs and patients. The initial audit shows that performance levels are not achieving the current contractual targets. (Same day for inpatient services, 48 hours for community) The following actions are planned:-

 A repeat audit is being carried out, as part of the clinical audit programme. The scope of the audit is being extended to gain an understanding of how long the discharge summaries take to be communicated. The audit team are looking to include the NHS net emails to evidence the timeliness of communication.  Agree and implement standard templates for discharge summaries and use NHS.net to eliminate faxing, in line with the new national requirements.  The automation of Discharge Summaries is being planned for the implementation of Carenotes in Adult Services.

October 2015 9 Adult Services

Specialist Services

Performance Dashboard

October 2015

www.sussexpartnership.nhs.uk Sussex Partnership October 2015 Specialist Services Dashboard NHS Foundation Trust

Page RESPONSIVE

Routine assessments within 4 weeks of referral (Sussex) - target 95% CONTRACTUAL TARGET 1

Routine assessments within 4 weeks of referral (CAMHS Hants) - target 95% CONTRACTUAL TARGET 1

Routine assessments within 6 weeks of referral (ChYPS Kent) - target 95% CONTRACTUAL TARGET 1

Delayed Transfers of Care - Timely discharge of patients - less than 7.5% MONITOR TARGET 1

Early Intervention in Psychosis - New Cases - performance against target MONITOR TARGET 2

Responsive narrative 2 WELL LED

Sickness absence - 3.5% or less TRUST-ONLY TARGET 4

Temporary and Agency costs - 11% or less TRUST-ONLY TARGET 4

Income/Expenditure performance against budget TRUST-ONLY TARGET 4

Cost Improvement Plan (CIP) performance against target TRUST-ONLY TARGET 4

Well led narrative 5 SAFETY

Serious Incidents - Reporting on and demonstrating learning No Target 6

Safety narrative 6 CARING

Reporting Patient Experience Feedback - Friends and Family Test No Target 7

CPA Patients having a Formal Review at least every 12 months - target 95% MONITOR TARGET 7

Complaints resolved within 25 working days - target 85% CONTRACTUAL TARGET 7

Caring narrative 8

performance meets or exceeds target

performance is within 10% of target

performance is 10% or more below target

October 2015 2 Index October 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

4 week waiting time to assessment 100% Specialist Services - CAMHS & LDS Sussex (Local Ind) 95% Month: October 2015 Target: 95% 90% Month YTD 85% Number of Assessments 397 2,591

% assessments <4 Weeks 93.7% 96.0% 80%

Average Wait Days 16.3 14.3 75% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Indicator covers CAMHS Sussex and LDS. % assessments <4 weeks Target Average Wait Days = average wait time from receipt of Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 referral to assessment. SUSSEX 98.5% 99.4% 99.6% 98.5% 98.9% 96.6% 99.5% 97.3% 95.0% 96.1% 93.1% 96.0% 93.7% TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

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

Month: October 2015 Target: 95% 60% Month YTD 40% Number of Assessments 272 1,684 % assessments <4 Weeks 42.6% 40.4% 20%

Average Wait Days 57.3 54.7 0% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Indicator covers CAMHS Hampshire. % assessments <4 weeks Target Average Wait Days = average wait time from receipt of Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Responsive referral to assessment. HANTS 46.0% 45.2% 40.5% 40.0% 45.7% 39.2% 43.5% 35.0% 42.8% 35.2% 40.2% 43.7% 42.6% TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

6 week waiting time to assessment 100% Specialist Services - ChY PS Kent (Local Indicator) 80% Month: October 2015 Target: 95% 60% Month YTD 40% Number of Assessments 334 2,364 % assessments <6 Weeks 46.7% 55.1% 20%

Average Wait Days 63.3 52.4 0% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Indicator covers ChYPS Kent. % assessments <6 weeks Target Average Wait Days = average wait time from receipt of Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 referral to assessment. KENT 47.7% 52.5% 55.6% 51.0% 58.5% 54.5% 60.6% 59.1% 60.5% 63.7% 42.0% 45.5% 46.7% TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Delayed Transfers of Care (DTC) 15% Specialist Services (MONIT OR indicat or)

Month: October 2015 Target: <7.5% 10% Month Quarter YTD % Delayed (Specialist) 0.4% 0.4% 2.0% 5% % Delayed (TRUST) 7.9% 7.9% 9.3% % CAMHS Delayed 1.1% 1.1% 3.4%

% LDS Delayed 0.0% 0.0% 18.2% 0% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 % S&F Delayed 0.4% 0.4% 0.5% % delays Target

S&F and LDS with dual diagnosis figures are included in Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 SPECIAL0.9%2.1%5.5%3.6%3.9%3.7%2.7%2.7%3.2%1.9%2.4%0.7%0.4% TRUST (MONITOR) indicator. CAMHS is for internal TARGET 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% reporting only.

October 2015 1 Specialist Services October 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

EIS - New Psychosis Cases 200 Specialist Services (MONIT OR indicat or)

Month: October 2015 150

National Target: 48 cases/quarter 100 Month Quarter YTD

50 West Sussex 8 8 56

East Sussex 1 1 45 0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Brighton & Hove 9 9 28 EIS New Cases - TRUST - YTD Target

TRUST 18 18 129 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 NEW CASES 19 33 58 76 89 111 129 Reported to MONITOR quarterly. TARGET 16 32 48 64 80 96 112 128 144 160 176 192

Waiting times to assessment and treatment in Hampshire: Performance against waiting times in Hampshire Children and Young people’s services is not achieving the contractual targets. 43.7% of patients assessed in October were seen in 4 weeks.

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

A mobilisation plan is being agreed with Commissioners to reduce the existing waiting times. The existing waiting list is planned to be reduced using a combination of assistant psychologists on 6 month contracts, support from No Limits, a third sector provider concentrating on tier 2 work and existing staff working extended hours and agency staff where required. Responsive

The service is planning to achieve the 4 week target for assessment and 18 weeks target for treatment by end of March. The current risks identified are the volume of those waiting in the New Forest, Fareham and Gosport and Havant teams and delays in getting staff IT equipment (approx. 30 laptops required for a limited period), and IT log-ons which are needed to access clinical systems and evidence activity and reduced waiting times.

Waiting times to assessment, CAMHS Kent & Medway: 78% of assessments were seen in 6 weeks (the contractual target). It should be noted that some CCG areas are performing better than others. This is expected as a number of areas have recovery plans in place which include seeing those patients who have been waiting the longest as a priority. Seeing these patients has the effect of increasing the average wait reported in the month for those assessed and reducing the average percentage performance reported.

The service is working closely with the commissioner and have been able to give assurance that the Trust is utilising all resources to best effect towards achieving the specified waiting times targets. With the existing funding it is not possible to improve significantly on all waiting times targets, specifically with the increases in referrals that the service is experiencing.

West Kent CCG have indicated that they will provide additional funding although this is currently not expected until January.

The service is experiencing concerns with the quality of data captured and reported and is reliant on manual processes for some areas of reporting. A workshop is took place in October to review the issues and agreed a plan to move to electronic reporting. This has full clinical involvement

October 2015 2 Specialist Services October 2015 Sussex Partnership

Key Indicators - Responsive NHS Foundation Trust

Sussex CAMHS and LD Waiting times. Demand & Capacity: 93.7% of specialist routine referrals were seen within the 4 week target (CAMHS and Learning Disabilities). Whilst the CAMHS service achieved the target at over 98%, the Learning Difficulty service saw 75% in the 4 week period. This related to the specialist clinical assessment service, which has a small team and suffered staff shortages in the period.

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

The Early Intervention Service: The Early Intervention service has achieved the monthly Monitor target for Care Programme Approach reviews to be completed every 12 months. Additionally the service is working towards meeting the new waiting times targets in April 2016. The service will begin reporting against those new targets in shadow form from January 2016. Additional funding has been provided to enable the teams to deliver a full range of NICE recommended interventions, to have the capacity to respond to a wider age group, patients with an “at risk mental state” and a quicker access timeframe. The service has a comprehensive action plan in place to build the capability of the team, and the ability to report against the new performance indicators. Progress towards achievement of these new targets is positive. Responsive

October 2015 3 Specialist Services October 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

Sickness Absence 6.5% Specialist Services (Local indicat or) 6.0% 5.5%

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

Month Year 4.5% Trust absence rate 4.19% 4.03% 4.0% 3.5% Specialist Services absence rate 3.86% 3.55% 3.0%

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

Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 TRUST 3.85% 4.10% 4.39% 4.99% 5.30% 5.10% 4.98% 4.10% 3.90% 3.95% 4.10% 3.95% 4.19% SPECIAL 3.75% 4.08% 4.90% 5.13% 5.57% 5.29% 4.94% 4.03% 3.13% 3.29% 3.38% 3.61% 3.86%

Temporary Costs (Bank & Agency) 20% Specialist Services (Local indicat or) 15% Month: October 2015 Target: 11%

Month YTD 10% Temporary Spend 11.71% 10.26% Agency Spend 6.42% 4.84% 5%

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16

SPECIALIST 9.89% 10.08% 9.19% 9.64% 10.69% 11.00% 11.71% 0.00% 0.00% 0.00% 0.00% 0.00% Well Led AGENCY 4.65% 4.52% 4.37% 4.39% 4.53% 5.00% 6.42%

Income/Expenditure Budget £1,500

TRUST-WIDE (Local indicator) £1,000

£500 Month: October 2015 £K Month YTD £0

(000s) (000s) -£500

-£1,000

Income/Expenditure Variance -99 -1,014 -£1,500 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

YTD Variance against I&E Budget -Specialist YTD Variance against I&E Budget - Trust Target

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 SPECIALIST ‐80 ‐257 ‐413 ‐664 ‐843 ‐913 ‐1,014 00000 Any positive variance against budget is an overspend

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

80% Month: October 2015 YTD 60%

(000s) 40%

CIP Target 2,197 20% CIP Achieved 1,479 0% CIP % Achieved 67.3% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 CIP Recurring/Non-recurring - Specialist Target

Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 Recurring and non-recurring actual costs YTD against plan SPECIALIST 0.00% 51.43% 52.20% 56.13% 60.64% 61.41% 67.32% 0.00% 0.00% 0.00% 0.00% 0.00% TARGET 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

October 2015 4 Specialist Services October 2015 Sussex Partnership

Key Indicators - Well Led NHS Foundation Trust

Sickness absence is 3.9% in September in Specialist Services (reported one month in arrears). The Secure & Forensic service is 4.2% in September.

Temporary Costs as a proportion of Pay: The temporary costs as a proportion of pay is 12% in Special- ist Services. Agency spend is 6% of the total pay bill.

Learning Disability Services: Temporary staff 11% as a proportion of pay, agency 3%. Recruitment pressures exist in the Selden Centre and Mayfield court. Intensive support is being provided by the organisational development team, and focus has been given on the recruitment process.

Secure & Forensic services: Temporary staff 14% as a proportion of pay, agency 2%. Alternative advertising platforms have been explored by these services, including the use of social media such as twitter, to attract new staff. Agency costs have partly been incurred due to increase seclusion and enhanced observation of patients. Two nurses have been appointed this month. The service is looking to better utilise the bank staff available to reduce this spend.

CAMHS: Temporary staff 12% as a proportion of pay, agency 9%. Hampshire and Kent have high agency use at 13% and 15% of pay bill respectively. A retention strategy is being developed in this area, and a recruitment day has been successful this month. A multi-strand and focused recruitment campaign is happening across the CAMHS service to attract new staff to the service. The campaign, led by the Communications team, includes a combination of media including radio coverage, personal stories from staff, a post campaign and approaches to make it easier for candidates to access NHS Jobs.

Income & Expenditure / Cost Improvement: Specialist Services have spent £33.1m against a budget of £34.1m at Period 7. (Variance £1m). Although Specialist Services have identified all of their Cost Improve-

ment plan, it is not all on a recurring basis. More work is underway to improve this position through service Well Led remodelling to make some of those savings permanent.

October 2015 5 Specialist Services October 2015 Sussex Partnership

Key Indicators - Safety/Caring NHS Foundation Trust

Serious Incidents - reported in month 24

Specialist Services (Local indicat or) 20

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

Specialist Services 8

Sussex 3 2 0 4

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

Kent 2 00 Specialist Services Level 1 Sis Specialist Services Level 2 Sis

Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Level 11413615111059335 Level 22210453220012

Serious Incidents: A number of serious incidents have occurred in CAMHS services in relation to information governance issues in recent months, particularly in Hampshire CAMHS. The service has developed a comprehensive action plan to respond to the issues highlighted from a review of each incident. This has led to a significant reduction in SIs for the Care Delivery Service and no incidents related to information governance in October. CAMHS is no longer reporting bed delays as serious incidents

Safety

October 2015 6 Specialist Services October 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

Patient Experience Feedback 100% Specialist Services (Local indicat or) 80%

Month: October 2015 60% Month Quarter YTD 40% Friends & Family Test 93 93 588

% Positive 84.9% 84.9% 81.6% 20%

% Extremely Likely 52.7% 52.7% 44.7% 0% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 % Negative 4.3% 4.3% 7.1% % Positive Feedback

% Extremely Unlikely 2.2% 2.2% 3.4% Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 SPECIAL 73.7% 82.4% 80.6% 88.8% 93.3% 82.8% 76.8% 98.0% 92.7% 70.5% 83.3% 81.0% 84.9% Figures reported from September 2014 onwards TARGET 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

CPA 12 month Formal Review 100% Specialist Services (MONIT OR indicat or) 80%

Current Month: October 2015 Target: 95% 60% Month 40% Adults on CPA at end of month 227 Last Review within 12 months 215 20%

% adults with review <12 months 94.7% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

% <12 month Review Target This indicator shows a snapshot position as at the end of Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 the month and is submitted to MONITOR quarterly EIS 94.8% 89.0% 97.0% 95.3% 96.6% 96.6% 94.7% 0.0% 0.0% 0.0% 0.0% 0.0% Caring TARGET 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

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

Month: October 2015 Target: 85% 60% Resolved within 25 working days or agreed timeframe 40% Complaints resolved this month 15 Resolved within the agreed timeframe 14 20%

% resolved within agreed timeframe 93.3% 0% Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Average number of days to resolution 25.7 TRUST - resolved within timeframe Specialist Services resolved within timeframe Target

Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 TRUST 90.0% 96.1% 86.2% 87.9% 85.1% 82.5% 70.5% 70.0% 86.9% 83.1% 84.5% 85.7% 87.0% Complaints received (as at month end) 15 SPECIAL 86.7% 100.0% 80.0% 86.2% 86.7% 91.7% 63.6% 83.3% 100.0% 88.9% 90.0% 90.0% 93.3%

25 Total Number of complaints received

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

Specialist new complaints

Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 Apr‐15 May‐15 Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 SPECIAL333425031518121515

October 2015 7 Specialist Services October 2015 Sussex Partnership

Key Indicators - Caring NHS Foundation Trust

Complaints: 15 new complaints were received in Specialist Services. 93.3% of complaints responded to in October were responded to in the agreed timeframe.

The service has systems in place to ensure the information regarding the types of complaints is triangulated with other quality indicators including serious incident, friends and family and staff sickness.

All specialist services are putting tracking systems in place to highlight to the management team the status of complaints and Serious Incidents to ensure that responses are dealt with in a timely manner. Within CAMHS the CDS Leadership Team has been looking at themes and developing plans to address these issues. For example delivering agreed proactive communication to MPs and other stakeholders about demand and capacity and team and service activity. Caring

October 2015 8 Specialist Services

Board of Directors: 25 November 2015 - Public Agenda Item: TBP50.5/15 Attachment: F For Information By: Richard Bayley, Non-Executive Director & Chair, Finance and Investment

FINANCE AND INVESTMENT COMMITTEE SUMMARY REPORT

SUMMARY & PURPOSE

This report provides a summary of the papers and discussions held at the Finance and Investment Committee meeting held on the 23rd October 2015 in order to provide the Board with assurance on the Trust’s financial and operational performance and investment decisions.

The purpose of this Committee is to drive excellent financial performance and ensure that the Trust has an investment strategy that supports the business and is financially deliverable. The Committee is responsible for ensuring that robust scrutiny is in place, taking action to commission further work as required in the achievement of this objective.

Given the Trust’s current financial position, in October the Committee’s main area of focus was the Trust’s financial recovery plan. The Committee expressed their concerns regarding the results for September and highlighted that significant work and focus is required over the second half of the year if the Trust is to report a break even position by the end of the financial year. The Committee requested a more detailed update on North West Sussex and the Corporate Savings Plans at the next meeting.

The Committee discussed a number of other key areas including the Quality & Performance Report, and financial planning and contracting round for 2016/17.

It should be noted that a summary of the Finance and Investment Committee is reported to the Board on a monthly basis and the paper is public part of the Board and therefore the paper is available on the Trust’s website.

LINK TO ANNUAL PLAN

This paper relates to the Trust’s strategic goals:- 1. Safe, effective, quality care 2. Local joined up care 3. Putting research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Live within our means

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to note the contents of this report and ask any questions of the Chair of the Finance and Investment Committee.

FINANCE AND INVESTMENT COMMITTEE SUMMARY REPORT

1.0 Executive Summary

This report provides a summary of the papers and discussions held at the Finance and Investment Committee meeting held on the 23rd October 2015. It should be noted that Michael Decker and Elizabeth Hall were the governor representatives at the meeting.

The Committee Received papers on a number of current topics including:-

 Month 6 Financial position  Update on Cost Improvement Programme for 2015/16 and Financial Recovery Plan  Themed Review on the Community Services Improvement Plan  Changes to Monitor’s Risk Assessment Framework  Quality & Operational Performance Reports  Capital Expenditure Report  Financial Planning for 2016/17  Hampshire CAMHS Waiting List Project  Commercial Report  Future of 78 Crawley Road

2.0 Introduction

The Finance and Investment Committee usually meet in the week before the Board meeting. The next Committee meeting is due to be held on the 16th November 2015. This report provides a summary of the meeting held on the 23rd October 2015, the main areas of discussion are set out in the body of the report below.

3.0 Report

Month 6 Financial Report and Delivery of the Financial Recovery Plan

The Committee received a report on the Trust’s financial performance for month 6 noting that the Trust was reporting a deficit of £128k for Month 6, taking the year to date deficit to £866k. However, this now moves the Monitor Capital Service Cover Rating to a rating of 2. Although, this is only with a small headroom of £18k, it does mean that the Trust is now back to reporting an overall Financial Sustainability Risk Rating of 3.

The Committee noted that overall in the month, the pressure on beds in Adult Services continued to be well managed, with no external placements in September. A similar clinically led approach has also started to tackle the issues relating to the over spend on Adult in-patient units, with the overspend reducing in the month by £35k, down to £207k. However, of more concern is the lack of progress in releasing savings in Adult Community Services as part of their service improvement programme. In addition, activity levels were under plan in Learning Disability and Nursing Home Services and very little progress was made in delivering the Plan C Corporate Savings in the month. The Committee also raised their concern regarding the level of overspend in North West Sussex, which is reporting an overspend of £1.1m year to date.

The Committee received papers on other work being undertaken to address the Trust’s financial pressures, including the Agency Reduction Programme and update on use of the e-Rostering System, together with verbal updates on the non-pay work stream and the Adult Services Community service improvement programme. The update on community services provided details of the demand and capacity work that is being piloted in Brighton and North West Sussex. Given the significance of this work, not only in respect of this year’s savings plan, but an area for recurrent savings for 2016/17, the Committee requested that they be kept up to date on the progress being made in this area.

The Committee expressed their concerns regarding the results for September and highlighted that significant work and focus is required over the second half of the year if the Trust is to report a break even position by the end of the financial year. The Committee requested a more detailed update on North West Sussex and the Corporate Savings Plans at the next meeting.

The Committee also had a lengthy discussion regarding the forecast out-turn to be reported to Monitor with the Quarter 2 return and agreed to report a best, mid and worst case position. It was agreed to still aim for a breakeven position although recognising that based on performance over the first half of the year, this was currently the best case position.

Changes to Monitor’s Risk Assessment Framework The Committee received a paper setting out the key changes to Monitor’s Risk Assessment Framework that came into effect in August. The Committee requested that the Value for Money Test is discussed with the Trust’s internal and external auditors well in advance of the year end in order to give the Trust the best change of obtaining an un-qualified opinion in this area for 2015/16.

The Committee also requested that the internal auditors follow up the Cost Improvement Audit in Quarter 4 with a view to improving the opinion, as it was agreed that the final opinion on this audit (which is currently red) may have an impact on the Value for Money Test.

Operational Performance Report The Committee received the Performance Reports for Adult and Specialist Services for Month 6, which highlighted the following key areas of concern:

(i) 7 Day Follow Ups The Trust had just met the target for patients followed in 7 days post discharge in September, achieving 95.1%, again a target of 95%. However, given the CQC’s concern regarding deaths in the first three days after discharge, the Committee were informed that the Trust would be setting its own internal target to follow up patients within 3 days. The Committee welcomed this proactive approach.

(ii) Delayed Transfers of Care The Committee noted that at the end of September the Trust was still reporting high levels of delayed transfers of care, i.e. 10.9% against a target of 7.5%. However, it noted was that the number of patients delayed had reduced to 40 at the end of the month and that good work was being undertaken in this area.

(iii) New Monitor Waiting Time Targets The Committee were updated on the new waiting time targets being introduced by Monitor for Improving Access to Psychological Therapies (IAPT) from Quarter 3 and Early Intervention in Psychosis (EIP) from Quarter 4.

(iv) Data Quality Concerns regarding data quality where also highlighted to the Committee and it was agreed that this issue would be raised through the Executive Assurance Committee.

Capital Expenditure Report The Committee received an update on this year’s Capital Programme, noting that although the capital programme was overspent year to date, capital expenditure is expected to come back in line with plan by the end of the financial year.

Contract Update The contract report provided the Committee with details of the how the additional investment from commissioners was being used to improve services to patients. The contract update also set out the details of the performance against the Trust’s CQUIN schemes for 2015/16 and development of plans for the 2016/17 contracting round. It was noted that the themes in the CQC Quality Improvement Plan would be used as themes for new investment in the contract negotiations with CCGs. It was also noted that the Trust had received the commissioning intentions from commissioners for 2016/17.

Financial Planning for 2016/17 The Committee received a paper setting out the financial planning assumptions and time table for 2016/17 planning round, noting that the assumptions may change subject to the national planning assumption and financial settlement for the NHS expected to be published by Monitor in early December.

The Committee agreed to the overarching assumption that the Trust should aim to deliver a breakeven plan for 2016/17, which would require delivery of a £12.2m service improvement plan, based on the current assumptions on the national financial settlement. It was requested that the draft financial plan for 2016/17 be presented to the Committee in January.

Hampshire CAMHS Waiting List Project The Committee received the project plan for the Hampshire CAMHS Waiting List Project and were asked to discuss and sign off the plan, as commissioners were looking for evidence that the plan had full support and commitment from the Board. The Committee were in full support of the plan and ask this to be conveyed to commissioners.

Commercial Report The Committee received and discussed the Commercial Report noting the current bids, an update on current tenders and new developments being considered by the Trust.

Future of 78 Crawley Road The Committee received a paper that provided an update on the termination of the joint venture with Care UK and supported the proposal to transfer the business into the Trust. However, the Committee requested that consideration be given to where the management of Crawley Road sits within the Trust’s management structure and how the service is incorporated into the Trust’s overall strategy for rehabilitation services.

4.0 Recommendation/Action Required

The Board is asked to note the contents of this report and ask any questions of the Chair of the Finance and Investment Committee.

5.0 Next Steps

The next Finance & Investment Committee is on 16th November 2015 and the Chair of the Committee will be able to provide a verbal update on the discussions held at the November Committee meeting, highlighting any matters for action or ratification by the Trust Board.

Board of Directors: 25 November 2015 – Public Agenda Item: TBP50.5/15 Attachment: G For Information By: Sally Flint, Executive Director of Finance and Performance

FINANCE REPORT – MONTH 7

SUMMARY & PURPOSE

The Finance Report sets out the Trust’s financial position for Month 7, setting out the main issues and the work being undertaken to address the financial pressures.

LINK TO ANNUAL PLAN

This paper relates to the Trust’s strategic goal “ To live within our means” and relates to our Corporate Objectives:- 5.1 To maintain sound financial performance to deliver financial governance and stability 5.2 To fully deliver the agreed cost improvement plan

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to:-

 note the performance for Month 7 and work being undertaken to address the financial pressures to ensure that the Trust breaks even by the end of the financial year.

FINANCE REPORT – MONTH 7

1.0 Executive Summary

In October the Trust saw a slight improvement in the Trust’s financial position, reporting a deficit of £54k (Month 6: £128k), taking the year to date deficit to £920k. This provides the Trust with an overall Financial Sustainability Risk Rating of 3, with a head room of £118k on the Capital Service Cover Rating of a 2.

Overall in the month, the pressure on beds in Adult Services continued to be managed well, with only 2 external placements in October. In the month there was also an improvement in underspend of community services ahead of the implementation of service improvement plans and Specialist Services continued to perform well. However, there continues to be concern around the level of overspend on the Adult in-patient units and lack of progress in delivering Corporate savings.

Currently the Trust is reporting a best case forecast of breakeven, with mid and worst case deficit of £0.8m and £1.6m respectively. However, work continues to aim to deliver a breakeven position, in order to improve the Trust’s underlying financial position in preparation for 2016/17.

2.0 Introduction

The Finance Report sets out the Trust’s financial position for Month 7, setting out the main issues and the work being undertaken on the financial recovery plan to ensure that the Trust breaks even by the end of the financial year.

The areas of concern contributing to the financial position and the work being undertaken to address these issues are set out in the body of the report, together with the details of the overall financial position.

3.0 Report

Income & Expenditure Position

In October the Trust saw a slight improvement in the Trust’s financial position, reporting a deficit of £54k (Month 6: £128k), taking the year to date deficit to £920k.

Income In October income was on plan, with a year to date favourable variance of £33k. In the month there was an improvement in the occupancy levels in the Nursing Home, improving the overall performance in income.

Pay Pay was overspent by £62k in the month, increasing the year to date adverse variance to £450k. Pay costs increased by £173k in the month, which was mainly as a result of an

increase in agency use, as well as a reduction in substantive vacancies.

Non-pay Non-pay was overspent by £116k in October, which was an increase of £81k in the month. There was a significant improvement in the use of external placements and drugs costs were also underspent. However, these were off-set by overspends across a number of areas including the cost of provisions and patient travel costs.

A summary of the income and expenditure position is set out in the table below.

Income and Expenditure Account A NNUA L In Month - Oct-15 Year to Date - Oct-15 BUDGET Budget Actual Variance Budget Actual Variance £000's £000's £000's £000's £000's £000's £000's

Revenue from Activities

Total operating Revenue (234,089) (19,675) (19,676) (0) (137,380) (137,412) (33)

Operating Expenses Total Pay Costs 185,555 15,704 15,766 62 109,061 109,511 450 Total Non Pay Costs 37,692 3,113 3,229 116 22,351 23,925 1,574 Total Operating Costs 223,247 18,817 18,995 178 131,412 133,437 2,025 Reserves 0 0 (183) (183) 0 (1,283) (1,283)

EBITDA (10,841) (859) (864) (5) (5,968) (5,259) 709

Retained Surplus For the Year 0 (0) 54 54 0 920 920

Non Trading (Gains)/Losses (1,293) 0 0 0 (547) (590) (43)

Retained (Surplus)/ Deficit For the Year (1,293) (0) 54 54 (547) 330 877

Financial Sustainability Risk Rating The financial position for Month 7 provides the Trust with an overall Financial Sustainability Risk Rating of 3, with details of the rating set out in the table below.

Financial Sustainability Risk Ratings

Year to Date Plan Oct-15 2015/16 Revenue A vailable for Capital Service 5.5 11.1 Capital Service -4.3 -7.3 Capital Service Cover Metric 1.3 1.5 Capital Service Cover Rating 2 2 Cash for CoS Liquidity Purposes 17.0 18.6 Operating Expenses within EBITDA -132.2 -227.0 Liquidity Metric 27.1 29.5 Liquidity Rating 4 4

I & E Margin -0.67% 0.0% I& E Margin Rat ing 2 2

I & E Margin Variance to Plan -0.67% 0.0% I & E Margin Variance to Plan Rating 3 3

Overall Financial Sustainability 33 Risk Rating

Operating Position and Financial Risk Rating of the Care Delivery Units

Based on the Month 7 position the Financial Risk Ratings for the Care Delivery Services, where a rating of 4 is determined as low risk and 1 high risk, is set out in the table below, with comparisons to the previous month.

Financial Risk Rating Accredited Care Delivery Services Month 7Month 6 Learning Disability 4 4 Primary Care & Well Being 4 4 Secure & Forensic, incl Prison Services 43 Children & Young People's Services 3 3 Shadow Care Delivery Services Complex Care Pathways 4 4 Coastal West Sussex 2a 2a East Sussex 2a 2a Nursing Home 2b 3 Brighton & Hove 2b 1 North West Sussex 1 1

Corporate Services were £4k underspent in the month, which was a deterioration in performance compared to the £68k underspent last month. Year to date Corporate Services are £141k overspent.

Main Issues

The main issues that continue to affect the Trust’s financial performance are use of temporary staffing and over spending in Adult in-patient units, slow progress in maintaining the level of under spends in community teams, lack of progress in to delivering additional savings in Corporate Services and realising savings through cost improvement plans. Further details for each of these areas are set out below.

Use of Temporary Staffing After a reduction in the use of temporary staffing in Month 6 to £1,786k, costs increased again in Month 7 to £1,871k. In October bank and agency staffing accounting for £1,016k (Month 6: £1,083k) and £855k (Month 6: £703k) of the pay bill respectively. This equates to 11.9% of the pay bill being spent on temporary staffing of which 5.4% was spent on agency staff (Month 6: 4.6%). However, it should be noted that most of the £152k increase in the use of agency staff was in Hampshire Children and Young People’s Services (£100k) due to an increase in staffing to address waiting times for assessment and treatment that has been funded by commissioners. There was also a £72k increase in the use of medical agency in the month, with the main users being Coastal West Sussex, Brighton & Hove and Kent Children & Young People’s Service. This issue is being addressed by trying to attract NHS locums to these posts, whilst recruitment is undertaken.

Good work is also being undertaken in addressing the recruitment issues for nursing staff. The Trust is in the process of finalising a secondment opportunity for a nurse recruitment specialist. Pilot schemes are also in place in North West Sussex to recruit to

new roles for in-patient services including, apprentices, occupational therapists and clinical support workers.

Monitor continue to take a keen interest in the use of agency staff and required the Trust to provide significant details of where the Trust is not using agencies on the national framework, including information on hourly rates and quality checks on these agencies. Currently, the Trust is sourcing 82% of its agency staff from framework agencies, with the aim to move to 100% as soon as possible.

At the end of October there were 324 vacancies that were actively being recruited to, 164 of these are in Adult Services and 55 in Children and Young People’s Services.

Pressure on Adult In-patient Beds Good progress continues to be made in reducing the use of external placements, with only two bed day used for external placements since the middle of August. Work continues to reduce the level of delayed transfers of care and length of stay, with the aim of getting each area into balance to allow patients to be admitted to their local units. This will address the CQCs concerns around patients being transferred across the Trust, and will also reduce patient transport costs, which are currently running at around £20k to £30k per month.

The level of overspend across the Adult Services in patient units was £202k in the month, with only a small reduction compared to the £207k overspend in September. Although, each ward now has an individual action plan to ensure staffing levels are keep within budget, this is slow to realise a reduction in the overspend. However, it should be noted that in October, the overspend on the wards in Langley Green Hospital was reduced to £2k, which is a significant improvement for the unit. The position is also expected to improve in East Sussex, as meetings have been held with ward managers and daily bed calls are helping them manage their staffing levels.

The October Performance Contract meeting brought together all the Adult Service CDSs and areas of good practice were shared to help address these pressures.

Community Services The other main area of concern is the slow progress being made to realise savings in Adult Community Services. However, there was a significant improvement in the underspent in October to £207k (Month 6: £112k). The demand and capacity pilots are now well underway in Brighton and Hove and North West Sussex which is helping to provide more clarity on how staff are using their time to provide assessment and on- going treatment for patients. Establishment of the patient pathways is also essential in taking this work forward, particularly for patients with psychosis and mood disorder.

Cost Improvement Plan (CIP) Overall in the month £478k was saved against the target of £986k, which is £508k less than planned. However, the savings delivered in month increased compared to last month, due to additional savings being achieved in Specialist Services. Year to date there is a recurrent shortfall of £4,383k, partly off-set by non-recurrent savings of £3,463k.

The key reasons for the shortfall at the end of Month 7 include the significant planning gap in the CIP, which accounts for £1,036k of the variance. This mainly relates to unidentified savings in Corporate and Specialist services, which is being addressed by the Financial Recovery Plan. £853k of the variance relates to the standardisation of community services. A further £997k of the shortfall variance related to the cost of external placements and inpatient cost reduction.

Financial Recovery Plan & Year End Forecast In October the Trust’s performance was slightly better than the mid-case forecast deficit set out in the financial recovery plan, reporting a deficit of £920k against a forecast deficit of £1,013k, with the main improvements in the position coming from improvement in community savings, increased underspends in Specialist Services and savings realised in Corporate Services.

Based on the Month 7 position, the financial recovery plan has been updated to give the following range of outcomes:-

 Best Case Breakeven  Mid Case Deficit of £883k  Worst Case (Run Rate) Deficit of £1,604k

In order to address the shortfall on the financial recovery plan, further planned savings totalling £1.6m have been agreed as a Plan C Corporate Savings plan. However, to date slow progress has been made in delivering these savings.

The Trust is still aiming to achieve a break even position by the end of the financial year, but this requires real focused effort on delivering the financial recovery plan and addition planned savings by Corporate Services (Plan C Savings Plan). Without this the Trust will end the year in deficit, which will only increase the financial pressures on 2016/17.

Summary and Conclusion

4.0 Recommendation/Action Required

The Board is asked to note the financial performance for Month 7 and work being undertaken to address the financial pressures.

5.0 Next Steps

Progress on the delivery of the Trust’s financial position will continued to be monitored through the Finance and Investment Committee. However there will additional scrutiny of the cost improvement plan by the Transformation Board and financial position through the Executive Assurance Committee, as well as the monthly Performance Contract meetings with Operational Services. Capital expenditure will continue to be monitored through the Estates & Facilities Executive Group and reported to the Finance & Investment Committee.

Board of Directors: 25 November 2015 – Public Agenda Item: TBP50.6/15 Attachment: H For: Information By: Diana Marsland, Non Executive Director

PEOPLE COMMITTEE SUMMARY REPORT

SUMMARY & PURPOSE

The People Committee met on 20 November 2015. This report provides a summary of the meeting; the main areas of discussion are set out below.

ACTION REQUIRED BY BOARD MEMBERS

This report is for discussion.

PEOPLE COMMITTEE SUMMARY REPORT

1. Executive Summary

The Committee received and considered papers/presentations on the following:

 Listening into Action  Improving working lives – Staff Health and Wellbeing programme  Exit interview feedback  Values and Behaviours Framework  Update on statutory and mandatory training compliance  Employee Relations cases – analysis and improving resolution timescales  Exceptions report on workforce indicators  Finance and agency programme updates

The agenda was focussed on staff experience, organisational development and performance identifying key risks and mitigation

2. REPORT

2.1 Listening into Action

The Committee were updated on actions to embed Listening into Action principles into the “way we work” across the trust. In particular this included the opportunity at the 27 November Leadership conference for “pass it on” learning from LiA changes. There were two sessions planned for staff to pass on their learning as well as a stand to showcase changes so far and a booth to encourage sharing of innovative ideas and changes made to improve services. Care Delivery Services (CDS) were also leading local events between October and December. The events will include LiA champions and those leading pioneer projects. The LiA Coordinator would continue to run events with local teams supporting them to embed the LiA model as the way we work.

Sue Morris also presented outcomes of a review of LiA six months into implementation. The review and outcomes would help to inform how we progress LiA into 20161/17, including changes to the Sponsor Group to reflect the development of CDSs and increased clinical engagement.

2.2 Improving Working Lives

Caroline Haynes, Deputy People Director and Fiona Long, Occupational Health Manager presented an analysis of data on sickness absence; referrals to occupational health services and the priorities for 16/17. The two main reasons for sickness absence: anxiety/stress depression and musculo-skeletal problems would continue to be the focus of health and wellbeing programmes. Current support such as mindfulness sessions; psychologist sessions funded for the occupational health service and health and wellbeing events had a positive impact. The Committee asked whether we could assess who is most at risk and also whether there was more detail on what was actually wrong with staff on sickness absence rather than the general categories in the repot as this would help target services in future. For 16/17, the programme to re-tender the Occupational Health and

Employee Assistance Programmes at the end of the current contracts offered a further opportunity to place increasing emphasis on education and promotion of healthy lifestyles and early interventions for staff with long term conditions. Learnings from Health in Mind will also be sought. The Committee would review progress again in March 2016.

2.3 Values and Behaviours Framework

The Committee noted that consultation had now been completed and this version will be launched at the Leadership Conference on 27 November 2016. This was recognised as very important framework supporting the cultural changes to achieve the 2020 Vision goals and would be supported by a programme to embed the values and behaviours in interview processes, induction, supervision and appraisals over the next two years. The Committee asked whether the wording on the framework could be simplified for the launch.

2.4 Statutory and Mandatory Training Progress

The Committee expressed their thanks for the detailed and improved report covering both compliance and places to address capacity gaps in classroom based training. The Committee noted improvements against target in a number of subjects but requested assurance about plans to meet the minimum overall target of 75% compliance by March 2016. Adrian Whittington confirmed compliance figures were now available for all managers to view team compliance and to enable them to review the figures urgently with their teams to put in place plans to address shortfalls. It was noted that compliance was also now being included in the “heat maps” showing overall CDS performance.

Diana Marsland requested that that a plan to address capacity issues be brought to the committee with progress reported against this plan until full compliance is achieved. Areas of exception should be available to this Committee so that the Board could be provided with assurance that plans were in place to achieve the agreed targets set. This would be provided for the next Committee in January. There was discussion about specific lower compliance figures such as Fire safety awareness and fire safety on site. It was noted that staff could not achieve compliance currently in one aspect such as the e-learning module as compliance currently required on-site training to be completed as well. There were proposals currently being considered for changing on-site training requirements for staff working in non-ward environments.

The Committee were also advised that all Directors were focussing on 100% compliance on e-learning modules across operational and corporate services.

4. PERFORMANCE – EXCEPTIONS

Sue Esser gave an overview of performance against the Workforce Strategy actions as outlined in the Our People report and the Committee noted there wold be a full report at the January People Committee and February Board.

The Committee discussed specific exceptions on sickness absence, initiatives to address vacancies and the implementation of the new job roles.

4.1 Sickness absence – 4.29% overall in September but higher in certain CDSs such as North West Sussex at 6.73%. The Committee noted intense focus on both short

term and longer term cases and some real positive improvements in some services with reductions in long term sickness cases through proactive management.

4.2 New roles – The new Band 4 roles had now been advertised for Langley Green Hospital and there had been a very positive response so far. The role is designed to pick up functions from the current Band 5 role to release time from current Band 5 posts for essential duties

4.3 Vacancies and “time to hire” – the Committee noted another month of net increase of external starters (56) against leavers (46). The time to hire figure had reduced back to 14.69 weeks. Diana Marsland raised concerns that the figure had not reduced further for some time. In response Sue Esser advised exceptions such as consultants with long notice periods were included in these figures and the team would review ways of presenting the figures by staff group.

4.4 Disciplinary policies – In response to a question from Diana Marsland, Caroline Haynes confirmed that the revised policies were now complete and included more specific timescales for delivering the different stages of the process.

5. ANALYSIS OF EXIT INTERVIEW INFORMATION

The Committee received a first detailed analysis of the 17 electronic responses received when the report was produced. There was a significant amount of detail and the team were thanked for the analysis. It was noted 58.8% of those who had responded were admin and clerical staff with 11.8 being qualified nursing staff. The main reasons for leaving were lack of job satisfaction and not feeling valued by the organisation (both 47%) More positively 78.6% were aware of the Trust’s 2020 Vision and 85% aware of their team objectives.

Given the very small number of responses to date the Committee would review regularly as data built up. The data would also be shared regularly with operational and corporate service teams to inform actions to improve staff engagement and retention.

6. FINANCE AND AGENCY SPEND

The Committee noted the slight improvement in the overall Trust financial position with a deficit of £54k. A discussion then focussed on the specific ongoing concerns about the level of overspend on adult inpatient units and lack of progress in delivering corporate savings being achieved through the financial recovery plan. A number of actions were in place including freezing of vacancies and reduction in spend on maintenance and a continuing requirement to underspend each service until the end of the financial year. However there were some areas not achieving the level of savings required and these were being scrutinised through another level of Exec team review and peer review.

The Committee also noted work on the plans to deliver the £3.2m CIP required from corporate services in 16/17 and the work that the Exec team were doing to define this by late January in preparation for implementation from April. This was supporting work already being done in individual corporate team to identify the savings plan for 16/17.

The Committee reviewed agency spend noting the increase from £703k in September to £832k in October. This was partly as a result of spend in medical agency predicted in last month’s report as a result of vacancies and an additional £100k in CHYPS Hampshire,

funded by commissioners, to address waiting times. The challenges continue to be agency use on dementia wards, less predictable use on adult wards and North West Sussex. In particular there has been increased clinical leadership focus on use of additional staff covering observations and inconsistent application of the policy. A programme of master classes is in place.

The Committee were updated on the transition to the framework agencies with 82% of shifts now through framework agencies.

7. RECOMMENDATION/ACTION REQUIRED

To note the report, including the risks identified, for information.

Board of Directors: 25 November 2015 – Public Agenda Item: TBP50.6/15 Attachment: I For Discussion By: Sue Morris, Executive Director of Corporate Services

OUR PEOPLE

SUMMARY & PURPOSE

The Board of Directors is asked to consider the information and analysis provided in the November report and ask any questions of the People Director.

LINK TO ANNUAL PLAN

The need to retain a strong focus on reducing agency to improve quality of care remains a priority whilst at the same time maintaining focus on the longer term strategic solutions of service and workforce transformation.

ACTION REQUIRED BY COMMITTEE MEMBERS

The People Committee is asked to note progress against the update progress under each of the 7 workforce programmes as well as the areas identified of concern and ask any questions of the People Director.

Our People

1.0 Executive Summary

The People report for November 2015 aligns with the Trust’s 2020 Strategy and Vision, in particular, goal four, ‘ To be the provider, employer and partner of choice’ and is structured to reflect the 7 programmes outlined in the Workforce Strategy to achieve this goal.

The aim of the report is to inform the Board of developments across the 7 key programmes of work, to highlight areas of concern or risk and provide a high level overview of the key workforce metrics to assure the Committee and the Trust Board of the safety and sustainability of our workforce.

Sickness and turnover continue to be our main causes for concern and those which are being managed very closely. There are a number of initiatives underway to address vacancies and sickness; however the national shortages in qualified nursing staff create added pressure in closing our vacancy gap. We have appointed on a temporary basis, a senior nurse who will support the delivery of the nurse recruitment strategy plans and it is expected that this will accelerate the delivery of outcomes.

In terms of recruitment and retention, there were 95 starters in October (56 External and 39 Internal) and 46 leavers. The WTE percentage turnover rate for October was 15% compared to 15.10% in September. The findings from the completed surveys show that 47% of leavers had worked for the Trust for more than 5 years and 23.5% less than 1 year. The main reasons given for leaving were: not feeling valued by the Trust (47%); lack of job satisfaction (47%); working environment (29%) and to broaden experience (23.5%). 35.5% of leavers were going to other NHS Trusts with 23.5% to same graded NHS positions.

The average time to hire for October was 14.69 weeks compared to 15.07 in September.

Agency spend increased to £845k in October from £703k in September. Medical agency increased by £75k and there was an increase of £100k in Hampshire use of agency with new additional temporary funding to reduce wait times. Total agency now equates to 5.38% of the total month's pay bill, 4.59% in the previous month, with the target being 2/3%.

The monthly sickness absence rate for September 2015 was 4.3% a slight increase on 4.1% the previous month against a target of 3.5%. ’Anxiety/stress/depression’ continues to be the top reason for absence. Nationally the average for other mental health Trusts continue at 4.71%.

Following the completion of the Leadership Forum engagement sessions, feedback from staff on our values and behaviours framework has been taken into account and the framework has been revised accordingly. We will now embark on the new phase of embedding these values through the next round of Leadership Forums. The launch of our Values and Behaviours framework is scheduled to take place at our leadership conference on 27th November.

Page 2 of 3

Appraisal training 2016 dates are being arranged and venues are being booked. The behavioural framework will be embedded in the appraisal paperwork for the 2016 round, accompanied by a training offer for new appraisers and those who want to refresh. Online resources will also be available to provide solutions for staff that cannot attend face to face training during winter pressures.

2.0 Introduction

Please see attached full report

3.0 Report

Please see attached full report.

4.0 Recommendation/Action Required

The Board of Directors is asked to consider the information and analysis provided in the November report and ask any questions of the People Director.

5.0 Next Steps

As outlined in previous months, the key operational priorities will remain focussed on improving and tackling the issues that lead to high agency spend and impact on the quality of services.

Page 3 of 3

Our People Report July-2015 Our People November 2015

Overview

Sussex Partnership NHS Foundation Trust

1. Overview

1.1 Sussex Partnership 2020 Strategy and Vision sets out a clarity of purpose, a set of stretching objectives and an aspirational culture that define the experience that patients, carers and families, staff and our partners should expect from working with us.

1.2 Goal 4: Be the provider, employer and partner of choice sets the context and aims for which

the People Directorate directly align and work towards to accelerate the achievement of this Overview strategic goal.

1.3 The People Directorate Workforce Strategy sets out 7 key areas of work that provides an architecture for the work we carry out to achieve Goal 4: Resourcing and Workforce Planning; Organisational Development and Cultural Change; Improving People Management Systems and Workforce Information; Developing the People Directorate to Support the Delivery of the Workforce Strategy; Developing the Medical Workforce; Performance, Re- ward and Recognition and; Leadership, Management and Staff Development.

1.4 Our People Report is one part of the key monthly strategic reports. The other element is the CDS reports, which have a greater level of workforce detail and are discussed at performance contract meetings and local multi-disciplinary leadership meetings.

1.5 Our aim is to inform the Board of developments across our 7 key programmes of work, to highlight areas of concern or risk. Also to provide a high level overview of the key metrics required to inform the Board of the safety and sustainability of our workforce.

1.6 The People Report is presented to the People Committee bi-monthly before it is presented to the Executive Assurance Group and then the Board. The CDS reports are presented at CDS board and divisional leadership teams.

2 Performance Summary

Sussex Partnership NHS Foundation Trust

Dashboard

The latest Trust figures are as follows:

Substantive Staff in Post (wte) as at 31 October 2015 3737 ▲ PerformanceSummary

Vacancy Rate (wte funded vacancies) - October 2015 11.4% ▼

Vacancy Rate (wte vacancies with HR) - October 2015 6.7% ▼

Average Time to Hire (weeks) - October 2015 14.69 ▼

Monthly Sickness Absence Rate - Septem- ber 2015 4.3% ▲

Agency Spend - October 2015 845K ▲

Agency Spend - October 2015 % of Paybill 5.38% ▲

DBS Compliance % 97% -

Staff Retention Rate (wte 12 months ending October 2015) 87% -

Staff Turnover Rate (wte 12 months ending October 2015) 15% -

WTE—Whole Time Equivalent

3 Performance Summary

Sussex Partnership NHS Foundation Trust

Exception Reporting

Workforce Metrics Exception Reporting Three key areas are currently being monitored: annual turnover % rate, monthly sickness absence % rate and the monthly vacancy % rate. The exceptions are reported below.

CDS Areas of Action Concern PerformanceSummary

Adult East 5.30% Sickness Active Long Term sickness cases has reduced to 333 WTE equivalent calendar days in September (521 WTE in August). Of the 12 LTS cases, 2 were closed in September, 4 are known to have returned in October, 1 is due to return in December – leaving 5 on-going cases, all of which are of 30 days or less. Advise and training has been given on managing short-term sickness and STS reporting is now more accurate which may equate to the increase this month.

17.4% Vacancy rate Vacancies are being assessed and managed decisions taken on the replacement recruitment. 14 staff that have been recruited with start dates agreed, 3 candidates are awaiting start dates and a further 6 are going through pre-employment checks.

Adult Coastal 5.97% Sickness Coastal continue to work closely with their HR Advisor on addressing Long and Short Term Sickness cases and currently have 19 active sickness cases. The Division continues to use the ER reporting data to identify the areas where sickness absence is highest and these are the areas that additional support on absence management and team development is given. The Senior HR Advisors have recently opened bookings for front-line management training sessions, including how to manage sickness absence and wellbeing, for which a number of Coastal Managers have signed up.

Adult North 6.73% Sickness Absence increased in the division last month with absence in the division being reported at 6.7%. The Brad- ford Score has been introduced and managers have been supported and trained in its application, this is likely to be a contributing factor to the increase due to an increased focus. Regular absence meetings supported by the Senior HR advisor continue. Bite size management training is being delivered in the division by the Senior HR Advisor over the next 2 months with one of these sessions focussing on sickness absence.

Recruitment is still challenging in Crawley and Horsham. The vacancy rate over the past 3 months is slowly 16.9% Vacancy rate decreasing from 18.00% to 16.9%. The recruitment co-coordinator completed a review of the previous months disappointing conversion rate of applicants to posts offered which has resulted in ward managers at LGH prioritising recruitment. An LiA event took place on 9 th October lead by the LGH General Manager to discuss the skills mix paper and clinical support worker JD/trial at LGH. Rolling adverts have been reinstated on NHS jobs for qualified nursing posts and HCA’s with ward managers inviting all suitable nursing candidates to interview once shortlisted to speed up the process and reduce the risk of losing potential candidates. The next recruitment event at LGH is 26 th November for both substantive and bank support workers .

Monthly meetings with each of the ward managers now take place as per the recruitment and retention strate- 22.4% Turnover gy in the division with the HRBP for the CDS and the recruitment manager to review recruitment and turnover activity. Ward Managers have been encouraged to actively carry out exit interview discussions at point of receipt of resignation letter. The numbers of leavers in the division saw an increase this month from 2 in Sep- tember to 5 in October. Reasons for leaving are as follows 2 x Retirement 1 x ill health retirement x 2 voluntary resignation . One of the retiring employees has returned undertaking a project working via trust bank.

ChYPS - Hants 18.3% Turnover A retention strategy is being finalised and will address the main reasons staff give for leaving and explore ChYPS - Kent 18.1% incentives, methods of engagement and development opportunities.

ChYPS - Hants 11.9% Vacancy Additional funding and the confirmation of the contract award to SPFT means that new posts are being recruited to. This additional funding also accounts for a significant rise in agency spend to cover posts as soon as the money has been made available. A major recruitment campaign was launched in November and say more details can be found later in this report.

Corporate 20.6% Turnover The number of leavers (10) compared to starters (16) within the month of September is not an area for concern and the reasons for leavers is constantly being analysed for any reoccurring themes and trends.

Facilities & Estates 4.7% Sickness Sickness remains an area for concern in E&F. The HR Business Partner ran a workshop (20 October) for E&F Supervisors on ‘Managing Concerns Regarding Employees’ which covers Conduct, Capability & Sickness Absence. There are further workshops scheduled for the New Year which will hopefully assist in building capabilities and confidence in dealing with employee issue at the informal stage.

Prison 25% Turnover The number of leavers over the last 12 months has decreased but this has not yet been reflected in the turno- Services ver rate. The highest number of leavers were from Quarter 4 2014/15 when 7 staff left the Prison Service. This was predominantly driven by 5 leavers in December who TUPE transferred out of the Trust. It is anticipated this turnover rate will decrease next month.

7.97% Sickness It has been identified reporting errors have inflated this figure by 44 days which would have raised the sickness rate by approximately 2.5%. The Senior HR Advisor will address this with the relevant managers and make the relevant amendments. 20 FTE days being shown as lost to anxiety/depression, these can be attributed to a member of staff who quickly decided that the Prison environment was not the right one for him and he has since resigned.

10.1% Vacancy rate There are only 5 live vacancies on Stepchange. Interviews have been held for 3 of the vacancies. There are no hard to recruit areas within the Prison Service.

Learning Disabili- 19.9% Turnover Support Workers are the largest group of leavers in the Service from the PDCA. The review of Mayfield Court ties will consider the turnover / retention strategy as a key priority.

16.5% Vacancy rate There are 9 nursing vacancies with 6 proving to be hard to recruit month on month. A recruitment action plan is in place which may also need to be expanded to some of the 3 nursing roles. A major recruitment campaign was launched in November and say more details can be found later in this report.

Secure & 5.65% Sickness Although this sickness absence rate is still high, this is a reduction of 2% from last month and is the lowest it Forensic has been all year. A thorough review of sickness absence data will take place this month to identify how the Service can continue to reduce this figure.

16% Vacancy Rate There are 13 nursing vacancies at Hellingly which are hard to fill vacancies which is keeping the vacancy rate high. There is also headroom of 27 vacancies included in this figure.

4 Summary

Sussex Partnership NHS Foundation Trust Overall Monthly Absence Percentage 6.00%

5.00%

4.00% 2014 Summary 3.00% Target

2.00% 2015

1.00%

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

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 4.16% 4.10% 3.93% 3.89% 3.71% 3.44% 3.66% 3.45% 3.99% 4.18% 4.38% 5.08% 2015 5.40% 5.09% 5.00% 4.13% 3.91% 3.94% 4.12% 4.06% 4.29%

The sickness absence rate for September increased slightly to 4.3% from 4.1% in August. Compa- rable to the chart below we are below the average sickness rate for other Mental Health Trusts.

Average Sickness rate for the Year Mental Health Sussex Partnership Trusts NHS Trust 2013 4.77% 4.24% 2014 4.83% 4.00% 2015 5.14% 4.71%

Top 5 Sickness Reasons - Sept-15 WTE Days Lost

381 982 432 Musculoskeletal problems Anxiety/stress/depression Cold, Cough, Flu - Influenza 697 Injury, fracture 884 Gastrointestinal problems

5 Summary

Sussex Partnership NHS Foundation Trust

Staff Turnover

WTE % Turnover Rate

18.00%

15.05% 16.00% 13.85% 14.19% 14.00%

12.00%

10.00% Summary

8.00%

6.00%

4.00%

2.00%

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

12 Months ending

External Starters & Leavers - October 2015

Starters & Leavers Oct-15 80 Starters & Leavers by Professional Group

60 25

40 20 56

20 15 Starters 10 0 Leavers Starters (Headcount) Leavers (Headcount) 5 -20 -46 0 -40 Add Prof Additional Administrative & Allied Health Estates & Medical & Dental Nursing & Scientific & Clinical Services Clerical Professionals Ancillary Midwifery -60 Technic Registered

Add Prof Scientific & Technical - Clinical Psychologists, Psychotherapists, Pharmacists

Allied Health Professionals - Occupational Therapists, Therapists

Additional Clinical Services - Healthcare Assistants, Occupational Therapy Assistants, STAR Workers

Compliance DBS Renewals 96 24 The total number of staff with expired DBS as at 1st November is 120 Of these 96 have yet to respond or are on long In Date term sick or maternity leave and have Expired (maternity, Long term sick, No response) been passed to the HR Business Part- ners to take further action. Processing by Capita 3708 Compliance

Revalidation There were a total of 9 Doctors due for Revalidation in October, 7 Consultants and 2 Specialty Doc- tors. 7 Doctors were recommended and 2 deferred. Whistleblowing We currently have one Whistleblowing case in North West Sussex. Appraisal Appraisals logged on my learning as at November-15 is 774.

6 Summary

Sussex Partnership NHS Foundation Trust

Core Mandatory Training

Training Course e-learning November 2014 Q1 Q2 available Compliance Compliance Compliance (estimated) % against 40 % target against 50% target

Courses for all staff

Health and Safety Awareness 48 71 65 Summary Moving and Handling Awareness 48 71 64

Fire Safety Awareness - 33 39

Fire Safety On Site 36 24 24

Infection Prevention and Control Level 1 - 30 48

Equality and Diversity 23 30 45

Information Governance - 98 98

Safeguarding Adults Level 1 9 42 55

Safeguarding Children Level 1 48 71 72

Additional / Alternate Courses for Community Clinical Staff Clinical Risk 10 35 49

Safeguarding Children Level 3 Core 27 32 40

Safeguarding Children Level 3 Specialist 53 16 62

Basic Life Support 49 45 35

PMVA Breakaway - 27 11

Infection Prevention and Control Level 2 - 21 31

Mental Health Act - 12 11

Mental Capacity Act - 19 19

Additional / Alternate Courses for Inpatient Clinical Staff PMVA Physical Interventions - 50 33

Patient Handling 41 19 17

Immediate Life Support 34 32 26

Medicines Management 30

59 59 Compliance

Rapid Tranquilization 7 20 35

Compliance key is as follows:

- Performance equals or exceeds 95% - Performance against Business objective equals or exceeds quarterly target - Performance is below target but going up - Performance is below target and going down

Note that the compliance data contained within this report applies to Substantive and Fixed Term Appointment staff only.

7 Recruiting and Retaining the Right People with the Right Skills and Val- ues for the Right Roles Sussex Partnership NHS Foundation Trust

Programme One Summary • Supporting CDS to produce local workforce plans • Recruiting and retaining the right people with the right skills and values for the right roles • Improving the recruitment experience • Promoting our rewards option to attract and deploy a flexible workforce • Developing a retention strategy Programme1 Recruitment Campaigns A recruitment campaign for the Selden Centre went live on the 9th November. Their recruitment action plan has various strands to fill vacancies including a social media campaign developed by the Communications department; a skill mix review; advert re-wording; introducing hard to recruitment initiatives and developing relationships with universities. The Dementia teams in Brighton & West Sussex have designed an advertisement which has been placed in the Sussex Care magazine.

Exit Questionnaire To date 17 staff have completed the on-line Exit Questionnaire. 59% of respondents were in administrative and clerical roles and 12% were qualified nurses. The findings from the completed surveys show that 47% of leavers had worked for the Trust for more than 5 years and 23.5% less than 1 year. The main reasons given for leaving were: not feeling valued by the Trust (47%); lack of job satisfaction (47%); working environment (29%) and to broaden experience (23.5%). 35.5% of leavers were going to other NHS Trusts with 23.5% to same graded NHS positions. More detailed analysis is under way.

University Careers Fairs The Trust attended a careers fair at Surrey University on the 14 th October 2015 and attracted some interest from some student RGN’s and RMN’s, plus a number of psychology graduates. The Trust will be attending another careers fair at Southampton University on the 17th November 2015

Open Days Open days are planned for Hampshire CAMHS on the 16th November and Langley Green on the 26th November

Nursing Times Live Recruitment Event A number of services will be attending the above event which is taking place in London on the 14th November.

Recruitment Initiatives Secure and Forensics have been offering a hard to recruit supplement for Band 5 and 6 Nurses and have seen a reduction to 1 leaver in 4 months from 13 leavers in the previous 9 months. Mill View and North West Sussex have offered incentives (Golden Hello/Hard to Recruit Supplement) to 19 candidates and these will be monitored to assess their impact on recruitment and retention. Whilst Learning Disabilities have yet to appoint a candidates they report a positive impact on the number of applicants as a result of offering an incentive.

Bank – New Starters Satisfaction Survey Reasons for Leaving Oct-15

Feedback from the bank pre-employment Death in Service survey questionnaires showed that 100% Dismissal 2 1 of candidates rated the bank recruitment 3 3 End of Fixed Term Contract 2 team as good or excellent. 76% of candi- 2 Mutually Agreed Resignationt 5 Retirement - Ill Health dates said they were satisfied with the Retirement Age 1 recruitment process with 57% being either Voluntary Resignation - Better Reward Package very or extremely satisfied. 86% of candi- 14 Voluntary Resignation - Health Voluntary Resignation - Other/Not Known dates said that, based on their first im- 10 Voluntary Resignation - Promotion 1 pressions of the Trust, they would recom- 2 Voluntary Resignation - Relocation mend the Trust as a place to work. Voluntary Resignation - Work Life Balance

Time to Hire The time to hire from requisition raised to start date has decreased from 15.07 weeks in September 2015 to 14.69 weeks in October 2015.

Average Time to Hire in Weeks - Nov-14 to Oct-15

15.04 15.07 15 14.96 14.99 15 14.81 14.73 14.69 14.66 14.46 14.35

14.04 13.82 14

8 Organisational Development and Cultural Change Sussex Partnership NHS Foundation Trust

Programme Two Summary • Improving staff experience and staff engagement • Developing strong team practices • Introducing new roles • Recruiting for values • Promoting equality, diversity and human rights • Improving the health and wellbeing of our staff • Improving communications and embedding LiA

Programme2 Values and Behaviours Following the completion of the Leadership Forum engagement sessions, feedback has been integrated and kindly reviewed by members of staff that volunteered to do so. Following a presentation to members of the Board, their feedback has now been integrated and the People Director and Director of Communication are reviewing ahead of release to the organisation for final feedback. The launch of Values and Behaviours following feedback from people across the organisation is planned for late November/early December 2015.

Values and Behaviours – associated work Appraisal training 2016 dates are being arranged and venues are being booked. The behavioural framework will be embedded in the appraisal paperwork for the 2016 round, accompanied by a training offer for new appraisers and those who want to refresh. Online resources will also be available to provide solutions for staff that cannot attend face to face training during winter pressures.

Improving People Management systems and Workforce information Sussex Partnership NHS Foundation Trust

Programme Three Summary • Improving the quality of the data held in Electronic Staff Record (ESR) • Utilising e-systems to improve efficiency • Maximising e-rostering

• Establishing workforce planning Programme3 • Introduce Annex W • Reviewing the workforce reports we produce • Establishing robust governance frameworks • Establishing robust governance frameworks.

ESR The Employee Self-Service (ESR SS) function is now live and communication will shortly go out to staff about the functionality of ESR SS including accessing payslips and the Total Reward Statement, as well as amending personal information directly on the system. The project will now start focusing on the implementation of Manager Self-Service with a view to implementing it in some CDSs in early 2016.

Nursing workforce planning Grove Ward in Chichester are recruiting RGNs to complement the skill-mix. They will support the ward with the physical care needs of the dementia patients.

A Project Coordinator will soon be recruited to the team to focus on nursing recruitment in the Trust and promote SPFT as an employer of choice. They will work closely with the Head of Resourcing on Trust-wide and CDS-focused nursing recruitment strategies and initiatives.

E-Rostering The Hellingly Centre have recently recruited an e-rostering administrator to support the ward teams in the utilisation of STAR and to maximise the use of the system for booking bank workers. In conjunction with the Director of Hampshire CAMHS, a project plan has been agreed to roll out E-Roster across the Service, the implementation stage commencing in January 2016

Workforce Planning Building on the ‘Nurse workforce planning workshop’ and ‘Corporate Services away day’ last month. The Director’s of each CDS are currently being contacted to further understand their workforce information needs, with a view to providing each with a bespoke workforce profile. This will enable them to understand in more detail their current workforce and how they will need to plan for likely gaps and potential skill shortages in the future.

9 Developing the People Directorate Sussex Partnership NHS Foundation Trust

Programme Four Summary • Becoming a highly customer focused team • Becoming a sustainable and efficient service • Increasing the skills and knowledge of all people services staff • Embedding the business partner model • Enhancing our services to the organisation Programme4 Listening into Action The HR team welcomed the LiA Coordinators for a conversation this month. The team identified a number of improvements that could be made within the department. The time to reflect gave the team a chance to create action plans and to discuss how to take things forward.

Governance Workshop A governance workshop was arranged for the team to carry out the annual performance audit. The workshop was informative and allowed the team to identify gaps in individual’s knowledge and in the department’s systems. An action plan has now been put together to address those gaps.

Support Services Workshop The second part of the workshop is being held this month. The work is helping the team develop the service so that it continues to strive to meet the needs of CDSs. The next step is to finalise the Part- nership Agreements with operational services.

Leadership Development Programme 4 staff within the team have now taken part in the programme and more are planned for future co- horts. The HRBPs and HRAs continue to develop their facilitation skills through the delivery of key elements of the leadership and management development programmes.

Developing sustainable terms and conditions

Programme Five Summary • Ensuring that the terms and conditions of staff fit the Trust’s vision, values and objectives • Ensuring that they meet the needs of services and deliver workforce flexibility • Ensuring clinical resources are used effectively and improve clinical engagement Programme5

Junior Doctors’ terms and conditions

The Trust has been informed that the BMA is currently holding a ballot of its Junior Doctor members in England, for industrial action. The ballot is in relation to the trade dispute in respect of the proposed imposition of new terms and conditions of employment for junior doctors. At this stage we do not know whether the outcome of the ballot will be to take strike action or action short of a strike. The date of the action has not yet been confirmed. Preparation is underway to minimise risks and ensure continuity of patient care is underway.

10 Performance, Reward and Recognition Sussex Partnership NHS Foundation Trust

Programme Six Summary • Embedding Trust values and behaviours in our operational structures for performance management and development • Developing an integrated approach to reward recognition and performance • Improving overall performance and productivity

The launch and roll out of the values and behaviours framework will start towards the end of November/ early December. We are currently finalising the embedding plans which will be done in conjunction and alignment with the new appraisal training, review of values based recruitment and our new Trust Induction Programme6 to be launched in January 2016.

The Clinical Excellence Awards policy for Consultants are currently under review. This policy will address issues relating to productivity.

During Q4 we will be reviewing opportunities to introduce recognition schemes linked to length of service and attendance.

Leadership Management and Staff Development

• Behavioural Feedback • Identifying priority areas to support Care Delivery Services development • Improving leadership and management capacity • Prioritising clinical leadership development • Recognising different roles and needs of managerial levels

Leadership – Current programme

Engagement of CDS leadership teams is on-going, with the nomination of LDP delegates by leadership Programme7 teams proving to be successful as Cohort 6 launched with 29 leaders this month.

Cohort 4 are in the final moments of completing their reports and preparing for their presentations later this month. Learning from feedback from cohort 4 has meant a greater clarity at launch day around timelines and ex- pectations of 360 participants, report deadlines and communication with course administrators. The Training Journal Awards’ night is on 25th November…fingers crossed!

Management Development Programme The Management Development Programme for managing people (disciplinary, capability, investigation, sickness, grievance, recruitment & retention, bullying & harassment, whistleblowing, managing change, supervision, engagement, health, wellbeing & flexible working) started in September with 20 people having already started the programme. It is led by Jo Russell, HR Business Partner and delivered by the Sen- ior HR Advisors to teams across the Trust in partnership with Staff Side colleagues.

Leadership – Future Programme A Leadership Development programme for bands 2 to 6 is in its initial planning stage.

Leadership Conference The next Leadership Conference will take place at the end of November and all staff irrelevant of their banding or role have been invited to attend.

Board of Directors: 25 November 2015 – Public Agenda Item: TBP 50.7 /15 Attachment: J For Information By: Helen Greatorex, Executive Director of Nursing & Quality

SAFE STAFFING

SUMMARY & PURPOSE

The Board of Directors is presented at every meeting, with a report setting out the previous month’s performance in relation to safe staffing on the Trust’s wards.

The report is populated by the Trust’s Lead Nurse for Safe Staffing, and its contents informed by Matrons.

A key pressure continues to be created by the national shortage of Registered Mental Health Nurses (RMNs) as a consequence of which, the Trust is working to reintroduce a programme of rolling secondment of Healthcare Assistants to undertake training. In the meantime, assertive, creative and dynamic recruitment campaigns, area by area, have some positive results This work continues, supported and informed by the developing Care Delivery Services’ engagement and focus on their areas of highest need.

LINK TO ANNUAL PLAN

The provision of high quality, safe care

ACTION REQUIRED BY BOARD MEMBERS

The board is asked to consider the report, asking any questions of the executive.

Safer Staffing Summary Report ‐ September 2014

Day Duty Night Duty Day Duty Night Duty TOTAL

Qualified Nurses Healthcare Assistants Qualified Nurses Healthcare Assistants Qualified Nurses Healthcare Assistants Qualified Nurses Healthcare Assistants Total monthly Total monthly Total monthly Total monthly planned staff Total monthly planned staff Total monthly planned staff Total monthly planned staff Total monthly Average Fill Rate Average Fill Rate Average Fill Rate Average Fill Rate Average Fill Rate Ward name Type of ward hours actual staff hours hours actual staff hours hours actual staff hours hours actual staff hours % WTE Variance % WTE Variance % WTE Variance % WTE Variance % WTE Variance Comments 1 Bodiam Acute 930 930 930 930 651 651 651 651 100% ‐ 100% ‐ 100% ‐ 100% ‐ 100% ‐ 2 Maple Ward Acute 930 915 1,395 1,418 310 310 930 910 98%‐ 0.09 102% 0.14 100% ‐ 98%‐ 0.12 100%‐ 0.07 3 Oaklands Ward Acute 930 930 930 930 667 683 667 689 100% ‐ 100% ‐ 102% 0.10 103% 0.14 101% 0.24 4 Rowan Ward Acute 816 816 816 834 327 327 654 654 100% ‐ 102% 0.11 100% ‐ 100% ‐ 101% 0.11 5 Woodlands Centre Acute 946 782 1,070 2,385 713 675 1,070 2,139 83% ‐ 1.02 223% 8.16 95% ‐ 0.24 200% 6.63 157% 13.53 X 6 Amberley Ward Acute 930 899 1,163 1,230 651 651 651 798 97%‐ 0.20 106% 0.42 100% ‐ 123% 0.91 105% 1.13 7 Coral Ward Acute 930 963 930 1,162 620 620 620 770 104% 0.20 125% 1.44 100% ‐ 124% 0.93 113% 2.57 X 8 Jade Ward Acute 900 954 900 922 300 300 615 655 106% 0.33 102% 0.14 100% ‐ 107% 0.25 104% 0.72 9 Caburn Ward Acute 1,095 1,163 930 1,393 620 580 310 610 106% 0.42 150% 2.87 94% ‐ 0.25 197% 1.86 127% 4.91 X 10 Regency Ward Acute 620 1,112 620 944 620 632 310 391 179% 3.05 152% 2.01 102% 0.07 126% 0.50 142% 5.64 X 11 Chalkhill CAMHS 1,125 1,080 1,125 1,097 620 605 610 610 96%‐ 0.28 98%‐ 0.17 98%‐ 0.09 100% ‐ 97%‐ 0.55 12 Beechwood Dementia 930 853 930 2,425 310 600 930 1,400 92% ‐ 0.48 261% 9.27 194% 1.80 151% 2.91 170% 13.51 X 13 St Gabriel Ward Dementia 357 591 1,070 1,214 357 357 713 1,024 166% 1.45 113% 0.89 100% ‐ 144% 1.93 128% 4.27 X 14 Burrowes Ward Dementia 930 825 1,395 1,582 310 310 620 726 89% ‐ 0.65 113% 1.16 100% ‐ 117% 0.66 106% 1.17 X 15 Grove Ward Dementia 930 653 1,395 1,611 324 423 667 981 70% ‐ 1.72 115% 1.34 131% 0.61 147% 1.95 111% 2.18 X 16 Brunswick Ward Dementia 930 1,089 1,628 2,261 620 524 620 1,267 117% 0.99 139% 3.93 85% ‐ 0.60 204% 4.01 135% 8.33 X 17 Iris Ward Dementia 900 892 1,350 1,361 300 320 600 1,032 99%‐ 0.05 101% 0.07 107% 0.12 172% 2.68 114% 2.82 X 18 Heathfield Ward Integrated 930 915 930 938 326 389 651 588 98%‐ 0.09 101% 0.05 119% 0.39 90%‐ 0.39 100%‐ 0.04 19 Larch Ward Integrated 930 893 930 1,026 620 570 310 360 96%‐ 0.23 110% 0.60 92% ‐ 0.31 116% 0.31 102% 0.37 X 20 Meridian Ward Integrated 620 875 930 1,581 620 631 310 604 141% 1.58 170% 4.04 102% 0.07 195% 1.82 149% 7.51 X 21 Opal Ward Integrated 930 832 930 887 310 310 620 642 89% ‐ 0.61 95%‐ 0.27 100% ‐ 104% 0.14 96%‐ 0.74 X 22 Orchard Ward Integrated 930 585 1,395 1,298 333 366 667 634 63% ‐ 2.14 93%‐ 0.60 110% 0.20 95%‐ 0.20 87% ‐ 2.74 X 23 St Raphael Ward Integrated 713 759 713 1,050 713 702 713 713 106% 0.29 147% 2.09 98%‐ 0.07 100% ‐ 113% 2.31 X 24 Selden Centre LD 744 526 1,860 2,343 372 372 744 912 71% 0.00 126% 3.00 100% ‐ 123% 1.04 112% 2.69 X 25 Fir Ward Low Secure 713 706 713 1,029 713 575 713 840 99%‐ 0.04 144% 1.96 81% ‐ 0.86 118% 0.79 110% 1.85 X 26 Hazel Ward Low Secure 713 754 713 1,071 713 368 713 1,162 106% 0.25 150% 2.22 52% ‐ 2.14 163% 2.78 118% 3.12 X 27 Pine Ward Low Secure 713 754 713 1,071 713 368 713 1,162 106% 0.25 150% 2.22 52% ‐ 2.14 163% 2.78 118% 3.12 X 28 Southview Low Secure 713 700 1,426 1,368 713 472 713 907 98% ‐ 0.08 96%‐ 0.36 66% ‐ 1.49 127% 1.20 97%‐ 0.73 X 29 Ash Medium Secure 690 801 1,380 1,193 345 345 1,035 1,070 116% 0.69 86%‐ 1.16 100% ‐ 103% 0.22 99%‐ 0.25 30 Oak Ward Medium Secure 1,070 1,067 1,415 1,459 713 437 1,015 1,272 100%‐ 0.02 103% 0.27 61% ‐ 1.71 125% 1.59 101% 0.14 X 31 Willow Ward Medium Secure 713 725 1,783 1,737 357 368 1,426 1,415 102% 0.07 97%‐ 0.29 103% 0.07 99%‐ 0.07 99%‐ 0.21 32 Amber Ward PICU 1,395 1,170 1,860 2,050 620 620 1,240 1,280 84% ‐ 1.40 110% 1.18 100% ‐ 103% 0.25 100% 0.03 X 33 Pavillion Ward PICU 930 1,061 930 1,332 620 632 310 391 114% 0.81 143% 2.49 102% 0.07 126% 0.50 122% 3.88 X 34 Amberstone Rehab 930 892 930 994 310 319 581 591 96%‐ 0.24 107% 0.40 103% 0.06 102% 0.06 102% 0.28 35 Bramble Lodge Rehab 357 357 713 701 357 357 357 357 100% ‐ 98%‐ 0.07 100% ‐ 100% ‐ 99%‐ 0.07 36 Connolly House Rehab 795 872 600 551 333 333 333 333 110% 0.48 92%‐ 0.30 100% ‐ 100% ‐ 101% 0.17 37 Rutland Gardens Rehab 630 645 465 413 310 330 310 290 102% 0.09 89%‐ 0.32 106% 0.12 94%‐ 0.12 98%‐ 0.23 38 Shepherd House Rehab 465 500 930 930 310 310 310 330 108% 0.22 100% ‐ 100% ‐ 106% 0.12 103% 0.34 39 Dove Ward Substance Misuse 713 691 357 364 357 357 357 357 97%‐ 0.14 102% 0.04 100% ‐ 100% ‐ 99%‐ 0.09 40 Promenade Ward Substance Misuse 930 893 465 488 300 300 300 300 96%‐ 0.23 105% 0.14 100% ‐ 100% ‐ 99%‐ 0.09

TRUST TOTAL 33,396 33,420 41,658 49,573 19,398 18,399 25,679 31,817 100% 119% 95% 124% 111% Sussex Partnership NHS Foundation Trust Board of Directors: 25 November 2015 - Public Agenda Item: TBP50.7/15 Attachment: J For Information By: Helen Greatorex, Executive Director of Nursing & Quality

SAFE STAFFING APPENDIX 1

Set out below are the 23 wards whose returns for October prompted questions about levels of staffing. This included shift where the RMN fill rate is below 95%.

Ward staffing levels are reviewed every shift and an overview and required action taken by the responsible Ward Manager and Matron. The report outlines the ward’s establishment, shift pattern; the current Nursing vacancies; fill rate and Incidents to help us review and support the wards in order to deliver safe, effective and quality care.

Ward / No. of Beds Staffing Current Nursing Shift Pattern Fill Rate Action Plan Incidents Establishment * Vacancies includes allied professionals 5. Woodlands 44 WTE 9 WTE HCAs Long day - 2 RMNs and Overall fill rate (157%)  Daily monitoring and Incidents: 12 vacancies. 4 HCA review of 1:1 by MDT 23 mixed acute High numbers of patients on 1:1 staff. 1 Breach of beds throughout October required  3 pm bed call to review Confidentiality Night - 2 RMNs and 3 1 additional staffing level. observation level. Woodlands Centre, HCA 3 Failed to return to ward. Hastings (2 on unescorted leave, 1 1 RMN 9-5  Review of ward safety on S17 leave) Overall fill rate for RMNs on day duty at handover and (83%) monitor during shift. 2 Self harm (Head  Support at ward banging) Patients’ safety prioritised. manager and Matron Level. 2 Ill health

Additional WTE: 2 Physical assault (pt on staff with 1 near miss) 8.16 HCA for day shifts 6.63 HCA for night shifts 1 OD on prescription meds.

1 Incorrect frequency prescribing.

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7. Coral 27 WTE 12 WTE RMNs Early – 2 RMN and 2 HCA Overall fill rate (113%)  Daily review of Incidents: 12 and HCA observation level and 19 mixed acute vacancies. High numbers of patients required during handover by 3 Self harm Late – 2 RMN and 2 HCA beds eyesight observation throughout MDT. October. On a few days as high as 2 Meds Administration 1 RMN started  Observation tracker Langley Green Night – 1 RMN and 2 HCA 8 patients required observation. errors. (1 unintentionally 9/11/15. form. Hospital  Support from Matron omitted and 1 not Up to 3 patients required arm length Level. covered by protocol) observation intermittently. 1 Contraband items

1 OD non-prescription meds

1 Exposure to fire

Additional WTE: 1 patient handling

0.20 RMN for day shifts 3 Physical assault (patient on visitor and 1.44 HCA for day shifts patient) (1 alleged staff 0.93 HCA for night shifts on pt currently being investigated).

9. Caburn 30 WTE No vacancies Early - 2 RMN and 2 HCA Overall fill rate (127%)  Daily review of Incidents: 37 observation level and Had a patient on daily eyesight obs during MDT handover. 13 Physical assaults (8 pt Weekdays extra 1 RMN. 20 female acute throughout October. Had a few days  Support at Matron on staff, 4 pt on pt, 1 pt beds where 3 patients required 1:1 due to Level. on public) Late – 2 RMN and 2 HCA high risk level. Millview Hospital 4 Med administration errors. (1 incorrect dose, Night – 2 RMN and 1 HCA  Review of ward safety Fill rate for RMN on night is 94%. at handover and 1 at incorrect time, 1 monitor during shift. unintentionally omitted, 1 Patients’ safety maintained as  Support from ward PRN meds incorrect priority. manager. frequency)

4 falls (2 from Additional WTE: standing/collapse)

0.42 RMN for day shifts 2 Info governance breach

2.87 HCA for day shifts 5 Verbal abuse (4 pt on 1.86 HCA for night shifts staff and 1 verbal threat)

1 near miss accidental event

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2 Absconded without permission

1 Slip

1 Ingestion

4 self-harm

10. Regency 26 WTE 3 WTE RMNs and Early - 2 RMN and 2 HCA Overall fill rate (142%)  Additional staff Incidents: 15 HCA vacancies required to ensure new 20 male acute beds 6 new staff started throughout staff attend induction 2 contraband items Late – 2 RMN and 2 HCA October. and mandatory Monthly open day Millview Hospital While waiting for NMC pin number, trainings and delivering 3 Ill health recruitment at Night – 2 RMN and 1 HCA the new staff started as safe service. Millview Hospital. supernumerary for induction and 1 Pt concern mandatory training.

1 fire/smoke

Additional WTE: 5 Physical assault (4 pt on staff, 1 near miss pt on 3.05 RMN on day shifts pt)

2.01 HCA on day shifts 2 Verbal abuse (pt on 0.50 HCA on night shifts staff)

1 Disinhibited behaviour

12. Beechwood 27 WTE 9 WTE Early – 2 RMN and 2 HCA Overall fill rate (170%)  Review of ward safety Incidents: 33 at handover and 14 mixed dementia Throughout the month one person monitor during shift. 1 Ill health Merging with St Late – 2 RMN and 2 HCA beds Gabriel and on 2:1; average 3 people on 1:1  Support at ward 5 Fall (2 found on the waiting in throughout month; average 4 people manager and matron Night – 1 RMN and 3 HCA floor, 1 fall from December. on 15 minute observations level. Uckfield Hospital standing/collapse) throughout month; average 4 people needing 2 or more staff for personal 1 Refused to return to care throughout month. ward

 Review of ward safety 1 Med administration

at handover and error (incorrect dose) Fill rate for RMN day is 92%. monitor during shift. 25 Physical assault ( 6 pt Patients’ safety prioritised.  Support at ward manager and Matron on pt, 1 unintentional pt on staff, 17 pt on staff, 1 Additional WTE: Level.

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1.80 RMN for night shifts near miss pt on staff))

9.27 HCA for day shifts 2.91 HCA for night shifts

13. St Gabriel 26 WTE Long Day – 1 RMN and 3 Overall fill rate (128%)  Review of ward safety Incidents: 6 HCA at handover and 14 mixed dementia monitor during shift. 5 falls (1 missed footing, Moving to beds Throughout the month average 2 2 found on floor, 1 Trip Beechwood in Night – 1 RMN and 2 HCA  Support at ward people on 1:1; average 6 people on and 1 slip) December manager and matron St Anne’s Centre, 15 minute observations; average 3 level. Hastings people needing 2 or more staff for 1 Med administration personal care. error (incorrect dose)

Additional WTE:

1.45 RMN on day shifts

0.89 HCA for day shifts 1.93 HCA for night shifts

14. Burrowes 29 WTE 8 WTE Early – 1 RMN and 3 HCA Overall fill rate (106%)  Review of ward safety Incidents: 16 at handover and 10 mixed dementia Fill rate for RMN on day is 89%. monitor during shift. 13 Physical assault (3 2.5 WTE RMNs Late – 1 RMN and 3 HCA beds  Support at ward near miss pt on pt, 2 pt Patients’ safety prioritised. manager and matron on pt,, 7 pt on staff and 1 Salvington Lodge, 5.5 WTE HCA Night – 1 RMN and 3 HCA level. near miss pt on staff) Worthing 1 fall Matron aware.

This is a hard to 1 Policy not adhered to recruit area. Plan

is to set up rolling 1 Incorrect storage of recruitment. items

15. Grove 28 WTE 6 WTE Early – 1 RMN and 3 HCA Overall fill rate (111%)  Daily review and Incidents: 8 monitoring of 1:1 and 10 mixed dementia Several patients required 1:1 at handover 4 near miss accidental 5.21 WTE RMNs Late – 1 RMN and 3 HCA beds throughout October due to risk of fall  Review patient’s care event and personal care intervention. needs. Harold Kidd Unit 0.79 WTE HCA Night – 1 RMN and 3 HCA 3 person found on the Fill rate for RMN on day is 70% and  Review of ward safety floor for night is 131%. at handover and Matron aware. 1 Physical assault (pt on This is a hard to monitoring during shift. Patients’ safety on day shifts staff) recruit area. Plan  Support from Ward

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is to set up rolling prioritised and maintained. manager and Matron. recruitment.

Additional WTE:

1.34 HCA for day shifts 1.95 HCA for night shifts

16. Brunswick 34 WTE 9 WTE vacancies Early – 2 RMN and 2 HCA Overall fill rate (135%)  Daily review and Incidents: 14 for RMNs and monitoring of 15 mixed dementia Funding increased by HCAs. observations. 2 Info governance breach Late – 2 RMN and 2 HCA beds 7 WTE this month. Had 2 patients requiring 1:1  Review 1:1 at throughout October due to falls risk 3 falls (1 found on floor, 1 This is a hard to handovers. Millview Hospital Night – 1 RMN and 2 HCA and poor physical health. In Slip and 1 fall from recruit ward and additional had another patient standing) managers are required intermittent enhance aware. observation. 1 leak/spill

Monthly open day 1 cuts in general recruitment at Fill rate for RMN on night is 85%.  Review of ward safety Millview Hospital. at handover and 5 Physical assault (2 pt Patients’ safety prioritised and monitoring during shift. on pt, 1 pt on staff, 1 maintained. unintentional pt on pt, 1  Support from Ward manager and Matron. near miss pt on staff)  Covered with Additional WTE: additional support 2 Record – blank workers. administration 0.99 RMN for day shifts

3.93 HCA for day shifts 4.01 HCA for night shifts

17. Iris 29 WTE 5 WTE HCAs Early – 2 RMN and 3 HCA Overall fill rate (114%)  Daily review of 1:1 and Incidents: 7 eyesight obs by MDT 12 mixed dementia Had 3-4 Intermittent and at handover. 2 fall (person found on HCAs recruitment Late – 2 RMN and 3 HCA beds observations, 2-3 eyesight floor) process in place.  Support at Matron observations with fluctuating Level. Horsham Hospital Night – 1 RMN and 3 HCA 2:1 eyesight obs. 1 Policy not adhered to Matron aware. This is a hard to Some patients needing 3 1 left ward without

recruit area. Plan staff for personal care permission is to set up rolling intervention at nights. recruitment. 1 Contact with a Escort for appointments. stationary object

1 Near miss accidental

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event

1 Physical assault (pt on staff)

19. Larch 29 WTE 4 WTE Early – 2 RMN and 2 HCA Overall fill rate (102%)  Review of ward safety Incidents: 10 at handover and 18 mixed integrated Fill rate for RMN on night is 92%. monitor during shift. 6 fall (3 found on floor, 2 4 WTE HCA Late – 2 RMN and 2 HCA beds  Support at ward fall, 1 slip) Patients’ safety prioritised and manager and matron Meadowfield Rolling recruitment Night – 2 RMN and 1 HCA maintained. level. I near miss accidental Hospital in place. event

1 contact with a moving object

1 Lack of care by staff

20. Meridian 27 WTE 7 WTE Early – 2 RMN and 3 HCA Overall fill rate (149%)  Daily review and Incidents: 16 monitoring of 19 mixed integrated High number of patients required observations. 1 Ill health 1 WTE RMN Late – 2 RMN and 2 HCA beds eyesight observations throughout  Regular planning of October. staffing level to support 4 fall (1 missed footing, 1 Millview Hospital 6 WTE HCA Night – 2 RMN and 1 HCA ECT treatments. slip and 2 fall)

Several numbers of those also have 2 Near miss accidental Both posts will be complex healthcare needs requiring event recruited at the additional staff for care interventions. VBR (Value based 1 needle stick/sharp recruitment) day in Escorts for physical health OPA and injury October. ECT (Tuesdays and Fridays). 3 Med error (1 incorrect  Support at ward dose, 1 loss of

manager and matron medication, 1 contrary to

level. MHA form T2 or T3)

Additional WTE: 1 cut in general

1.58 RMN for day shifts 1 theft of personal

property 4.04 HCA for day shifts

1.82 HCA for night shifts 1 left ward without

permission

2 Physical assault pt on staff

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21. Opal 31 WTE 15 WTE RMNs Early – 2 RMN and 3 HCA Overall fill rate (96%)  Review of ward safety Incidents: and HCAs at handover and 19 mixed integrated vacancies. Fill rate for RMN on day is 89%. monitor during shift. None reported for Late – 2 RMN and 2 HCA beds  Support at ward October. Patients’ safety prioritised and This is a hard to manager and matron Night – 2 RMN and 1 HCA maintained. recruit area. level. Langley Green Hospital

Matron is aware and LGH has appointed a temporary recruitment coordinator to support all the wards.

22. Orchard 28 WTE 6 WTE Early – 2 RMN and 3 HCA Overall fill rate (87%)  Review of ward safety Incidents: 7 at handover and 12 mixed integrated Fill rate for RMN on day is 63%. monitor during shift. 3 Near miss (1 accidental 2 WTE RMN Late – 2 RMN and 3 HCA beds event, 2 Fall, slip & Trip) currently being  Support at ward Patients’ safety prioritised and advertised. manager and matron Harold Kidds Unit Night – 1 RMN and 2 HCA maintained. level. 1 self-harm

4 WTE HCA 2 falls (1 found on floor)

vacancies. 1 Med error (administration at

incorrect time)

23. St Raphael 27 WTE 9 WTE Long Day – 2 RMN and 2 Overall fill rate (113%)  Daily review and Incidents: 10 HCA monitoring of 15 mixed integrated Had 2 patients on 1:1 due to high observations. 4 Near miss (1 ill health, 5 WTE RMN beds risk of fall throughout October. 1 assault pt on staff, 1 Night – 2 RMN and 2 HCA  Support at ward manager and matron accidental event, 1 fall, St Anne’s Centre slip & trip) 4 WTE HCA level. Additional WTE: 4 fall (1 found on floor, 1 Matron aware. slip, 2 fall from standing) 2.09 HCA for day shifts

This is a hard to 1 Pre-existing medical recruit ward. condition Matron aware. Support from HR 1 Structure/platform and Recruitment. collapse

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24. Selden 29.23 WTE 8 WTE Long day – 2 RMNs and 5 Overall fill rate (112%)  Review clients’ need Incidents: 11 HCAs regularly and care 10 mixed LD beds Had 6 patients presenting with planned accordingly. 8 Physical assault (1 near 4 WTE RMN challenging behaviours and required miss pt on pt, 7 pt on Night – 1 RMN and 2 HCAs  Client’s needs linked Swandean intermittent 1:1 throughout October. and funded individually staff) 4 WTE HCA by Commissioners. Plus 1 Twilight HCA 2 Contact with stationary object Matron is aware.

Fill rate for RMN on day is 71%*. 1 Verbal abuse pt on This is a hard to staff. recruit speciality. Patients’ safety maintained as  Review of ward safety priority. at handover and monitor during shift. Trust is supporting Selden with  Support at ward Additional WTE: manager and matron Recruitment Drive in October through level. 3.00 HCA for day shifts  * Unfilled RMN day the 1.04 HCA for night shifts Communication shifts covered by Team. additional HCA.

25. Fir 32 WTE 5 WTE vacancies Long Day – 2 RMN and 2 Overall fill rate (106%)  Review of ward safety Incidents: 4 HCA at handover and 15 male low secure Fill rate for RMN on day is 92%. monitor during shift. 1 Breach of security Recruitment in beds process. Night – 2 RMN and 2 HCA  Support at ward Fill rate for RMN on night is 65%. manager and matron 1 Contraband item Chichester Centre level. Patients’ safety prioritised and 1 Info governance breach maintained. 1 failed to return from S17 leave

26. Hazel 31 WTE 7 WTE vacancies Long day – 2 RMN and 3 Overall fill rate (110%)  Review patients on 1:1 Incidents: 10 for RMNs and HCA daily and at handover. 16 female low HCAs Had a few patients who required two 4 Self-harm secure beds line site observations for 4 days. Night – 2 RMN and 2 HCA 1 head banging Recruitment in Chichester Centre Fill rate for RMN on night is 50%. process for 2 WTE 1 Personal RMNs. Patients’ safety prioritised and  Review of ward safety monitored on each shifts. at handover and 2 Cut with a sharp object monitor during shift. Able to request for help within  Support from ward 1 Physical assault pt on Chichester Centre from other wards manager and matron. staff

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onsite if required.  * Unfilled RMN night shifts covered by Additional WTE: additional HCA.

1.23 HCA for day shifts 2.93 HCA for night shifts *

27. Pine 28 WTE 5 WTE vacancies Long day – 2 RMN and 3 Overall fill rate (110%)  New staff requiring Incidents: 2 for RMNs and HCA training and PMVA to 16 male low secure HCAs Had new staff requiring Induction deliver safe service. 1 Section 17 issue beds and PMVA training over a three Night – 2 RMN and 2 HCA weeks period. 1 Alcohol/substance Recruitment in Chichester Centre process. Fill rate for RMN on night is 57%.  Review of ward safety at handover and Patients’ safety prioritised and monitor during shift. monitored on each shifts.  Support from ward manager and matron. Able to request for help within  * Unfilled RMN night Chichester Centre from other wards shifts covered by onsite if required. additional HCA.

Additional WTE:

0.25 RMN for day shifts

2.25 wte HCA for day shifts 2.78 wte HCA for night shifts *

28. Southview 36 WTE 7 WTE RMNs and Long Day – 2 RMN and 3 Overall fill rate (97%)  Review of ward safety Incidents: 8 HCAs vacancies HCA at handover and 15 male low secure Fill rate for RMN on day is 98% and monitor during shift. 2 Breach of security rehab ward on night is 66%. Rolling recruitment Night – 2 RMN and 2 HCA  Covered with 1 Policy not adhered to in place. additional unqualified Hellingly Centre Patients’ safety prioritised and staff. maintained.  Support from ward 1 Med unintentionally This is a hard to manager and Matron. omitted recruit area. Able to call for support within the Matron is aware. Hellingly Centre for redeployment if 2 Failed to return after required. unescorted leave

Recruitment 1 near miss accidental strategy in place event for Hellingly Centre. 1 cut with sharp object

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30. Oak 41 WTE 8 WTE RMNs and Long day – 3 RMN and 4 Overall fill rate (101%) . Incidents: 10 HCAs vacancies HCA  Review of ward safety 15 medium secure Fill rate for RMN on night is 61%. at handover and 4 Contraband items (1 male ward monitor during shift. alcohol) Rolling recruitment Night – 2 RMN and 3 HCA Patients’ safety prioritised. in place.  Support from ward Hellingly Centre manager and matron 1 Personal Able to call for support within the  * Unfilled RMN shifts This is a hard to Hellingly Centre for redeployment if covered by additional 1 Breach of security recruit area. required. HCA. Support from HR 1 Belief or religion and Recruitment. 2 Physical assault pt on pt

1 contact with sharp object

32. Amber 42 WTE 13 WTE Early – 3 RMN and 4 HCA Overall fill rate (100%)  Review of ward safety Incidents: 18 vacancies for at handover and 12 mixed PICU RMNs and HCAs. Fill rate for RMN on day is 84%. monitor during shift. 2 attempted to leave ward Late – 3 RMN and 4 HCA beds  Support from ward Patients’ safety prioritised and 1 left ward without Matron is aware. manager and Matron. Langley Green Night – 2 RMN and 4 HCA supported. permission This is a hard to  * Unfilled RMN shifts Hospital recruit speciality. covered by additional 1 Ill health Temporary HCA.

Recruitment co- 1 Breach ordinator in place

to support LGH 1 inappropriate behaviour recruitment drive.

1 near miss accidental event

1 contact with a stationary object

1 Dispensing error – incorrect supply

7 Physical assault (6 pt on staff, 1 pt on pt)

1 Verbal threat

1 Verbal abuse (pt on staff)

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33. Pavilion 32 WTE 2 WTE Vacancies Early – 2 RMN and 3 HCA Overall fill rate (122%)  Daily review and Incidents: 22 monitoring of patients 10 male PICU beds High number of patients required eyesight observations 3 Physical assault (2 pt Monthly Late – 2 RMN and 3 HCA eyesight observations throughout and at handover. on pt, 1 pt on staff) recruitment day at Millview Hospital October. MVH.  Support from Matron Night – 2 RMN and 2 HCA Level. 5 Contraband items

Additional WTE: 1 Contact with a stationary object 0.81 RMN for day shifts 1 Race 2.49 HCA for day shifts 0.50 HCA for night shifts 2 Inappropriate behaviour

1 Sexual harassment

1 Incorrect storage

2 Prescribing contrary to MHA form T2 or T3

2 Policy not adhered to

2 Verbal threat

1 Loss of Trust property

1 Section papers found to be invalid

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Board of Directors: 25th November 2015 – Public Agenda Item: TBP50 .8/15 Attachment: K For: Information/Discussion By: Caroline Armitage, Chair Vincent Badu, Strategic Director of Social Care & Partnerships

MENTAL HEALTH ACT COMMITTEE SUMMARY REPORT

SUMMARY & PURPOSE

This report summarises the discussions and papers presented at the quarterly Mental Health Act (MHA) Committee held on 12 November 2015. The MHA Committee monitors Trust compliance with the Mental Health Act 1983, the Code of Practice 2008 and associated legislation.

Good governance requires the Board to be sighted of MHA activity and performance.

LINK TO ANNUAL PLAN

The Annual Plan objective(s) this paper relates to –

1.1 Safe Services 1.3 Effective Services 2.1 Improve services for people who use adult mental health services 2.2 Improve services for people who use specialist services

ACTION REQUIRED BY BOARD MEMBERS

This report is for information

MENTAL HEALTH ACT COMMITTEE SUMMARY REPORT

1.0 Executive Summary

The Committee received papers on:  Use of the Mental Health Act 1983 between 1 July 2015 – 30 September 2015, incorporating the use of Section 136 MHA report between 1 July 2015 – 30 September 2015  A summary of feedback from Associate Hospital Managers’ (AHM) feedback forms and Tribunal feedback forms  A report from care group service directors on MHA issues affecting respective areas of responsibilities

2.0 Introduction

This report informs the Board of MHA activity across the Trust, discussed at the MHA Committee on 12 November 2015.

3.0 Report

Use of the Mental Health Act 1983

The Committee received a detailed report on use of the MHA 1983 between 1 July 2015 – 30 September 2015 (hereinafter “Quarter 2”).

Quarter 2 reported:

 Use of Section 2 remained high and was used on 288 occasions, compared with 282 in the previous quarter. The use of Section 2 in this quarter is the highest section 2 activity seen by the Trust. Admissions under S2 accounted for the highest proportion of s2 activity actors the Trust (88%).

 In particular, Woodlands Unit for acute care accounted for 30% of the total section 2 activity in East Sussex. The Committee agreed the need to analyse the reasons for the peak in S2 activity at Woodlands and to present the data to CDS’s for review. In addition, the Committee supported the following action:

o Approach Research and Development colleagues for support to investigate the reasons for higher s2 activity in East Sussex. o Support from junior doctor colleagues to establish a research project to investigate clinical reasons for high s2 activity in East Sussex compared with other localities in the Trust.

o An open discussion with AMHP colleagues on whether training is supporting a use of s2 as an initial application, rather than s3. o The s2 data to be taken to and discussed at Quality Committee.

 The HSCIC’s annual report on ‘Inpatients formally detained in hospital under the MHA 1983 and patients subject to supervised community treatment’ in England and Wales 2014-15 was published end of October 2015. Annual figures from across England and Wales demonstrate a 22.3% increase in the use of s2 across the Country, whilst the trust has seen a rise of 5.6%.

 The Committee was pleased to receive detailed and comprehensive data on use of Section 136 around the Trust and the outcomes. There were, in total, 285 detentions under section 136 during the reporting period relating to 256 people (42 admitted to and remaining in Police custody, 234 into Hospital places of safety and 9 transfers between the two). This signifies a rise of 8% on the previous quarter, but a significant fall on the same period in 2014. The Committee was advised that the Trust is ahead of plan to reduce use of s136 by 50% in two years.

 The Committee was presented with data on MHA breaches in quarter 2 (11), the majority pertaining to use of s5(2). The Committee agreed the need for additional training for doctors on use of s5(2), supported by the Executive Medical Director.

AHM Feedback reports – Key themes

In the last quarter, feedback reports from both the AHMs and the Tribunal were received; a detailed report was received by the MHA Committee. The AHMs and Tribunal gave feedback on a variety of issues. In the last quarter, 45 feedback forms were received from the Tribunal, and 43 from the Associate Hospital Managers. A significant amount of good practice was observed relating to the quality of the reports and quality of evidence provided by the patient’s care team and knowledge of the patient. Good practice and any required improvements in practice has been reported to the relevant care group director or resolved immediately where possible. In particular the Committee was pleased to note the extremely positive feedback for staff at the Selden Centre who supported a patient through a Section 3 renewal hearing.

Issues reported centred around the detail of the report and repetition within and between reports. The Committee was assured that the current report templates reflect the Tribunal requirements as set out in the Practice Direction. An issue fed back by AHM colleagues around factual inaccuracy of a medical report was discussed and the Committee agreed further investigation to be conducted outside of the meeting into this matter.

The Committee discussed patient representation at AHM hearings, particularly where the panel are informed that the patient lacks capacity to make decisions about the hearing. The Committee asked the MHA Services team to explore the options for providing the panel with more information on how the patient has been supported to access advocacy services. This item will be tabled again at the next Committee meeting.

CQC Report

There have been seven MHA CQC inspections during the quarter. The Committee was advised that the number of MHA Monitoring visits has now increased to pre-wave inspection numbers this quarter. There was a noted improvement in Consent to Treatment issues raised and good practice in the area was highlighted in Coral ward, Langley Green Hospital. However, broader issues remain relating to patient participation in care planning, evidencing discharge planning, copies of section 17 leave forms being given to patients, and the recording of advance decisions.

The Committee discussed sharing positive practice. In particular the LD service informed the Committee of tools used that support patients to understand and be involved in their care. The Committee discussed establishing a knowledge hub to share information, materials and good practice.

MHA Committee Terms of Reference

The Committee reviewed the terms of reference and agreed the following amendments:

 Update job titles of permanent members of the Committee  Remove the need for a Non Executive Director Deputy Chair  Remove the need for two Non Executive Directors to attend Committee.

Revised terms to be circulated to the Committee for approval.

4.0 Recommendation/Action Required

This report is for information only.

5.0 Next Steps

This report is for information.

Board of Directors: 25 November 2015 – Public Agenda Item: TBP 51.1/15 Attachment: L For Decision By: Helen Greatorex, Executive Director of Nursing & Quality

Board Assurance Framework

SUMMARY & PURPOSE

Version 3 of the Board Assurance Framework (BAF) is presented to the Board of Directors for consideration. In addition to the board, the Audit Committee reviews the BAF at least twice a year.

The Trust’s internal auditors regularly review the BAF and its contents and recommend improvements. Attached as appendix 1, for the board’s information, is a summary of current recommendations.

Over the last quarter, work has been undertaken to further strengthen the BAF and respond to internal audit’s recommendations. As a result of this work, and attached for the Board’s consideration, is an example of a new summary of “Strong Assurance Mapping”.

One of the Trust’s current extreme risks has been used to populate the example for consideration. The board is asked to consider receiving at each meeting such a summary table for each of the current extreme risks. In this way, a clear line of sight to extreme risk is established at all board meetings, and assurance can be tested in relation to the mitigation in place. Movement of each extreme risk could also be easily tracked.

LINK TO ANNUAL PLAN

The BAF is set out against the annual plan’s headings

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to consider whether the content of the BAF is accurate. Board members are also asked to comment on the proposed improvement to reporting on extreme risks.

Board Assurance Framework 2015 - 16

Version 3: Nov 2015 Changes made to Version 2 in order to create V3 are shown in bold italics

Strategic Goals

1. Safe, effective, quality care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means

Contents Page

Assurance Framework

3.0 Key to Abbreviations 3

4.0 Board Assurance Framework 4

Appendices

A Likelihood Risk Rating

B Likelihood x Consequence/Impact Rating Table C Risk Radar

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3.0 Assurance Framework Key to Abbreviations

Organisations and Functions

MEWS Medical Early Warning Signs BbD Better by Design NHS LA NHS Litigation Authority BbE Better by Experience NICE National Institute for Health & Clinical Excellence CCG Clinical Commissioning Groups NIHR National Institute for Health Research CDS Care Delivery Service PBR Payment by Results CIP Cost Improvement Programme PEAT Patient Environment Action Team CMO Change Management Office R&D Research & Development CQC Care Quality Commission SGC Strategic Governance Group CQUIN Commissioning fo Quality & Innovation SMART Specific, Measurable, Achievable, Realistic and Time DLT Divisional Leadership Team specific EAC Executive Assurance Committee STAR Staff Time Attendance Rostering EHRC Equality Human Rights Commission SI Serious Incident EMB Executive Management Board TiA Transition in Action EOS Equality Objectives Scheme U1R Under One Roof FFT Friends and Family Test

HR Human Resources IM&T Information Management & Technology KPIs Key Performance Indicators LiA Listening into Action

Key Personnel

CAD – Clinical Academic Director CE – Chief Executive DS&I – Director of Strategy& Improvement EDCS – Executive Director Corporate Services EDFP – Executive Director of Finance & Performance EDNQ – Executive Director of Nursing & Quality EDSD – Executive Director of Strategic Development EMD – Executive Medical Director MDCS – Managing Director Core Services MDSS – Managing Director Specialist Services SDSC – Strategic Director of Social Care & Partnerships

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All Assurances shown are Positive Risk Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objective Key Controls Gaps in Control post achievement of Assurance Lead Impact Impact Ref Impact Treat-

Director Director objective) Independent Management Likelihood Likelihood Likelihood Likelihood ment

1. Safe Effective Quality Care 1.1 Deliver 5 Sign up to ED  Inadequate  SMART objectives  CCG  Progress  Inconsistent  Initial gaps Safety pledges: NQ capacity and  EAC reports feedback on reports compliance due to 1. Put safety first engagement  Clear plan with CQIN  Milestones  programme 2. Continually learn to deliver milestones achievement met setting up 3. Honesty  Quarterly Board  Perform- 4.Collaborate reports ance Mtgs 54 34 12 5. Support  Care Delivery Service Development  Integrate into CDS governance framework 1.2 Improving SD  Lack of  Agreed care  FFT  Audits of  In areas of high  Feedback experience for PS consistency pathways feedback care use of mechanism people who use C of approach  Clear standards pathway temporary not yet as services permits poor agreed adherence staffing, more sophisticate standards  Performance and difficult to d or fast as  Failure to quality assurance ensure we would 55 33 9 engage  Care Delivery consistent like. service Service approach users and Development and  Pace of CAG carers in co- CAGS– included development production of service user and care models carer input

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1.3 Achieve a  Lack of clear  Physical health   MEWS  In areas of high  CareNotes measurable baseline data strategy reports use of not yet improvement in and delivery  Matrons’ training  Physical temporary rolled out – physical health for plans to  Physical health Health staffing, more mix of those using our address 54 champions Strategy difficult to manual and 34 12 services needs  Care Delivery  CQUIN ensure electronic Service consistent records Development approach  CQUIN monitoring

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All Assurances shown are Positive Risk Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objectives Key Controls Gaps in Control post achievement of Assurance Lead Impact Impact Ref Impact treat-

Director Director objective) Independent Management Likelihood Likelihood Likelihood Likelihood ment 1.4 Continue to SDS  Failure to  Improvement Plan –  Reduction of  Bed Data  Level of long  None improve the Crisis CP deliver Crisis to include 5% in  Re-admission term investment identified Care Pathway Care Psychosis Care unplanned and length of from external Concordat Pathway readmissions stay data partners pledges  Crisis Care to hospital  Care Concordat Group within 28 Pathway  Concordat days of Audits Declaration discharge  136 Reports  Targets re Section  Feedback Data from 55  35 15 136 from partners admission  Street Triage (including audits  A&E Liaison Police)  Psychosis Masterclasses  Care Delivery Service Development

1.5 Improving the CAD  Failure to  Quarterly reporting:  Audit reports  Performance  CDS  CDS delivery of care as capture, 90% of actions are Meetings engagement in engageme a result of learning share and implemented by the  Report & recording nt in action from Clinical Audit test required agreed date Learn process planning changes  Quality Committee information  Accountability and re- reporting  CDS – Audit during CDS audit 33 23 6  All Care delivery Committees transition Service have audit lead.  Revision of the process / dashboard

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1.6 Successful CAD  Pace of  Service Plan  Internal audit  Timescales  System is new  As yet implementation of change not  Steering Group set are met to Trust untested Carenotes fast enough  Agreed Milestones  Staff fully in Trust  Slippage 45 Reports to EAC feedback 35 15 against  Care delivery implementat Service ion plan Development

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Director Director objective) Independent Management Likelihood Likelihood Likelihood Likelihood ment

2. Local Joined up Care 2.1 Joint working with DS&I Lack of  Identified exec team  CCG feedback  Performance  CCGs intentions  Realtime Commissioners to meaningful & leads for each CCG.  FFT feedback data re tendering patient ensure we meet the honest  Clear agreement  CDS feedback services feedback not needs of each local engagement 44 about priorities.  Reduction in yet available. 24 8

population  CDSs provide local complaints engagement  Stakeholder survey 2.2 Increase ownership EDFP CDS model fails  Validation process  Staff survey  LiA feedback  CDs are newly  Model is new and engagement of to deliver  Pairing with exec feedback  Milestone appointed, will to SPFT and clinical services by expected and non-exec  FFT feedback reports take time to untested. devolving decision benefits  Clear pathway  Stakeholder  EAC scrutiny orientate  Corporate Services survey  Production of  CDs are not yet in making to clinical 44 34 12 place everywhere teams. support business  Project support plans  Team development  Heatmaps project

2.3 Deliver evidence – MDA Pathways not  Clinical Academic  Internal audits  Audit reports  CDs are newly  CareNotes based clinical S agreed or Groups of adherence  Mini audits appointed, will not yet pathways MDS audited.  MDs’ objectives  Performance take time to implemented S  CD appointments reports orientate Pace of  CDs are not yet in progress while place everywhere CDSs develop. 44  CAG 44 16 accountability Process  Interface adopted by between CAGs CAGs to and CDSs. produce care pathways

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2.4 Establish local SDS Lack of a robust  2020 events  Audit of  Feedback  None identified  None community fora for C participation and  Meetings with CCGs meetings and reports identified receiving / listening involvement outputs  Stakeholder to feedback and strategy 44 Audit 34 12 reporting progress and improvement

2.5 Each Care Delivery MDS Capacity to  Exec and Non-Exec  Business plan  Timescale  Pressures on  None Service to have S deliver in the pairing scrutiny  Clear plan services vary identified their own business MDA midst of 44 Validation process  Authorisation 34 12 plan S competing  Project support Process demands

Director Director objective) Independent Management Likelihood Likelihood ent

3 Put research innovation and learning into practice

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3.1 Meet statutory CAD  Lack of take  Individual  MyLearning  Weekly  Sickness  CQC training up of objuectives reports update Absence, Inspection requirements MyLearning  Clear trajectory reports turnover rates feedback   EAC oversight  Supervision unpredictable  Board Reporting  Appraisals  Availability of local reports to enable compliance to be monitored  Availability of training 55 45 20 courses, ease of booking, volume of staff requiring training  Capability of My Learning system in first year of implementati on 3.2 Establish the CAD  Pressure on  Clear Plan - CAGs   Update  CAG  None Clinical Academic services and in place by end of reports by accountabilit identified Groups (CAGs) lack of clarify Quarter 1. Terms of CAG y during the results in reference and  Clear ToR transition to inertia 34 membership and outputs CDS 24 8 approved by Transformation Board.

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3.3 Develop and DSI  Insufficient  Improvement  Strategic  Update  None identified  None implement Trust capacity ot approach and partner reports Identified approach and ensure capabilities plan by feedback  Approach capabilities for universal end of Quarter 1  agreed and continuous buy-in 33 Strategic partner to implemented 23 6 improvement support continuous drawing on best improvement evidence and secured by end of methodologies. Quarter 2

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Director Director objective) Independent Management Likelihood Likelihood Likelihood Likelihood ment

4. Be the provider, employer and partner of choice 4.1 Improved staff EDC  Lack of  LiA implementation  Staff Survey  EAC reports  Variation in  Difficult to engagement S mgmt.  FFT feedback  Improved levels of assess capacity to  Survey informal commitment changes as 55 20-20 35 15 focus on Monkey feedback they change reports  Appraisal happen required  LiA reports 4.2 Development of EDC  Length of  Clear Chief Exec &  FFT  Leadership  Reliant on each  Not all skills and S time taken to team commitment  Staff Survey fora individual to activity is behaviours in line embed  Leadership  Survey understand and seen all the with our Trust’s behaviours development Monkey concur with time. values course values  Supervision 55 35 15  Appraisal feedback  Behaviours framework through OD Development  Appraisal uptake on My Learning

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Director Director objective) Independent Management Likelihood Likelihood Likelihood Likelihood ment

4.3 Recruiting and EDC  Shortage of  Workforce strategy  Reduction  Developing /  National  None retaining high S candidates  People Committee from 27% to implement- shortages identified calibre staff  Circle of oversight 20% of ting CDU-  Hard to work  Individual joiners based compete with pressures on objectives leaving in retention locations near wards  OD programme first 2 years strategies & Gatwick impacting on  Demand & by Q4 increasing retention Capacity  Reduction of opportuni- 55 Programme time to hire ties in hard 35 15 to 14 weeks to recruit by end of areas. Q4  Improving retention of staff in areas with very high turnover 4.4 Improving working EDC  Pressure on  Partnership Forum  Reduction in  Monthly  Current high  Indepen- environments and S services and work programme sickness reports (20%) turnover dent the wellbeing of financial  LiA absence days  Performance of joiners sources of staff challenge  Estates work lost to 3.5% meetings feedback makes this programme by end of Q4  Supervision (eg staff un-  Clear local  Appraisal survey) are deliverable  Improvement often 44 management feedback 33 9 plans in results of  LiA events published a  CDS business staff survey on consider- plans work able time  Leadership pressures after discussions from 3.28 to completion  2020 priorities 3.07 (National – time lag average) therefore.

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All Assurances shown are Positive Risk Principal Risk unless marked Negative (-ve) Trust Rating (to Gaps in Risk Objectives Key Controls Gaps in Control post achievement of Assurance Lead Lead

Ref Impact Impact treat-

Director Director objective) Independent Management Likelihood Likelihood ment 4.5 Delivering EDF  Capacity of  KPIs agreed  Governance  Regular  Newly  System as intelligent P performance information for the review report reports introduced yet workforce team to CDS’s dashboard  CQC  Managers system will take untested. information deliver to ensure inspection feedback time to embed triangulated with  Lack of triangulation of feedback  Accurate quality and support from information. identification 33 9 financial data to CDS to use  Review dashboard of trends determine data to  EAC scrutiny and risks trends/risks improve  Clinical senate patient and staff experiences

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Director Director objective) Independent Management Likelihood Likelihood ment

5. Living within our Means 5.1 Maintain sound EDF  Failure to  Budget management  Q1 Monitor  Specialist  Agency and  Reporting financial P deliver meetings and scrutiny rating Services private bed from performance to investment at all levels  Internal Audit savings spend is agencies deliver financial stragegy  Daily ICD 1 conf call reports delivery unpredictable not sent governance and resulting in meeting  External Audit  Private bed due to clinical immediately stability organisation’l  Bed pressures actio use need and out of . vulnerability plan reduction hours pressure.  Failure to  Ward spend action  Improveme  Lack of real deliver plan nt in time reporting service  Agency review group Rosterpro on agency redesign and  Clear communication use. usage. achieve CIP 55 plan and consistent  CDSs and  Incomplete 45 20  Lack of messaging clinical compliance & operational  Adult Services ownership grip. grip on detail redesign of delivery  CDS implementation plan –  F&I Committee locally  EAC scrutiny driven  Budget manager training,  Salary  Over payment control and triggers

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5.2 Fully deliver the EDF  Failure to  Chief Exec team  Q1 Monitor  Budget  Pace of change  Not all agreed Cost P deliver plans objective rating reports is affected by agreed Improvement or find  Individual objectives  Internal Audit showing multiple, plans Programme. alternative  EAC scrutiny reports some simultaneous delivering schemes to  Next in line meeting  External Audit savings pressures yet. meet shortfall  Budget reports delivered  Incomplete  Budget forecasts  compliance and 45 45 20  Budget manager grip. training,   Salary  Over payment controls and triggers  5.3 To meet EDF  Increasing  Performance  CCG  Internal  Unpredictable  None contracted levels P demands on meetings Reports reports peaks in identified of performance services  CCG performance  Internal audit  Board demand  Failure to meetings reports reports  Availability of identify early 55  Performance reports workers to 53 15 shortfall in  SD & CDs resolve performance objectives shortfalls  Supervision

5.4 To improve EDC  Admin  Clear programme  Other areas  Key  Some staff  None effectiveness and S Services  Exec Leadership where this milestone may leave identified efficiency of our review fails  Comms plan model has met during the admin services to deliver worked. process  Timing coinciding with other 44 24 8 key programmes such as CareNotes implement- tation

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Appendix A LIKELIHOOD RISK RATING

Likelihood Rating is a matter of personal judgement; the table below provides some structure to aid thinking.

Likelihood Descriptor Score This type of event will happen or certain to occur in the future, (and Certain frequently) 5

This type of event may happen or there is a 50/50 chance of it happening High again 4 probability This type of event may happen again, or it is possible for this event to Possible happen (occasionally) 3

This type of event is unlikely occur or it is unlikely to happen again (remote Unlikely chance) 2

Rare Cannot believe this type of event will occur or happen again (in the 1 foreseeable future)

Appendix B

Table LIKELIHOOD X CONSEQUENCE/IMPACT = RISK RATING

Assess the likelihood of the occurrence and multiply by the likely impact to arrive at a rating CONSEQUENCES / IMPACT Insignificant Minor Moderate Major Catastrophic (1) (2) (3) (4) (5) Certain (5) 5 10 15 20 25 High probability (4) 4 8 12 16 20 Possible (3) 3 6 9 12 15 Unlikely (2) 2 4 6 8 10 LIKELIHOOD

Rare (1) 1 2 3 4 5

Low Moderate High Extreme 1 – 3 4 – 6 8 – 12 15 – 25

BOARD ASSURANCE FRAMEWORK 2015-16 TRACKER

(This tracker sets out changes made to Version 2 in order to create Version 3)

November 2015

Trust risk Change Rationale No. 1.1 Added under Key Controls,: Integrate into CDS Essential control, key role of CDSs Governance framework

1.2 Added under Key Controls: and CAGs included Their involvement was essential in service user and carer input addressing the risk of failure to engage 1.2 Added under Gaps in Control,: Pace of CAG CAGs need to develop at different development rates. This creates a gap in control

1.3 Added under Key Controls, CQUIN Monitoring An important element of control

1.4 Added under Key Controls, : As above, important elements of  Improvement plan to include Psychosis Care additional risk control Pathway  A&E Liaison  Psychosis Master-classes

1.5 Added underKey Controls, : Revision of the As CDSs develop, their influence on process/Dashboard the control, mitigation and reporting Added under Management Assurance, : CDS – Audit of risks becomes more apparent Committees and critical. Added under Gaps in Control,:  CDS engagement in recording process  Accountability Added under Gaps in Assurance, : CDS engagement in action planning and re-audit

1.6 Added under Principal Risk,: Slippage against Newly identified Principal Risk given implementation plan. decision to revise AMHS implementation date. 2.1 Added under Key Controls : Both key controls in relation to joint  CDS provide local engagement working objective  Stakeholder survey  2.2 Added under Key Controls : Team Development New sources of control and Project assurance identified Added under Independent Assurance: Stakeholder survey Added under Management Assurance, :  Production of business plans  Heatmaps

2.3 Added under Gaps in Control, Pace of progress with work to  CAG accountability develop and evidence, evidence  Interface between CAGs and CDSs based clinical pathways is not as Risk Ratings adjusted; Pre treatment to 5x4. Post fast as anticipated. Revision of Care treatment likelihood increased to 4 Notes implementation date for Change Risk rating post treatment to Red - Extreme AMHS adds risk.

2.4 Under Gaps in Control, add: Stakeholder audit.

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3.1 Added under Gaps in Control, Failure to meet agreed My Learning  Availability of local reports to enable compliance targets in Q1 and Q2, result in to be monitored significant risk. Risk rating  Availability of training courses, ease of booking, increased to Extreme. volume of staff requiring training  Capability of My Learning system in first year of implementation Change Likelihood to 4 Change Risk Rating post Treatment to 20

3.2 Added under Gaps in Control, CAG accountability Newness of CDS and CAG during the transition to CDS. interface creates risk.

4.2 Added under Key Controls,: Appraisal uptake on My My Learning permits recording of Learning. appraisal offering improved control.

5.1 Added under Key Controls, New controls in place  Daily ICD 1 conference call meeting  Bed pressures action plan  Ward spend action plan. Added Under Management Assurance: New sources of management  Improvement in Rosterpro use. assurance  CDSs and clinical ownership of delivery plan – locally driven.

Page 2 of 2 Board Assurance Framework V1 2015/16 – Risk Radar – July 2015 (showing risk grading)

1. Safe, Effective Quality KEY: Care  Shows movement from last 2 version. 5. Living within our 3  Indicates risks with an impact of means ‘4-severe’ and ‘5-catastrophic’ 4 1. Quality  Objective 5

6 2.1  Sub-objective 1.5 8 2 - 5.4 25  2 – 25 indicate risk rating 9 1.2 10

12 1.1 1.3 5.3 15 1.4 16 1.6 52 2.1 20 5.1 2. Local, joined up care 25 2.2 4.5 43 2.3 4.2 3.1 4.4 41 2.4 4. Be the Provider, 2.5 Employer & Partner of Choice

3.2

3.3

3. Put research, innovation & learning into practice

5.4

Risk Radar Key to Abbreviations

1. Safe Effective Quality Care 1.1 - Deliver five Sign up to Safety Pledges 1.2 - Improving experience for people who use services 1.3 - Achieve a measurable improvement in physical health for those using our services 1.4 – Continue to improve the Crisis Care Pathway 1.5 – Improving the delivery of care as a result of learning from Clinical Audit 1.6 – Successful implementation of CareNotes 2. Local Joined up Care 2.1 – Joint working with Commissioners to ensure we meet the needs of each local population 2.2 - Increase ownership and engagement of clinical services by devolving decision making to clinical teams 2.3 – Deliver evidence-based clinical pathways 2.4 – Establish local community for a for receiving and listening to feedback and reporting progress and improvement 2.5 – Each Care Delivery Service to have their own business plan 3. Put Research, Innovation and Learning into Practice 3.1 – Meet statutory training requirements 3.2 – Establish the Clinical Academic Groups (CAGs) 3.3 – Develop and implement Trust approach and capabilities for continuous improvement, drawing on best evidence and methodologies 4. Be the Provider, Employer and Partner of Choice 4.1 – Improved staff engagement 4.2 – Development of skills and behaviours in line with our Trust’s values 4.3 – Recruiting and retaining high calibre staff 4.4 – Improving working environments and the wellbeing of staff 4.5 – Delivering intelligent workforce information triangulated with quality and financial data to determine trends/risks 5. Living Within our Means 5.1 – Maintain sound financial performance to deliver financial governance and stability 5.2 – Fully deliver the Cost Improvement Programme 5.3 – To meet contracted levels of performance 5.4 – To improve effectiveness and efficiency of our office services.

Appendix 1

Internal Audit BAF Review Observations and Trust Response

Internal Audit Report Observation Trust Response Internal Audit’s Recommended Timescale for Resolution (Low Priority) National best practice under consideration in By April 1st 2016 The levels of inherent risk are not detailed on combination with Monitor and Care Quality the BAF. This leads to a risk that management Commission documents on risk and risk cannot make informed risk mitigation decisions management based on how inherent a risk is.

(Low Priority) New negative assurance column to be included By April 1st 2016 There is no area within the BAF to detail from Version 4. negative assurances, as opposed to positive assurances. This leads to a risk that negative assurances are not being monitored which could affect management decision making.

(High Priority) New Quality Committee standing agenda item By 31.12.15 Through review of agendas and minutes, we Key Strategic Risks (and links to BAF) were unable to confirm evidence demonstrating performance monitoring by the Quality Committee.

16 November 2015 Strong Assurance Mapping

Strategic Objective 3. Put research innovation and learning in to practice Committee: People Committee 3.1 Meet statutory training requirements Risk Owner: Clinical Academic Director Date last reviewed: October 2015 Risk: Lack of take up of My Learning Current Risk Rating:RED

Residual Risk: RED

Rationale for current score: 25  Planned trajectory not met for Q1 and Q2, feedback from services is that the system is not yet perfect

20 Controls/Influences: (What are we currently doing about the risk?) 15  New trust-wide dashboard introduced Oct 2015 Risk Appetite  Revised reporting to People Committee showing performance by training subject 10 Target Risk  Frequency of required training reviewed and revised in line Actual Reported risk with national guidance 5  Executive Assurance Committee monitoring progress

0 Gaps in controls/influences:  Real time reporting not yet fully robust  Pressures on services result in some difficulty in releasing

staff  Booking for some courses not available through MyLearning

Clear linking of strategic Clear format, not Long term trend of risk outlined, Appropriate level of Rationale for inclusion objectives to risks necessarily tabular graphical output aids clarity detail & current score

Board of Directors: 25th November 2015 – Public Aggenda Item: TBP51.2/15 Attachment: M For Information By: Tim Masters, Non-Executive Director and Committee Chair

AUDIT COMMITTEE SUMMARY REPORT

SUMMARY & PURPOSE

This report provides a summary of the papers and discussions held at the Audit Committee meeting held on 2nd November 2015.

The Audit Committee is responsible for monitoring and reviewing matters such as the integrity of financial statements, internal controls and overseeing the internal audit function. It is also focused on providing assurance to the Board that the systems and processes are functioning effectively (so that the Board is discharging its duty) and that those committees that are reviewing quality information in more detail are doing so effectively. The Audit Committee’s annual work plan is designed to cover these responsibilities and sets the agenda for each meeting, which is built around the following areas:-

• Risk Management • Governance • Financial Controls • Acccountability • Self-Assessment

Minutes of the meeting are circulated to all Board members.

LINK TO ANNUAL PLAN

The Audit Committee acts on behalf of the Board to review audits designed to assess whether or not management’s systems and processes are working effectively and support the delivery of the Trust’s annual plan. Additionally the Committee reviews management’s preparation of the Board Assurance Framework, to assess whether oor not risks and mitigating controls are properly reported and reflect the Trust’s planned activities.

ACTION REQUIRED BY BOARD MEMBERS

The Board is asked to note the contents of the summary report and address any questions to the Chair of the Audit Committee.

AUDIT COMMITTEE SUMMARY REPORT

This report provides a summary of the papers and discussions held at the Audit Committee meeting held on 2nd November 2015. It should be noted that there was no the governor representative at the meeting.

The Committee received papers including:-

• Risk Management - progress reports from the Internal Auditors and Local Counter Fraud Service - Risk Register Summary – Top 5 Risks by Division - Summary from the Executive Assurance Committee - Compliance Summary • Financial Controls - Review of Losses & Special Payments - Debtor & Creditor Balances over £5k & over 6 months old • Accountability - Preparation for the Committee’s annual Self-Assessment & Other Matters - Audit Committee Terms of Reference - Data Quality Update - Update on Information Governance

2.0 Introduction

This report summarises the detailed discussions of the Committee. Information which is confidential to the Trust or its employees is not included in the report.

3.0 Report

The Audit Committee in November included agenda items covering a number of areas across risk management, accountability and assurance and included discussion of the following reports. The Committee acknowledged the appointment of KPMG as the Trust’s new external auditors and welcomed Neil Hewitson, Engagement Director to the meeting. The Committee also noted that Gordon Ferns, Non-Executive Director (NED) has agreed to stand in as the third member of the Committee, whilst recruitment to the vacant NED posts takes place.

Internal Audit Update Report on progress being made to deliver the 2015/16 internal audit plan – the Trust’s Internal Auditor presented an update on the progress being made to deliver the Internal Audit Plan for 2015/16. The report highlighted 32% of the audit plan had now been completed, 23% of assignments were in progress and 45% were not due to start before the last five months of the financial year. Since the last Committee meeting two further reports had been completed with the opinion issued are set out in the table below:-

Assignment Opinion Issued Clinical Information Systems Project Management Amber/ Green Cost Improvement Planning - Design & Application Amber / Red - Effectiveness Red

The Committee noted that the Cost Improvement Report had already been discussed in detail at the October Finance and Investment Committee therefore the Committee summarised the key outcomes it was anticipating arising from the findings of the report. These were:

(i) Evidence of robust accountability and project management in the delivery of cost saving measures for the remainder of 2015/16 financial year. (ii) Evidence of effective turnaround of the weakest performing Care Delivery Services; and (iii) Clearly defined lines of accountability and performance management in the financial plans for 2016/17. (iv) It was agreed that the re-audit of these areas would take place in the last quarter of this financial year, with the anticipation that it would provide evidence of improvement of the Trust’s effective use of resources. (v) The Internal Auditors also advised that they had recently provided the Trust with some benchmarking data from all of their mental health clients. It was agreed that the Internal Auditors would organise a forum inviting the mental health trusts to share their ideas for efficiency savings programmes.

The Committee noted the comment from the Internal Auditors that they were pleased to give the amber / green opinion for the Clinical Information Systems Project Management audit, as it demonstrated that the Trust had made a significant improvement in this area.

The Committee also discussed the request from the Council of Governors (CoG) to audit the Trust’s provision of occupational therapy in its in-patient services. The Internal Auditors confirmed that they would be happy to support this work and have appropriate skills within their team to perform the audit.

Local Counter Fraud Service (LCFS) – the Committee received an update on the progress being made to deliver the LCFS plan for 2015/16. Proactive work has included monthly meetings between Finance and Human Resources, Fraud and Bribery awareness training, a local proactive exercise to review losses and compensation claims, participation in the National Fraud Initiative and a policy review of the Trust’s IT & Information Security and Travel Costs Reimbursement policies, providing feedback on the strengthen the policies and associated processes.

The Trust’s LCFS Manager also updated the Committee on the national concern regarding cyber fraud. It was noted that a particular case in the NHS had been highlighted to the Trust IT department and LCFS will be meeting with them to discuss how to mitigate against these type of risks.

The LCFS report also included details of the progress being made on reactive cases, with no new referrals received since the last meeting. 10 cases were carried forward, of which 5 of these have since been closed, with the final reports due to be issued imminently. The Committee also reviewed the newly developed Counter Fraud Recommendation Tracker.

Risk Register Summary – Top 5 Risks by Division The Committee were informed that the Quality Committee regularly receive an update from each Clinical and Service Director of the Care Delivery Services (CDSs) setting out the top risks for their service. However, the Audit Committee considered how they could seek assurance that controls and mitigations are in place to address the main risks in the CDSs. It was agreed to ask the internal and external auditors to assist with this work, in ensure that a reporting mechanism is in place in the near future.

Summary from the Executive Assurance Committee – the Committee received an update from the Executive Assurance meeting held in October, noting that the key items on the agenda were progress against CQC Compliance actions, delayed transfers of care, the quarter 2 financial position and development of the Care Delivery Services. The Committee noted that the Executive Assurance Committee was proving to be a very useful forum and provided the Committee with assurance that the Executive Team had sight of the key issues in the Trust. Compliance Summary - the Committee received an update on compliance statistics, noting that the latest report showed a similar position to that previously reported with a high level of non- purchase order activity and no reduction in the number of salary overpayments. The Committee requested that given these on-going concerns that a much more wide ranging financial compliance

report for each Care Delivery Service and Corporate Service is presented at the next Committee meeting.

Preparation for the Committee’s annual Self-Assessment Survey - The Committee reviewed the draft questions for the annual Audit Committee Self-Assessment survey and it was agreed that the questions and format used for the previous year would be used for the 2015 survey. The Committee also agreed to ask the Audit Committee Governor representatives to complete the survey.

The Committee noted the questionnaire would be circulated via Survey Monkey to members of the Audit Committee, Trust Chair, Chief Executive, all Non-Executive Directors and Audit Committee Governor representatives, with the results of the survey being presented to the Committee in January.

Audit Committee Terms of Reference The Committee undertook its annual review of the Terms of Reference. It was noted that the Board Governance review had highlighted that it may not be best practice for the Chair of the Finance and Investment Committee, to be the vice chair of the Audit Committee. This was noted and will be given further consideration once the review of the Board sub-committees and appointment to the non-executive vacancies is complete. Other than the changes to the membership, the Committee agreed the Terms of Reference.

Other Reports The Committee received and discussed a number of other papers including the regular review of Losses and Special Payments and debtor and creditor balances over £5k and 180 days old.

The Committee also received reports on Data Quality and Information Governance that were referred to the Quality Committee to action.

4.0 Recommendation/Action Required

The Trust Board is asked to note the contents of the summary report and address any questions to the Chair of the Audit Committee.

The reports on Data Quality and Information Governance have been referred to the Quality Committee to action.

5.0 Next Steps

The next Audit Committee is due to be held on 26th January 2016.