COUNCIL of GOVERNORS Monday 13 July 2020 10.00Am Via Microsoft Teams

COUNCIL OF GOVERNORS Monday 13 July 2020 10.00am via Microsoft Teams

AGENDA

ITEM ACTION PRESENTED BY TIME 01 Welcome and Introductions To Note Rupert Nichols, Chair 10.00am 02 Apologies for Absence To Note Rupert Nichols, Chair 03 Declarations of Interest in Agenda Items To Note All 04 Minutes of the Council of Governors To Approve Rupert Nichols, Chair 10.05am Meetings held 10 February 2020 and 12 May 2020 05 Matters Arising and Action Log To Note Rupert Nichols, Chair 06 Chair and Chief Executive’s Brief – COVID-19 To Note Rupert Nichols, Chair and Neil 10.10am Update Thwaite, Chief Executive 07 Governor Open Forum To Note All 10.30am

Governors are invited to share feedback from any meetings/events they have been involved in recently in their local communities

STRATEGY 08 Presentation - Park House Development To Note Andrew Maloney, Director of HR 10.35am / Deputy CEO 09 Draft Membership Engagement Strategy To Note Maureen Burke, Lead Governor 11.05am 2020 – 2023 and Steph Neville, Head of Corporate Affairs

QUALITY AND GOVERNANCE 10 GMMH Quality Account 2019/20 To Note Gill Green, Director of Nursing 11.15am and Governance 11 Appointment of Lead Governor To Ratify Rupert Nichols, Chair 11.25am

WORKING GROUP AND COMMITTEE REPORTS 12 Nominations Committee: 11.30am

12.01 - Re-appointment of Julie Jarman, To Approve Rupert Nichols, Chair Non-Executive Director

12.02 – Notes of the Nominations To Note Rupert Nichols, Chair Committee Meeting held 30 June 2020 13 Committee and Working Group Membership To Note Rupert Nichols, Chair 11.35am

BOARD OF DIRECTORS 14 14.01 – Ratified Minutes of the Board of To Note Rupert Nichols, Chair 11.40am Directors Meeting Held in Public on 21 May 2020

14.02 – Chair’s Report on Part 2 Items To Note Rupert Nichols, Chair (Verbal)

14.03 – Governor Feedback on Board of To Note All Directors Meetings (Verbal)

ANY OTHER BUSINESS 15 Any Other Business To Note All 11.45am

DATE AND TIME OF NEXT MEETING

The next Council of Governors’ Meeting will take place on Monday 14 September 2020 at 10.00am. As it currently stands, this meeting will be held remotely via Microsoft Teams.

Council of Governors

TITLE OF REPORT: Minutes of the Council of Governors Meetings held 10 February 2020 and 12 May 2020 DATE OF MEETING: Monday 13 July 2020 AGENDA ITEM: 04 PRESENTED BY: Rupert Nichols, Chair AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: The Council of Governors are asked to review and approve the minutes of the last formal Council of Governors meeting held on 10 February 2020 and the notes of the briefing session held on 12 May 2020.

RECOMMENDATIONS: To approve

UNRATIFIED

COUNCIL OF GOVERNORS MEETING, MONDAY 10 FEBRUARY 2020 AT 10.00AM, CONFERENCE ROOM 7, GROUND FLOOR, THE CURVE

PRESENT:

COUNCIL OF GOVERNORS: Rupert Nichols - Chair Anita Arrigonie - Staff Governor (Non-Clinical) Rob Beresford - Public Governor (Other England and Wales) Maureen Burke - Public Governor (Salford) Nayla Cookson - Public Governor (City of Manchester) Stuart Edmondson - Staff Governor (Nursing) Nasur Iqbal - Staff Governor (Psychological Therapies) Jane Lee - Staff Governor (Allied Health Professionals) Iris Nickson - Public Governor (Trafford) Lesley O’Neill - Staff Governor (Nursing) Nathan Prescott - Service User and Carer Governor Dan Stears - Service User and Carer Governor David Sutton - Public Governor (Salford)

IN ATTENDANCE: Anthony Bell - Non-Executive Director Gill Green - Director of Nursing and Governance Ismail Hafeji - Director of Finance and IM&T Mary Lee - Associate Director of Development and Performance Andrew Maloney - Director of HR / Deputy CEO Tony Morrison - Assistant Director, Research and Innovation Steph Neville - Head of Corporate Affairs Caroline Pickwell - Marketing and Communications Manager Kim Saville - Company Secretary Alice Seabourne - Medical Director Neil Thwaite - Chief Executive

No. Item Action 01/20 Welcome and Introductions Noted

Rupert Nichols, Chair welcomed all those in attendance to the meeting. 02/20 Apologies for Absence Noted

Apologies for absence were received from the following Governors:

• Angela Beadsworth – Public Governor (Other England and Wales) • Stewart Lucas – Appointed Governor (VCSE Sector) • Albert Phipps – Lead Governor / Public Governor (Bolton) • Margaret Rowe – Appointed Governor (University of Salford) • Margaret Willis – Service User and Carer Governor • Rick Wright – Staff Governor (Social Care)

Apologies for absence were also received from:

• Helen Dabbs – Non-Executive Director • Liz Calder – Director of Performance and Strategic Development • Stephen Dalton – Non-Executive Director • Andrea Harrison - Non-Executive Director • Julie Jarman – Non-Executive Director • Pauleen Lane, Non-Executive Director • Deborah Partington - Director of Operations 03/20 Declarations of Interest in Agenda Items Noted

There were no declarations of interest in agenda items. 04/20 Minutes of the Council of Governors Meeting held 9 December 2019 Approved

The minutes of the previous meeting of the Council of Governors held on 9 December 2019 were accepted as a true and correct record. 05/20 Matters Arising and Action Log Noted

The Council of Governors noted the progress made against the agreed actions. 06/20 Chair’s Report to the Council of Governors (February 2020) Noted

Rupert Nichols presented his Chair’s Report for February 2020. He highlighted the following key items of interest:

• General Election and Queen’s Speech – The Queen’s Speech on 19 December 2020 introduced three bills directly related to health and social care (NHS Funding Bill, Health Safety Services Investigations Bill and Medicines and Medical Devices Bill). Rupert Nichols advised that the government has also signalled its intention to introduce draft legislation to implement the NHS Long Term Plan.

• People Changes – Sarah Price has been appointed as Interim Chief Officer of the Greater Manchester Health and Social Care Partnership following Jon Rouse’s departure at the end of January 2020.

• Council of Governors Elections – The deadline for receipt of completed nominations closed on 3 February 2020. 31 nominations have been received for the 14 seats up for election, with all but two of the seats (Public – Trafford and Staff – Social Care) contested. Voting in the elections will close on 12 March 2020. Rupert Nichols extended thanks on behalf of the Board of Directors for the contributions of those governors who have chosen not to stand again in the current elections: namely, Albert Phipps, Rob Beresford, Nasur Iqbal, Victoria Sullivan and Anita Arrigonie.

• Director of Finance and IM&T – Ismail Hafeji is retiring from his role as Director of Finance and IM&T at the end of March 2020, having worked in NHS finance since 1983 and as an Executive Director at the Trust since 2011. Rupert Nichols thanked Ismail Hafeji for his skilled financial leadership and dedication to the Trust over the last nine years, highlighting in particular his contribution to the successful acquisition of Manchester Mental Health and Social Care NHS Trust. He advised that Suzanne Robinson, current Director of Finance and Deputy CEO at Pennine Care NHS Foundation Trust, has been appointed as Ismail Hafeji’s successor following a thorough recruitment process involving the Trust’s service user and carer governors.

• Appointment of GMMH’s First Rabbi – Rabbi Dr Chanan Tomlin MBE has been appointed as the Trust’s first rabbi. Working as part of the Trust’s Chaplaincy Team, Rabbi Dr Tomlin will support service users across the Trust with their religious and spiritual needs.

• BAME (Black, Asian and Minority Ethnic) Staff Network – All governors are welcome to attend BAME Staff Network meetings. Rupert Nichols highlighted the 2020 meeting dates.

Neil Thwaite, Chief Executive briefed the Council of Governors on his participation in a panel event organised by Salford Mental Health Forum and chaired by Dan Stears, Service User and Carer Governor on 30 January 2020. Other panel members included Andy Burnham (Mayor of Greater Manchester), Paul Dennett (Mayor of Salford), Barbara Keeley (MP for Worsley and Eccles South) and Markus Greenwood (CEO of Mind in Salford). The event provided opportunity for service users, carers and members of the public to ask a wide range of questions about mental health provision in Salford.

In response to a question from Nathan Prescott, Service User and Carer Governor, Kim Saville advised that every effort is made to understand the different reasons why governors choose not to stand again. These range from 3

personal reasons to changes in other commitments. She provided assurance that any learning from governors’ experiences is taken into account when planning elections and governor activities.

The Council of Governors noted the Chair’s Report for February 2020. 07/20 Presentation – Research and Innovation Noted

Alice Seabourne, Medical Director and Tony Morrison, Assistant Director (Research and Innovation) provided an overview of mental health research nationally and at the Trust. Alice Seabourne identified research and innovation as the middle pillar of the Trust’s over-arching Trust Strategy 2019 – 2024, with a focus on achieving the best outcomes through translating research into clinical practice.

In response to a question from Iris Nickson, Public Governor – Trafford, Alice Seabourne summarised the sources of funding for research and innovation. Tony Morrison confirmed that the majority of funding is issued by the National Institute for Health Research) and research councils. He noted the disproportionate funding (spend per person) for mental health research compared to physical health research. Alice Seabourne committed to sharing information with governors on the total spend on mental health research Action: AS compared to cancer research.

Tony Morrison outlined why research and innovation is important for service users and carers from a clinical and recovery perspective. He highlighted the importance of co-production of research with service users, service user groups and communities. Dan Stears shared his positive experience of involvement in research, including in terms of taking the opportunity to help others by increasing knowledge and the evidence base.

Alice Seabourne advised that over 1,000 service users have taken part in Trust research during 2019/20 to date. She noted that this position is positive, but the number remains relatively low compared to the Trust’s total number of service users. Neil Thwaite recognised that the Trust can do more but confirmed that the Trust remains one of the country’s most research active mental health trusts.

Iris Nickson sought understanding as to service drop-out rates from research studies. Alice Seabourne outlined the Trust’s current approach to recruiting service users to research projects.

Nasur Iqbal, Staff Governor – Psychological Therapies, questioned whether research is skewed towards particular service user populations or therapies as this may impact on service user involvement. Tony Morrison advised that a relatively high proportion of current studies are focused on psychosis, due to targeted NHS and government funding, and also cognitive behavioural therapies.

Alice Seabourne outlined the Trust’s future ambition to be able to offer everyone

the opportunity to take part in research if they want to. She also summarised why research is important for the Trust’s staff from a clinical perspective and in terms of personal and professional development.

Jane Lee, Staff Governor – Allied Health Professionals, suggested that establishing a more effective feedback loop from the Research and Innovation Team to the frontline would enable more research to be put into practice. Alice Seabourne acknowledged this point and confirmed that more effective communication will be a key priority in the refresh of the Trust’s Research and Innovation Strategy. Stuart Edmondson, Staff Governor – Nursing, highlighted the challenge of building capacity in clinical teams for engagement in research and innovation. David Sutton suggested the value in identifying ‘Research Champions’ in each division.

Neil Thwaite advised that the Board of Directors meeting in public receives regular updates on progress in implementing the Trust’s Research and Innovation Strategy. He has asked for future updates to include case studies demonstrating the impact of research into practice.

Maureen Burke, Public Governor – Salford, referenced the Care Quality Commission’s recent feedback on supervision, culture and environment. Tony Morrison confirmed that there are increasing opportunities to undertake more socially-focused research, including in these areas.

In response to a question from Nayla Cookson, Public Governor – City of Manchester, Alice Seabourne provided assurance with regard to the application of exclusion and inclusion criteria for case studies and how service user capacity to participate is tested.

In response to a question from Lesley O’Neill, Staff Governor – Nursing, Tony Morrison advised that a relatively small proportion of the Trust’s current research is focused on nursing. The Trust is, however, working with the University of Manchester to develop a Mental Health Nursing Research Unit.

Alice Seabourne provided an overview of the Trust’s six current research units, noting that the Psychosis Research Unit is the most well-established. She also circulated a list of current studies to governors and encouraged interested governors to complete the Talking with Voices survey.

Alice Seabourne and Tony Morrison thanked the Council of Governors for their helpful feedback and committed to looking into all suggestions/ideas put forward Action: by governors. AS/TM 08/20 Presentation – Forward Planning - Our Strategy and Priorities for 2020/21 Noted

In line with the Trust’s statutory duty under the Health and Social Care Act 2020, Mary Lee, Associate Director of Development and Performance sought the views of governors on the Trust’s forward plans. She set the context for the discussion

5 with reference to the mental health commitments set out in the NHS Long Term Plan, the refreshed Greater Manchester Health and Wellbeing Strategy 2020 – 2024 and the Trust’s over-arching Strategy 2019 – 2024. She advised that the Trust has contributed to the refresh of the Greater Manchester Health and Wellbeing Strategy and that the Trust’s strategy is aligned with the national and regional direction of travel. The Trust’s five-year strategy forms the basis of the annual Operational Plan 2020/21, which is being developed in line with Operational Planning and Contracting guidance from NHS England and NHS Improvement. Mary Lee summarised the key points from the national guidance, including the approach to systems planning, mental health deliverables and the changes to the financial recovery fund rules and financial reward scheme to enable more effective upfront planning. Mary Lee summarised the Trust’s business planning process, which is complete and informs the development of the Trust’s Operational Plan and its contribution to the system-led narrative plan, and the timescales for finalising both plans. The deadline for submitting the final Trust Operational Plan 2020/21 and system-led narrative plan is 29 April 2020.

Mary Lee sought the views of the Council of Governors on the Trust’s key priorities for progression during 2020/21 either at the meeting or via email ([email protected]) outside of the meeting.

Jane Lee welcomed the increased investment in specialist mental health services, but questioned whether additional investment will also be forthcoming for ‘backbone’ community mental health services, including Community Mental Health Teams (CMHTs). She referenced the challenges faced in CMHTs relating to high caseloads and staff turnover. Mary Lee provided examples of quality improvement work underway or being planned to support the Trust’s community mental health services to increase productivity and enable more face to face contact with service users.

Iris Nickson questioned the identification of falls reduction as a key quality improvement priority for the Trust. Alice Seabourne provided a rationale for this, including in terms of the impact falls can have on mental health care provision.

Iris Nickson also sought information on the Trust’s future recruitment strategy, specifically in terms of nursing. Andrew Maloney, Director of HR / Deputy CEO advised that workforce supply remains one of the biggest challenges nationally. A clear workforce plan to support the Long Term Plan investment is awaited. Andrew Maloney provided assurance that the Trust is focused on establishing as many supply lines as possible – including by growing its own workforce - and is also continuing to influence the system at a regional and national level. Gill Green, Director of Nursing and Governance, reference the new ways of working and new roles being introduced by the Trust, including Nurse Associates, to help address this challenge. She also advised that the Trust has well-established relationships with its ‘feeder’ universities and that all have fully recruited to their nursing degree courses for this academic year. This is understood to be a positive position compared to other universities. Jane Lee highlighted the opportunity to

review the wider skill mix and also briefed the Council of Governors on occupational therapies apprenticeships.

Dan Stears opened a discussion as to the impact on Trust policy on the capacity of staff to deliver person-centred care. Alice Seabourne advised that Trust policies have been developed with a view to enabling service user involvement in co-producing care. Nathan Prescott referenced the results of the Trust’s most recent Community Mental Health National Patient Survey in this context and sought understanding as to how learning from the Survey is taken forward. Neil Thwaite advised that the Trust commissions an extended sample – i.e. over and above the relatively small mandated sample of 850 - to enable more meaningful results and targeted action. In response to a query from Iris Nickson, Neil Thwaite confirmed that the Patient Survey sample is selected randomly.

Nathan Prescott, Service User and Carer Governor sought an update on action taken to enable outpatient access to the Friends and Family Test. Gill Green confirmed that the Friends and Family Test is being completed in community services, but further work is required to improve access to and collection of feedback in Manchester. She advised that the Trust is preparing for changes to the Friends and Family Test effective from 1 April 2020. GG to provide an update on the Trust’s approach to gathering Friends and Family Test feedback at a future Action: GG Council of Governors meeting. 09/20 Care Quality Commission (CQC) Inspection Report – Final Report Noted

Andrew Maloney presented the final report on the Care Quality Commission’s inspection of a number of the Trust’s key services during 4 June to 10 July 2019. He confirmed that the Trust has maintained its overall ‘Good’ rating and that all domains, with the exception of ‘Safe’, have also been rated as ‘Good’. He summarised the individual ratings for core service lines and provided an explanation for any changes to the previous inspection outcomes. He also highlighted the key actions being taken forward to address the inspection feedback, including the replacement of Park House; the launch of a new Supervision Policy and a centralised system for monitoring supervision compliance; the redesign of community mental health services in Manchester; and ongoing support for the development of Bolton Community Child and Adolescent Mental Health Services (CAMHS).

Iris Nickson drew the Council of Governors’ attention to the ‘Must Do’ requirement to ensure care plans in specialist community mental health services for children and young people are personalised, holistic and recovery-oriented. She noted that care plans were also discussed in the Council of Governors focus group with the CQC. Neil Thwaite advised that this is the first time the Bolton Community CAMHS service has been inspected since it transferred to the Trust in 2018. He noted the significant progress made since the service transfer, whilst acknowledging that further quality improvement is still required. Stuart Edmondson advised that work is underway at a national level to review the Care Programme Approach (CPA) framework.

The Council of Governors noted the final CQC Inspection Report and the planned next steps. 10/20 CQC Mental Health National Patient Experience Survey 2019 Noted

Gill Green presented a summary of the outcomes of the 2019 Community Mental Health Patient Experience Survey, as published on 26 November 2019. She advised that the Trust’s scores are ‘more or less the same’ as the other participating mental health trusts and minor improvements have been noted in nine of the ten thematic response areas compared to the Trust’s 2018 results. With regard to the 23 question areas where comparisons can be drawn to 2018, Gill Green advised that scores have increased in 16 areas, remained the same in two areas and reduced in five question areas. She highlighted two question areas where scores have significantly improved – help or advice with finding support for financial advice and benefits and information about getting support from people who have experience of the same mental health needs - and advised that there were no questions where the Trust’s scores were significantly lower than those reported in 2018.

Gill Green advised that the Trust has applied a PDSA (Plan Do Study Act) approach to taking forward improvements following the 2018 survey. A key area of focus based has been on information regarding medications. A similar approach will be taken this year. Gill Green also advised that this year’s survey outcomes have been triangulated with other feedback sources, including complaints, to identify cross-cutting themes. Contact and communications is emerging as a key priority for improvement action.

In response to a question from Iris Nickson, Gill Green outlined the steps the Trust is taking to improve the response rate to future year surveys. These include raising awareness with Care Coordinators and service users via the Trust’s intranet and website, encouraging Care Coordinators to discuss the survey with their service users and also making interpreters available, if needed, to support service users to complete the survey. Although the Trust’s response rate of 20.2% in 2019 was lower than the 23% response rate achieved in 2018, the response rate remains comparable to other Trusts. Iris Nickson highlighted the difficulties of discussing the survey with service users who are on annual CPA. Gill Green accepted this point but advised that the timing of the survey is outside of the Trust’s control. She reiterated that sample is selected at random and, as such, any discussion would be a general discussion rather than targeted at those service users in the sample. She confirmed that the Trust has challenged the relatively small sample size with the CQC on a number of occasions and, as previously advised, commissions an extended sample to enable more meaningful results. She also noted that the Survey is just one of a number of mechanisms employed by the Trust to gather service user feedback.

The Council of Governors noted the outcomes of the Trust’s Community Mental Health National Patient Experience Survey 2019.

11/20 Presentation – Developing the 2019/20 Quality Account Noted and Agreed Gill Green updated the Council of Governors on the work in progress to develop the Trust’s 2019/20 Quality Account and summarised the production timescales. She confirmed that the mandated indicators for testing by the Trust’s external auditors are unchanged from 2018/19 – i.e. remain as Early Intervention in Psychosis and Out of Area Placements – and sought the Council of Governors views on a locally selected indicator for 2019/20. She advised that the locally selected indicator must be quantifiable and reportable and that the scope of the audit is relatively narrow. The Council of Governors discussed the relative merits of selecting acquired pressure ulcers or seclusion use as the local indicator, noting that the Trust already monitors performance in both areas, and reached a consensus on seclusion use. 12/20 Feedback from the Service User and Carer Experience Operational Meeting Noted held 31 January 2020

In Margaret Willis’ absence, Dan Stears shared a number of items of feedback from the Service User and Carer Experience Operational Meeting held on 31 January 2020. He advised that the total number of volunteers working across the Trust has risen from 156 to 190 and that the Trust has now appointed nine Carer Peer Mentors. He also advised that the Recovery Academy student population has achieved a 50/50 split between service users/carers and professional students. With reference to the earlier discussion regarding the Friends and Family Test, he provided examples of the work being progressed by the Service User and Carer Experience Operational Meeting to deliver improvements in this area.

Dan Stears also reminded the Council of Governors that a performance from Terry Corbett’s Café Diagnosis is taking place on 14 February at 3pm in the Waterdale Restaurant. All Governors are welcome to attend. 13/20 Chair and Non-Executive Director Appraisal Process 2019/20 Approved

Rupert Nichols summarised the proposed approach to, and timetable for, the 2019/20 round of Chair and Non-Executive Director appraisals. He advised that the approach has been updated in line with the new national ‘Framework for Conducting Annual Appraisals of NHS Provider Chairs’.

The Council of Governors approved the proposed new process, documentation and timetable for the 2019/20 Chair appraisal, subject to any final amendments agreed between the Chair and Senior Independent Director, and also the new process, documentation and timetable for the 2019/20 Non-Executive Director appraisals.

The Council of Governors also agreed to convene a meeting of the Nominations Committee in late June/early July 2020 to consider the outcomes of the appraisal processes. 14/20 Council of Governors Annual Review of Effectiveness Noted 9

Rupert Nichols thanks Governors for their contribution to the annual effectiveness review. He confirmed that, as with previous years, the Membership Engagement Working Group will review and update its action plan to respond to the feedback received. He advised that effective engagement with membership communities is a challenge faced by all foundation trust governors and that the Trust is happy to consider any ideas from governors on how best to enable this. He also welcomed governor attendance at Board of Directors meetings and Board committee meetings, and encouraged more active contribution from governors in agenda setting for Council of Governors meetings and the governor development programme.

Maureen Burke suggested the inclusion of a regular agenda slot or report where governors can feedback news and views from their local constituencies. Kim Saville, Company Secretary, advised that the Open Forum slot is designed for the purpose but can be moved up the agenda to increase focus on this at meetings. Action: KS

The Council of Governors noted the outcomes of the annual effectiveness review and agreed the proposed responses to the feedback received. 15/20 Membership Engagement and Governor Development Plan 2018 – 20 Noted

Dan Stears and Maureen Burke presented an update on progress in the delivery of the Membership Engagement and Governor Development Plan. Dan Stears summarised the current focus of the Membership Engagement Working Group in terms of membership community, membership engagement and governor development. With regard to the latter, he advised that a schedule of service visits has been planned for governors but uptake to date has been relatively low. He encouraged all governors to take the opportunity to participate in service visits. Nathan Prescott shared positive feedback from his participation in service visits. Dan Stears advised that the Membership Engagement will be seeking to understand the barriers faced by governors in participating in service visits with a view to supporting governors to overcome these.

The Council of Governors noted the update on the implementation of the Membership Engagement and Governor Development Plan 2018 – 2020. 16/20 Board of Directors: Noted

• Ratified Minutes of the Board of Directors Meetings Held in Public on 25 November 2019

The Council of Governors noted the ratified minutes of the Board of Directors meetings held in public on 25 November 2019.

• Chair’s Report on Part 2 Items

Rupert Nichols briefed governors on key items discussed recently in the private session of the Board of Directors meeting, including the ongoing work to develop 10

the Trust’s role as Lead Provider for adult secure services across Greater Manchester in advance of the planned October 2020 ‘Go Live’ of the Lead Provider Collaborative (LPC).

• Governor Feedback on Board of Directors Meetings (Verbal)

Rupert Nichols advised that Margaret Willis took the opportunity to observe the most recent Board of Directors meeting. 17/20 Governor Open Forum Noted

Rupert Nichols invited Governors to share feedback from any meetings/events they have been involved in in their local constituencies. 18/20 Any Other Business Noted

• Coronavirus - Gill Green provided assurance that the Trust is monitoring the developing situation closely. She advised that the Trust is complying with all advice and guidance issued by Public Health England (PHE) in relation to the coronavirus outbreak and is linking in with the regional and national PHE teams as required. She confirmed that the Trust’s infection prevention and control (IPC) Team are prepared, and that policies and procedures are robust, and committed to keeping the Council of Governors briefed on any significant changes to the current position. • Staff Attendance at Council of Governor Meetings – In response to a question from Iris Nickson, Neil Thwaite provided assurance that all staff governors should be supported by their Line Managers to attend Council of Governors. He invited any staff governors to share any issues their have experienced in this regard so that appropriate action can be taken.

There were no further items of other business. 93/19 Date and Time of Next Meeting Noted

The next Council of Governors meeting is scheduled to take place on Monday 27 April 2020 at 10.00am in Conference Room 7, Ground Floor, The Curve

Certified as a true record of the meeting

………………………………………………………… …………………………………………………………… Chair – Rupert Nichols Date

Action Log

Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion Sept-19 65/19 Membership Gill Green committed to looking into 10/02/20 Gill Green, PLACE documents to be Engagement and mechanisms for digitally-enabled PLACE Director of shared electronically for Governor inspections in future i.e. documentation Nursing and future PLACE inspections Development Plan shared electronically Governance Dec-19 90/19 Governor Open Neil Thwaite to share issues raised regarding 10/02/20 Neil Forum – Park House maintenance to ensure Thwaite, Maintenance of appropriate action is taken Chief Park House Executive Dec-19 90/19 Governor Open Presentation on the Trust’s Capital 27/04/20 13/07/20 Andrew Scheduled for April 2020 Forum – Capital Investment Programme to be scheduled for a Maloney, meeting. April 2020 meeting Investment future Council of Governors meeting Director of stood down due to COVID-19. HR / Deputy Public – Manchester and CEO Service User and Carer Governors invited to contribute to a meeting on 22 May 2020 focused on improving mental health services in North Manchester. Park House update to be brought to the full Council of Governors meeting in July 2020 Feb-20 07/20 Research and Alice Seabourne to share information with 27/04/20 13/07/20 Alice Innovation governors on the total spend on mental Seabourne. health research compared to cancer research. Medical

Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion Director Feb-20 07/20 Research and Alice Seabourne and Tony Morrison to look 13/07/20 Alice Innovation into all suggestions/ideas put forward by Seabourne, governors in terms of maximising the Medical opportunities for research participation Director and Tony Morrison, Assistant Director (R&I) Feb-20 08/20 Forward Planning – GG to provide an update on the Trust’s 12/05/2020 Friends and Family Test Our Strategy and approach to gathering Friends and Family paused in the context of Priorities for Test feedback at a future Council of COVID-19. Verbal update 2020/21 Governors meeting. provided during Council of Governors Teams Meeting on 12 May 2020 Feb-20 14/20 Annual Review of Open Forum to be moved up the agenda to 13/07/20 Kim Saville, Effectiveness increase focus on governor feedback from Company local constituencies Secretary

Not yet due Completed on time In progress Incomplete and overdue

Council of Governors Notes of Informal Meeting held on Tuesday 12 May 2020 via Microsoft Teams

Attendees: Council of Governors:

• Rupert Nichols, Chair • Mat Ainsworth, Appointed Governor (GMCA) • Les Allen, Public Governor (Bolton) • Angela Beadsworth, Public Governor (Other England and Wales) • Tim Bradshaw, Appointed Governor (University of Manchester) • Maureen Burke, Public Governor (Salford) • Avril Clarke, Service User and Carer Governor • Paul Connelly, Public Governor (Salford) • Terry Corbett, Public Governor (City of Manchester) • Stuart Edmondson, Staff Governor (Nursing) • Judy Harrison, Staff Governor (Medical) • Stewart Lucas, Appointed Governor (VCSE) • Sharon Mason, Public Governor (Other England and Wales) • Iris Nickson, Public Governor (Trafford) • Lesley O’Neill, Staff Governor (Nursing) • Arif Patel, Staff Governor (Non-Clinical) • Nathan Prescott, Service User and Carer Governor • Diomidis Psomas, Staff Governor (Psychological Therapies) • Margaret Rowe, Appointed Governor (University of Salford) • Dan Stears, Service User and Carer Governor

Other Attendees:

• Gill Green, Director of Nursing and Governance • Andrea Harrison, Non-Executive Director • Andrew Maloney, Director of HR / Deputy CEO • Steph Neville, Head of Corporate Affairs • Kim Saville, Company Secretary • Neil Thwaite, Chief Executive 1. Welcome and Rupert Nichols, Chair welcomed all those in attendance, in particular the recently Introductions elected governors. He set the context and tone for the meeting and advised that the next formal meeting of the Council of Governors will take place as planned in July 2020.

2. Apologies for Council of Governors: Absence • Nayla Cookson, Public Governor (City of Manchester) • DCI Amanda Murray, Appointed Governor (Greater Manchester Police) • Margaret Willis, Service User and Carer Governor 3. Profile of the Profile of governors as of 1 April 2020 noted. All seats, with the exception of the GMMH Council Appointed Governor seat representing Greater Manchester Clinical Commissioning of Governors Groups (CCGs), are currently filled. 4. Welcome to Neil Thwaite, Chief Executive presented an overview of the Trust as part of the new our New governors’ induction programme. Topics covered included the Trust’s vision and Governors values, scope, strengths and progress made against the Trust’s five strategic aims and objectives. The latter are as follows:

• Objective 1 – Work with service users and carers to achieve their goals by delivering high quality care (Best Care, Every Day) • Objective 2 – Create an outstanding place to work, ensuring staff feel valued and are supported to reach their potential (Compassionate, Supported, Motivated Staff) • Objective 3 – Continuously improve services for users through research, innovation and digital technology (Best Outcomes) • Objective 4 – Work in partnership with others to improve wellbeing and challenge stigma (Individualised, Seamless Care) • Objective 5 – Be a sustainable, well-led organisation that delivers social value (Sustainable Services, Adding Value)

Governors received a copy of the Trust’s five-year Strategy 2019 – 2024 (‘Delivering Excellent Care and Supporting Wellbeing’) to review alongside the presentation.

Rupert Nichols outlined the differences between NHS trusts and NHS foundation trusts (FTs), including the freedoms envisioned for FTs which have been eroded over time. He confirmed that during COVID-19, FTs (like other trusts) are operating within a centrally-led command and control structure to enable an effective national crisis response. Rupert Nichols summarised the differences between the governor and non-executive director role and the statutory duties of a governor. He directed governors towards the Governors’ Handbook and Member and Governor Zone on the Trust’s website for further reading and confirmed that governors will have opportunity to participate in service visits and PLACE inspections, once the crisis has passed, as well as accessing external training and networking opportunities.

For further support, Governors were invited to contact:

• Steph Neville, Head of Corporate Affairs ([email protected]) – for queries regarding membership engagement and governor development • Kim Saville, Company Secretary ([email protected]) – for queries regarding Council of Governors meetings

5. Briefing on Neil Thwaite briefed governors on the Trust’s response to COVID-19 and the current COVID-19 key challenges. He outlined the Trust’s Gold Command governance arrangements, Response which have been in place since early March 2020 and include daily Situation Reporting (SitReps) from services to enable real-time monitoring of the situation and appropriate action. He advised that the current number of COVID-19 positive patients across the Trust’s inpatient services is relatively low (12) and noted that, sadly, the Trust has experienced nine COVID-19 related deaths in the Trust’s later life services.

Neil Thwaite drew governors’ attention to the ‘Changes we Have Made to Services’ slide, highlighting the following:

• Development of a 24/7 helpline for all service users and carers • Development of five mental health urgent care centres at acute hospital sites across Greater Manchester • Increased access to RADAR alcohol detoxification beds in the Trust’s Chapman Barker Unit • Use of digital solutions to continue providing IAPT (improving Access to Psychological Therapies) services

Gill Green, Director of Nursing and Governance briefed the governors on the Trust’s expanded physical healthcare provision, including the approach to infection prevention and control and end of life care, during the crisis. She advised that the Trust has been able to support patients on end of life pathways without requiring transfer to acute hospitals and has taken the ethical decision to allow relatives to visit (wearing the required PPE (Personal Protective Equipment)) during this difficult time. She confirmed that the focus has remained on providing the most person-centred care possible within the necessary constraints.

Andrew Maloney, Director of HR / Deputy Chief Executive outlined the significant changes to the way both clinical and non-clinical staff are working, with over 20% of the Trust’s workforce currently supported to work from home. He briefed the governors on the numbers of staff currently self-isolating due to COVID-19 symptoms, the numbers classed as ‘high risk’ (including BAME staff) and the enhanced support available, and the arrangements for staff and their families to access testing. There have been no staff deaths due to COVID-19. He outlined the range of mental health and wellbeing resources available to the workforce and the expected increase in demand for mental health support as the crisis enters the recovery phase. He thanked staff and the Trust’s trade union partners for their support.

Both Rupert Nichols and Neil Thwaite acknowledged the efforts and commitment of staff across the Trust in delivering the Trust’s crisis response. Appointment of GMMH Lead Governor

6. Statutory Rupert Nichols outlined the role of Lead Governor and invited expressions of interest Duties and from those governors who meet the eligibility criteria. Expressions of interest to be Other Business sent via email to Rupert Nichols (cc Kim Saville, Company Secretary in) by 22 May 2020. If more than one expression of interest is received, a fair and transparent process will be established to identify the most suitable candidate. Governors approved the process for appointing a new Lead Governor and the delegation of decision-making authority to Rupert Nichols, Chair for the appointment. The appointment will be for an initial period of one year and formal ratification of the Chair’s decision will be sought at the Council of Governors meeting on 13 July 2020. Non-Executive Director Re-appointment

Rupert Nichols advised that the second term of office of one of the Trust’s non- executive directors (Julie Jarman) ends on 31 July 2020. Responsibility for the appointment and re-appointment of non-executive directors sits with the Council of Governors. He outlined the re-appointment process and advised that a Nominations Committee meeting will be convened for late June 2020 to review the reappointment. A recommendation will follow from the Nominations Committee to the Council of Governors meeting in July 2020. Improving Mental Health in North Manchester

Steph Neville, Head of Corporate Affairs advised that the work to develop the Outline Business Case (OBC) for the new Park House development in North Manchester has continued during COVID-19. Service User and Carer Governors and Public Governors (City of Manchester) have been invited to attend a briefing session on 22 May 2020 (3 – 4.30pm), where they will have opportunity to share their views on the plans. She encouraged as many governors as possible to join this session. A presentation/briefing to the full Council of Governors will follow on 13 July 2020. 7. General Rupert Nichols reminded governors that they are welcome to observe/listen into Housekeeping public Board of Directors meetings to understand more about how the Board operates. The next Board of Directors meeting is due to take place on Thursday 21 May 2020 and the agenda and Microsoft Teams details will be shared with governors in advance. 8. Questions Nathan Prescott, Service User and Carer Governor raised concerns about the experience of service users accessing outpatient services, including their ability to provide feedback, and the levels of awareness of the new 24/7 helpline. Gill Green advised that the Friends and Family Test feedback tool is currently suspended as part of the national COVID-19 response. She noted that the previous issues with the electronic kiosks had been resolved just as the COVID crisis unfolded and confirmed that service user and carer feedback is a key strand of the Trust’s emerging COVID- 19 recovery programme with, for example, research projects being planned to gather service users’ views.

Nathan Prescott also sought a response to the recent report on deaths of patient detained under the Mental Health Act during COVID-19. Neil Thwaite advised that all COVID-related inpatient deaths at GMMH have been patients on end of life care pathways, rather than detained patients.

Avril Clarke, Service User and Carer Governor, shared her positive experiences of care received in the community and of access to the 24/7 helpline. Rupert Nichols acknowledged the concerns raised by Iris Nickson, Public Governor (Trafford) and Dan Stears, Service User and Carer Governor regarding their personal experiences of care and confirmed that these will be picked up by Gill Green, Director of Nursing and Governance and the Customer Care Team outside of the meeting.

Dan Stears raised concerns about people who may need support from mental health services but have felt unable to access provision. He asked how the Trust has monitored/supported these individuals. Neil Thwaite confirmed that the Trust has participated in a recent regional campaign focused on encouraging people who need help to step forward. He acknowledged that there was more the Trust could do from a communications perspective, including to promote the helpline, and this will be addressed through the recovery programme. Gill Green outlined the risk stratification process undertaken by community teams to identify and prioritise the most vulnerable service users. She advised that the Trust is planning on the basis of an increase in demand for services over the coming months. In response to a further question from Dan Stears, Gill Green outlined how the Trust is supporting service users whose carers become ill during this period. This includes working with local authorities and the voluntary sector to put appropriate support packages in place.

Maureen Burke, Public Governor (Salford) thanked the Trust for including governors in the circulation for the Trust’s daily COVID-19 communications. She advised that these have been well-received and enable governors to feel connected to the Trust during this time.

Rupert Nichols thanked the governors for their questions and advised that feedback is always welcome. 9. Any Other There were no further items of business. Business 10. Date & Time of Next formal meeting of GMMH Council of Governors to be held of Monday 13 July Next Meeting 2020 at 10am via Microsoft Teams

Council of Governors

TITLE OF REPORT: Chair and Chief Executive’s Brief– COVID-19 Update DATE OF MEETING: Monday 13 July 2020 AGENDA ITEM: 06 PRESENTED BY: Rupert Nichols, Chair AUTHOR(S): Marketing and Communications Team Kim Saville, Company Secretary

EXECUTIVE SUMMARY: The following report from the Chair and Chief Executive provides an update on the Trust’s COVID-19 response and recovery plans. Information on other current items of interest and key issues is also provided, including an overview of the Trust’s financial and operational performance.

RECOMMENDATIONS: Members of the Council of Governors are invited to note the Chair and Chief Executive’s Brief.

Chair and Chief Executive’s Brief

Council of Governors – 13 July 2020 Chair and Chief Executive’s Brief - July 2020

This document Our Response to COVID-19 identifies the key • GMMH Response to COVID-19 Pandemic – Second Phase national, • National Guidance regional and • Headline Statistics local issues that • Support for BAME Communities are impacting • Windrush 2020 upon or are • Home Working Survey relevant to the • NHS Reset Blog – Staff Mental Wellbeing During COVID-19 Trust • COVID-19 Antibody Testing Programme Roll Out • Restoring CYP Health Services • Helpline for Service Users and Carers • buzz Mental Health and Wellbeing Service

Action required Other Local News / in progress • Future Provision of Wigan Mental Health Services • Park House Development For information • Veterans’ Mental Health High Intensity Service • Aspirant Nurses • Our LGBT+ and Disabled Staff Networks 2 Chair and Chief Executive’s Brief - July 2020

This document Other Local News identifies the key • NHS Virtual Pride national, • NHS 72 regional and • Awareness Weeks local issues that • Annual Report and Accounts 2019/20 are impacting • Quality Account 2019/20 upon or are • Performance Overview relevant to the • Finance Overview Trust

Action required / in progress

For information

3 Chair and Chief Executive’s Brief - July 2020 Our Response to COVID-19

GMMH Response to COVID-19 Pandemic – escalation and governance processes. Second Phase We have set up a Recovery Planning Group to take forward our recovery plans across seven priority workstreams, aligned with Throughout the COVID-19 pandemic our services have the national timeframes of ‘Release of Lockdown’, Living with remained safe, with service users well-cared for and staff COVID-19’ and ‘Building Back Better’. As well as focusing on our continuing to offer high standards of care. We have made a future service offer and support for users and carers, a key number of significant changes at a very rapid pace, including workstream is looking at our safe working arrangements for the the setting up of a 24-hour helpline for all our service users future. This includes establishing a framework to ensure our and carers and five urgent care centres. This all happened buildings are safe, secure and suitable for staff and visitors. against a backdrop of an organisation progressing significant programmes of change. Despite the major incident The Recovery Group is also leading our contribution to regional conditions, we still welcomed new colleagues from capacity planning to respond to potential future surges in Bridgewater Community Healthcare NHS Foundation and demand for bed-based and community services. This includes Delphi across our secure settings from 1 April 2020. taking into account required infection prevention and control standards and incorporating our learning from Phase One into We are currently in Phase Two of the NHS’s national planning for any future waves of COVID-19. response to COVID-19 and, on 19 June 2020, the national COVID alert level was reduced from Level 4 to Level 3. We Our heartfelt thanks go out to all our staff and volunteers for the have retained our Emergency Preparedness, Resilience and extraordinary way in which they have risen to this Response (EPRR) incident coordination functions given the unprecedented global health challenge. uncertainty and ongoing need. Gold Command continue to oversee our response and connections into wider system Lead: Neil Thwaite, Chief Executive 4 Chair and Chief Executive’s Brief - July 2020 Our Response to COVID-19

National Guidance Guidance on the Use of Face Masks and Coverings in Hospital Settings to Prevent COVID-19 Transmission Visiting Healthcare Inpatient Settings During the COVID-19 Pandemic New infection prevention and control (IPC) measures on the use of face masks to help prevent the spread of COVID-19 The national suspension on visiting imposed under infection in hospitals advised that from Monday, 15th June guidance issued on 8 April 2020 is now lifted. New 2020, all staff in hospitals in England, must wear face masks guidance has been issued on 5 June stating that visitors to reduce the risk of transmission in hospitals. This has must wear masks or face coverings at all time within a meant changes to current practice. The Trust has issued hospital setting and the number of visitors at the detailed guidance along with Frequently Asked Questions bedside is limited to one close family contact or and communication materials to support the changes. We somebody important to the patient. The guidance is have provided sufficient supplies of FFP2 masks to services consistent with the NHS advice on compassionate and staff have responded quickly to such important changes. visiting arrangements at end of life and wider government advice on social distancing. Reducing Restrictive Practice Guidance

The Trust is continuing to maintain its current visiting GMMH has played a key role in developing national arrangements, which include facilitating visits to service guidance on reducing restrictive practice. It is great to see users at the end of life. We will keep these such innovation and quality improvement flourish during arrangements under constant review. times of significant challenge for staff and service users. Lead: Gill Green, Director of Nursing and Governance 5 Chair and Chief Executive’s Brief - July 2020 Our Response to COVID-19

Headline Statistics Staffing We are continuing to collect data on suspected and Highest Daily Covid Related Sickness 35 confirmed cases of COVID-19, staff absences and service Current Covid Related Sickness 17 pressures on a daily basis, whilst also responding to Highest Daily Non-Covid Related Sickness 269 national SitRep returns. Current Non-Covid Related Sickness 245 Our position for the period ended 30 June is as follows: Highest Daily Self-Isolation 628 Current Self-Isolation 373 Patients Highest Daily Working from Home 1305 Highest number of Diagnosed Covid Cases reported in a day 105 Current Working from Home 1247 Total number of Individual Diagnosed Cases up to 30.6.20 197 Highest Overall Planned Staffing Difference 7.8% Highest number of Suspected Cases reported in a day 167 Current Overall Planned Staffing Difference 2.66% Total number of Suspected Cased up to 30.6.20 292

Total Deaths 147

Community Services Deaths 137

Inpatient Deaths 9

Detained patients deaths in other Trust 1

Highest Daily Deaths 7 6 Chair and Chief Executive’s Brief - July 2020 Our Response to COVID-19 Support for BAME Communities We were delighted to hold our second BAME Staff Engagement Event on 26 May. These A report published by Public Health England on 2 events provide opportunity to understand first- June presented the disparities in the risk and hand how our BAME staff are feeling and outcomes of COVID-19. Virus death rates were ensure they remain supported and informed. highest among people of Black and Asian ethnic We have also made a range of resources groups compared to white British ethnicity, with available to our BAME staff and communities. people of Chinese, Indian, Pakistani, other Asian, For example, our BAME Network distributed welfare packs to Caribbean and other Black ethnicity having a 10% to our Muslim colleagues who were fasting during Ramadan and 50% higher risk of death when compared to white ‘buzz’ have set up a COVID-19 resource hub on their website. British people. The risk of dying with the virus is also higher among those living in more deprived parts of At a Board-level, Anthony Bell, Non-Executive Director, has the UK and certain occupations are at higher risk. joined a regional BAME Advisory Group chaired by Bill McCarthy, NHSEI Regional Director and Evelyn Asante- With emerging evidence of the impact of COVID-19 Mensah, Chair of Pennine Care. Gill Green, Director of Nursing on BAME communities, local managers have been and Governance, is co-chairing a regional group focused on the asked to complete workplace risk assessments for use of the MHA in BAME communities with the CEO of the all of our BAME staff (and other vulnerable workers) Muslim Heritage Centre. The full Board also participated in a with a view to agreeing support plans and making development session on 29 June aimed at understanding the any required adjustments. Webinars took place in value of inclusion as a key organising principle for the Trust and early June to support managers in this task. agreeing the key issues that, if addressed, will make a significant difference. Chair and Chief Executive’s Brief - July 2020 Our Response to COVID-19

Windrush 2020 87% response rate and are grateful to all those staff who took the time to share their views. During June we marked 72 years since the Empire Windrush arrived at Tilbury Docks in Essex, carrying The results indicate that many staff are experiencing a better several hundred people from the Caribbean. As work life balance and feeling more productive. Over 40% of immigration law changed in the subsequent years, staff indicated they would be happy to continue to work from individuals from the Windrush generation were left home for approximately 50% of the time. For those individuals struggling to demonstrate their status and right to live in who have had a less positive experience of home working, we the UK. As a result, some lost their jobs, their homes will work with them to understand what support we can offer to and their sense of identity and wellbeing. provide suitable and safe working environments.

We thank everyone from the Windrush generation and NHS Reset Blog – Staff Mental Wellbeing During COVID-19 all BAME communities for their contribution to the NHS over the last 72 years and during the COVID-19 NHS Reset is a new NHS Confederation Campaign pandemic, where so many have gone above and contributing to the national public debate on what the health beyond to support our Trust. and care system should look like in the aftermath of COVID- 19. We have recently contributed a blog to the campaign, Home Working Survey published on 13 June, which reflected on the steps we have taken as an organisation to protect the wellbeing of our We recently completed a survey of over 1,200 workforce during this period. members of staff who have been working from home since the start of lockdown in March. We achieved an Lead: Andrew Maloney, Director of HR / Deputy CEO Chair and Chief Executive’s Brief - July 2020 Our Response to COVID-19

COVID-19 Antibody Testing Programme Roll Out The results of the antibody testing process will inform the Government’s surveillance as to how prevalent COVID- We are offering all staff a Covid-19 antibody test over 19 has been and help improve our understanding of the the month of June and to 13 July 2020. virus and how immune systems respond.

Testing is carried out on a local level across eight sites, Staff choosing not to take an antibody test, are being with services identifying priority staff members for asked to complete a short survey to allow us to capture testing. This includes vulnerable workers in high risk some important details and understand any reasons our groups as well as staff who have worked in high-risk staff might have for not taking the antibody test. areas such as inpatient areas. Testing is not, however, limited to these groups and is being carefully assessed by services.

Access to the appointments is via an online booking system, which requires staff to have a mobile phone in order to receive the results of their tests.

All inpatients will be offered an antibody test when undergoing other blood tests, with patients receiving Lead: Gill Green, Director of Nursing and Governance their results from the Team looking after them.

9 Chair and Chief Executive’s Brief - July 2020 Our Response to COVID-19

Restoring CYP Community Health Services and determine any additional support needs or required escalation in the event of an immediate concern. Within two working days, staff visited and were able to confirm the As part of the national COVID-19 response, all providers welfare of 38 potentially vulnerable young people. Plans were asked to review and restore their community were put in place for the two people the Team were unable to services for children and young people, as required, in reach. Phase Two, to meet local need. The service has since set up a Task and Finish Group to Bolton Community CAMHS – The Bolton Community collate and review key learning from this period to inform CAMHS service has continued to operate throughout the future service delivery and development. pandemic. The majority of contacts have been via phone/Microsoft Teams and in accordance with ongoing Community Forensic CAMHS - FCAMHS has continued to risk stratification and prioritisation of need. Plans are in deliver a service throughout the period, although the service place to increase numbers of face to face contacts, with a offer has been adjusted in line with national guidance around specific focus on vulnerable groups. social distancing and working from home. The team provides a regional service and so already incorporated the use of At the beginning of lockdown, the CAMHS team contacted teleconferencing into its normal business e.g. for everyone on the waiting list to provide support whilst the consultations with other agencies about a young person who young person waited for their appointment. This included had been referred. The team have maintained its service signposting people to a alternative resources. The team offer during the lockdown period. were, however, unable to make contact with 40 young people, so practitioners visited their homes to check in Lead: Deborah Partington, Director of Operations 10 Chair and Chief Executive’s Brief - July 2020 Our Response to COVID-19

Helpline for Service Users and Carers Along with other GM mental health trust helplines, the GM Clinical Assessment Service(CAS) and NWAS, we are On the 20th March we launched our 24/7 service trialling the implementation of a phased expansion to the user and carer helpline. The helpline supports helpline to include diversions from the GM CAS and NHS 111 members of our mental health community who may service. This will provide open access to unknown service- be struggling with COVID-19 as well those missing users/the public who require specialist mental health support face-to-face appointments and group sessions. during this crisis. This trial commenced on 25th May 2020.

Calls to the Helpline from service users and carers From Wednesday 17th June 2020 the GMMH Helpline was have been consistently high over the past three available via a free phone number – 0800 953 0285. months with the highest demand being in the evenings, overnight and at weekend.

The Helpline staff have worked closely with community teams to ensure the Helpline offers appropriate and timely support as part of service user crisis plans. The Helpline has also been able to offer translation services and a mobile number for people who need to use visual communication, to ensure the service is accessible. Lead: Deborah Partington, Director of Operations 11 Chair and Chief Executive’s Brief - July 2020 Our Response to COVID-19

buzz Mental Health and Wellbeing Service

buzz have been working tirelessly to help Manchester residents stay connected, creative and healthy during lockdown. Their Physical Activity Referral Service (PARS) have moved their exercise classes, including tai chi and strength and balance classes, online.

buzz neighbourhood Health Workers have also been teaming up with Manchester Urban Diggers to distribute Mini Kitchen Garden Kits as well as arts and crafts packs to children. They have also set up an COVID-19 Resource Hub and Mutual Aid Groups.

Lead; Deborah Partington, Director of Operations Chair and Chief Executive’s Brief - July 2020 Other Local News

Future Provision of Wigan Mental Health Services within Greater Manchester.

In September 2019, the Board of North West Boroughs Alongside the development of the Strategic Case, executive Healthcare NHS Foundation Trust (NWBH), in to executive discussions have taken place between NWBH, consultation with its Council of Governors, took the Mersey Care, Wigan Clinical Commissioning Group, decision that the preferred future direction for the Trust GMHSCP and providers (including GMMH) to understand was to be acquired by Mersey Care. Work current opportunities and challenges and how organisations subsequently commenced on the development of a can work together to improve the health and wellbeing of the joint Strategic Case by NWBH and Mersey Care for the Wigan population. As part of this, Wigan CCG have acquisition, with the support of NHSI. A joint completed an options appraisal to determine the way forward Transaction Oversight Board was also established. for the borough’s mental health services. Completion of the Strategic Case was delayed by COVID-19, but both Trusts’ Boards recently approved Formal confirmation of the options appraisal outcome is the case in May 2020. expected in mid-July 2020. GMMH are, however, understood to be in a strong position to potentially be identified as the The Strategic Case included a caveat that clarity on the preferred future mental health provider. Any transaction future provision of a significant element of NWBH’s would be subject to the completion of robust due diligence. portfolio - namely, Wigan mental health services – was The acquisition of NWBH by Mersey Care is planned to to be agreed. Options for this include keeping Wigan complete by 1 April 2021 and it is expected that any transfer within the portfolio of services to be acquired by Mersey of Wigan services will be subject to the same timeframe. Care or transferring Wigan services to another provider Lead: Neil Thwaite, Chief Executive 13 Chair and Chief Executive’s Brief - July 2020 Other Local News

Park House Development Further detailed work on the clinical/operational model and the economic case to support the OBC is underway. We have continued to develop the Outline Business Board of Directors’ support for the OBC will be sought in Case (OBC) for our Park House development during July 2020. COVID-19. This has included participating in positive discussions with the NHSEI Regional Team regarding Lead: Andrew Maloney, Director of HR / Deputy CEO the identified funding gap; finalising agreement with Manchester University NHS Foundation Trust (MFT) on Veterans’ Mental Health High Intensity Service the specifics of the new GMMH zone on the North Manchester General Hospital site; and progressing the A recent bid submitted by Leeds and Yorkshire commissioning of a Principal Supply Chain Partner. We Partnership NHS Foundation Trust to NHS England for the have also taken steps to engage with key stakeholders provision of a Veterans’ Mental Health High Intensity – including staff, service users, governors and Service across the North West and the North East and commissioners – on our proposal within the constraints Yorkshire has been successful. GMMH is one of a number of COVID-19 and have collated recent research to of mental health service providers contributing to the inform our design. Provider Collaborative for this new service. Taking into account the impact of COVID-19, the service is expected to become operational from November 2020.

Lead: Deborah Partington, Director of Operations

14 Chair and Chief Executive’s Brief - July 2020 Other Local News

Aspirant Nurses Locality leads, service managers and matrons then We have welcomed over 240 aspirant nurses, engaged came together to discuss in either the second or third and final year of their how an effective induction nursing degree, to GMMH during COVID-19. We are could be delivered extremely proud to have had these nurses join our our clinical teams. We filmed virtual ‘welcomes’ to new staff and aspirant On joining the Trust, our new nurses on behalf of the Resource Operational Cell executive team. This formed (ROC), HR and Operations part of their interactive Teams worked incredibly induction, which all staff hard to contact each nurse attended before going to within 24 hours to learn more work on our wards. about their clinical experience and match that We are pleased to say that of those aspirant nurses, over against the needs of the 100 who have recently qualified, or are soon to qualify, Trust. have chosen to take on substantive roles across GMMH.

Lead: Gill Green, Director of Nursing and Governance

15 Chair and Chief Executive’s Brief - July 2020 Other Local News

Our LGBT+ and Disabled Staff Networks sharing some invaluable insights into their experiences in work. As an outcome of this meeting, we committed to raising Both our Disabled Staff Network and our LGBT+ awareness and providing education for staff about LGBT+ Network met during June 2020. issues. We also committed to ensuring that all of our Senior Leaders practise openness in their language. To support this, The Disabled Staff Network had an amazing turnout, we will be circulating guidance soon on the inclusion of with attendance from around 50 people. The event preferred pronouns in email signatures. This may feel like a provided opportunity to discuss our approach to risk small thing but to staff this recognises every person’s individual assessment and our plans to positively support staff preference and demonstrates our key value of ‘We Value and with disabilities now and into the future. Having an Respect’. Finally, the Network discussed the homophobia and employer and a transphobia that our staff face from some of our service users. manager that is Our hate crime protocol, which is currently being developed, compassionate and will address this issue along with race. enables you to remain safe at work Along with our BAME Staff Network, our Disabled and LGBT+ is crucial and goes Staff Networks create fantastic spaces for our diverse far beyond the workforce to have a voice. Please all promote and support current crisis. these networks to grow and develop.

Our LGBT+ Network also recently met for the first Lead: Neil Thwaite, Chief Executive and Andrew Maloney, time. The meeting was well-attended, with staff Director of HR / Deputy CEO 16 Chair and Chief Executive’s Brief - July 2020 Other Local News

NHS Virtual Pride NHS 72

NHS England and NHS Improvement’s LGBT+ Staff We are asking staff to share with us a picture or a recorded Network organized an online event on Friday 26 June message about who has helped them get through this 2020, on what would have been Pride in London. difficult time – a friend, neighbour, family member of colleague, to mark the 72nd birthday of the NHS. Despite being unable to march this year, On Saturday 4 July 2020 everybody will be asked to put a GMMH’s LGBT+ Staff light in their windows in remembrance for those we have Network supported this lost during the pandemic. Public buildings will be lit up in nationwide celebration to NHS blue, including the Royal Albert Hall, Blackpool Tower, allow everyone to the Shard and the Wembley Arch. participate, despite being physically and There are also plans for the nation to take part in the graphically dispersed. biggest ‘thank you’ ever, in a round of applause at 5pm pm 5 July 2020. Broadcasters will suspend normal Lead: Andrew Maloney, Director of HR / Deputy CEO transmissions at 5pm and the NHS itself will be taking part to say thank you to everybody who has helped us face its biggest challenge.

Lead: Andrew Maloney, Director of HR / Deputy CEO 17 Chair and Chief Executive’s Brief - July 2020 Other Local News

Awareness Weeks We also shared how we are adapting our services to support carers in innovative ways, including encouraging Carers Week (8-14 June) is an annual campaign to service users to write letters to their families, setting up raise awareness of caring, highlight the challenges ward Skype accounts to enable video calling, ensuring care unpaid carers face and recognising their contribution. coordinators are regularly phoning carers to check in on them and virtual support groups! At GMMH we used Carers Week as an opportunity to highlight the support we provide for carers, to signpost Volunteers Week (1-7 June) is an annual celebration of the to the resources available for the family and friends of contribution millions of people make across the UK through our service users and staff who are carers and to volunteering. At GMMH we focussed on sharing real-life emphasise the vital role carers play in our stories from volunteers within the Trust to staff and across communities. our social media platforms. We launched a new carers film during the week to reassure carers that we are still here for them and the person they support.

Lead: Gill Green, Director of Nursing and Governance 18 Chair and Chief Executive’s Brief - July 2020 Other Local News

Awareness Weeks cont. donations to #GMMHGivesBack and via their nominations for GMMH Superstars. Mental Health Awareness Week (18-24 May) is focused on raising awareness of mental health and During the week, we promoted mental health services mental health problems and inspiring action to promote available to all adults and children across Greater the message of good mental health for all. The theme Manchester by signposting them to our Wellbeing hub, for this year was kindness. where we have links to a number of initiatives including Kooth and 42nd Street, and we shared our Self Help resources, including newly developed films of some of our Recovery Academy courses. International Nurses’ Day

International Nurses' Day is celebrated on 12 May each year, the anniversary of Florence Nightingale's birth. On Nurses’ Day, we said thank you to nursing staff We took part in the week by signposting staff to our everywhere for the remarkable health and wellbeing hub on our intranet and contribution they make to encouraging them to promote acts of kindness through millions of lives. 19 Chair and Chief Executive’s Brief - July 2020 Other Local News

Annual Report and Accounts 2019/20 Quality Account 2019/20

Despite the onset of COVID-19 in Month 12, we ended COVID-related amendments to this year’s annual reporting 2019/20 in a positive position. Our accounts for 2019/20 requirements removed the need for providers to include a show delivery of a small, net retained surplus of Quality Account in their Annual Reports. Auditor assurance £3.625million, which will support our programme of work on Quality Accounts also ceased in March 2020. The capital improvement works this year. We also achieved statutory requirement to produce a Quality Account was, the vast majority of our key performance indicators, however, unchanged. whilst progressing a number of new developments and strategic initiatives. The Board of Directors approved the Trust’s Quality Account 2019/20 on 29 June 2020. The content of the Our final Annual Report and Accounts 2019/20 were Quality Account follows national guidance, with two new signed-off on 22 June 2020 by the Audit Committee, sections this year providing detail on the Trust’s Freedom operating on behalf of the Board. This followed receipt of to Speak Up arrangements and increases in community a clean audit opinion from KPMG, our external auditors. mental health services capacity. The Quality Account The Annual Report and Accounts have subsequently celebrates the steps taken during 2019/20 to continually been submitted for laying before parliament and will be improve quality of care, including through the launch and made publicly available and shared with the Council of delivery of the Trust’s Quality Improvement Strategy. It also Governors once the laying process is complete. sets out quality improvement priorities for 2020/21, which will align with/support the Trust’s COVID-19 recovery plan. Lead: Neil Thwaite, Chief Executive and Janine Taylor, Acting Director of Finance Lead: Gill Green, Director of Nursing and Governance 20 Chair and Chief Executive’s Brief - July 2020 Other Local News

Performance Overview this can be delivered consistently and in all IAPT service areas. National requirements to achieve performance targets have been suspended during the COVID-19 response GMMH continue to show good performance in reducing with the focus on delivery of frontline care. Sadly, the out of area bed nights. The focus on reducing delayed number of patient deaths has increased as a result of discharges to improve patient flow remains to support COVID-19 mainly in acute hospitals and the care home this. sector. Staff sickness continues to be higher than target however non COVID-related sickness reduced in May. The Board report has been redesigned in terms of content, presentation and timing and introduced this Changes in referrals and presentation along with month for 20/21 reporting. changes to service delivery necessary to enable services to continue during the COVID-response period have Lead: Liz Calder, Director of Performance and Strategic impacted on performance. This includes our Early Development Intervention waiting time for 2 weeks from referral to treatment which, along with other community services, is delivering alternatives to face to face contacts where appropriate. Improvements continue in IAPT services with the Trust overall achieving both 6 and 18 week waiting targets this month. Work will continue to ensure

21 Chair and Chief Executive’s Brief - July 2020 Other Local News

Finance Overview The financial position for the 2 months ended 31 May 2020 is as follows: The Draft Operational plan for Greater Manchester Mental Health NHS Foundation Trust (GMMH) was • The Trust is reporting a breakeven position – this is submitted to NHS England and NHS Improvement in line with national guidance (NHSEI) in line with the national timetable in March 2020. • The Trust has claimed £2,037k for COVID-19 costs The plan was based on the planning guidance issued by to the end of May NHSEI and covered the financial year to the end of • The Trust is monitoring performance against 2 plans March 2021. – the draft 2020/21 budget (as submitted to NHSEI in March) and the NHSEI Income & Expenditure Plan For the financial year 2020/21, the GMMH draft plan was (Breakeven plan) a deficit of £5.202m. • The draft 2020/21 budget gives an understanding of where actual spend (and resulting income) is As a result of the COVID-19 pandemic, financial incurred and is the basis under which services will be reporting has been affected by the interim requirements monitored put in place by NHSEI. These temporary measures have • NHSEI Income & Expenditure plan is based on prior been introduced to support the NHS in responding to the year run rates of expenditure and income. (Income pandemic. These arrangements are currently in place as at M9 2019/20 and Expenditure (average M8-M10 until [at least] 31 October 2020 and should ensure all 2019/20) Trusts have sufficient cash to fund operations and deliver a breakeven position where possible. 22 Chair and Chief Executive’s Brief - July 2020 Other Local News

Finance Overview cont.

Good financial discipline is still expected and the Trust will continue to assess performance against key criteria and the expectation of a break-even position for the year (taking into account additional costs of COVID-19 response)

The Trust is facing pressures resulting from Agency and Bank staff costs, shortfall in the delivery of Cost Improvement Programmes and the cost of Out of Area Placements (OAPs).

The Finance Oversight group continues to monitor Operational Services performance against budget, and a new Corporate oversight group is being established to oversee progress in the Business Support areas.

Lead: Janine Taylor, Acting Director of Finance

Council of Governors

TITLE OF REPORT: Draft GMMH Membership Engagement Strategy 2020-2023 DATE OF MEETING: Monday 13 July 2020 AGENDA ITEM: 09 PRESENTED BY: Maureen Burke/Steph Neville AUTHOR(S): Maureen Burke/Steph Neville

EXECUTIVE SUMMARY: GMMH is required to have a Membership Strategy to help governors meet one of their statutory duties in representing the interests of members of the Trust and the public.

Here at GMMH we have revised our membership strategy from the one written a number of years ago. In doing so we are focusing on the challenge of engaging with the 11,000 members we already have and the wider population, looking at examples of engagement and best practice from elsewhere.

The Strategy should help guide the approach of Governors in their role of engagement with local communities and, with increased confidence, help to improve services for our users and carers through understanding the needs of the community they serve. It also encourages Governors to build on their already formed networks, developing new ones, to work across organisational boundaries and in partnership with other like-minded organisations in the interests of service users, carers, local communities and the wider population.

The Strategy identifies three priorities – the membership community, membership engagement and governor development and if accepted by the Council of Governors as an approach then a draft action plan will be developed by the Membership Working Group and brought back to the September meeting of the Council of Governors.

RECOMMENDATIONS: The Council of Governors is asked to approve the Membership Engagement Strategy 2020-2023 and ask that the Membership Working Group develop an action plan for its implementation.

Greater Manchester Mental Health Membership Engagement Strategy

2020 – 2023

Improving Lives

Foreword

This Strategy has been developed for governors of Greater Manchester Mental Health Foundation Trust to help them represent the interests of members of the Trust and the public – this is one of the governors’ statutory duties.

Foundation Trusts are built on the principle of local accountability and it is fundamental that there is a good relationship between governors and the membership community – the success of a Trust very much lies in the success of the Governors role.

The Strategy should help guide the approach of Governors in their role of engagement with local communities and, with increased confidence, help to improve services for our users and carers through understanding the needs of the community they serve. It also encourages Governors to build on their already formed networks, developing new ones, to work across organisational boundaries and in partnership with other like -minded organisations in the interests of service users, carers, local communities and the wider population.

The Strategy should become a document that doesn’t sit on a shelf but that it becomes an iterative document, owned by Governors which is refined and developed as experience of engagement grows.

We look forward to proactively working on the three key priorities identified in the Strategy – the membership community, membership engagement and governor development at an exciting time of change in the development of mental health services across Greater Manchester.

Rupert Nichols, Chair Maureen Burke, Lead Governor

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Contents

1. Introduction

2. What is Membership?

3. Our Membership

4. Key Priorities

5. Membership Community

6. Membership Engagement & Governor Development

7. Playing a Key Community Role

8. Working with Other Membership Organisations

9. Evaluating Success

10. Glossary of Terms

Appendices

Appendix A - Membership Engagement and Governor Development Action Plan – to be developed by the Membership Engagement Group

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1. Introduction

NHS Foundation Trusts (FT) were established as a new type of NHS Trust that was based upon a mutual organisation model. NHS Foundation Trusts (FTs) were created to devolve decision making from central government to local organisations and communities, with a strong and clear line of local democratic accountability. They created a new governance structure designed specifically for Foundation Trusts, which ensures the direct participation of local communities, and provides and develops healthcare according to the core NHS principles of free care, based on need and not ability to pay.

The governance structure of all Foundation Trusts is comprised of the following components:

Members:

Members of staff and the general public from the local community can join the Foundation Trust as Members. Members vote to elect Governors and can stand for election themselves.

Council of Governors:

Represents the interests of Foundation Trust Members and partner organisations in the local community, holds the Board to account for the performance of the Trust and exercises statutory duties. The composition of the Council of Governors is set out in the Constitution.

The Board of Directors:

Made up of Executive and Non-Executive Board members has collective responsibility for the performance of the Trust and exercises power on behalf of the Trust. The chair of the Board of Directors also acts as the chair of the Council of Governors.

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The diagram below demonstrates the governance structure at Greater Manchester Mental Health as set out in the Constitution:

15 Elected Public Governors from the Following Public Constituencies

City of Other England Service user Bolton Salford Trafford Manchester & Wales & Carer 2 2 2 3 2 4

Trust 6 Appointed &

Management Partnership

Team Stakeholder Governors Council of Governors Non -Executive Chair 28 Voluntary Sector Directors Focus on 1 Communities University of Manchester Board of 1 Directors

Salford University 2 Elected Staff Executive 1 Governors Directors from Staff Greater Constituency Manchester Police 1

Greater

Manchester

Combined

Authority 1

Greater Manchester Association of Clinical Commissioning Groups 1

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Those living in constituencies that are served by the FT can become members. The Membership Community is made up of public (including service users and carers) and staff members. From these members, Governors are elected to sit on the Council of Governors to represent members’ interests in the running of the organisation. Members are therefore given a bigger say in the management and provision of services within the FT. They are able to engage in establishing the direction of service provision and ensure that mental health and substance misuse services more accurately reflect the needs and expectations of local people.

The diagram below demonstrates the relationship between the FT and its serving communities:

Governors

Constituency

Foundation Membership Public Trust

All FTs have a duty to engage with their local communities and encourage local people to become members of the organisation and in so doing ensuring that membership is representative of the communities that they serve. By this method, FTs provide greater accountability to service users, carers, local people and NHS staff with the overriding principle being that Trust members have a sense of ownership over the services that the FT provides.

As Governors are elected by Public, Service Users and Carers as well as Staff Members they are accountable to those Members. In turn, the Non-Executive Directors are accountable to the Governors; this chain of interlocking relationships drives the performance of the organisation and is the mechanism for local accountability.

Public Governors face both directions. On the one hand they are the link between the local community, and its’ needs and views on services whilst on the other Governors have responsibility for communication from the Board of Directors to the

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local community. The success of a Foundation Trust very much lies in the success of the Public Governors’ role in linking the Trust to the community.

2. What is Membership?

Being a Member of an NHS Foundation Trust provides the general public and staff with the opportunity to get involved with their local health services and participate and positively influence plans for the development of the Trust and its services for the benefit of service users and carers.

All NHS Foundation Trusts must legally have at least one public constituency (made up of people who live in the public constituency areas) and a staff constituency (made up of employees of the Trust). Membership to both the Public, Service Users and Carers and Staff constituencies is free, and Members of each constituency will have the right to elect one or more Members to become a Governor serving on the Council of Governors, in line with the Trust Constitution.

At the onset of becoming a Foundation Trust in 2008, an additional constituency of Service Users and Carers was created to reflect their importance in the shaping of the Trust.

2.1 Public, Service Users and Carers Constituencies

Greater Manchester Mental Health Foundation Trust has a membership community made up of Public, Service User and Carers aged 14 years and over who live in the area and Staff Members. The Public Constituencies are defined on the basis of one or more local government electoral areas and comprise of patients, carers and members of the public and aims to be representative of the communities of the Trust – they can be found at Section 3.1 below. The Service User and Carer Constituency requires members to have been in receipt of Trust services, either for themselves or someone they care for, in the preceding 5 years.

2.2 Staff Constituency

The staff constituency is made up from staff employed at the Trust who have been permanently employed for a continuous period of at least twelve months or have a contract of employment with a fixed term of at least twelve months. The Trust can allow members who have carried out functions for the Trust but are not employed by the Trust ie volunteers, academic staff, nurses and doctors who are employed by a recruitment agency. However, to be eligible they must have carried out these functions at the Trust for at least twelve months.

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2.2 Benefits of Membership

In line with the terms of the Trust Constitution, members of the Trust have the following rights and benefits to:-

• Be able to elect Governors; • Be able to stand as a Governor; • Receive regular information about our activities, such as newsletters; • Provide opinions and be kept informed of plans for future developments depending on members choice of engagement level; • Be involved and consulted on issues such as changes and improvements to services; • Attend member events;

In addition the Trust’s Governors will :-

• Assist with developing relationships with other organisations; • Represent and promote the Trust and its services; • Explore opportunities for joint working with other organisations.

3. Our Membership?

Greater Manchester Mental Health NHS Foundation Trust provides a large range of services across a wide and disparate geographical footprint covering Greater Manchester, the wider North West and beyond. To reflect the diverse service portfolios and geography the Trust has a large Council of Governors with wide ranging knowledge and skills.

3.1 Public and Service User and Carer Members

In terms of public governors and service users and carers, we have a total of 20 elected by public members during Governor election processes with five key public constituencies covering over 5000 members as follows: -

• 3 City of Manchester • 2 Bolton • 2 Salford • 2 Trafford • 2 Other England and Wales • 4 Service User and Carer

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3.2 Staff Members

The Trust currently has around 5000 staff members with staff being automatically invited to become members, however, staff are free to “opt out” if they prefer. As with public members, staff members can also become more involved in the work of the Trust through its Council of Governors with staff members voting for staff governors during the election process.

There are currently 7 staff governors elected by the staff members.

3.3 Appointed and Partnership Stakeholder Governors

A total of 6 stakeholder governors are nominated from the following stakeholder organisations: -

Stakeholder Organisation Number of Seats

Greater Manchester Association of Clinical Commissioning 1 Groups

Greater Manchester Combined Authority (GMCA) 1

Manchester University 1

Salford University 1

Greater Manchester Police (GMP) 1

Voluntary Sector 1

Greater Manchester Association of Clinical Commissioning 1 Groups

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3.4 Current Position

Over recent years, the Trust has continued to monitor its membership in terms of numbers and representativeness through quarterly and annual reporting to the Board of Directors and to NHSE&I, and membership numbers are around 11,000. The potential opportunity members can provide in terms of a ready pool of feedback, local knowledge and support whilst acting as ambassadors for the Trust’s services has largely been underutilised and attempts at communicating with the existing membership has not had sufficient structure.

Governors are the key link between the community and the Trust, ensuring that our Trust is rooted in its community, owned by the community and responds to community needs. Having a broad and representative membership community and a Council of Governors elected from and by our members is key to working together to better meet the needs of our communities. The Trust is afforded huge opportunities and benefits as a result of embracing new ways of operating and engaging with our members.

Although Governors are small in number they represent large constituencies. This can be daunting but over the next few years elected Governors will work alongside the Trust to strengthen those lines of communication with constituencies to allow Governors to meet their statutory responsibility in being accountable to the local communities that elected them.

Some of the 11,000 members we currently have will choose to have a very active membership, whilst others will choose to only receive a newsletter. The level of engagement is up to the individual, and they can choose their level of engagement with the Trust such as:-

As little as:

• Receiving newsletters and regular updates Level 1 • Receiving invites for members’ events and meetings

• Receiving voting papers for Governor elections

As above and a little more

• Participating in surveys/questionnaires Level 2 • Attending Members’ events

• Voting for a Governor to represent them in the election process

As per Levels 1 and 2 plus:

Level 3 • Standing for election as Governor

• Attending council of Governor meetings

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Governors will be communication with their constituent members to be clear on their engagement preferences.

4. Key priorities

As FTs are built on the principle of local accountability it is fundamental that there is a good relationship between governors and the membership community. This would benefit the Trust as the local community members move towards a shared understanding of the challenge the Trust faces and potential solutions.

Benefits of engagement for Governors and the Trust include: -

• Good engagement can make governance processes more effective; • Enables Governors to meet statutory duty of understanding the views of members; • Clarity of Governor role leading to more fulfilled and energised in their role

Engagement should have clear aims and objectives to target the approach to public engagement, making best use of resources. Governors are integral to the strategy, adding insights and experience from the community to shape its development.

Key priorities for Governor engagement with the membership base are:

Membership Community

To uphold our membership community by addressing natural attrition and membership profile short fallings.

Membership Engagement

To develop and implement best practice and focussed engagement methods;

Governor Development

To support the developing and evolving role of our Governors.

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5. Membership community

The Foundation Trust has a duty to ensure that it engages with its local communities and encourages local people to become members of the organisation, ensuring that membership is representative of the communities that it serves. Therefore, it is important for the Trust to undertake membership recruitment campaigns each year to address any membership profile imbalances (eg hard to reach groups, young members) and to compensate for natural attrition.

5.1 Membership

The benefits of Trust membership will be promoted using a variety of communication methods which include the Trust website, press releases, hosting and attending local events and membership newsletters framed by Governors.

The Trust will be aiming over the term of this strategy to better understand its members and their preferred methods of communication.

5.2 Role of Governors

Trust Governors have an important role to play in member recruitment and engagement. They are our link with members (determining their needs/views on the delivery of services) and the Directors who make the decisions about services and hold responsibility for their delivery.

All Governors have a responsibility to convey information from the Board of Directors to members about affordability, service plans and health improvement initiatives, and also to represent their constituency at the Council of Governors – the structure of the Council meetings allows for this This helps to ensure that our Trustis informed about and can respond to community needs. Having a broad and representative membership community and a Council of Governors elected from and by our members, is key to this. We believe that the Trust is afforded huge opportunities and benefits as a result of embracing new ways of operating and engaging with our members.

The Council of Governors also play a crucial role in key areas via advising on issues, assist in developing ideas, acting as a sounding board, commenting upon Trust strategic developments and as a critical friend and indeed with the continual review and revision of the Membership Strategy.

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5.3 Membership Aim

Whilst the Trusts main aim has been to have a representative membership, the publication of Monitor’s guidance places greater emphasis on the need for Governors to represent the interests of members. At the onset of Foundation Trusts, Governors were given important duties when we were first authorised in 2008, but Since then the 2012 Health and Social Care Act gave Governors an expanded range of responsibilities. In 2013 the Francis Inquiry, and subsequent Keogh and Berwick Reports identified Governors as a vital channel for communications feedback from patients, service users and carers and the public to the Board of Directors.

In short public engagement is becoming an increasingly important part of what Governors do.

5.4 Membership Engagement & Governor Development Action Plan

A Governors’ Membership Working Group, as a Sub Committee of the Council of Governors, will monitor progress against the agreed action plan and there will be an annual review by members of the Membership Strategy.

The Trust will endeavour to establish a more active membership with increased engagement from Governors which will demonstrate local accountability.

The Trust will seek to ensure meaning full membership through involvement, collaboration and empowerment. In order to achieve this, the Trust will develop plans which will include:

• Engagement with new staff members as part of the staff induction process; • Explore new and effective ways of effectively communicating with our members; • Governors to promote membership across their respective constituency; • Benchmark with other FTs who have high levels of members’ engagement.

To meet their statutory activities, Governors will need support and ongoing development to support elected Governors in maximising the opportunities for member engagement.

A Membership Engagement and Governor Development Plan is attached at Appendix A to guide the work of the Membership Working Group and will be supported by the Head of Corporate Affairs and Communications Team. In addition, a recurrent resource for managing the member’s database and additional resources to support the development of a Membership Engagement Plan has been identified centrally.

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6. Membership engagement and governor development

As a Trust we aim to ensure effective two-way communication and appropriate engagement with our members via a combination of Trust and Governor managed formal and informal communications.

6.1 Membership Engagement and Communication

We will focus on ways of regularly making contact with our members and will look at using a variety of communication methods including:

• Trust website on internet with a designated section for members; • Email addresses all governors • Face to face through Trust events with Governors in attendance; • E-newsletter produced quarterly; • Twitter and Facebook; • Media releases for local media.

It would be tempting to strive for additional members, but the agreed priority will be to look at cost effective methods of engaging the large number of members we already have with their elected governors whilst also focussing on membership from hard to reach groups, such as young people.

6.2 Opportunities for Membership Engagement and Involvement

There are various opportunities for members to become more involved with the Trust, below are some examples:

• Attending Governor constituency meetings; • Attending Annual Members’ Meeting; • Trust promotional members’ events • Recruiting new members; • Voting in Governor elections; • Standing for election as Governor; • Fundraising activities; • Participating in surveys; • Participation in consultation of Trust plans; • Find out more about the work of the Trust; • Join the Trust’s volunteer services • Attending Trust Recovery Academy courses • Shadowing their constituent Governors at a Council of Governor meeting

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6.3 Council of Governors

The Council Governors will need to: -

• Maintain and develop a programme of events; • Review and develop membership materials and ensure the language is clear and accessible; • Develop strategies to inform the wider public and stakeholders about the Trust; • Evaluate the membership’s response to different levels of information and methods of delivery; • Use various communication methods to facilitate effective communication with members; • Establish a framework for constituency meeting with members and reporting back to Council of Governor meetings

An agreed engagement plan is attached at Appendix A which will be monitored by the Governor Working Group with regular reports to the wider Council of Governors.

7. Playing a key community role

We continue to work closely with our partners in local authorities, Clinical Commissioning Groups (CCGs), NHS England and partnership organisations. However, the Trust is aware that it needs to maximise the existing and seek new partnerships with like-minded organisations and key stakeholders in the community. In addition, it needs to ensure that the membership is fully aware of services provided by the Trust and that we maximise opportunities for positive public relations in the local community.

8. Working with other membership organisations

We aim to develop a strong sense of shared purpose with other likeminded organisations to raise the profile of community activity and to share best practice with such partners on membership, co-operation and community relations.

We shall support our Governors to also help us strengthen existing links with local organisations and to create new ones.

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9. Evaluation process

The Trust supports the time, resources and infrastructure to enable the continued development of an effective membership function, the management of stakeholder relationships and ongoing recruitment, induction and development activities for members and Governors.

We shall review existing membership information and ensure that a comprehensive information pack is produced for new members about the Trust, and the role of a Foundation Trust Member. The Trust’s membership database and community profiling data will be available for managing data and will be available for managing membership information.

The Council of Governors will review and refine the Membership Engagement Strategy to ensure the document is kept up to date and relevant. The intention is that the Strategy is owned and driven by the Council of Governors to fulfil its ‘statutory duties of engagement with its membership community.

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10. Glossary of terms

A Board of Directors is the executive body responsible for the Board of operational management and conduct of the Trust, comprising Directors Executive and Non- Executive Directors.

Members of NHS Foundation Trusts are grouped into Constituency constituencies representing different types of Members.

A group of Governors who are either elected by Members (Public Members elect Public Governors and Staff Members Council of elect Staff Governors) or nominated by partner organisations. Governors The Council of Governors is the Trust’s direct link to the local community; the community’s voice within the Trust in forward planning.

Executive Directors are senior employees, for example the Chief Executive and Finance Director, of a NHS Foundation Executive Trust who sit on the Board of Directors. Executive Directors Directors have decision-making powers and a defined set of responsibilities, thus playing a key role in the day to day running of the Trust.

People with an interest in the development and well-being of Members an NHS Foundation Trust are able to apply to become a member of the organisation.

Non-Executive Directors (NEDs) are appointed by Governors Non-Executive to sit on the Board of Directors of the NHS Foundation Trust. Directors NEDs are not employees of the organisation but do receive payment for their work.

Clinical Organisations that allocate the money given to them by the Commissioning government to all healthcare service providers in line with local Groups delivery plans and priorities

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Council of Governors

TITLE OF REPORT: GMMH Quality Account 2019/20 DATE OF MEETING: Monday 13 July 2020 AGENDA ITEM: 10 PRESENTED BY: Gill Green, Director of Nursing and Governance AUTHOR(S): Patrick Cahoon, Head of Quality Improvement

EXECUTIVE SUMMARY: The Quality Account for 2019/20 is now complete. The format of the Quality Account follows strict mandated contents, as set out in guidance. There are 2 new sections this year providing details on freedom to speak up arrangements, and describing how community mental health service capacity has increased throughout 2019/20, set out in part 2.

In a significant change for 2019/20, it was confirmed that there was no longer a requirement to include a quality report in the annual report and that auditor assurance work on quality accounts should cease for 2019/20. This was set out in NHSE/I guidance issued in March 2020.

As a result, the draft Quality Account has not been shared with KMPG. KPMG has also confirmed that there was no need for external testing of data indicators for this year’s Quality Account. The Council of Governors had selected seclusion use as the local indicator for data testing.

A working draft was shared with external stakeholders on 15th May 2020 for comments as part of the mandated consultation process. The feedback, which is predominantly positive is included as verbatim in part 4 of the Quality Account.

For 2020/21, it was decided to maintain the existing Quality Improvement Priorities (QIPs), which were agreed and set out in last year’s Quality Account. This will allow GMMH to continue with the significant progress already made, and to develop and implement further additional improvement programmes that relate to these areas.

The QIPs for 2020/21, will therefore continue to be:

• To improve outcomes • To Minimise harm • To integrate care around the person

The Quality Account has undergone some minor branding by the communications department, and was uploaded onto the NHS Choices website on 30th June, in accordance with the national guidance.

Planning for the 2020/21 Quality Accounts will commence in November 2020.

RECOMMENDATIONS: The Council of Governors is asked to note the 2019/20 Quality Account.

Quality Account 2019/20 1

Quality Account 2019/2020 Greater Manchester Mental Health NHS Foundation Trust

Improving Lives Contents

PART 1 – Our Commitment to Quality ...... 4 1.1 Chief Executive’s Welcome ...... 4 1.2 Quality Assurance at GMMH ...... 5 1.3 Quality Improvement at GMMH (QI Strategy Phase 1) ...... 6 1.4 Accolades and Developments ...... 8

PART 2 - Statements of Assurance from the Board for 2019/20 ...... 12 2.1 Review of Services ...... 12 2.2 Participation in Clinical Audits and National Confidential Enquiries ...... 12 2.3 Participation in Clinical Research ...... 17 2.4 Commissioning for Quality and Innovation (CQUIN) ...... 19 2.5 Registration with the Care Quality Commission (CQC) ...... 21 2.6 CQC Mental Health Act Monitoring ...... 22 2.7 Data Quality ...... 22 2.8 Information Governance ...... 23 2.9 Clinical Coding ...... 23 2.10 Department of Health Mandatory Quality Indicators ...... 23 2.10.1 Preventing People from Dying Prematurely - 7 Day Follow-Up ...... 23 2.10.2 Enhancing Quality of Life for People with Long-term Conditions – Gatekeeping ...... 24 2.10.3 Ensuring that People have a Positive Experience of Care – Staff Survey ...... 25 2.10.4 Ensuring People have a Positive Experience of Care – Community Mental Health Patient Survey...... 27 2.10.5 Ensuring that People have a Positive Experience of Care – Friends and Family Test (FFT) ... 29 2.10.6 Treating and Caring for People in a Safe Environment and Protecting them from Avoidable Harm – Patient Safety Incidents: ...... 31 2.10.7 Learning from Deaths ...... 34 2.11 Freedom to Speak Up ...... 37 2.12 Increasing Community Mental Health Services Capacity ...... 38

QUALITY ACCOUNT 2019/20 2

PART 3 – Review of Quality Performance in 2019/20 ...... 39 3.1 Delivery of Quality Improvement Priorities in 2019/2020 ...... 39 3.2 Performance against Quality Indicators Selected ...... 54 3.3 Performance against Key National Priorities ...... 55

PART 4 – Priorities for Quality Improvement in 2020/21 ...... 58 4.1 Consultation feedback ...... 58 4.2 Improvement Priorities for 2020/2021 ...... 58 4.3 Monitoring our Quality Improvement Priorities ...... 59 ANNEX 1 Feedback from Key Stakeholders ...... 60 ANNEX 2 Statement of Directors’ Responsibilities in Respect of the Quality Account ...... 67 ANNEX 3 Equality Impact Assessment ...... 69 ANNEX 4 Local Clinical Audits Reviewed in 2019/20 ...... 71 ANNEX 5 Glossary of Terms ...... 75

QUALITY ACCOUNT 2019/20 3

PART 1 – Our Commitment to Quality

1.1 Chief Executive’s Welcome

On behalf of the Trust Board, I am proud to present our Quality Account for 2019/20. This describes the steps taken during what have been extraordinary times to continually improve the quality of care

2019/20 has been a challenging year, not just for GMMH, but for all Trusts, public services and our colleagues in the voluntary sector. The speed and spread of Covid-19 has affected how we work on a day to day basis. We have entered a phase that none of us are familiar with, which at times has been uncomfortable and challenging. However, I have been truly humbled by the way our staff, right across GMMH, in our clinical, operational and corporate services have responded to what is undoubtedly one of the biggest challenges that the NHS has ever faced.

I want to acknowledge and thank our workforce, and our volunteers for everything they have been doing at this incredibly challenging time. They have shown courage, compassion and dedication and have come together going beyond the call to make sure we can continue with our essential services.

In addition to setting out our approach to quality, this Quality Account also reports on how we have performed against key national and locally determined quality standards, and demonstrates our commitment to further quality improvement in the year ahead. It includes some notable achievements and accolades, and sets out the progress we have made since publishing our Quality Improvement Strategy in May 2019.

In our annual report 2019/20, we have set out how the organisation has grown, despite the challenges we have faced, both in terms of the services we provide and our shared goals. This included our 5-year strategy, the steps we are taking to support our staff and improve our environments, our plans to become more digitally enabled, our partnership working and the need to work efficiently throughout 2020/21.

The launch of our Quality Improvement Strategy marked the continuation of our journey to provide high quality, safe and clinically effective care for our service users and their families. Through our work to build improvement capability across our workforce, using tried and tested tools and methods, we are now in a strong position to deliver our Quality Improvement Priorities (QIPs) for 2020/21. Further information on our QIPs is set out in section 4.2 of this report.

Section 1.3 of this Quality Account describes some of the progress we have already made, with the three key enablers that were set out in phase one of our Quality Improvement strategy. These were, to build improvement capability across GMMH, to development improvement orientated data reporting, and to identify an improvement methodology to complement our vision and values.

QUALITY ACCOUNT 2019/20 4

Next year will see us continuing with our efforts to become an organisation with a culture of continuous improvement. Despite the challenges, we will continue to do everything we can to improve outcomes and experiences, provide the safest care across the breadth of our services and continue with our efforts to integrate care around our service users. We will do this by building on the steps we have already taken, to develop improvement capacity and capability throughout GMMH.

Looking ahead, 2020/21 promises to be just as challenging - not only in relation to Covid-19 – but also from a financial perspective, the increasing demand for our services and in national shortfalls in workforce supply. As a Trust, we will continue to take every opportunity we can to deliver continuous quality improvement in this environment.

Finally, I am pleased to inform you that the Board of Directors has reviewed this 2019/20 Quality Account and confirm that it is an accurate and fair reflection of our quality and performance. I hope that this report provides you with a clear picture of our robust approach to quality across GMMH. On behalf of the Board, I want to thank all staff for their contribution.

As Chief Executive of Greater Manchester Mental Health NHS Foundation Trust (GMMH), I can confirm that, to the best of my knowledge, the information contained in this report is accurate. The ‘Statement of Directors’ Responsibilities’ at Annex 2 summarises the steps we have taken to develop this Quality Account and external assurance is provided in the form of statements from our commissioners, local HealthWatch organisations and Scrutiny Committees in Annex 1.

Neil Thwaite, Chief Executive

1.2 Quality Assurance at GMMH

As an organisation that seeks to continually improve, we take steps to quality check our current activities to provide the best possible care to our service users. Our Board of Directors hold ultimate accountability for the quality of the services that we provide. In order to ensure robust quality assurance and a culture of continuous improvement, the Board has established a committee with delegated authority to set the strategy for quality and to ensure delivery against it.

The Quality Improvement Committee (QIC) is chaired by a non-executive director and has representation from the Trust Board, lead clinicians from all clinical services and from corporate leads with responsibility for quality improvement. The structure and business of the QIC has been informed by an assessment against the national Quality Governance Framework.

QIC provides leadership and oversight for the Trust’s quality and integrated governance framework. It maintains a strategic overview of the Trust’s approach to quality improvement, and ensures that it encompasses a robust range of improvement methodologies that reflect our local and regulatory requirements. QIC develops the Trust’s quality strategy on behalf of the Board and identifies key

QUALITY ACCOUNT 2019/20 5

quality priorities, goals and standards for GMMH. This is set out both in our Quality Governance Framework and in our Quality Improvement Strategy.

Trust Board and QIC members are visible within clinical services. This provides members with opportunities to triangulate evidence, speak to service users and staff about their experience and ensure that there is an open and transparent culture across GMMH. Throughout the year, we have continued to embed our quality improvement approach, within a strategic framework offering ward to Board level assurance that our services are safe, positive and effective.

GMMH’s Executive Management Team and Board review intelligence gathered from a wide range of sources. These include:

• Service specific performance monitoring • Clinical governance reports (including frameworks incidents, compliments and complaints) • Quality improvement project reports, and • Corporate governance reports (Compliance our Lean A3 single page plans with the NHS Improvement Oversight • Quarterly quality reports, using statistical Framework and Monitor ‘Code of process control charts to drive and monitor Governance’) our improvement programmes • Board performance reports and presentations • Commissioning for Quality and Innovation at Board meetings (CQUIN) activity • Quality Board performance reports, which • Contractual Performance Key Performance have been adapted to become more Indicators improvement orientated • Care Quality Commission insight reports • NHS Benchmarking Network reports • Insight reports • Additional activities including deep dives and • Staff and patient surveys external reviews, as commissioned by the QIC

1.3 Quality Improvement at GMMH (QI Strategy Phase 1)

Our Quality Improvement strategy for phase one was launched in May 2019, following a significant engagement process with a wide range of stakeholders across the GMMH footprint. We agreed three key enablers which were put in place throughout 2019/20 to support the delivery of our quality improvement priorities and our wider vision for QI. These were as follows:

1. Supporting staff to deliver QI - building capacity and capability 2. Identifying improvement methodology to complement workflow 3. The development of improvement orientated data throughout the organisation, from Board to team/ward

Supporting staff to deliver QI – building capacity and capability

In delivering phase one of our QI strategy, we have focussed on the provision of high-quality training, that supports our staff to have the capability, enthusiasm and motivation to make, sustain and spread QI across GMMH. Building capability in this way will enable us to create a culture, where staff members are trained and empowered to focus on where they can make improvements to the work they do; whether that is in clinical care, governance, financial systems, estates and facilities or

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human resources. To date, over 120 members of GMMH staff have participated in QI training, across a wide range of areas ranging from advanced Plan Do Study Act (PDSA) and measurement, Lean in healthcare and appreciative enquiry training, through to human factors, improvement practitioner and measurement masterclass training.

Throughout 2020/21, we will focus on developing an accredited in-house programme. This will be available to all staff including our service users across GMMH, at different levels to complement the current Advancing Quality Alliance (AQuA) offer.

Identifying improvement methodology to complement workflow

Within the phase one implementation of the QI strategy, GMMH made a commitment to identifying an improvement methodology that reflects the vision, values and principles of our Trust. In delivering this aim, we worked closely with an expert adviser from the National Collaborating Centre for Mental Health, to develop an options appraisal framework for selecting a QI methodology.

Our QI team then developed an outline framework that described our strategic context, current approaches, capability and programmes, a consideration of the criteria that our chosen methodology should fulfil and an appraisal of the key improvement methodologies promoted resourced and adopted in front line services throughout the NHS. Working with our national advisor, we were able to define both our local context and our starting point, as well as a number of important criteria that needed to be fulfilled when appraising methodology for QI approach in GMMH.

The options appraisal highlighted the IHI-QI Model for Improvement as the single methodology that best meets each of the individual criteria set that we set out. However, in selecting an improvement approach there is a need to ensure it shouldn’t be so exclusive that it could potentially prevent the trust from applying QI in specific circumstances, for example system-wide improvement when our methodology is better suited to local, small scale innovation.

The evidence tells us that QI approaches are underpinned by a philosophy and a set of consistently applied competencies. Research indicates that improvement initiatives are more successful if frontline staff have capability in a range of improvement methods, approaches, tools and techniques, and importantly, that this is backed up by a clear philosophy and organisational strategy to enable QI to take place and flourish. For this reason, we have therefore adopted the Model for Improvement as our core methodology, but have decided to blend this with other QI methods and methodologies when this might be necessary, for example, Lean, or 6 Sigma. We will continue to adapt our chosen methodology throughout 2020/21, and will continue to train our staff in its consistent application to our improvement effort.

The development of improvement orientated data throughout the organisation, from Board to team/ward

Our final key enabler for phase one was the development of improvement data reporting across GMMH. In delivering this, we made a a commitment to exploring how to make better use of data in order to drive, monitor and inform our QI activity. We are now moving from measurement for judgement, which satisfies our internal assurance and external regulation, toward measurement for improvement, which will be a key enabler in delivering our longer-term improvement goals.

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A key part of measurement for improvement is established baselines, measurable aims and a means of tracking progress over time. It also requires organisations to report data in a time series analysis format and to develop knowledge and appreciation of variation. At GMMH, we started this process with a ‘plot the dots’ session, delivered by NHSI at our Board development session in September 2019. Shortly after this, we decided to adopt Statistical Process Control (SPC) as a method for measuring and tracking our improvement efforts, primarily for Board performance reporting. To support this, we established a task and finish group to pave the way and prepare for this important transition. The task and finish group also undertook a value stream mapping process, which resulted in a significant reduction in the time it takes to prepare data for Board reporting purposes.

We have also tested out this new approach at our Quality Improvement Committee, which has received its last two quarterly quality reports using SPC charts. This has enabled committee members to develop a knowledge and appreciation of measurement, common cause and special cause variation. We will continue to introduce our services to improvement orientated data reporting throughout 2020/21, providing further training where this might be needed.

We are pleased to be able to report on the substantial progress we have already made at this early stage of our QI journey. We will continue with our efforts to build capacity and capability throughout 2020/21.

1.4 Accolades and Developments

The last 12 months have seen a number of achievements across the Trust and are testament to the calibre of staff whose dedication and enthusiasm have contributed to these. Here are a few highlights:

Chief Nursing Officer Dr Ruth May visited Park House during 2019, to see first-hand the care delivered there as well as plans for improving the environment. She also visited the Section 136 suite – the first of its kind in the city – and saw how people in mental health crisis are cared for in a much more suitable environment rather than a busy A&E department or a police station. Dr May has introduced the Chief Nurse Officer’s badge which is a lifetime achievement accolade to nurses who have demonstrated nursing excellence. As part of her visit, Dr May awarded Tara McGinley the gold Chief Nursing Officer’s badge – the highest honour she can give. Tara has worked in community settings for over 30 years and is a highly regarded and respected Advanced Nurse Practitioner. Tara is the first mental health nurse in the UK to be awarded the Chief Nursing Officer’s badge.

GMMH was singled out for praise during the 2019 Annual Apprenticeship Conference. During her keynote speech, Amanda Spielman, Ofsted Chief Executive, discussed the apprenticeship landscape, current challenges that providers face and Ofsted's approach to apprenticeships. She said:

"The Greater Manchester NHS Mental Health Trust uses apprenticeships both for recruitment of new staff, as well as to help existing staff get on in their careers. Managers use apprenticeships as part of their recruitment strategy. They look at their available jobs and decide which can be filled by apprentices new to the Trust. They also offer apprenticeships to existing health care workers. This allows existing staff to develop their knowledge and skills enough to gain promotion and fill vital roles throughout the Trust. "

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GMMH established a new Greater Manchester Universities Mental Health Service development. The new service receives referrals from the existing Universities’ counselling services. This is the first service of its kind to work in partnership between the NHS, Universities and the voluntary sector. The service provides proactive mental health assessment, support and interventions from experienced mental health professionals to students to enable them to fulfil their university ambitions and experience. The team works across GM to support students with mental health issues, in a variety of community settings, including the university sites, or undertaking home visits, encouraging the principles of the recovery approach.

In August 2019, GMMH received the news that we were successful in obtaining £72.3million capital funding to build a replacement for Park House inpatient unit on the North Manchester General Hospital site. This meant we were one of the 20 NHS organisations which obtained capital funding across England. GMMH received the third biggest share of the national allocation and the highest in the North West. Park House has always been an improvement priority, as we wanted to move away from dormitory-style accommodation and sub-optimal indoor and outdoor space. We want the environment to reflect the excellent care delivered by our staff to service users. This is a fantastic opportunity to build a modern, fit-for-purpose facility which will offer a fully therapeutic environment to support recovery as well as providing much improved working surroundings for our staff.

Working in partnership with Manchester City Council and Manchester Health and Care Commissioning, GMMH have invested over £900,000 into the former Harpurhey Wellbeing Centre to be a vital community resource and provide NHS services for Harpurhey and the North Manchester area. The newly named No.93 hosts community activities, volunteer led groups and also has an exercise room and creative arts space open to everyone including centre users, local groups and

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residents in the wider community. The financial investment also provided Improving Access to Psychological Therapies, with No.93 providing an NHS psychological therapies service for the community with the introduction of nine dedicated therapy rooms together with a group room, making the centre an inclusive space and a place to challenge stigma associated with mental health generally.

Pride in Practice is a programme provided by The LGBT Foundation to healthcare settings to support improvements in health outcomes for their lesbian, gay, bisexual and trans (LGBT) service users, as well as strengthen their engagement with, and understanding of, that community. GMMH has rolled this programme out and staff have been trained on LGBT inclusion, sexual orientation monitoring, myth busting and confidence building. Endorsed by The Royal College of GPs, Pride in Practice's support package enables health professionals to effectively and confidently meet the needs of LGBT service users. The initiative supports environments to be LGBT friendly, review local policies and procedures and implement an accreditation scheme to recognise the positive steps services have made for LGBT service user inclusion.

A new partnership was formed to tackle substance misuse issues in Bury. Achieve Bury delivers alcohol and drug services to those needing help and support to break the cycle of addiction. As a partnership model, GMMH, The Big Life Group and Early Break already run drug and alcohol recovery services – known as Achieve - across Bolton, Salford and Trafford in the first cluster-commissioned tender in the North West. Now the partnership has been successful in becoming the provider of substance misuse services in Bury. Achieve Bury takes a whole-person approach and help to address issues such as employment, education, housing, finances and relationships which can prevent or slow down recovery.

The Mental Health In-Reach Team (MHIT) at HMP Manchester won Placement of the Year award at the University of Manchester Recognising Excellence and Achievement Awards ceremony in November 2019. The team were shortlisted for this student nominated award from over 80 student nursing placement nominations. The MHIT team were described as “welcoming… engaging… fantastic team communication and... encouraging student involvement in multi-disciplinary discussions and decision making.”

GMMH’s Care Quality Commission report was published in January 2020 following the inspection which took during 2019. The Trust maintained the overall rating of ‘GOOD’ with individual ratings for each of the core service lines; achieving ‘Good’ ratings for six core services, ‘Requires Improvement’ for two core services and an ‘Outstanding’ rating for substance misuse services. During their inspection, the CQC team acknowledged many positives. They noted that staff treat patients with compassion and kindness, and respect their privacy and dignity. They recognise that staff involve service users in care planning and risk assessment and actively seek feedback on the quality of care provided. The CQC highlighted a number of areas of ‘Outstanding’ practice, including the Safewards programme, the new mental health service for Greater Manchester University students and the partnership approach with housing providers.

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Borrowdale Ward at the Trust’s medium secure unit, Edenfield underwent extensive refurbishment following a £500k investment. This investment was a result of research carried out in 2018 of 200 women who had spent time in secure facilities. The research showed that these service users needed stability to feel safe and secure in familiar and comfortable environments. The other major finding was the importance of relationships within the service. The refurbishment of Borrowdale means that women are cared for in one place, within Edenfield. The average length of stay for service users has been approximately two years, but under this new model of care, there have been some quicker discharges. Future plans include the development of a family room so women have somewhere to meet with their children when they visit.

Buzz brings Manchester communities together through common interests that benefit residents’ physical and mental health wellbeing, focussing on supporting residents of local communities to take control of their health and wellbeing in ways that interest them and excite them. During 2019, Buzz took a new approach. Neighbourhood Health Workers now cover the 12 neighbourhoods of the City of Manchester. There are also specialist workers whose role it is to specifically engage with older people and families with young children. Furthermore, Fallowfield, Rusholme, Gorton and

Wythenshawe have been officially recognised as ‘age friendly’ neighbourhoods by Andy Burnham, Mayor of Greater Manchester. The Mayor’s Age Friendly Challenge Award scheme acknowledges communities that are committed to looking out for one another and that older people feel empowered to have a say in what is going on their local area.

Over the last 12 months, we have established our Disabled and LGBT+ Staff Networks. In addition, our proactive and vibrant Black Asian and Minority Ethnic (BAME) Staff Network continues to flourish. The aim in 2020 and beyond is to grow the network and ensure BAME staff can influence and improve care for service users and make GMMH a truly diverse and inclusive outstanding place to work.

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PART 2 - Statements of Assurance from the Board for 2019/20

This section of our Quality Account includes mandated information that is common across all organisations’ Quality Accounts. This information demonstrates that we are performing to essential standards; measuring clinical processes and performance; and are involved in national projects and initiatives aimed at improving quality.

2.1 Review of Services

During 2019/2020 Greater Manchester Mental Health NHS Foundation Trust provided and/or sub- contracted a wide range of relevant health services. Services provided include:

• Community and inpatient mental health • Prison healthcare and in-reach services services • IAPT– primary care psychology • Adult forensic mental health services • Rehabilitation services • Adolescent forensic mental health services • Perinatal services • Inpatient Child and Adolescent mental • Community Child and Adolescent Mental health services Health Services • Mental health and deafness services • Public Health Improvement Services • Community and inpatient alcohol and drug services

More detail on the services provided by us can be found on our website www.gmmh.nhs.uk.

GMMH has reviewed all the data available on the quality of care in all of these services.

The income generated by the relevant health services reviewed in 2019/20 represents 100% of the total income generated from the provision of relevant health services by GMMH for 2019/20.

2.2 Participation in Clinical Audits and National Confidential Enquiries

During 2019/20, There were 5 national clinical audits and 1 national confidential inquiry covering relevant health services that GMMH provides. During that period, GMMH participated in 100% of the national clinical audits and 100% of the national confidential inquiries which it was eligible to participate in.

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The national clinical audits and national confidential inquiries that GMMH was eligible to participate in during 2019/20 are as follows:

• Prescribing Observatory for Mental Health: Monitoring of Patients Prescribed Lithium • Prescribing Observatory for Mental Health: Prescribing for Depression in Adult Mental Health • Prescribing Observatory for Mental Health: Use of Depot/LA Antipsychotic Injections for Relapse Prevention • National Audit of Early Intervention in Psychosis re-audit • National Audit of Inpatient Falls • National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness (NCI/NCISH)

The national clinical audits and national confidential inquiries that GMMH participated in and for which data collection was completed during 2019/20, are listed below alongside the number of cases submitted to each audit or inquiry as a percentage of registered cases required of that audit or inquiry (list and percentages are in the table below).

National Clinical Audits:

Audit Title Participation % of cases Submitted Prescribing Observatory for Mental Health: Yes 100% Monitoring of Patients Prescribed Lithium

Prescribing Observatory for Mental Health: Yes 100% Prescribing for Depression in Adult Mental Health

Prescribing Observatory for Mental Health: Yes 100% Use of Depot/LA Antipsychotic Injections for Relapse Prevention

National Audit of Early Intervention in Psychosis re- Yes 100% audit

National Audit of End of Life Care Yes 100%

Information about the Audits

Prescribing Observatory for Mental Health: Monitoring of Patients Prescribed Lithium. Report issued July 2019.

The clinical practice standards used for this audit are based on NICE Clinical Guideline 185 (2014) Bipolar Disorder; Assessment and Management and looks at the tests/measure that should be completed before initiating treatment with lithium and also during maintenance treatment.

1 The following tests/measures should be completed before initiating treatment with lithium: a Renal function tests; urea and electrolytes (U&Es), e-GFR and calcium

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b Thyroid function tests (TFTs) c Weight or BMI

2 The following tests/measures should be conducted during maintenance treatment: a Serum level every 6 months b U&Es, e-GFR, calcium, and TFTs every 6 months c Weight or BMI

Prescribing Observatory for Mental Health: Prescribing for Depression in Adult Mental Health. Report issued in November 2019.

The standards are derived from NICE guideline CG90 depression in adults: recognition and management (NICE, 20091) and the BAP guideline for treating depressive disorders with antidepressants (Cleare et al, 20152) and make recommendations on the identification, treatment and management of depression in adults aged 18 years and older, in primary and secondary care.

The audit explored how depression is managed along with the information that is given to patients about their antidepressant medication. Patients prescribed continuing antidepressant medication should have a care/crisis plan that identifies potential triggers/precipitating factors that may lead to their condition worsening and include strategies to manage such triggers. For those patients prescribed continuing, long-term antidepressant medication, an annual review addressing therapeutic response to medication including severity and frequency of depressive episodes should be undertaken. This should also include medication adherence and side effects, comorbid conditions, including alcohol and substance use and both psychiatric and physical disorders.

Prescribing Observatory for Mental Health: Use of Depot/LA Antipsychotic Injections for Relapse Prevention. Report due March 2020

The standards are derived from NICE Guideline CG178 ‘Psychosis and schizophrenia in adults: prevention and management’.

The audit data will provide evidence of compliance with the practice standards to ascertain if a patient’s care plan is accessible in the clinical record and whether the patient was involved in the generation of their care plan. To also establish that the patient’s relapse ‘signature’ signs and symptoms are documented in their care plan together with a crisis plan. The care plan should include a clinical plan for response to default from treatment, i.e. if a patient fails to attend an appointment for administration of their depot injection or declines their depot injection

There should also be a clear rationale for initiating a depot/long-acting injectable antipsychotic medication recorded in the clinical records and a review of the medication conducted at least annually. The review should include consideration of therapeutic response, adverse effects and adherence.

National Audit of Early Intervention in Psychosis (re-audit). Report due in July 2020.

The Early Intervention in Psychosis (EIP) audit will help to establish the extent to which services comply with a framework of NICE standards of care, NICE quality standard for psychosis and schizophrenia in adults (QS80), which put particular emphasis on early access, physical health, family

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intervention and supported employment programmes and will enable participating services to identify their strengths as well as the areas for improvement.

The aim is to achieve compliance and provide evidence to NHS England that patients have been screened for all seven cardio metabolic parameters (as per the ‘Lester tool’) which are:

• Smoking status • Blood pressure • Alcohol • Glucose regulation (HbA1C or fasting • Drugs glucose or random glucose as appropriate) • Body Mass Index • Blood lipids

Where clinically indicated they were directly provided with, or referred onwards to other services for interventions for each identified problem.

National Audit of Inpatient Falls: Report issued August 2019

The National Audit of Inpatient Falls (NAIF) audit is undertaken to understand inpatient hip fracture to help hospitals, trust and health boards improve their inpatient falls care. An inpatient is defined as a patient in a non-permanent bed-based setting commissioned or managed by an acute, community or mental health Trust/health board.

From 1 January 2019, onwards to 14 August 2019 any patient entered into the National Hip Fracture Database (NHFD) documented as having had an inpatient fall is automatically entered into the audit.

The aim of the audit is to identify that NICE compliant protocols were followed for a fall that caused a hip fracture. Key considerations were: -

• Time and date of fall • Time and date patient admitted to hospital where the fall resulting in the hip fracture occurred • Type of ward where fall that resulted in the hip fracture happened • Nice compliant protocols • Level of harm attributed to the fall that resulted in the hip fracture

Standards audited were primarily derived from NICE (National Institute for health and Clinical Excellence) CG 161 (Falls: assessment and prevention) and NICE QS 86 (Falls in older people), with additional standards derived from evidence-based guidance from NICE, NPSA (National Patient Safety Agency) and the MHRA (the Medicines and Healthcare Products Regulatory Agency).

National confidential Questionnaires received Questionnaires % inquiry from NCI 2018/2019 completed and returned back to NCI Suicide 34 34 100

The National Confidential Inquiry examines suicides and homicides by people who have been in contact with secondary and specialist mental health services in the preceding 12 months. Previous findings of the Inquiry have informed recommendations and guidelines produced by the National Institute for Clinical Excellence (NICE), the National reporting and learning system (NRLS) and the

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Inquiry itself aimed at improving outcomes and reducing suicides rates for individuals with mental illness.

The reports of 4 national clinical audits were reviewed by GMMH in 2019/20 and GMMH intends to take the following actions to improve the quality of healthcare provided as per the table below:

Audit Title Key Actions Prescribing Observatory for • Improve documentation around side-effect monitoring Mental Health: Assessment • Encourage staff to utilise LUNSARS / GASS tools on Paris. of the side-effects of • Physical assessment in relation to in relation to side- depot/LAI antipsychotics. effects should be conducted and documented in Paris. Reported issued April 2019 • When side-effects have been identified, a treatment/care plan detailing the management to be documented. Prescribing Observatory for • To improve uptake and documentation of giving Mental Health: Monitoring information on lithium using purple booklets. of Patients Prescribed • Services to check if lithium booklets are still available Lithium. Report issued July and are being given to patients on lithium treatment and 2019 to check if a record is being made in Paris if purple booklet is given. Prescribing Observatory for • To ensure patients are routinely given information about Mental Health: Prescribing the medication they are prescribed and that patients for Depression in Adult prescribed continuing antidepressant medication have a Mental Health. Report issued care/crisis plan that identifies potential triggers. in November 2019 National Audit of Inpatient Compliance with the standards was met, no further action is Falls: Report issued August required. At the time of data collection GMMH had a low number 2019 of reported hip fractures. It was evidenced in the clinical notes that the patients were checked for signs/symptoms of potential spinal injury and fracture before they were moved. Patients also had documented evidence that a medical assessment (or transfer to ED organised) was carried out within 30 minutes following the fall.

We also undertook and reviewed the reports of 109 local trust clinical audits in 2019/20. A full list of these local audits is included in Annex 4. Recommendations and action plans for each local audit has been agreed and shared with relevant people/services in line with our Clinical Audit Policy. If you are interested in learning more about the actions we are taking to improve the quality of healthcare provided based on the outcomes of these audits, please contact:

Patrick Cahoon Tel: 0161 357 1793 Head of Quality Improvement E-mail: [email protected] All national and local clinical audit reports, and resulting action plans, are reviewed by our Quality Improvement in Clinical Care Group (QICC) (Formally the NICE Implementation and Audit Group

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(NIAG), which meets on a bi-monthly basis and is chaired by the Trust’s Medical Director, QICC aims to ensure that actions agreed following audit reports are supported and completed. The outcomes of discussion at QICC are reported up to, and considered at, the Trust’s Quality Governance Committee.

2.3 Participation in Clinical Research

The NHS Constitution for England requires us to offer access to research and innovative treatments to all service users. Evidence suggests that research-active Trusts deliver higher quality care overall, which is reflected in the development of research indicators within the CQC inspection framework. The level of research activity within GMMH sets us apart from the majority of mental health Trusts nationally and this has been further enhanced by Research and Innovation (R&I) becoming an explicit part of the Trust strategic objectives in 2019/20.

R&I functions continue to be supported by external funding streams including National Institute for Health Research (NIHR) grant funding and Research Capability Funding (related to our grant successes), income from the NIHR Greater Manchester Clinical Research Network (GM:CRN), Health Innovation Manchester (HinM) and our commercial research portfolio. The R&I infrastructure has also benefitted this year from a contribution from the Trust to support core functions. Our total NIHR grant income for 2019/20 for all active grants and fellowships was £3,051,432. We also achieved a number of new NIHR grant successes over the last 12 months, which will run over the next three to five years. Areas of focus include looking at avoidable harm in prison settings and a peer-delivered disclosure course as an intervention to combat the stigma of psychosis. Other key areas include:

• A peer-delivered disclosure course as an intervention to combat the stigma of psychosis: intervention refinement and feasibility, Melissa Pyle (£243,439, NIHR Research for Patient Benefit) • Children with OCD: Identifying Accessible Support Strategies for Parents (COASSIST), Rebecca Pedley (£149,987, NIHR Research for Patient Benefit) • An investigation into aftercare planning for those remitted to prison from secure services: a mixed methodology exploratory study, Jenny Shaw (£149,386, NIHR Research for Patient Benefit) • In addition to the above grant income, Jenny Shaw has also received a NIHR Senior Investigator award

NIHR grant income generates additional Research Capability Funding (RCF) from the NIHR, which enables us to support research growth across the Trust. In 2019/20 the Trust received £795,498 in Research Capability Funding. In line with our strategy, this funding has supported a number of internal research initiatives including the continued support of six successful Research Units in the following areas:

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• Psychosis • Youth Mental Health • Dementia • CAMHS.digital • Complex Trauma and Resilience • Patient Safety

In order to ensure continued access to this funding stream, the Units are required to demonstrate clear service user involvement, alignment with clinical services and applications for NIHR or commercial funding.

Smaller RCF awards in areas including substance misuse, forensic services, metacognitive therapy, perinatal mental health and nursing have led to pilot projects and grant submissions to the NIHR. A significant development in 2019/20 has been the appointment of a Clinical Research Fellow in Mental Health Nursing. This is a shared post between R&I, Nursing and Governance and the University of Manchester and will drive forward nurse led research across the Trust. Further awards have been made in March 2020 in areas including mental health nursing, specialist perinatal services and common mental health problems.

Research Delivery

During 2019/20, over 2000 patients, staff, relatives and carers participated in research projects approved by the Health Research Authority in GMMH. GMMH has been involved in 87 clinical research studies throughout the year ending 31 March 2020, including 9 Clinical Trials of Investigational Medicinal Products (CTIMPs) and 8 studies which are sponsored by GMMH. Our 2019/20 annual project audit showed that 63% of Principal Investigators of studies declared some level of service user involvement in the research process itself.

Bringing research to our service users

Ensuring increased access to research opportunities for all service users has been enhanced during 19/20 with the development of research communications in all service user facing areas and the addition of research messages in the footer of all letters generated by our healthcare records system. However, research in GMMH is not just about study participation but involvement in every aspect of the research process. Service user involvement is central to our strategy and is a key deliverable for all Research Units contributing to the development of research questions and the design, conduct and dissemination of all research studies including clinical trials. A very successful event was held in May 2019 which showcased the level of co-production in research across our Research Units and NIHR funded research projects and programmes.

Impact of research and innovation

Ensuring clinical services benefit from research and innovation developments within the Trust is an essential part of the R&I strategy. The Complex Trauma and Resilience Research Unit and the Psychosis Research Unit support the Trust-wide quality improvement programme specifically in relation to implementation of trauma informed care. Our innovation work stream has taken a step forward this year with the appointment of a dedicated Innovation Manager working within GMMH and in partnership with Health Innovation Manchester. The Innovation Manager and the Youth Mental Health Research Unit have supported quality improvement particularly in relation to physical health initiatives. In addition, the Psychosis Research Unit contributes to a working group looking at increasing access to psychological therapy for service users with serious mental health conditions

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(psychosis, bipolar, personality disorder) and is involved in regional and national training initiatives to facilitate this work.

For further information about any aspect of our Research and Innovation work streams please contact Sarah Leo, Head of Research & Innovation Office (0161 271 0076 or [email protected]).

2.4 Commissioning for Quality and Innovation (CQUIN)

A proportion of GMMH’s income in 2019/20 was conditional upon achieving quality improvement and innovation goals agreed between GMMH and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation (CQUIN) payment framework.

For 2019/20 the value of the CQUIN payment is £2,705,506.

At the time of writing, we are pleased to report that we have made significant progress towards GMMH agreed CQUIN schemes as at Q3 for 2019/20. This reflects the hard work of staff across the organisation. We would like to take this opportunity to say ‘thank you’ to everyone involved. There are two categories of CQUINs in 2019/20 – national CCG commissioned services CQUINs and NHS England commissioned service CQUINs. These CQUINs are for a twelve- month period (April 19 – March 20) and are summarised below: -

National CCG indicators

CCG2 Staff Flu Vaccinations The aim of this CQUIN is to achieve an 80% uptake of flu vaccinations by frontline clinical staff. Staff flu vaccinations are a crucial lever for reducing the spread of flu during the winter months, where it can significantly impact on the health of patients, staff, their families and the overall running of NHS services. GMMH ran a comprehensive flu campaign with dedicated flu fighters and incentives to promote vaccination. This helped GMMH to achieve this target in 19/20.

CCG3a Alcohol and Tobacco Screening Achieving 80% of inpatients admitted to an inpatient ward for at least one night who are screened for both smoking and alcohol use. GMMH have embedded this in practice and achieved this target in all areas.

CCG3b Alcohol and Tobacco: Tobacco Brief Advice Achieving 90% of identified smokers given brief advice. GMMH have embedded this in practice and achieved this target in all areas.

CCG3c Alcohol and Tobacco: Alcohol Brief Advice Achieving 90% of patients identified as drinking above low risk levels, given brief advice or offered a specialist referral. As above GMMH have embedded this in practice and achieved this target in all areas.

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CCG4 72hr follow up post discharge Achieving 80% of adult mental health inpatients receiving a follow up within 72 hrs of discharge. 72 hour follow up is a key part of the work to support the Suicide Prevention agenda. The National Confidential Inquiry into Suicide found that the highest number of deaths occurred on day 3 post discharge. Completing follow up in 3 days also supports timely well-planned discharge. GMMH have consistently achieved this target in 19/20.

CCG 5a Mental Health Data Quality: MHSDS Data Quality Maturity Index The aim of this CQUIN is to improve data quality and reporting in mental health services. The target is to achieve a score of 95% in the MHSDS Data Quality Maturity Index (DQMI). This score is made up of submissions of 36 data fields. The latest published figures show that GMMH are below target however there has been sustained improvement during the year which is expected to continue given the actions implemented.

CCG5b Mental Health Data Quality: Interventions Improving data quality and recording of interventions enables patients and clinicians to make more informed decisions about treatment options. The target is achieving 70% of the referrals where the second attended contact takes place between Q3-4 with at least one intervention recorded using the referral start date and the end of the reporting period. GMMH have been consistently achieving this target in 19/20.

CCG 6 Use of Anxiety Disorder Specific Measures (ADSM) in IAPT The aim of the CQUIN includes ensuring patients are benefiting from the most appropriate therapy. The target is to achieve 65% of referrals with a specific anxiety disorder problem finishing a course of treatment having paired scores recorded on the ADSM. GMMH are below the maximum target currently however have been showing steady improvement which is expected to continue during 19/20. This CQUIN remains a target in 20/21 which will enable continued dedicated focus on this.

NHS England Indicators

These CQUIN schemes apply to our specialist services commissioned by NHS England (Adult Medium and Low Secure, Young People’s Forensic Service, the Child and Adolescent Mental Health In-patient Services, and our Mental Health and Deafness Service).

PSS4: Healthy Weight in Adult Secure MH services This CQUIN is aimed at tackling obesity rates among service users which contributes to earlier recovery for individuals. GMMH have embedded a number of proactive systems under the below work streams:

• Food and Nutrition • Physical Activity • Treatment Interventions (including medication) • Workforce (skills, knowledge and confidence)

Measurement and reporting on outcome measures have also been developed and implemented to support individual progress and show changes over time. Comprehensive reports are shared with commissioners and GMMH consider the CQUIN as being achieved.

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PSS5: Addressing CAMHS Tier 4 Staff training needs The overall aim of this CQUIN is improving patient outcomes and ensuring clinically appropriate lengths of stay. A detailed training needs analysis was completed and this informed a development programme. Care plans were also reviewed and updated. Audits of use of psychological interventions by staff are in place. Comprehensive reports are shared with commissioners and GMMH consider the CQUIN as being achieved

PSS6: Enabling better assessment of communication needs of deaf people Improved assessment of communication should support expediting access to effective treatment. GMMH conducted an audit of patient communication assessments which showed that all patients have a communication assessment. The majority also had additional supporting reports or assessments of their language and communication skills and staff were aware of the need for patients to have a Communication Assessment. Training has been provided to ensure all staff were captured and there is a plan in place to ensure this will include new staff going forward. Comprehensive reports are shared with commissioners and GMMH consider the requirements of the CQUIN as being achieved

Further details of the agreed CQUIN goals and achievements for 2019/2020 and for the following 12-month period are available on request from:

Miranda Washington Deputy Director of Performance and Business Development Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, The Curve Bury New Road, Prestwich, Manchester M25 3BL

Tel: 0161 358 1366 E-mail: [email protected]

2.5 Registration with the Care Quality Commission (CQC)

GMMH is required to register with the CQC. The CQC has not taken any enforcement action against GMMH during 2019/20, and GMMH has not participated in any special reviews or investigations by the CQC.

The table below provides a summary of the ratings received from the CQC within their inspection report, which was received on the 9th January 2020. We are pleased to have retained our CQC inspection overall rating ‘Good’ and for the recognition received by the CQC in relation to outstanding practices introduced across the organisation. We are however aware that further improvements are required to bring all our services in line with the CQC requirements.

One of our key priorities for improvements will be related to how we can develop robust systems and processes for the monitoring and delivery of supervision of staff across the organisation.

Domain Rating CQC Domain GMMH rating Safe Requires Improvement Effective Good

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Caring Good Responsive Good Well Led Good Overall rating for GMMH Good

Following receipt of the CQC inspection report the Trust Associate Leadership Team have formulated a comprehensive Trust action plan in response to the CQC areas for improvement. The plan identifies key actions to be taken to address the issues raised and each action has an identified Executive lead and Associate Director with responsibility for delivery. The action plan has been agreed by the Trust Quality Improvement Committee and Board of Directors. The Associate Leadership Team will coordinate progress reports to the Quality Improvement Committee on delivery of the action plan.

2.6 CQC Mental Health Act Monitoring

Between 1 April 2019 and 31 March 2020, CQC undertook Mental Health Act monitoring visits to the following GMMH wards:

• Bolton – Maple House, Beech, • Manchester – Redwood, Safire, Maple, Juniper, Anderson, Blake, Mulberry, Poplar, Elm, Laurel, Bronte • Rehab – Bramley, Anson Road, Braeburn House • Salford – Delamere, Keats, Holly, Hazelwood, • Trafford – Irwell • Specialist Services Network – Gardener Unit, Phoenix, J17, Rydal, Keswick, Ullswater, Ferndale, Pegasus, Wentworth House, John Denmark Unit.

2.7 Data Quality

The Trust recognises that accurate, complete and timely information is vital to support both the delivery of safe and efficient patient care and the management, planning and monitoring of its services.

GMMH submitted records during 2019/2020 to the Secondary Uses Service (SUS) via the MHSDS for inclusion in the Hospital Episodes Statistics, which are included in the latest published data (January 2020). The percentage of records in the published data:

• which included the patients valid NHS Number was: 100% • which included the patient’s valid General Medical Practice Code was: 100%

During 2019/20 GMMH has continued to build on the improvements of previous years, to ensure that the importance of accurate quality data and ensuring effective collection processes are fully embedded across the organisation, this is achieved by:

• All Information Quality Assurance policies and procedures are reviewed annually as part of our assurance processes for the Data Security and Protection Toolkit • Providing constructive and supportive feedback to colleagues when data quality errors are identified

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• A proactive programme of audits undertaken throughout the year, the findings of which inform the Trust on areas of strengths and weaknesses and ultimately guide ongoing developments • Continuing to communicate key messages regarding accurate recording of clinical activity • The development of a new SAR (Subject Access Request) reporting system to assist in the monitoring and delivery of personal information in line with nationally mandated requirements and legislation

2.8 Information Governance

We aim to deliver excellence in Information Governance by ensuring that information is collated, stored, used, transferred and disposed of, securely, efficiently and effectively and that all our processes adhere to national mandates and legal requirements.

This ensures that information is accessible when needed, to support the delivery of the best possible care to our service users. All our Information Governance polices are reviewed annually and the Trust is fully compliant with the Data Security and Protection (DS&P) toolkit which outlines the management requirements of all service user, staff and organisational information in terms of the Data Protection Act (2019), GDPR and all other relevant legislation. The DS&P toolkit sets national standards for achievement to ensure that organisations maintain high levels of security and confidentiality of information at all times.

GMMH achieved full compliance with the DS&P toolkit in 2019/20.

2.9 Clinical Coding

GMMH outsources its clinical coding processes. This arrangement is audited for accuracy annually by an external expert as part of the Data Security and Protection toolkit submission.

During 2019/2020 the audit report confirmed an accuracy level of 100% for primary diagnosis and 98.62% for secondary diagnosis against a sample of 50 randomly selected patient records.

This has reaffirmed Trusts confidence in the existing system. GMMH will continue to work with clinicians to maintain the high levels of clinical coding accuracy.

2.10 Department of Health Mandatory Quality Indicators

We have reviewed the required core set of quality indicators which Trusts are required to report against in their Quality Accounts and are pleased to provide you with our position against all indicators relevant to our services for the last two reporting periods (years).

2.10.1 Preventing People from Dying Prematurely - 7 Day Follow-Up

GMMH achieved the Oversight Framework (OF) target of >95% of patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric inpatient care.

The latest published benchmark results available for comparison of performance against this indicator relate to YTD Q3 2019/20. Due to the COVID-19 pandemic, collection of the Mental Health Community

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Teams Activity for Quarter 4 2019-20 has been postponed by NHS Digital. Q4 results are therefore unavailable at the time of publishing.

Performance CPA 7 Day Follow-Up YTD Q3 2018/19 (%) * YTD Q3 2019/20 (%) * GMMH 95.0% 96.0% National Average 95.7% 95.0% Lowest Trust 79.1% 85.9% Highest Trust 100.0% 100.0%

*Source: https://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams- activity/ 2018/19 figures are YTD Q1-Q3 2019/20 figures are YTD Q1-Q3

This shows that GMMH performance is above the national target in Q3. All of our staff understand the clinical evidence underpinning this target and are committed to improving clinical outcomes for patients. GMMH is taking the following actions to consolidate this performance, and so the quality of our services:

• Continue to embed processes to record accurately in our Paris clinical information system. • Embed the new requirements for follow up within 72 hours as from April 2020 within clinical teams building on the achievement of the CQUIN in relation to this during 19/20. • Continue to monitor the offering of telephone contact in days 4-7 in addition to 72 hour follow up as best practice for service users following discharge from inpatient services • Review individual breaches to ensure best practice can be shared and identify learning opportunities to minimise breaches wherever possible • Identify any potential training issues as they arise, and provide training to address these issues • Ensure our operational and data quality policies and procedures remain up to date and reflect new requirements providing clear guidance for staff

2.10.2 Enhancing Quality of Life for People with Long-term Conditions – Gatekeeping

GMMH achieved the UNIFY target of >95% of admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper during the reporting period.

Performance Gatekeeping YTD Q3 2018/19 (%) * YTD Q3 2019/20 (%) * GMMH 99.1% 99.5% National Average 98.1% 97.9% Lowest Trust 87.0% 91.9% Highest Trust 100.0% 100.0%

*Source:

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https://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams- activity/ 2018/19 figures are YTD Q1-Q3 2019/20 figures are YTD Q1-Q3

Please Note: Due to the COVID-19 pandemic, collection of the Mental Health Community Teams Activity for Quarter 4 2019-20 has been postponed by NHS Digital. Q4 results are therefore unavailable at the time of publishing.

This shows that GMMH performance is above the national target. All of our staff understand the clinical evidence underpinning this target and are committed to improving clinical outcomes for patients. GMMH has the below actions in place to consolidate performance, and so the quality of our services:

• Continue to embed processes to record accurately in our Paris clinical information system. • Review individual breaches to ensure best practice can be shared and identify learning opportunities to minimise breaches wherever possible • Identify any potential training issues as they arise, and provide training to address these issues • Ensure our operational and data quality policies and procedures remain up to date and reflect new requirements providing clear guidance for staff.

2.10.3 Ensuring that People have a Positive Experience of Care – Staff Survey

This is the second year that the survey has been broken down into themes. The themes cover the following eleven areas of staff experience:

• Equality, diversity and inclusion • Safe environment – bullying and harassment • Health and wellbeing • Safe environment – violence • Immediate managers • Safety culture • Morale • Staff engagement • Quality of appraisals • Team working (new for 2019) • Quality of care

The Trust received a response rate of 49.9% against a national average of 54%. Whilst still below the national response rate the Trust saw a 2% improvement in this rate, whereas the national rate remained the same. The full staff survey is attached.

Key changes in 2019 Staff Survey

Theme 2017 2018 2019 Benchmarking Group Equality, Diversity & Inclusion 9.0 8.8 8.9 9.0 Health & Wellbeing 6.0 5.8 5.7 6.0 Immediate Managers 7.1 7.1 7.1 7.3

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Morale New 6.0 6.1 6.3 category for 2017 Quality of Appraisals 5.3 5.4 5.4 5.8 Quality of Care 7.2 7.1 7.1 7.4 Safe Environment (Bullying & Harassment) 7.9 7.9 7.9 8.0 Safe Environment (Violence) 9.1 9.1 9.2 9.3 Safety Culture 6.7 6.7 6.7 6.8 Staff Engagement 7.0 6.9 6.9 7.0 Team work 6.8 6.6 6.7 7.0

Although not classed as statistically significant overall the Trust has shown some marginal improvements, only achieving a lesser score in the theme of Health and Wellbeing. Similarly, nationally there has been no statistically significant improvement, and a reduction in the theme of Health and Wellbeing also.

More positively, the Trust has increased the theme score from 9.1 to 9.2 in the theme of Safe Environment – Violence, however, this improvement has not been replicated within the peer average for other Mental Health Trusts and the overall score has remained static.

Once broken down we can see across the Trust that improvements have been made across many Divisions, most notably North Manchester and Forensic Mental Health, however the lack of consistent improvement across all divisions has caused little or no movement on the overall Trust figure.

Main areas for improvement

Following on from last year’s survey, and in line with the actions contained within the Workforce & OD Strategy, there are a number of pieces of work completed or in progress that will positively influence staff experience throughout the year and it is recommended that these are continued to enable positive change to take place, and many of these are highlighted throughout the summary of the results. More specifically areas are outlined below.

Health and Wellbeing

Whilst the Trust would welcome improvements across all areas, special attention needs to be given to Health & Wellbeing. Both the declining score in this area and the detailed results highlighting the responses received from disabled staff means this should be a priority area for the Trust moving forward.

In support of this, together with Staff Side the HR Directorate have commenced a quality improvement programme in relation to the way we manage staff when they become unwell in work. The output of this is expected to be a new Workplace Wellbeing Policy with a number of toolkits and resources for managers to access to ensure early intervention and a speedy and supportive response to those who may require workplace adjustments. This is underpinned by ensuring all other employment policies, upon review and harmonisation, are updated to reflect the vision articulated in the Interim NHS People Plan, and further reinforced through the Trust Workforce & OD Strategy, to create a positive and inclusive culture.

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Morale and Immediate Managers

Additionally, we need to ensure that the Trust’s new approach to supervision and appraisals is seen as a key opportunity to make improvements for staff, as empowered managers who know, understand and develop their staff and treat them compassionately is ultimately what will impact on staff’s day to day experience at work. As such training to support these two areas is under development to enable appraisals and supervision discussions to take on more meaning and be viewed as a key tool for managers to use to support staff. This will be accompanied by the new Leadership Strategy which will be launched in April 2020 to support improvements in the leadership culture.

Staff Engagement

Working in partnership with Communications and Engagement a comprehensive staff engagement plan needs to be developed which is sustained throughout the year and progress monitored throughout the year.

Equality, Diversity & Inclusion

By continuing the focused work on the WRES and the WDES which has seen some improvements from 2018 to 2019, evidence shows that this will impact positively on the whole workforce, and this work needs to continue.

GMMH results for specific indicators relating to bullying and equal opportunities are set out below:

• Indicator KF 26 - % of staff experiencing harassment, bullying or abuse from colleagues was 15.6% (national average 15.8%) • Indicator KF21 - % of staff believing that the Trust provides equal opportunities for career progression or promotion was 84.3% (national average 85.3%)

2.10.4 Ensuring People have a Positive Experience of Care – Community Mental Health Patient Survey

The annual community mental health patient survey undertaken by the Care Quality Commission compares 56 mental health providers from across the country with results published nationally in November 2019. As in previous years, we used an independent approved contractor (Quality Health) to run the survey on our behalf in 2019.

People aged 18 and over were eligible for the survey if they were not currently an inpatient, were receiving specialist care or treatment for a mental health condition and had been seen by the trust between 1 September 2017 and 30 November 2018. Fieldwork for the survey (the time during which questionnaires were sent out and returned) took place between February and June 2019.

GMMH considers that this data is as described for the following reasons. Overall Trust scores are ‘more or less the same’ as the other mental health trusts that took part in this year’s programme.

As the table below highlights, improvement can be noted in nine out of the 10 thematic sections, in comparison to 2018. Scores remained the same in the ‘organising care’ section (8.4). It was not

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possible to make a comparison with the ‘feedback’ thematic section. This is new for 2019 and was not therefore included in the 2018 programme.

Table one: Thematic scores for 2019, in comparison with 2018

Thematic section 2019 score 2018 score

1. Health and Social care workers 7.5 7.3 2. Organising Care 8.4 8.4 3. Planning Care 6.9 6.8 4. Reviewing Care 7.8 7.3 5. Crisis Care 7.1 6.5 6. Medicines 7.3 6.9 7. NHS Therapies 7.7 7.6 8. Support and Wellbeing 5.2 4.5 9. Feedback1 2.9 N/A 10. Overall Views of Care and Services 7.6 7.3 11. Overall Experience 7.1 7.0

For 2019, there are 23 out of 29 questions, where comparisons can be drawn with data from 2018. There are four question that are new for 2019, and two further questions where wording was amended to the extent that they are now incomparable with similar questions asked as part of the 2018 survey programme.

Scores increased for 16 out of 23 question areas, in comparison with those reported in 2018. This was more notable for a number of question areas including:

• In the last 12 months have you had a formal meeting with someone from NHS mental health services to discuss how your care is working? • Were you involved as much as you wanted to be in decisions about which medicines you receive? • Were you involved as much as you wanted to be in deciding what NHS therapies to use? • In the last 12 months, did NHS mental health services give you any help or advice with finding support for financial advice or benefits? • In the last 12 months, did NHS mental health services give you any help or advice with finding support for finding or keeping work? • Have you been given information by NHS mental health services about getting support from people who have experience of the same mental health needs as you?

1 This section is new for 2019, and therefore no comparison to 2018 scores can be made QUALITY ACCOUNT 2019/20 28

Scores remained the same in two out of the 23 areas, in comparison to those reported in 2018. Scores reduced in five out of the 23 question areas, in comparison to those reported in 2018. In four out of five cases, the reductions were marginal. This was more notable however for one question area:

1. Do you know how to contact this person if you have a concern about your care?

In relation to banding, the 2019 results for GMMH were better than other mental health trusts in one area:

2. Have you been given information by NHS mental health services about getting support from people who have experience of the same mental health needs as you?

There were zero question areas where GMMH results were worse than those provided by other mental health trusts. Our results were more or less the same as other trusts for the other 28 questions.

In comparison with 2018 survey data, GMMH results were significantly higher this year for two questions. These are as follows:

• ‘In the last 12 months, did NHS mental health services give you any help or advice with finding support for financial advice or benefits?’ (3.9 in 2018 – 5.2 in 2019) • ‘Have you been given information by NHS mental health services about getting support from people who have experience of the same mental health needs as you (3.2 in 2018 – 4.5 in 2019)

There were zero question areas where GMMH scores were significantly lower than those reported in 2018.

GMMH has taken the following actions to improve these scores, and so the quality of our services. The results from the survey were presented to the QIC, and addressed by the Head of Service User and Carer Involvement. They were then discussed at a meeting of the GMMH CareHub, and a number of discrete improvement actions were identified. These improvement actions are currently ongoing across the Trust.

2.10.5 Ensuring that People have a Positive Experience of Care – Friends and Family Test (FFT)

Across GMMH, we continue to implement the service user FFT, as a consistent way to measure the service user and carer experience across the breadth of our services. At the end of Quarter 3 2018/19, 1565 service users had answered the FFT question. This is a decrease of 597 responses compared with the same reporting period of the previous year. The organisation has had some technical issues with the electronic feedback devices, however these issues will be resolved moving forward. During this period, an average of 81% of service users would recommend GMMH to their friends and family if they needed similar treatment.

Some of the positive feedback comments we have received from service users this year to date have included:

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While being support by the Community Inclusion service I have been to places that I would not have known about. Like Home theatre and Café Nexus. I also accessed an art group and green wellbeing session’ Manchester Inclusion Service

The staff really got me out of dark times by listening to me and not judging me. I am not fully better but there is time yet’ Bolton south community mental health team

‘The place inspires you to recover’ Anson road

The care and help I received was second to none’ Manchester north community mental health team

‘I feel that my experience at CBU has re-ignited what I am capable of and who I truly am’ Chapman Barker Unit

‘Excellent care’ Phoenix, Junction 17

‘Highly recommended’ Griffin Ward

All the staff top to bottom were great, I will really miss them’ McColl Ward , Meadowbrook

‘The reception staff are fab’ Cromwell House, Salford

‘Staff are friendly. I am treated with respect. Staff are attentive to people’s needs. I cannot find any faults. I was shown all my care files. I am very satisfied’ Irwell Ward, Trafford

Occasionally we receive feedback where people are dissatisfied with the service they have received. Whenever we receive such feedback, our governance framework ensures services take action to respond and improve. GMMH has a Quality Improvement programme to provide internal assurances surrounding care delivery, if service user feedback highlights any local issues the organisation can mobilise this programme to provide local support. GMMH continues to implement a ‘You said - We did’ campaign which is communicated locally and trust wide. Below are some examples of where we have used feedback to improve our services:

• Redwood ward, Manchester Service users requested more breakfast groups on the ward, so these have been provided more frequently as well as coffee mornings with newspapers

• Cavendish ward, Manchester Service users asked for a shed to support them with their gardening/woodwork. This has been ordered via charitable fund

• Honeysuckle Lodge– Rehabilitation ward Service users requested a cooking group for breakfasts, this has been facilitated every Wednesday

• Salford Achieve Service users were concerned the café would be closing, the service responded and continues to work with Asset Fund Budget managers CVS to find the right provider for the Cafe in the future. Additional Cafe Volunteers are being recruited

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2.10.6 Treating and Caring for People in a Safe Environment and Protecting them from Avoidable Harm – Patient Safety Incidents:

Information within this section of the Quality Account highlights the number and, where available, rate of patient safety incidents reported by GMMH to NHS Improvement via the National Reporting and Learning System (NRLS). The data below includes the number and percentage of patient safety incidents that resulted in severe harm or death and compares this data against the national average along with the highest and lowest incidents reported by other mental health organisations.

Patient Safety

GMMH continues to maintain an, open and honest and timely reporting culture when incidents occur. Timeliness for the reporting and reviewing of incidents is critical in enabling us to respond quickly to concerns that are identified to ensure the care we deliver is safe and of a high standard. The National Patient Safety Strategy published in July 2019 which sits alongside the NHS Long Term Plan and Implementation Framework highlights that ‘those organisations who identify, contain and recover from errors as quickly as possible will be alert to the possibilities of learning and continuous improvement’.

In November 2019, the GMMH Governance Team introduced three Patient Safety Practitioners who have been aligned to support each of the clinical divisions. The Patient Safety Practitioners have been attending network Senior Leadership Team meetings and Divisional Hub meetings so that information in relation to the patient safety agenda can be shared. The Patient Safety Practitioners have been working collaboratively with all our commissioners in relation to further strengthening the Trust Incident management and review processes.

A workshop held between the patient Safety team and our CCG colleagues on the 29th January 2020 was an opportunity for the Patient Safety Team to present to commissioners the many quality improvement initiatives being implemented across the organisation in response to the patient safety agenda. The Trust Director of Nursing and Governance received positive feedback from commissioners attending the event in recognition of how the Trust were responding to serious incident themes.

Improving our in-patient environments has always been a key priority for the Trust Board. The Trust has a comprehensive environmental risk improvement and audit programme that takes place on an annual basis in partnership with our Risk and Safety Team, Facilities team, Ward Managers and Matrons to continually ensure our in-patient environments are safe. Any environmental risk identified during the annual audit programme are then escalated to senior managers and the board through the Trusts risk register and Board Assurance Framework for consideration of further action. The Trust SharePoint system has been adapted to enable our ward teams quick and easy access to their local environmental risk audits and action plans. Every ward induction checklist has been

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strengthened to include the location of identified environmental risks which will assist new staff and agency staff who work across our in-patient areas in maintaining the safety of service users.

Over recent years the Trust has been aware of the emerging picture nationally in relation to the increase in the number of individuals particularly young people who are engaging in self harming behaviours. GMMH has a positive incident reporting culture which is supported by the Trust Incident, Accident and Near Miss policy which reminds staff of the importance of reporting all levels of incidents that have involved a service user who has self-harmed.

This positive reporting culture is also demonstrated through the 6 monthly reports published by the National Reporting and Learning system which highlights GMMH as a high reporting Trust compared to other Trusts. Self-harm data published by our colleagues at the University of Manchester National Confidential Inquiry Team has highlighted the significant increase in self harm figures across England and that around half of young people aged under 25 who died by suicide had previously self-harmed. Self-harm is a crucial indicator of risk which is why as a Trust we take incidents involving our service users who self-harm seriously and we are keen that our staff continue to report all actual or near miss incidents.

Since our 2018/19 Quality Account a number of initiatives have been developed to support staff to work effectively with and support service users who are presenting as a risk of self-harm. In November 2019 GMMH published its refreshed Self-harm Toolkit to be accessed by front line teams. 500 copies of the Toolkit were printed and distributed to all service managers for sharing across their teams. The Toolkit was developed in collaboration with our colleagues from the Manchester Self Harm Project and Patient Safety Research Unit at the University of Manchester for which we are extremely grateful for their assistance expertise and support.

The Toolkit was launched in November by our communications team through the Trust website and social media sites. The toolkit is accessed by staff via our Trust Policies and procedures intranet page. Sitting alongside the Self-Harm Toolkit and Trust Self-harm Policy the Trust Positive and Safe Team have developed a self-harm care plan and staff management plan to assist teams in their care and treatment of service users. We have agreed to share the Toolkit and care plan with those providers who have approached us in order to support front line teams and service users across other provider organisations.

To equip our staff with the competencies to work with individuals who may be a risk of self-harm or suicide in 2018 the Trust secured monies as part of the Trust Suicide Prevention CQUIN programme enabling us to introduce the STORM (‘Skills Training in Suicide Prevention and Self-harm Mitigation) Train the Trainer programme. Seven staff across the Trust were trained to deliver the STORM training across their divisions. The Trust renewed its STORM training licence in December 2019 to continue to develop staff to effectively support services users who are a risk of self-harm. The importance of reporting all incidents involving a service user who has self-harmed can also be demonstrated through reports published by the National Reporting and Learning system. These highlight GMMH as a high reporting Trust. Self-harm data published by our colleagues at the University of Manchester National Confidential Inquiry Team has highlighted the significant increase in self harm figures across England and that around half of young people aged under 25 who died by suicide had previously self-harmed. Self-harm is a crucial indicator of risk which is why as a Trust we take incidents involving our service users who self-harm seriously and are keen that our staff continue to report all related incidents.

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Data Source: National Reporting and Learning System (NRLS). The data reported only includes data released by the NRLS in October 2019. This data includes the period of April 2017 - March 2019.

Reporting No of Rate per No of % of No of % of period incidents 1000 incidents incidents incidents incidents occurring bed reported reported reported reported days as severe as as death as death harm severe harm Greater Oct 18 – 5190 Data not 3 0.06 27 0.6 Manchester Mar 19 available Mental Apr 18 – 4999 Data not 10 0.2 18 0.4 Health NHS Sep 18 available Foundation Oct 17 – 5827 Data not 7 0.1 23 0.4 Trust Mar 18 available Apr 17 – 3055 21.51 4 0.1 20 0.7 Sep 17 Total Oct 18 – 187496 Data not 556 0.3 1312 0.7 number of Mar 19 available incidents for Apr 18 – 169041 Data not 548 0.3 941 0.7 mental Sep 18 available health Oct 17 – 166787 Data not 569 0.3 1331 0.8 organisations Mar 18 available Apr 17 – 167477 Data not 532 0.3 1212 0.7 Sep 17 available Highest Oct 18 – 9058 97.63 48 2.1 75 3.71 value Mar 19 reported Apr 18 – 9204 65.8 128 2.1 110 2.3 from any Sep 18 mental Oct 17 – 8134 96.72 121 2.1 138 3.9 health Mar 2018 organisation Apr 17 – 7384 126.47 89 2 83 3.4 Sep 17 Lowest value Oct 18 – 1173 Data not 0 0 0 0 reported Mar 19 available from any Apr 18 – 16 Data not 0 0 0 0 mental Sep 18 available health Oct 17 – 1 14.88 0 0 0 0 organisation Mar 2018 Apr 17 – 12 16 0 0 0 0 Sep 17

*Benchmarking data reports from the NRLS continue to highlight that there is a positive and consistent incident reporting culture within the organisation. In accordance with the NRLS reporting criteria only deaths of current service users where the death is suspected to be as a result of an accident or suspected suicide are reported to the NRLS.

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The data above shows an increase of 1307 in incidents reported to the NRLS compared to the previous year. The vast majority if these incidents were reported as low harm or no harm and therefore required no further review. There was only a small increase by two from the previous year in the number of incidents resulting in severe harm and a similar picture in the number of incidents reported as deaths.

Incident reporting and reviewing processes

GMMH has robust processes for the reporting and reviewing of incidents supported by a comprehensive Trust Incident Accident and Near Miss Policy and Procedure (2015-20). This policy will be reviewed later 2020/21 in accordance with the anticipated publication of the new Patient Safety Incident Response Framework which will replace the National Serious Incident Framework 2015. In preparation for publication of the new framework the GMMH Governance Team has been working in partnership with our Manchester Commissioners to review how a multi-agency approach to the reviewing of serious incidents can be developed. This will allow for a more collaborative approach to learning from serious Incidents and improving the care and treatment pathways accessed by service users.

In January 2020, the Trust signed up to take part in the Royal College of Psychiatrists College Centre for Quality Improvement (CCQI) Serious Incident Review Accreditation Network. The network was launched in January 2020 and will begin work in the first quarter of 2020. The CCQI will work with mental health providers across the UK to assess and improve the quality of provider serious incident investigation processes by using a process of self-review and peer review against agreed CCQI standards. The Network will assist the Trust to work with other providers to share best practice approaches in order to strengthen the quality of our serious incident reviews.

2.10.7 Learning from Deaths

Following publication of the National Learning from Deaths Guidance 2017 the Trust has continued to strengthen its internal processes and procedures for how service user deaths are reported, reviewed and escalated to our Trust board through the quarterly Mortality Dashboard. GMHH take the death of a service user very seriously. Our Trust Mortality Review Group and also Trust Suicide Prevention Groups review all data of service users who die whilst under the care of the Trust and the commissioning by these groups of mortality deep dive reviews will continue in order to help us to review and respond to emerging themes.

Over the last three years the Mortality Review Group has commissioned deep dive reviews into drug related deaths of those service users under the care of our Substance Misuse Services. We are aware from national evidence that there is a higher mortality rate amongst this service user population compared to other service user groups. The Trust is keen to continue to review and learn from drug related deaths and has commissioned a further deep dive review to take place in 2020. The findings from the deep dive will be presented to our Trust Mortality Review Group and Quality Improvement Group. A learning Event to present the findings from this deep dive will take place during 2020.

Supporting Carers and families

Following publication of reports such as the National Suicide Prevention Strategy for England 2012 and Learning from Deaths Guidance 2017, which both highlighted a national gap in the support provision across the NHS for families who are bereaved, in December 2018 the Trust introduced a

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Bereavement Liaison Practitioner. Within the first 12 month of the Bereavement Practitioner commencing in post approximately 250 individual staff members or family members were supported. Our aim is to provide timely support to families and staff following an unexpected service user’s death. To enable our Bereavement Practitioner to provide this timely support we have introduced an email alert to be sent from our Trust Incident Risk Management System as soon as a service user death is reported.

The Bereavement Practitioner has delivered grief awareness workshops to staff across the Trust on how to support families following a death and further training workshops have been planned over 2020. The role has provided direct support to families throughout the Trust internal review process and also supported families during the coroner’s inquest process. The Trust are hoping to further develop the Bereavement Practitioner support as we recognise how critical this role is in supporting families and staff who are affected or bereaved.

During 1st April 2019 to 31st March 2020 804 GMMH patients died. There has been a decrease from 866 total deaths reported for 2018/19 to 804 deaths reported in 2019/20. The decrease is mainly attributed to unexpected outpatient deaths (down 55).

• 200 deaths in the first quarter • 198 deaths in the second quarter • 180 deaths in the third quarter • 226 deaths in the fourth quarter

Quarter Unexpected Unexpected Expected Expected Total Outpatient Inpatient Outpatient Inpatient Q1 116 3 76 5 200 Q2 124 3 70 1 198 Q3 108 2 65 5 180 Q4 127 1 96 2 226 Total 475 9 307 13 804

*Inpatient deaths refer to those service users who are inpatient or former inpatients who died within 6 months of discharge in accordance with the current National Serious Incident Framework 2015.

During 1st April 2019 to 31st March 2020 72 RCA’s have been commissioned in response to the deaths reported. The data highlights a decrease from 142 RCA’s commissioned for 18/19, with 70 fewer RCA’s commissioned over the same period.

The Trust ‘Learning from Deaths’ policy highlights to staff that all deaths should be reported through the Trust Incident Risk Management System. All deaths including deaths of service users with an identified learning disability are reported and are then reviewed by the Trust Patient Safety Team. A 3-day review is requested by the service for all unexpected deaths and also for those expected deaths where care concerns have been identified by the service during the service users end of life pathway.

Where a completed 3 Day review has indicated significant care delivery concerns and areas for learning a Root Cause Analysis Investigation or Structured Judgement Review will be commissioned. Data relating to service user deaths is reviewed by the Trust Mortality Review Group and presented

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to the Trust Board of Directors meeting through the Trust quarterly Mortality Dash board in accordance with the National Learning from Deaths Framework.

• 29 serious incident root cause analysis investigations, 1 case record reviews* in the first quarter • 26 serious incident root cause analysis investigations, 0 case record reviews* in the second quarter • 9 serious incident root cause analysis Investigations, 1 case record reviews* in the third quarter • 8 serious incident root cause analysis Investigations, 0 case note reviews* in the fourth quarter

*Structured Judgement Reviews are referred to as ‘case record reviews.

Zero representing 0% of the patient deaths during the reporting period are judged to be more likely than not to have been due to problems in the care provided to the patient. As mandated, this is broken down by quarter as follows:

• Zero representing 0% in the first quarter • Zero representing 0% in the second quarter • Zero representing 0% in the third quarter • Zero representing 0% in the fourth quarter

The National Quality Board Learning from Deaths Guidance published in March 2017 set out the key requirements ensuring organisations have mechanisms in place to effectively respond to, learn from and review all patient deaths. GMMH currently uses Root Cause Analysis as its primary investigatory methodology, in line with the requirements of the National Serious Incident Framework 2015 to review unexpected deaths. The Learning from Deaths Guidance also highlights the use by Trusts of the Structured Judgement Review (SJR) process as another method of reviewing deaths.

The SJR approach requires reviewers to make safety and quality judgements over 6 elements and phases of care accessed by a service user. In 2018 training for approximately 40 staff was delivered by the Yorkshire and Humber improvement academy who adapted the SJR Tool for mental health Trusts. Although the majority of deaths that occur in the Trust are reviewed using the comprehensive RCA methodology, GMMH will use the SJR process where a 3-day review has identified problems in care that may relate to treatment and management plans for those incidents relating to for example pressure ulcers, falls, some medication errors and also Venous Thromboembolism (VTEs). The SJR process is to understand the reasons for poor care and define further action or learning for the organisation.

All reviews completed into a service user death are presented and reviewed by the Trust Serious Incident Review (SIR) panel or Post Incident Review (PIR) Panel. One of the significant functions of both the SIR and PIR panels is to review the findings from all reviews and ensure recommendations made within the serious Incident report address the overall root causes and key areas for action by the Trust to reduce the likelihood for further similar incidents to occur.

Learning from Serious Incidents

The Trust continues to explore new methods of how learning from serious Incidents is effectively shared across the organisations. Currently we use Positive Learning Events, Splash Screens and 7- minute briefings which are shared across the Trust via our nursing and Governance Team. The Patient Safety Team are currently developing a Lessons Learned portal which sits on the Trust

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SharePoint system and will be supported by a dedicated Trust Positive lessons learned email to share learning from Learning Events, positive conversations, individual staff reflections, complaints, incidents and inquests. The lessons learned portal will also assist staff to access learning and assist with their professional revalidation process. This work will be launched during 2020/21 by the Trust Communications Team.

2.11 Freedom to Speak Up

The Trust has adopted the national ‘Freedom to Speak Up’ Policy to promote an open culture across the Trust to ensure staff feel safe to report incidents and raise concerns, this means that staff are encouraged to speak up in a variety of forums, whether that be directly to their line manager, a more senior manager or to the Trust’s Freedom to Speak Up Guardian.

The Trust has a nationally registered Freedom to Speak up Guardian whose role is to support and enable staff to raise concerns, in addition to both an Executive Lead and a Non-Executive Lead for Freedom to Speak Up. In line with the national policy, staff are encouraged to raise concerns with line managers and line managers are encouraged to listen and act on staff’s concerns. It is appreciated that, at times, staff may not feel able to do this and the role of the Freedom to Speak Up Guardian is widely promoted through a variety of methods including through the Corporate Welcome Day, as a continual feature on the Intranet Site and wide coverage within operational meetings held throughout the organisation.

The Guardian reports quarterly to the National Guardian’s Office on the number of speaking up cases, and in addition reports twice a year directly to the Trust Board. This report contains information in relation to the number of cases, but also themes of cases and organisational learning. The Freedom to Speak Up Guardian (our Senior Independent Director) reports directly to the Chief Executive, and meets on a quarterly basis with them, the Chair and the Executive and Non- Executive Leads for Freedom to Speak Up.

The Freedom to Speak Up Guardian works closely with Trade Union Representatives and others in trusted roles who are “Freedom to Speak Up Ambassadors” and they act as advocates for the Freedom to Speak Up route and guide staff accordingly when concerns may arise. The Trust is committed to ensuring that staff do not suffer any detriment as a result of speaking up. Trust wide this is achieved through ensuring that all messages relating to speaking up are delivered by a member of the Executive Team to outline the highest level of support for wanting staff to feel able to speak up.

More locally the Freedom to Speak Up Guardian keeps in close regular contact with those who raise concerns through the speaking up route, any such indicator that identifies that a staff member feels they are suffering a detriment will be dealt with immediately. The Freedom to Speak Up Guardian also regularly promotes the role through visits to Wards and other areas within the organisation to ensure that staff know that if they are raising concerns locally and these concerns are being dealt with and managed effectively, there is still a route for them to take should anything change within that process. Feedback in relation to concerns raised is achieved in a variety of methods, depending on the level or size of the concern.

Staff may either be met with or may receive a more formal letter, the Freedom to Speak Up Guardian will then maintain contact with the member of staff until the feel their concern has been heard and they no longer need support.

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2.12 Increasing Community Mental Health Services Capacity

Within this new section for 2019/20. GMMH is asked to include a statement on progress made in bolstering staffing in adult and older adult community mental health services, following additional investment from local CCGs’ baseline funding.

New models of working in primary and community mental health services

At GMMH, we are piloting new approaches to primary care mental health services in each of our localities, working with GPs, VCSE partners and neighbourhood teams to test new approaches to supporting people with mental health needs in primary care. This includes the Living Well national pilot in Salford which will continue into 2020/21. These pilots are funded from additional commissioner resources and will be evaluated to establish the most effective approach. In addition, we have well established Home-based Treatment Teams in each locality and have undertaken a comprehensive programme of support in 2019/20 to ensure that teams are able to maximise contact time with patients.

Adult Eating Disorders (AED)

Throughout 2019/20 GMMH has been working with commissioners to develop and agree an expansion in service provision to better meet demand for our community adult eating disorders services. In addition, a North West Provider Collaborative has been formed for Adult Eating Disorders with Cheshire and Wirral Partnership NHS Foundation Trust as Lead Provider. Initial discussions have taken place to link specialised inpatient and community pathways and these discussions, as well as those with commissioners regarding community services, will continue in 2020/21.

Individual Placement Support (IPS)

GMMH employs IPS co-ordinators already embedded in Community Mental Health Teams (CMHTs) and Early Intervention in Psychosis (EIP) Teams. In 2020/21 this will be enhanced by a new Greater Manchester IPS service. The Greater Manchester service, procured through the Greater Manchester Combined Authority, has been awarded to Remploy and new staff will be based with our CMHT and EIP Teams to further develop support and opportunities for people to access IPS.

Early Intervention in Psychosis (EIP)

During 2019/20 GMMH has worked with commissioners in each of our localities to invest in services to deliver the 56% access standard. Our Bolton and Salford EIP teams are operating at Level 3 NICE concordance. Our EIP team in Manchester is on track to achieve Level 3 in 2020/21. Our Trafford EIP team has received additional investment from Trafford CCG together with a change in service criteria to focus on under 35-year olds. Because of this the Trafford EIP team are likely to remain at Level 2. In February 2020, the NHSE/I Intensive Support Team undertook a two day visit to the Manchester and Trafford EIP teams with helpful feedback being taken forward through an action plan.

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PART 3 – Review of Quality Performance in 2019/20

3.1 Delivery of Quality Improvement Priorities in 2019/2020

As highlighted in last year’s Quality Account, we continue to deliver our annual Dragon’s Den quality innovation programme, which helps to support the delivery of our quality improvement priorities, and to make them meaningful and relevant for our local services. The Dragon’s Den is a Quality Innovation fund that was established to encourage quality improvement at local service level, and to support the delivery of the GMMH Quality Improvement Priorities (QIPs).

Each year, funding is made available to support a range of innovative projects. The fund is promoted annually during April/May, which is when the improvement priorities for the forthcoming year are drafted. Any bids into the fund must relate to at least one of these priorities.

All individuals, teams, services and departments that are part of GMMH are able to apply for the fund. Applications are also encouraged from social enterprises, charities, service user and carer groups and third sector organisations that operational services may be engaged with. There is no lower limit but funding bids are usually capped at £10k.

For 2019/20, there were over 130 bids for funds, with 58 of these being successful. Successfully funded projects ranged from animal assisted therapy and improving care environments, through to creative therapies, and staff wellbeing programmes. Financial support for the projects ranges from £189 up to £10,000.

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We have made significant progress against all of our 2019/20 priorities for improvement. Summaries of our key achievements are detailed in this section. Each achievement reflects the immense commitment of our staff, services users and carers to continually improving quality. We have provided evidence of our key achievements, with case studies from Dragon’s Den funded projects as follows:

Quality Improvement Priority One: To Improve Outcomes

Red to Green Days Acute Care Pathway Redesign

The overall aim of this project is to increase the This programme aims to improve community average number of Green Days on Bolton Acute pathway provision across District Services and the Wards by 10% by October 2020. interface between CMHTs, Inpatients, and HBTTs.

This project will improve patient, carer and staff The project will ensure best practice standards experience by ensuring that each day is value across our district services, ensuring the right care adding for the patient and that patient care is and treatment at the right time in the right place. delivered in the appropriate setting, with less time The project will also deliver an improved offer to spend in hospital. known CMHT service users in a crisis.

Progress, achievements and ongoing plans

Red to Green Days

The Red to Green Days Project was first introduced in November 2019 during the MDT Board Round following the production of Red2Green Operational Guidelines. The project team attended Introduction to QI training, developed a Driver Diagram and started testing first PDSA cycles. Early effort has focused on the Red2Green principles are well established with the CMHT and HBTT. The Boardround spreadsheet was modified aligned to and supportive of the project definitions and it includes proposed Discharge Dates as agreed on MDT meetings. The Measurement Plan is now finalised and a Project Evaluation is currently undertaken by the project team. Next steps include updating the Red2Green Operational Guidelines with clear distinction on what constitutes internal and external delay. The Quality Surveillance Analyst in collaboration with the project team will work on the proposed ‘Boardround’ spreadsheet introducing new recording parameters enabling better data monitoring. The project team is currently planning their next change idea for testing; adding proposed discharge dates on care plans and discussing with patients when appropriate.

Acute Care Pathway Redesign

The project team has worked to develop a consistent pathway through CMHTs, developing consistent approaches to Zoning meetings and the Duty Team function. The team is also promoting clinical leadership in each CMHT through providing clarity of roles within the CMHT leadership staff groups and focused CPD. In addition, quality guidance for crisis care planning, and robust caseload management – including good quality supervision and sharing learning from incidents involving CMHTs across GMMH

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is now in place. The team has also introduced a crisis care plan tile on PARIS, defined duty model and function, revised and relaunched zoning meeting practice standards, engaged with senior clinical leads in promoting robust MDT working on a daily basis and ensured that a Trust-wide steering group for CMHT is now in place. The Meridian Project has been implementing new scheduling and use of technology in HBTT to help with increasing face-face contacts with service-users and carers who require HBTT. All HBT services are demonstrating an increased face to face activity. Future plans include introducing a trusted assessor model across acute care in order to support the 72 hour follow up performance indicator and devising a forum where service users, carers, clinicians and managers can oversee clinical improvement of the Adult Care Pathway within each division.

Case Study Priority 1: To Improve Outcomes

Our ‘improving outcomes’ Dragon’s Den domain attracted many bids throughout 2019/20, but one which really caught the attention of the Dragons came from our Occupational Therapy team and a third sector organisation called Headspace. This was an innovative project that aimed to run two 12 week spoken word/beat poetry courses and 12 sessions with musicians. Their aim was that each course would engage up to 15 people with experience of autism/mental illness. It was envisaged that they would perform for around 150 members of the public over the year.

Headspace, an expert by experience led organisation, has developed a wide range of creative projects. Their recent Stand-up comedy course, funded by the Dragon’s Den programme in 2017/18 proved to be extremely effective with participants demonstrating great strides towards overcoming shame and internalised stigma (often described as more disabling than the illness itself). Their members have performed in a wide range of mainstream comedy venues and through their partnership with Cherry Moon Café and they have now established a regular comedy night in Bolton. This enables their participants to have a voice through comedy to educate the general public, demystify mental illness and demonstrate that people with a mental illness can be influential in our society.

Their members wanted to further this by creating a regular spoken word/music night at Cherry moon. The project included training with musicians and spoken word artists to develop high quality material for the events in a similar way to their stand-up comedy.

With all art forms, developing material relies on sharing personal experiences. The nature of the course, not only allowed, but required in-depth analysis of situations arising from having a condition and allowed participants to explore these issues alongside health professionals and artists. Through this sharing and normalising they identify that we have more in common. This approach allows us to cognitively reframe our experiences. Participants reported feeling empowered. They started viewing daily life struggles as sources of material. The challenge of performing to an audience further increased the shared commonalities and allowed them to educate the general public on living with mental Illness. The vulnerability and exposure of this genre creates strong group cohesion with participants supporting each other and developing a strong sense of community in their roles as artists rather than users of services.

Creative writing, spoken word, poetry and music are highly recognized as instrumental for exploring difficult issues, it’s a great medium to communicate difficult concepts to others and crafting these for a performance is a powerful way of enabling people with lived experience of mental illness to gain strength, improve their personal outcomes and gain hope from their adversity. It is a particularly

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accessible medium for young people enabling us to support people at the early stages of recovery. This form of communication supports principles of compassion from self and others.

Cherry Moon Café is an alternative independent café in the heart of Bolton selling comic books and running regular game nights and hosts our comedy. Its friendly atmosphere attracts a lot of people who often struggle to access their community as well as people who seek out independent local cafes. It is rapidly becoming a supportive community centre offering an alternative way of socialising that does not revolve around alcohol consumption. The partnership with Headspace is creating an alternative way of tackling social isolation for people living with mental illness.

The overall aim of the project was to achieve similar outcomes by using their well tested, successful comedy model working with a different medium to widen engagement and provision; attracting new participants via a different medium.

Quality Improvement Priority Two: To Deliver the Safest Care

Reducing Restrictive Practice

This project aims to reduce the use of restrictive practice and restrictive interventions by a further 5% by 31st Dec 2020 across all GMMH inpatient services.

This project will mean that our patients will become more engaged in their care and recovery. This is empowering and validating for patients and can reduce risk of harm or re-traumatisation by preventing incidents.

Progress, achievements and ongoing plans Increasing training compliance has continued to be a key area of focus for this programme. This has improved with the input of our operational leads across GMMH. The review of training content remains ongoing in line with the RRN training standards. A new training module with a greater focus on trauma- informed care is being developed currently. This will be approved by the Positive and Safe Task and Finish group and begin running over the next month. Increases in training compliance are expected to reduce the number of incidents involving restraints. This is balanced by the number of NHSP staff on the wards who have not received the same training and usually increases at times of high acuity.

Supervision

The overall aim is to improve the quality, frequency and management systems for all supervision across the whole workforce across the GMMH footprint. We aim for the frequency of staff engaging in supervision will improve to 85% compliance by 31st December 2020.

It is important for a clear and robust oversight around staff supervision, this will give the provision of safe, high quality and effective care in productive environments with consistent delivery and with an engaged workforce which focuses on continual improvement.

Progress, achievements and ongoing plans The Supervision policy has been ratified and distributed across GMMH services. The frequency of staff engaging in supervision will improve to 85% compliance by 1st December 2020. An electronic reporting system was launched in January 2020. The Quality Surveillance Analyst is obtaining access to the

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electronic data from the Learning Hub to enable the provision of statistically robust monitoring of the compliance of supervision monthly or as required. Once access is available (date to be confirmed by IM&T) this plan will be updated with an SPC chart which will initially provide a baseline and going forward will be updated on a monthly basis to provide assurance that supervision is being completed and recorded throughout all areas of GMMH. The quality audit has been out for comments and will be being rolled out throughout the Trust during April 2020. A set of FAQs has been devised and is to be published on the Learning Hub in March 2020.

Falls Reduction

The overall aim of this programme is to reduce inpatient falls across GMMH by 15% by December 2020, and to introduce and test of range of rapid improvement ideas.

This project is important because reducing falls will reduce the likelihood of harm (pain and injury) and will improve the patient experience. Reducing falls by 15% is likely to decrease LoS, decrease staff time required for enhanced observations, falls reporting and investigations and reduce the requirement to transfer patients to Acute Hospitals.

Progress, achievements and ongoing plans Overall aims, productivity and efficiency targets have now been set for this project. A measurement plan has also been identified for phase 1, and will adapt as the project evolves. This includes a range of outcome, process and balance measures to evaluate the impact of change ideas as defined in the driver diagram. The team has identified a number of areas, which will be tested out using a series of PDSA cycles. This includes use of assisted technology (Rambleguard), a push on falls prevention training, to understand the impact on falls incidents, and a third PDSA cycle around use of the FRAMP tool to increase both the quantity and quality of risk assessments. These will be tested out in ward areas with higher numbers of patient falls (identified using the Pareto tool), and via Datix listings. The team has also agreed to establish a learning set, and will scope out a delivery plan during Q4.

Case Study Priority 2: To Deliver the Safest Care

As part of our annual Dragon’s Den process, we requested bids from staff to come up with innovative projects which would improve the quality of care delivered to our service users. Under the ‘Delivering Safest Care’ domain, GMMH’s Substance Misuse Services requested £10,000 Naloxone Nasal Sprays to be distributed to the most vulnerable service users across Cumbria, Bolton, Salford and Trafford.

Drug-related deaths fell by 3% between 2016 and 2017. The first decrease seen since 2012. However, drug deaths remain historically high. There have been more than 2,300 drug misuse deaths and around 1,100 heroin deaths each year from 2015 – 2017.

Most overdoses occur in the presence of others and death is immediate in only a minority of cases. Most people will make an effort to resuscitate someone who has overdosed, however some may delay calling the emergency services. The provision of Naloxone, and overdose training has been demonstrated to decrease overdose related mortality. Substance Misuse Services at GMMH already provide Naloxone Ampules for low risk service users and Prenoxad - a pre-filled syringe for high risk service users. However, £162m (18%) has been cut from treatment budgets in England since 2014 meaning that the provision of Naloxone is becoming increasingly difficult and the implementation of this new product currently out of reach.

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Naloxone Hydrochloride single dose nasal spray is a new drug on the market and is used for the emergency treatment of opioid overdose. Being able to distribute Nasal Naloxone will without doubt save more lives. For people with discomfort or fear of needles it is easier to administer than injectable Naloxone and can carry less stigma in some communities. Being able to introduce Nasal Naloxone will without doubt save lives and as such GMMH’s Dragons were more than happy to support the bid.

Quality Improvement Priority Three: To Integrate Care Around the Person

Winning Hearts and Minds Trauma Informed Care

To improve the cardio vascular health of people This programme aims to Increase the awareness, with a SMI in North Manchester, thereby knowledge & confidence of all GMMH staff to contributing to the achievement of a Primary and work in a trauma informed way by implementing Secondary Care target to reduce cardiac deaths Trust wide TIC training programme by Feb 2020 from 85/100k to 50/100k by 2027. There is strong empirical evidence of a link This project will contribute to enabling service between the experience of trauma/adversity and users to live longer and healthier lives and to have the development/maintenance of mental distress. improved access to physical health interventions. Increased recognition of trauma/adversity will It will lead to improved parity of esteem, in terms inform and improve individual care planning and of access and outcomes. It also aims to reduce the service user experience. burden on carers by improving physical health outcomes.

Progress, achievements and ongoing plans

Winning Hearts and Minds

The planned, evidence-based approach to accomplish the aim, was to implement a bespoke smoking cessation service for people with SMI in North Manchester. This is on pause subject to a service user consultation, the call for which is due to be released, by the CCG, later in 2020, and which the Psychosis Research Unit (PRU) will apply to undertake. In the interim, attention has turned to two other work streams:

1. Review Safe Prescribing practices, involving GMMH and Manchester University pharmacists and medics to design an evidence based audit of current medicines in use in the context of QT lengthening risks and mitigation.

2. In the context of culture and capacity challenges in the North CMHTs apply QI. approaches to the activity of physical health practitioners in North Manchester, focusing on the use of BI data and engagement of CCs in the process, across the whole caseload.

Trauma Informed Care (TIC)

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The TIC QI Project involves a cultural change from ‘what is wrong with you?’ to ‘what’s happened to you’ and the first year of the project has been about building the knowledge and confidence of staff and the organization around the principles of TIC:

• The TIC project group has expanded with increased MDT representation. There is now a consistently well attended monthly meeting, met on 25th February 2020. • C-TRU and the Trust Psychological Forum held a second 1 day TIC conference in Feb 2020 that was attended by 100 GMMH staff (demand was high as evidenced by a significant waiting list & with significantly increased MDT attendance relative to the first conference in 2018). • TIC presentations are now a regular agenda item at the Trust Positive & Safe Forum. TIC presentation re: Use of Formulation tile, incl new guidance of the use of this tile 21/1/2020 • The PMVA training curriculum has been developed to incorporate TIC principles. Review of new training materials in PMVA Task and Finish Group planned on 6/3/20. TIC has been included as part of the Trust Induction programme. • Work is underway to develop a workbook to support nurse-led trauma-informed psychological formulations on inpatient wards. Draft workbook to be reviewed at upcoming TIC QI project group. • The Recovery Academy are auditing existing courses to integrate TIC where appropriate.

Case Study Priority 3: Integrating care around the person

Integrating care around the person is another domain where the Dragons were looking for new ideas and innovation. One such bid came from the staff at Meadowbrook – Salford’s mental health inpatient unit who asked for £2300 to fund ‘Home Safari’ sessions within the unit.

Home Safari are a team of people who visit the hospital environment with their animals/pets offering animal-assisted therapy (AAT). AAT or pet therapy helps someone recover from, or cope with, a mental health condition or a disorder. The sessions will fit with the safe wards initiative by providing opportunities to “know each other” and “calm down methods”. Proper diagnostic assessment in an inpatient mental health setting requires observation of patients under various conditions. Group activities such as animal-assisted therapy (AAT) or pet therapy can provide an excellent opportunity for assessment.

Pet therapy groups tend to attract the highest percentage of inpatients voluntarily choosing to attend an occupational therapy group. It has been found that pet therapy is one of the most effective of all groups offered in attracting isolated individuals regardless of diagnosis. Pet therapy can affect feelings of loneliness and the development of a therapeutic rapport through social facilitation positively. Adult bonds with animals have been shown to promote social interactions and behaviours, increase emotional comfort, decrease loneliness, and anxiety, and provide a source of self-esteem and a sense of independence, and has proved to help promote service user recovery.

As this bid showed that care can be delivered to fit the needs of the service users, Dragons were more than happy to fund this project. The third domain of improving outcomes attracted many bids, but one which really caught the attention of the Dragons came from out Occupational Therapy team and a third sector organisation called Headspace.

Single page Lean A3 plans (SPPs) have been produced for each of the seven QIPs including outcomes, improvement actions and measures, where these have been agreed. The A3 plans also highlight

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associated high-level quality, patient, staff and productivity gains for each QIP. The SPPs for each of the seven QIPs are set out on the following pages.

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3.2 Performance against Quality Indicators Selected

This section of our Quality Account provides an overview of quality as demonstrated by a range of indicators. The indicators cover the three domains of quality (experience, effectiveness and safety). We have continued to use a number of the same indicators as our previous years’ quality accounts. For all indicators we have provided historical data, in addition to 2019/20, to enable understanding of performance over time. Figures reflect the latest available position.

Patient Experience 2018/19 2019/20 Comments

PLACE inspections. *CLN: 99.5% **CLN: 99.4% *PLACE inspection published The assessment Food: 78.9% Food: 86.8% 16/08/2018. evaluates cleanliness, Org Food: Org Food: 88.6% **PLACE inspection published condition/appearance, 79.83% Ward Food: 30/01/2020 privacy and dignity Ward Food: 86.2% CLN – Cleanliness Score and food. 79.0% PDW: 93.2% Food – Food Score PDW: 88.9% CAM: 97.6% Org food: Organisation Food Score CAM: 97.2% DEM: 85.5% Ward Food: Ward Food Score DEM: 84.2% DIS: 85.0% PDW: Privacy, Dignity, Wellbeing Score DIS: 82.7% CAM: Condition, Appearance, Maintentance Score DEM: Dementia Score DIS: Disability Score Complaints – total 9.7 10.1 Source: PARIS and Datix number of complaints (As at Mar 2020) received per 10,000 recorded service user contacts Compliments – total 13.0 15.0 Source: PARIS and Datix number of (As at Mar 2020) compliments received per 10,000 recorded service user contacts

Clinical Effectiveness 2018-19 2019/20 Comments

Community Mental *Score – 67.7% **Score: 64.8% Source: *CQC (Community Survey 2018, Health Survey - % of Q37, Rank 7-10 as % of Ranks 0-10) responses that rated ** CQC (Community Survey 2019, Q35, the services received Rank 7-10 as % of Ranks 0-10) from our Trust as good, very good or excellent Friends and Family 79.8% 79.5% Source: Friends and Family Service Users Test – Service Users – Submission to Unify. (YTD As at Feb % of Service Users 2020) who responded as Please note: Due to Covid-19, the Friends and Family Service Users

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“Extremely Likely” or Submission was suspended for the “Likely”. March 2020 submission.

Total staff sickness 5.8% 6.6% Average sickness rate for Mental Health absence (%) – rolling / Learning Disability Trusts in the North 12-month position West is 6.4%* Source: Board Performance Report (Mar 2020) via Electronic Staff Record (ESR) *Source: https://digital.nhs.uk/data- and- information/publications/statistical/nhs- sickness-absence-rates/july-2019-to- september-2019

Safety 2018-19 2019/20 Comments

Degree of harm 74.7% 76.1% Source: Datix incurred by service (As at Mar 2020) users in incidents reported to the National Patient Safety Agency - % of all incidents reported that resulted in no obvious harm % of all patient safety 1.1% 1.6% Further information on this indicator incidents that resulted can be found in Section 2.10.7 of this in severe harm or Quality Account death Source: Datix (As at Mar 2020) Number of under 18s 14 35 Source: PARIS (Apr 19 – Mar 20) admitted to our adult mental health inpatient wards

Sickness continues to be higher than target. Reducing sickness levels remains a key priority for the Trust. Actions include fortnightly case reviews to promote timely and proactive management of long- term sickness and a review of the sickness policy. The work to improve staff experience and support improved staff health and wellbeing also continues. Progress is monitored via the workforce strategy programme board.

3.3 Performance against Key National Priorities

GMMH work hard to deliver all relevant national priorities and targets. Our performance against the mental health indicators set out by NHS England in the ‘Five Year Forward View for Mental Health’ and by NHS Improvement (NHSI) in the Oversight Framework are summarised here (please note operational Oversight Framework requirements only).

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We are registered with NHSI the regulatory body for Foundation Trusts and have consistently achieved all required targets and standards for continued registration. We are currently rated at level 3 (month 11) for the Finance and Use of Resources metric.

Similarly, we are registered with CQC without conditions, complying with all regulations. We have established robust mechanisms for monitoring compliance against all the outcomes detailed in the CQC Compliance Guidance to provide ongoing registration assurances. We are compliant with the NHS Quality Risk Management Litigation Authority Standards.

The figures reflect the latest available position.

Indicator Target 2018/19 2019/20 Comments 1. People with a first 56.0% 72.2% 72.7% 12 months YTD data as at March episode of psychosis begin 2019. treatment with a NICE- Source: Board Performance recommended package of Report (Mar 2020) care within 2 weeks of referral (SDCS and MHSDS) 2. Data Quality Maturity 95% 90.4%* **92.7% *Position as at January 2019 Index (DQMI) - MHSDS **Latest Published Figure Dataset Score. January 2020 3. Improving Access to Psychological Therapies (IAPT)/talking therapies (from IAPT minimum dataset): 3a. Proportion of people 50% 43.7% 46.5% As at March 2020. completing treatment who Source: Board Performance move to recovery (from Report (Mar 2020) IAPT minimum dataset) 3b. Waiting time to begin 75% 62.4% 68.1% 12 months YTD data as at March treatment within 6 weeks 2020. of referral Source: Board Performance Report (Mar 2020) 3c. Waiting time to begin 95% 91.0% 89.7% 12 months YTD data as at March treatment within 18 weeks 2020. of referral Source: Board Performance Report (Mar 2020) 4. Inappropriate out-of- A 5731 2117 12 months YTD data as at March area placements for adult reduction 2020. mental health services of 66% Source: Board Performance (Total number of bed days) from Report (Mar 2020) 17/18 position. Admissions to adult 0 0 0 12 months YTD data as at March facilities of patients who 2020 are under 16 years old Source: Board Performance Report (Mar 2020) Care programme approach 95% 95.0% 96.0% As at December 2019 (CPA) follow up - Source: proportion of discharges https://www.england.nhs.uk/statisti

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Indicator Target 2018/19 2019/20 Comments from hospital followed up cs/statistical-work-areas/mental- within 7 days health-community-teams-activity/ 2018/19 figures are YTD Q1-Q3 2019/20 figures are YTD Q1-Q3 Please Note: Due to the COVID-19 pandemic, collection of the Mental Health Community Teams Activity for Quarter 4 2019-20 has been postponed by NHS Digital. Q4 results are therefore unavailable at the time of publishing.

The above reflects good performance in most areas. It should be particularly noted that the 6 and 18-week referral to treatment times have been met in March 20 following ongoing improvement. This reflects ongoing improvement in Salford and Manchester services during 19/20 to deliver these targets with the support of commissioners. This has included the development of trajectories to clear historical waiting lists and more effective and timely management of new referrals. Additional investment was also agreed with commissioners in Manchester and Salford to address capacity issues. The IAPT service has also made significant progress in progressing the digital agenda offering alternatives to face to face clinic appointments for patients via video consultations for example. This has been an important choice to offer during the COVID response.

The IAPT recovery target has not been met however it should be noted that in Salford and Manchester GMMH only provide the Step 3 IAPT services. This impacts on our recovery rates for these services as the recovery target is linked to the delivery of the whole stepped-care IAPT pathway. The Step 2 IAPT services in these areas contribute to the achievement of the target at a CCG pathway level.

The target for reducing OAPs bed nights was also met with a reduction of 86% meeting the national target of a reduction of 66%. During 20/21 GMMH have also been focussing on achieving the national target of zero reportable OAPs be the end of March 21. This includes promoting timely discharges and developing alternatives to admissions in collaboration with the whole system including third sector partners and voluntary agency support.

The Data Quality Maturity Index (DQMI) reflects the completeness of MHSDS (Mental Health Services Data Set) recording in relation to 36 data categories. Our latest national published figures are from January 2020 and show the Trust as below the national target of 95% however this figure has improved throughout the year due to actions put in place to improve reporting of new data categories requested nationally. This is expected to continue and GMMH await the position when the March figures are released.

* Please note that GMMH scores for 2019/2020 will be provided as part of the National Clinical Audit of Psychosis report, published by the Royal College of Psychiatrists. The report is expected to be published by July 2020.

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PART 4 – Priorities for Quality Improvement in 2020/21

This section of the Quality Account sets out our priorities for improvement that we intend to deliver during 2020/2021. As referenced in the Chief Executives introduction, the speed and spread of Covid-19 has affected how we work on a day to day basis. As a result of this, we have unfortunately been unable to consult in the usual way with our staff, service users, carers, our Council of Governors and our other key stakeholders across the GMMH footprint. As a result, we have decided to maintain our existing QIPs, which were agreed and set out in last year’s Quality Account.

This will allow us to continue with the significant progress we have already made, and when we are able to, we will develop and implement further additional improvement programmes that relate to these important areas. Further detail on our quality improvement projects, enablers and programmes will be set out in phase two of our Quality Improvement strategy.

4.1 Consultation feedback

Consultation from staff, service users and carers has been used to inform the development of this Quality Account. Specific feedback from our mandated external stakeholders has been included as verbatim in section four, annex one.

4.2 Improvement Priorities for 2020/2021

The Quality Improvement Priorities for Greater Manchester Mental Health NHS Foundation Trust during 2019/20 include the following:

PRIORITY 1 – Improving outcomes

Quality Effectiveness and Service User Experience domain

PRIORITY 2 – Delivering the safest care

Quality Safety and Service User Experience domain

PRIORITY 3 – Integrating care around the person

Quality Effectiveness and Service User Experience domain

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4.3 Monitoring our Quality Improvement Priorities

These Quality Improvement Priorities will be subject to robust monitoring during 2020/21. Each priority area has an improvement lead, along with dedicated support from the QI team. Leads are required to produce monthly summaries for discussion at our Associate Leadership Team. The QI Team will also produce robust quarterly summaries that will be reported to our Quality Improvement Committee, and received at our Trust Board.

It is anticipated that the Dragon’s Den initiative will continue to support our ambition that the Quality Improvement Priorities remain meaningful and relevant for our local services. Through the programme, we will welcome bids from across the breadth of our services that aim to improve quality for our service users and their families, and ensure that they are linked to at least one of these priorities. We will continue to ensure that service users and carers are involved in supporting our decisions around bids that are funded through the Dragon’s Den process, and will provide further detail on we have done this in next year’s Quality Account.

This Quality Account provides an overarching picture of some of the work we have done and will do in the future as part of a much wider comprehensive quality agenda. This ensures that our services are provided to the highest possible quality standards and continue to meet changing needs in a person-centred way.

Please feel free to contact us if you would like to know more about any of the priorities for 20/21 or any other quality improvement activity at the Trust.

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ANNEX 1 Feedback from Key Stakeholders

Feedback from NHS Bolton CCG on behalf of Bolton Salford and Trafford Clinical Commissioning Groups

Greater Manchester Mental Health NHS Foundation Trust (GMMHFT) Quality Account 2019/20 - Feedback from Bolton, Salford and Trafford CCG’s

Bolton CCG has coordinated this response on behalf of the CCGs involved in the multilateral contract and we would like to thank staff across all services for their hard work throughout 2019/20, particular during the recent COVID-19 crisis. The CCG’s have once again worked closely with GMMHFT to gain assurance that the Trust has provided safe, effective and patient focused services. Performance and quality continues to be monitored via a collaborative and clinically led process and the content of this account is consistent with the information presented in year which showed largely high levels of attainment for both KPI’s and CQUINs.

We would like to congratulate the Trust on its overall CQC rating of ‘Good’ and we note the work that is being undertaken in areas that require improvement. We also acknowledge the implementation of the Trust’s Quality Improvement Strategy which should prove to be an enabler for further enhancing their Patient Safety Culture. Finally, this year’s Account has clearly measurable goals associated with the priority areas of improving outcomes, delivering safest care, and integrating care around the patient. We look forward to seeing progress against these throughout the year.

The CCG’s also noted the launch and implementation of the Trust’s Strategy for Equality, Diversity and Inclusion and look forward to seeing the positive impact of this for both staff and service users in future Accounts. The CCG’s note the numerous service developments that have taken place in 2019/20 and although there are too many to be mentioned in the Account it is important to recognise the positive impact these have had on each of our localities.

The Account reflects numerous accolades, examples of good practice and shows high levels of staff and user involvement. It is encouraging again to see good audit compliance, and it would be interesting to see in future accounts the practical application of the extensive research and innovation that takes place.

Last year there was a lack of integrated care reflected in the account and again it would have been good to see a greater emphasis on this as localities develop their neighbourhoods and primary care with mental health very much at the forefront.

Staff survey results remain under the national average and it is hoped implementation of the Workplace Wellbeing Policy will help to address this and support the recruitment and retention of the Trust’s most valuable asset.

The Account describes an organisation that is able to deliver services to a high standard, is innovative and patient focused. We look forward to working with the Trust in 20/21 to further develop the delivery of mental health services in line with Bolton, Manchester, Salford and Trafford’s extensive transformation plans.

Dr Jane Bradford - Clinical Director for Governance and Safety Michael Robinson - Associate Director for Governance and Safety

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Feedback from Manchester Health and Care Commissioning (MHCC)

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Feedback from HealthWatch, one narrative provided on behalf of HealthWatch Bolton, Manchester, Salford and Trafford

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Feedback from Manchester City Council Health Scrutiny Committee

Telephone +44 (0)161 234 3376 Fax +44 (0)161 274 7017 [email protected]

Governance and Scrutiny Support Unit Chief Executive's Department 3rd Floor, Town Hall Extension Manchester Councillor John Farrell M60 2LA Chair of the Health Scrutiny Committee

10 June 2020

Dear Mr Thwaite,

Manchester City Council Health Scrutiny Committee - Response to Greater Manchester Mental Health NHS Foundation Trust Quality Account 2019/20

As Chair of Manchester City Council’s Health Scrutiny Committee, I would like to thank you for the opportunity to comment on your Trust’s Draft Quality Account for 2019/20. Copies of the draft quality account were circulated to members of the committee for consideration and comments received have been included below. We would like to submit the following commentary to be included within your final published version.

At this unprecedented and challenging time the Committee would first like to take this opportunity to express our sincere gratitude and appreciation to all of the staff working at the Trust, both frontline and back office for their continued professionalism and dedication to ensure services continue to be delivered and vital support offered to Manchester residents. The Committee would be grateful if this appreciation could be communicated to all staff.

We acknowledged that the opening statement from the Chief Executive sets a tone of directness and transparency in the draft Quality Account and the statement identifies key achievements and priorities for the coming year and acknowledges the important work and contribution of both staff and volunteers.

In the current circumstances, we note and fully support the decision taken by the Trust to maintain the existing Quality Improvement Priorities for 2020/21, which were agreed and set out in last year’s Quality Account.

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The Committee welcomes this document as a positive draft Quality Account with evidence included such that chronological and organisational comparisons may be made across a range of activities and services, and where appropriate areas for improvement are identified and clearly described.

The Committee welcomes the overall rating of ‘Good’ by the Care Quality Commission following their inspection and we note the actions identified to address the area rated as ‘Requires Improvement’. The Committee were satisfied that throughout the report evidence was presented to demonstrate efficient governance arrangements are established at the Trust.

The report further describes a range of initiatives and the rationale for these, such as the work with those individuals who may be a risk of self-harm or suicide and the adoption of the national ‘Freedom to Speak Up’ policy. The Committee support the inclusion of case studies to describe a range of actions and progress against identified Quality Improvement Priorities; Quality Indicators and performance against Key National Priorities.

The Committee further welcomed the inclusion of anonymous comments and feedback from service users and note that when feedback was received where people were dissatisfied, governance arrangements were established to acknowledge these and where appropriate effectively respond to them.

The whole report is written in a clear and concise manner with the accompanying narrative and data, across a range of activities is presented in an accessible format. We note and welcome the inclusion of a list of acronyms that had been provided and commented that this is useful to assist the lay reader to understand the document. The Committee note that the draft document presented for consideration adequately fulfils the requirement that a Quality Account to be a mechanism for a local NHS service to report on quality and show improvements in the services they deliver to local communities and stakeholders.

We felt that overall the Quality Account was very positive and reflected the successful operation of a complex organisation that serves and responds effectively to service users, patients, their carers and families in an efficient and compassionate manner.

The Committee will continue to monitor the work of the Trust on behalf of the residents of Manchester and we will welcome you to a future meeting of the Health Scrutiny Committee where Members will have an opportunity to discuss and question you regarding the important work that you deliver.

Yours sincerely,

Councillor John Farrell Chair of the Health Scrutiny Committee

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ANNEX 2 Statement of Directors’ Responsibilities in Respect of the Quality Account

The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to review:

The content of the Quality Report to ensure it meets the requirements set out in the NHS foundation trust annual reporting manual 2019/20 and supporting guidance. The content of the Quality Report so that it is not inconsistent with internal and external sources of information including:

• Board minutes and papers for the period April 2019 to March 2020 • Papers relating to quality reported to the board over the period April 2019 to March 2020 • Feedback from Manchester Health and Care Commissioning dated 11th June 2020 • Feedback from Bolton, Salford and Trafford Clinical Commissioning Groups (CCG’s) dated 11th June 2020 • Feedback from governors dated 10th February 2020 • Feedback from local Healthwatch organisations dated 3rd June 2020 • Feedback from Manchester Health Scrutiny Committee dated 10th June 2020 • The 2019 National Patient Survey published November 2019 • The 2019 National Staff Survey published February 2020 • The Head of Internal Audit’s annual opinion of the Trust’s control environment provided in April 2020

• The Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered • The performance information reported in the Quality Report is reliable and accurate • There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice • The data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review • The Quality Report has been prepared in accordance with NHS Improvement’s annual reporting manual and supporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. Greater Manchester Mental Health NHS Foundation Trust

By order of the board:

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Rupert Nichols – Chairman Neil Thwaite - Chief Executive

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ANNEX 3 Equality Impact Assessment

Consideration Yes/ Comments No 1. Does the Quality Please see comments below Account affect a group with a protected characteristic less or more favourably than another on the basis of: • Age NO N/A • Disability NO N/A • Gender Re- NO N/A assignment • Marriage and NO N/A Civil Partnership • Pregnancy and Maternity NO N/A

• Race N/A NO

• Religion or NO N/A Belief

• Sex NO N/A

• Sexual NO N/A Orientation 2. Has the Quality YES This was taken into account as part of the planning Account taken into and production of the Quality Account. No specific consideration any issues have been identified throughout the privacy and dignity or production stages of this Quality Account. same sex accommodation requirements that may be relevant? 3. Is there any evidence NO There is no evidence that any groups are adversely that some groups are affected as a result of the Quality Account. affected differently? Monitoring and consideration will remain ongoing. 4. If you have identified NOT No valid, legal or justifiable discrimination has been potential APPLICABLE identified throughout the production of this Quality discrimination, are any Account. exceptions valid, legal and/or justifiable?

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Consideration Yes/ Comments No 5. Is the impact of the NO The impact of the Quality Account is not likely to be Quality Account likely negative. to be negative? 6. If so, can the impact NOT This does not apply as no negative impact has been be avoided? APPLICABLE identified 7. What alternatives are NOT This does not apply as no negative impact has been there to achieving the APPLICABLE identified Quality Account without impact? 8. Can we reduce the NOT This does not apply as no negative impact has been impact by taking a APPLICABLE identified different action?

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ANNEX 4 Local Clinical Audits Reviewed in 2019/20

AUDITS FROM THE GMMH CLINICAL AUDIT PROGRAMME

ADVANCING QUALITY / COMMISSION FOR QUALITY AND INNOVATION (CQUIN) /KEY PERFORMANCE INDICATOR AUDITS 1 CQUIN Improving Dementia Care: Memory Assessment and Treatment Service Team audit of case notes for carers views 2 Collaboration with Primary Care Clinicians 3 CPA Risk Assessment/Risk Management Plans 4 NICE Self-Harm Quality Standards PATIENT EXPERIENCE/SAFETY AUDITS, HEALTH AND SAFETY AUDITS

5 Care Planning in the Community 6 Annual Ligature Audit 7 Audit of under 18’s Admitted to Adult Wards 8 Seclusion Audit 9 Mattress Audit 10 Infection Prevention Hand Hygiene Audit 11 Infection Prevention Environmental Audit 12 Dementia Memory Assessment Teams – Improving Patient Care/Experience MENTAL CAPACITY/MENTAL HEALTH ACT AUDITS

13 Mental Capacity Act 14 Consent to Treatment (T2 and T3) 15 Patient’s Rights MEDICINES MANAGEMENT AUDITS

16 Antibiotic Prescribing 17 Controlled Drugs 18 Prescribing Valproate 19 Medicines Handling (Duthie Audit) 20 New Prescription Card Audit AUDITS COMPLETED WITHIN EACH DIVISION

MULTI –SITE AUDITS 21 Current compliance with escalation policies for MEWS/NEWS scores greater than or equal to 7 (663) 22 VTE Risk Assessment Audit in Older Adult In-Patients (843) MANCHESTER, CITY WIDE AND TRAFFORD DIVISION

MANCHESTER AND CITY-WIDE SERVICES 23 Sensory impairment in Manchester memory services (644) 24 Addenbrooke’s Cognitive Examination III (ACE-III) Audit. (639) 25 Outpatient Clinic Letters in Park House Outpatients (682) 26 An Audit of Discharge Summaries Completed on Safire Unit (687) 27 Waiting times and provision of post-diagnostic information in the North Manchester Memory Assessment Service Later Life CMHT and Memory Assessment Service (698)

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28 Audit of record of assessment of capacity to consent to treatment soon after admission to a psychiatry ward. (713) 29 Compliance with consent to Treatment Regulation at Park House, All Wards at Park House. (723) 30 Juniper PICU Bed Audit Park House June August 2018. (728) 31 Audit to examine completeness of PHIT tools on PARIS at Park House and Laureate House excluding SAFIRE. (733) 32 An Audit Exploring the Use of Clozapine in an Inpatient Setting Based Upon NICE Guidance for Treatment-Resistant Schizophrenia. (764) 33 Written communication of dementia and mild cognitive impairment diagnoses within a memory assessment service. (775) 34 Clinical Audit of Standards of Documentation for Risk Assessment within Home Based Treatment Teams (HBTT), Central Manchester (753) 35 Is PHIT tool care documentation being completed to Inpatients on Safire Unit (743) 36 Anticholinergic Side Effect Burden Audit (748) 37 Availability of interpreters for service user reviews in the Central West CMHT Older Adult Psychiatry Team (751) 38 Compliance with Risk Assessment Documentation in GMMH Psychotherapy Services (746) 39 Is clozapine prescription continued on medical wards in a community cohort of patients on clozapine (744) 40 Audit of the process of triage assessment within the Manchester Psychotherapy service (749) 41 Physical health monitoring of inpatients, Laurel Ward (686) 42 Assessing the record keeping around alcohol consumption in elderly patients and whether this is acted on appropriately via the correct services, Central Memory Clinic. (665) 43 Clinical audit on documentation of T2/T3 consent to treatment, Millbrook Independent rehabilitation Hospital and Douglas House. (668) 44 Management of Borderline Personality Disorder in a Community Mental Health Team in South Manchester Weight gain monitoring and management using CQUIN Targets Trafford EIT. (715) 45 Audit BP glucose and lipid monitoring and infection screening on admission to later life ward Cavendish. (692) 46 Re-audit BP glucose and lipid monitoring and infection screening on admission to later life ward Cavendish. (776) 47 End of Therapy Letters in the Gaskell and Macartney House Specialist Psychotherapy Service. (781) 48 No smoking audit Bronte Ward. (788) 49 Driving advice a legal requirement for dementia diagnosis South CMHT. (722) 50 An Audit to assess the implementation of trust smoking cessation policy, Poplar ward (693) 51 South Mersey CMHT Letters to GP assessment of compliance with GMMH standards. (768) 52 Driving and Dementia Central and East CMHT. (786) 53 GP Referral to Community Mental Health Team West (799) TRAFFORD SERVICES 54 Weight gain monitoring and management using CQUIN Targets Trafford EIT. (716) 55 Comparison of current clinical performance of counsellors record keeping at Step 3 level of Trafford Psychological Therapies. (717) 56 How and When to FP10 in a Home Based Treatment Team re-audit. (734) 57 Re -Audit of patients medical review within 7 days of admission to the Trafford Home Based Treatment Team (HBTT) (718)

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58 Availability of resuscitation medications & equipment on resuscitation trollies at Moorside Unit – a re-audit (731) 59 Monitoring of Myocarditis Risk in Patients Commenced on Clozapine (732) 60 An audit of service provision of intensive dementia care within the area of Trafford (736) 61 Smoking Status and Cessation advise at Moorside Hospital (752) 62 Evaluating MDT experience of psychology provision with CMHT across Trafford (754) 63 Did patients who were started on an antipsychotic in the last year received an appropriate workup on Moorside unit (791) 64 Monitoring Constipation in Inpatients on Clozapine (795) 65 How and when to use FP10 in Manchester MHHTT (849) REHAB, IAPT, BOLTON AND SALFORD DIVISION

REHAB SERVICES 66 Monitoring of physical health in patients on Antipsychotics as recommended by NICE (769) 67 To assess implementation of Trust Policy (Smoke Free Policy) in a locked rehabilitation setting, Acacia unit. (745) 68 Re-audit on high dose antipsychotic medication at Braeburn House (783)

BOLTON SERVICES 69 Review introduction of inpatient MDT reviews. (656) 70 Management of alcohol withdrawal in a psychiatric unit. (657) 71 Audit of Consent to Treatment Documentation for Patients Detained Under the Mental Health Act on Bolton Wards. (681) 72 Audit of Consent to Treatment Documentation for Patients Detained Under the Mental Health Act at Woodlands Hospital (680) 73 Audit of service user and (and if applicable, carer) involvement in the STAR V2 risk assessment tool/process. (685) 74 Audit into dementia post diagnostic support group: identifying potential factors influencing attendance at groups. (737) 75 Re audit on discharge letters to GP following an outpatient clinic appointment with Bolton Assessment service. (683) 76 Sodium Valproate (770) 77 VTE Risk Assessment (800) 78 High Dose Antipsychotics in Rivington and Honeysuckle (835) SALFORD SERVICES 79 Re-audit of High Dose Antipsychotic Medication Prescribing for Inpatients at Meadowbrook Unit, Salford (660) 80 High Dose Antipsychotics for inpatients at Meadowbrook (701) 81 An Audit of the use of Community Treatment Orders at Cromwell House CMHT (759) 82 Valproate Prescribing in women of child bearing age (691) 83 PIDS Process at Cromwell House. (704) 84 Assess Compliance in Meeting Quality Standards for Eating Disorders (712) 85 Discharge Planning in Salford Early Intervention Team (724) 86 Audit to compare insomnia management at Salford HBT against NICE guidance (750) 87 Assessment of the effectiveness of the clinical handover process at Meadowbrook mental health unit (771) 88 Compliance rates PHIT assessments Salford Older Age CMHT (782) 89 Anticholinergic Burden Score (785)

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90 Assess Quality of ACE-III Assessments re-audit. (711) 91 ECG and Methadone (810) 92 Emotionally Unstable Personality Disorder (809) 93 Quality of Out Patient Clinic Letters (841)

SPECIALIST NETWORK SERVICES

ADULT FORENSIC SERVICE 94 Consent to treatment in AFS. (730) 95 Use of Rapid Tranquillisation in Acute Forensic Services. (739) 96 Psychiatry Trainees Experiences of Teaching Students. (760) 97 Audit on High Dose Antipsychotic Medication at AFS MSU service. (790) 98 Outpatient letter standards (757) CAMHS 99 Consent to treatment audit at CAMHS (669) 100 Selective Serotonin re-uptake inhibitor (SSRI) prescribing in Bolton CAMHS. (689) 101 Audit of physical health monitoring for all patients on antipsychotic medication, regardless of indication, who are currently inpatients at J17. (725) 102 FCAMHS training needs. (774) 103 Audit of prescription cards in GMMH CAMHS inpatient units (777) 104 Re-audit of Rapid Tranquillisation in CAMHS inpatients SUBSTANCE MISUSE SERVICES 105 Kentmere Ward admissions from Unity from April 2017 - September 2017. (671) 106 Lung Health in substance misusers - can we motivate people to make changes? Is Pulse oximetry a useful test in substance misusers? (674) 107 Deaths in Substance Misuse Services 2016-2018. (719) 108 Retrospective re-audit on clinical management of Delirium Tremens (DTs) in an inpatient alcohol detox unit (721) 109 Use of SROM for patient with Opioid Dependence (780)

110 Re-audit on clinical management of Alcohol Withdrawal Seizures in an inpatient alcohol detox unit. (801)

Contact for Further Information: -

For further details about the information contained in this Quality Account, please contact:

Patrick Cahoon

Head of Quality Improvement

Greater Manchester Mental Health NHS Foundation Trust, The Knowsley Building, Bury New Road, Prestwich, Manchester M25 3BL

Telephone: 0161 357 1793

E-mail: [email protected]

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ANNEX 5 Glossary of Terms

A&E Accident and Emergency hospital services AC Accreditation Committee ACE 111 The Addenbrooke’s Cognitive Examination are neuropsychological tests used to identify cognitive impairment in conditions such as dementia Achieve Drug and alcohol recovery services AIMS Accreditation for Inpatient Mental Health Services ADSM Anxiety Disorder Specific Measures AMIGOS Former Manchester Mental Health and Social Care Trust current clinical patient record system AQuA Advancing Quality Alliance ARMS At Risk Mental State BAME Black and Minority Ethnic BD Bipolar Disorder BMI Body Mass Index BNF British National Formulary BP Blood Pressure BSL British Sign Language CAARMS Comprehensive Assessment of at-Risk Mental States CAMHS Child and Adolescent Mental Health Services Care Co- The professional who, irrespective of their ordinary professional role, has ordinator responsibility for co-ordinating care, keeping in touch with the service user, and ensuring the care plan is delivered and reviewed as required. CARE Hub The CARE hub was created in 2014 to support the Trust to develop a coordinated approach to Service User and Carer feedback and engagement. The CARE hub is a virtual network to engage with Service Users, Carers and Volunteers in a number of different ways. CARE stands for Compassionate and Recovery Focussed Every Time. Carer An individual who provides or intends to provide support to someone with a mental health problem. A carer may be a relative, partner, friend or neighbour, and may or may not live with the person cared for. CBT Cognitive Behavioural Therapy CBU Chapman Barker Unit, specialist service for those with substance misuse needs on the Prestwich site CCGs Clinical Commissioning Groups - groups of GPs are responsible for designing and commissioning local health services CG Clinical Guideline CMHT Community Mental Health Team COASSIST Children with OCD: Identifying Accessible Support Strategies for Parents CTIMP’s Clinical Trials of Investigational Medicinal Products CPA Care Programme Approach - a framework for assessing service users’ needs, planning ways to meet needs and checking that needs are being met. CQC The Care Quality Commission is the independent regulator of all health and adult social care in England and has responsibility for protecting the rights of individuals detained under the Mental Health Act.

CQUIN Commissioning for Quality and Innovation framework, which allows commissioners to link income to the achievement of quality improvement goals CRN:GM Clinical Research Network: Greater Manchester CROM Clinician Reported Outcome Measures DATIX The Trust’s Integrated Risk Management Software DH Department of Health DS&P Data Security and Protection DNAR Do not attempt resuscitation ECG Electrocardiography EDIE Early detection and intervention evaluation for people at risk of psychosis e-GFR Estimated Glomerular Filtration Rate EI Early Intervention EIP Early Intervention in Psychosis EQUIP ‘Enhancing the quality of user involved care planning in mental health services’. A collaborative project between the University of Manchester, University of Nottingham, Nottinghamshire Healthcare NHS Trust and Greater Manchester Mental Health NHS Foundation Trust to examine ways to improve user and carer involvement in care planning in mental health services. FFT Friends and Family Test GDPR General Data Protection Regulation GM Greater Manchester GMMH Greater Manchester Mental Health NHS Foundation Trust GMP Greater Manchester Police GMW Greater Manchester West Mental Health NHS Foundation Trust GM:CRN Greater Manchester Clinical Research Network GP General Practitioner HAELO Innovation and Improvement Science Centre in Salford HBT Home Based Treatment HealthWatch HealthWatch is an independent consumer champion. It was created to listen and gather the public and patient’s experiences of using local health and social care services. Local HealthWatches were set up in every local authority area to help put patients and the public at the heart of service delivery and improvement across the NHS and care services. HEE Health Education England HinM Health Innovation Manchester HMP Her Majesty’s Prison HoNOS Health of Nation Outcome Scales HR Human Resources HSJ Health Service Journal IAPT Improving Access to Psychological Therapies: National programme aiming to improve access to evidence-based talking therapies in the NHS through an expansion of the psychological therapy workforce and supporting services. ICO Integrated Care Organisation iESE Improvement and Efficiency Social Enterprise IM Intra-muscular JDR Join Dementia Research

JDU John Denmark Unit - Inpatient unit for deaf mental health services on the Prestwich site Junction 17 Inpatient unit for child and adolescent mental health services on the Prestwich site KPI Key Performance Indicator KPMG Professional Service Company and Auditors LeDeR Learning Disabilities Mortality Review Lester Tool Downloadable resource used in a range of healthcare settings to improve screening and to ensure a person’s physical and mental health conditions are jointly addressed providing a systematic framework for screening and recommendations for treatment and support. LGBTQI Umbrella term for people who identify as Lesbian, Gay, Bisexual, Transsexual. The “Q” stands for those who are questioning or in a state of flux with their gender and/or sexual identity. LQAF Library Quality Assurance Framework MATS Memory Assessment Services MBU Mother and Baby Unit MDT Multi-Disciplinary Team MH Mental Health MHSDS Mental Health Services Data Set MIAA Mersey Internal Audit Agency MMHSCT Manchester Mental Health and Social Care Trust Monitor The independent regulator of NHS Foundation Trusts MSK Musculoskeletal NCI National Confidential Inquiry NCISH National Confidential Inquiry into Suicide and Homicide NCSCT National Centre for Smoking Cessation and Training NG NICE Guidelines NHS National Health Service NIAG NICE Implementation and Audit Group NICE The National Institute for Health and Care Excellence NIHR National Institute for Health Research: The NIHR commissions and funds a range of NHS and social care research programmes NRLS National Reporting and Learning System NWAS North West Ambulance Service OPS Operations OCD Obsessive compulsive disorder OF Oversight Framework PAM Assist People Asset Management Assistance PARIS PARIS: GMMH current electronic patient record system. PbR Payment by Results PIR Post Incident Review panel PCFT Pennine Care NHS Foundation Trust PCMIS Clinical information system used in Manchester PHIT Physical Health Improvement Tool used in PARIS PICU Psychiatric Intensive Care Unit PLACE Patient-Led Assessments of the Care Environment PLAN Psychiatric Liaison Accreditation Network 77

PMVA Prevention and Management of Violence and Aggression PREM Patient Reported Experience Measures PRN Pro Re Natum (as the need arises) PROM Patient Reported Outcome Measures PRU Psychosis Research Unit PSI’s Psychological Interventions QIC Quality Improvement Committee (formerly Quality Governance Committee) QICC Quality Improvement in Clinical Care group QI Quality Improvement QIP’s Quality Improvement Priorities QPR Questionnaire about Process of Recovery R&D Research and Development R&I Research and Innovation RAG Red Amber Green RCA Root Cause Analysis investigation RCF Research Capability Funding SQI The Sustainability and Quality Improvement Group SUS Secondary Uses Service STORM Skills based suicide prevention training in risk assessment and safety planning for frontline staff SJR Structured Judgement Review SIR Serious Incident Review THOMAS Those on the margins of society WRES Workforce Race Equality Standard WDES Workforce Disability Equality Standard

Greater Manchester Mental Health NHS Foundation Trust Bury New Road, Prestwich, Manchester M25 3BL Telephone: 0161 773 9121 Website: www.gmmh.nhs.uk

This information can be provided in different languages, Braille, large print, interpretations, text only, and audio formats on request, please telephone 0161 358 1644.

Council of Governors

TITLE OF REPORT: Appointment of Lead Governor DATE OF MEETING: Monday 13 July 2020 AGENDA ITEM: 11 PRESENTED BY: Rupert Nichols, Chair AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: In May 2020 the Council of Governors approved an approach to appointing a new Lead Governor, which included the delegation of decision-making authority to Rupert Nichols, Chair.

This paper summarises the outcomes of the Lead Governor appointment process and seeks ratification of the Chair’s decision to appoint Maureen Burke, Public Governor (Salford) as the Trust’s new Lead Governor.

RECOMMENDATIONS: The Council of Governors are invited to ratify the appointment of Maureen Burke, Public Governor (Salford) as the Trust’s new Lead Governor.

Appointment of Lead Governor

1. Background

1.1 All Foundation Trusts are required to appoint at Lead Governor to carry out the role described in Appendix B of ‘The NHS Foundation Trust Code of Governance’.

1.2 In May 2020, the Council of Governors reviewed the Lead Governor role description and eligibility criteria and approved an approach to appointing a new Lead Governor following the retirement of Albert Phipps in March 2020. The agreed process included the delegation of decision-making authority to Rupert Nichols, Chair.

2. Appointment Process

2.1 One governor (Maureen Burke – Public Governor (Salford)) expressed an interest in becoming the Trust’s new Lead Governor following the discussion in May. Maureen fulfils the eligibility criteria, having been an elected public governor since 1 April 2019 and offering a first-hand understanding of the Trust, the mental health sector and the wider NHS. Maureen’s governor profile is provided below, which provides further detail on Maureen’s professional and personal background and her commitment and drive as a governor.

2.2 Rupert Nichols, Chair and Maureen Burke met (remotely) in mid-May to discuss the requirements of the Lead Governor role. Operating with the delegated authority of the Council of Governors, Rupert Nichols subsequently took the decision to appoint Maureen as Lead Governor for an initial 12-month period commencing with immediate effect (from 25 May 2020). The appointment was subject to ratification at a formal Council of Governors meeting.

2.3 As Lead Governor, Maureen Burke will automatically become a member of the Nominations Committee of the Council of Governors and Vice Chair of the Membership Engagement Working Group.

3. Recommendation

3.1 The Council of Governors are invited to ratify the appointment of Maureen Burke, Public Governor (Salford) as the Trust’s new Lead Governor.

Council of Governors

TITLE OF REPORT: Nominations Committee: • Re-appointment of Julie Jarman, Non-Executive Director • Notes of the Nominations Committee Meeting held 30 June 2020 DATE OF MEETING: Monday 13 July 2020 AGENDA ITEM: 12.01 and 12.02 PRESENTED BY: Rupert Nichols, Chair AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: At its meeting on 30 June 2020, the Nominations Committee of the Council of Governors considered the following report, which proposes the re-appointment of one current Non-Executive Director (Julie Jarman). Julie Jarman’s current term of office ends on 31 July 2020, at which point Julie will have served six years (two consecutive terms) as a Non-Executive Director on the Trust’s Board.

Following a review of Julie Jarman’s most recent appraisal outcomes, and discussion about Julie’s contribution to the Board, its sub-committees and wider Trust activities, the Nominations Committee agreed to recommend Julie Jarman’s re- appointment to the Council of Governors. As part of this recommendation, the Committee considered the length of Julie Jarman’s term of office, taking account of the provisions set out in ‘The NHS Foundation Trust Code of Governance’ and the Trust’s Constitution. The Committee also considered remuneration in the context of the new remuneration framework for NHS provider chairs and non-executive directors, as published by NHS England and NHS Improvement (NHSEI) in September 2019.

On the basis of the rationale provided, the Committee agreed to recommend Julie Jarman’s re-appointment for a further one-year term (effective from 1 August 2020) with no change to the current level of remuneration. This will take Julie Jarman’s tenure on the Board of Directors to seven years in total.

The (unratified) notes of the Nominations Committee meeting on 30 June 2020 are attached to support the Council of Governors’ decision.

RECOMMENDATIONS: The Council of Governors are invited to:

• Approve the re-appointment of Julie Jarman, Non-Executive Director based on the recommendation of the Nominations Committee. Re-appointment will be for a further one-year term (1 August 2020 to 31 July 2021), with no change to the current level of remuneration • Note the (unratified) notes of the Nominations Committee meeting held on 30 June 2020

NOMINATIONS COMMITTEE

Re-appointment of Julie Jarman, Non-Executive Director

1. Introduction

1.1 ‘The NHS Foundation Trust Code of Governance’ sets out provisions for the re-appointment of Non-Executive Directors. The code requires that:

• B.7.a – All Non-Executive Directors should be submitted for re-appointment at regular intervals.

• B.7.1 – The Chair should confirm to the governors that following formal performance evaluation, the performance of the individual (Non-Executive Director) proposed for re- appointment continues to be effective and to demonstrate commitment to the role.

• B.7.4 – Non-Executive Directors, including the Chairperson, should be appointed by the Council of Governors for the specified terms subject to re-appointment thereafter at intervals of no more than three years.

1.2 This paper confirms the Trust’s procedure for the reappointment of Non-Executive Directors and proposes the re-appointment of one Non-Executive Director (Julie Jarman) whose current term of office ends on 31 July 2020.

2. Procedure for the Reappointment of Non-Executive Directors

2.1 It is the responsibility of the Nominations Committee of the Council of Governors to advise the Council of Governors in respect of the re-appointment of the Chair or any Non-Executive Director.

2.2 The procedure for the re-appointment of Non-Executive Directors (including the Chair) is as follows:

• Approaching the end of a Non-Executive Director’s initial term of office, the Nominations Committee of the Council of Governors will meet to consider re-appointment.

• Subject to a satisfactory appraisal, the incumbent Non-Executive Director wishing to continue for a further term, and no other contra-indications, the Committee will recommend the re- appointment to the Council of Governors.

• At the end of two consecutive terms, the Nominations Committee will meet to consider the following:

o The balance of skills, knowledge, experience and diversity on the Board of Directors o The significant challenges and opportunities facing the Trust o The strategic context and any external pressures o The willingness of the incumbent Non-Executive Director to continue in post (subject to annual re-appointment thereafter) o The continued independence of the Non-Executive Director and compliance with the Fit and Proper Person requirements

Following this, the Nominations Committee will recommend to the Council of Governors either the re-appointment of the incumbent Non-Executive Director or the requirement for a new appointment to attract new/different skills and expertise. Where a new appointment is recommended, the Committee will lead the recruitment process.

3. Reappointment of Julie Jarman, Non-Executive Director

3.1 Julie Jarman chaired the Board of Directors’ Quality Improvement Committee (QIC) prior to its suspension in March 2020 as part of the Trust’s COVID-19 response. Since May 2020, Julie Jarman has chaired the new COVID-19 Board Assurance Committee (BAC). (The aim of the COVID-19 BAC is to provide the Board with assurance on the monitoring of safety, quality, risk, financial and contracting arrangements during the current crisis.) Julie Jarman is also a long- standing member of the Board’s Charitable Funds Committee (since 2017) and is the designated Non-Executive Director for Hospital Managers and oversight of the Mental Health Act, Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS).

Performance Evaluation

3.2 This year’s programme of Non-Executive Director appraisals, which were due to take place during Quarter 1 2020/21, have been temporarily suspended to release capacity to support the Trust’s COVID-19 response. The Chair has, however, completed an interim appraisal of Julie Jarman’s performance during 2019/20 to support and inform the re-appointment process. The interim appraisal included a self-assessment, feedback from peers (though more limited than the full process) and a virtual appraisal discussion in mid-June 2020 focused on past year performance and current year objectives.

3.3 The Chair’s summary of Julie’s performance during 2019/20 is as follows:

Julie continues to demonstrate her 100% commitment to service users and carers through her contributions to discussion at Board, her dedicated leadership of the Quality Improvement Committee (QIC), her role as lead NED for Mental Health Act (MHA)/Deprivation of Liberty Safeguards (DoLS), working to refocus the work of Hospital Managers and her membership of the Charitable Funds Committee.

Working closely with executive and non-executive colleagues, Julie has created, at some pace, a culture within the QIC where colleagues are focussed on delivering a quality improvement strategy whilst maintaining the committee’s effective quality and safety assurance role. By involving members of the committee in a workshop to reflect upon its role, the committee adopted new ways of working and clarified its role and appropriate membership. Julie has stepped up to chair the COVID-19 Board Assurance Committee, which has assumed a much wider responsibility for assurance and governance during this crisis. By introducing a peer appraisal process and supporting the MHA team in providing training Julie has ensured an improvement in the quality and consistency of process and outcomes of the important work of Hospital Managers. This is evidenced by the rapid move to holding remote hearings when COVID-19 made face-to-face meetings impossible so that our service users continue to get timely and effective service. Julie is also a member of the Advisory Committee on Clinical Excellence Awards panel and the NED member of Concerns.

Feedback confirms that Julie has a good and collaborative working relationship with colleagues and is “a great team player, making significant contribution. A ‘can do’ attitude” and “thoughtful and have the service users’ best interests at the heart of things”.

I assess Julie’s performance as outstanding making a critically important contribution to the work of the Board.

Term of Office

3.4 The Code of Governance and the Trust’s Constitution state that a Non-Executive Director should not hold office for more than six years (or two consecutive three-year terms). Non- Executive Directors may in exceptional circumstances serve longer than six years but this should be subject to rigorous review and annual re-appointment.

3.5 Julie Jarman’s initial term of office commenced on 1 August 2014. At the end of July 2020, Julie will have completed two consecutive three-year terms.

3.6 Julie Jarman has confirmed her wish to continue as a Non-Executive Director on the Trust’s Board of Directors. To retain Julie’s experience and expertise in relation to quality improvement, the Mental Health Act and the VCSE (Voluntary, Community and Social Enterprise) sector - and maintain stability on the Board during the Trust’s continued response to COVID-19 - it is recommended that Julie Jarman is re-appointed for a further one-year term. The option to extend this term at the end of the twelve-month period will be retained and subject to assessment of the strategic context, Board composition and opportunities and challenges facing the Trust at that point.

Remuneration

3.7 As previously discussed with the Nominations Committee, NHS England and NHS Improvement (NHS E and I) published a new remuneration framework for NHS provider chairs and non-executive directors in September 2019. The framework attempts to address the disparity between the remuneration of chairs and non-executive directors of NHS trusts and those of NHS foundation trusts by introducing a standard pay structure.

3.8 For Non-Executive Directors, the framework introduces a single uniform rate of £13,000 (with local discretion to award supplementary payments of up to £2,000 per annum in recognition of extra responsibilities). This compares to the Trust’s current basic remuneration of £13,160 and enhanced rate of £16,465. Julie Jarman receives the enhanced rate for her role as Chair of the Quality Improvement Committee / COVID-19 Board Assurance Committee.

3.9 The national framework sets an expectation that NHS foundation trusts will comply with the new rates for new appointments and re-appointments. The framework does, however, also recognise foundation trusts’ discretion to set remuneration rates locally via the Council of Governors. Where foundation trusts choose to operate outside of the framework, this should be on a ‘comply or explain’ basis. Foundation trusts’ adoption of the new framework was under discussion nationally prior to the onset of COVID-19. These discussions have not, however, progressed significantly during the crisis response.

3.10 Nominations Committee members welcomed the opportunity to ‘comply’ with the remuneration framework, or otherwise ‘explain’ non-compliance, when the development was discussed in October 2019. To maintain consistency across the Trust’s Non-Executive Directors, and avoid ‘rewarding’ Julie Jarman’s ‘Outstanding’ performance with a reduction in pay, it is recommended that no change (other than cost of living uplifts) is made to Julie Jarman’s current level of remuneration for the next twelve months i.e. to not adopt the new national rate.

3.11 Adoption of the new national framework will be considered again for future new appointments and re-appointments. At which point the approach being taken by Foundation Trust peers is expected to be clearer.

4 Recommendation

4.1 In line with the procedure for the re-appointment of Non-Executive Directors, the Nominations Committee are invited to recommend to the Council of Governors the re- appointment of Julie Jarman for a further one-year term (effective from 1 August 2020) with no change to the current level of remuneration.

Council of Governors Nominations Committee Notes of Meeting held 30 June 2020 at 2.00pm via Microsoft Teams

Title of Meeting Nominations Committee

Chair Rupert Nichols, Chair

Members Angela Beadsworth, Public Governor (Other England and Wales) Maureen Burke, Lead Governor / Public Governor (Salford) Nathan Prescott, Service User and Carer Governor Dan Stears, Service User and Carer Governor

Attendees Kim Saville, Company Secretary

1. Apologies for Stuart Edmondson, Staff Governor (Nursing) Absence Iris Nickson, Public Governor (Trafford) Margaret Willis, Service User & Carer Governor 2. Declarations of Dan Stears, Service User and Carer Governor declared an interest in agenda item Interest in Agenda 4 (Re-appointment of Julie Jarman, Non-Executive Director). Both Dan Stears Items and Julie Jarman are Trustees of Mind in Salford.

3. Minutes of the The Minutes of the Previous Meeting held 29 October 2019 were approved as a Previous Meeting true and correct record. held 29 October 2019 4. Re-appointment of Rupert Nichols, Chair reminded governors of their statutory duty to appoint and Julie Jarman, Non- re-appoint non-executive directors and outlined the Trust’s re-appointment Executive Director procedure. He advised that Julie Jarman, Non-Executive Director will have served six years (two consecutive terms) on the Board of Directors as at 31 July 2020 and summarised the proposal to re-appoint Julie Jarman for a further 12 months effective from 1 August 2020. He advised that any decision to extend a non-executive’s director term beyond six years should be an annual re- appointment only, subject to rigorous review and consider the non-executive director’s continued independence.

Rupert Nichols summarised the rationale for re-appointing Julie Jarman for a further twelve-month term, based on her performance over the last year, her dynamic leadership of the Quality Improvement Committee and her role in relation to Hospital Management and Mental Health Act compliance. He advised that Julie has also recently grasped the opportunity to chair the Trust’s new,

temporary COVID-19 Board Assurance Committee. He drew the Nominations Committee’s attention to the outcomes of his recent appraisal of Julie Jarman’s performance and advised that he had assessed Julie’s performance as ‘Outstanding’.

Committee members shared their positive experiences of interacting and working with Julie Jarman. Dan Stears, Service User and Carer Governor expressed the view that Julie ‘stands for’ service users and carers in everything she does and Maureen Burke, Lead Governor commended Julie Jarman’s leadership skills and focus, having observed a meeting of the Quality Improvement Committee. All governors supported the proposal to recommend the re-appointment of Julie Jarman for a further twelve-month term.

Rupert Nichols advised that governors also needed to consider remuneration in Julie Jarman’s re-appointment, following the publication of a national remunerational framework for NHS provider chairs and non-executive directors in September 2019. He briefed governors on the new national rates and confirmed that, as a foundation trust, the Trust has the option to comply or explain. Governors supported the proposal to not comply with the new national rate to maintain consistency across the Board and given Julie Jarman’s positive performance.

The Nominations Committee agreed to recommend to the Council of Governors the re-appointment of Julie Jarman for a further one-year term (effective from 1 August 2020) with no change to the current level of remuneration. 5. Any Other Business There were no items of other business.

6. Date & Time of Next To be confirmed. Meeting

Council of Governors

TITLE OF REPORT: Committee and Working Group Membership DATE OF MEETING: Monday 13 July 2020 AGENDA ITEM: 13 PRESENTED BY: Rupert Nichols, Chair AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: The following paper sets out the duties of the Council of Governors’ Nominations Committee and Membership Engagement Working Group and seeks expressions of interest from governors in contributing to the work of these groups.

RECOMMENDATIONS: Governors are invited to:

• Note and express interest in the opportunity to become a member of the Council of Governors’ Nominations Committee and Membership Engagement Working Group • Delegate authority to the Chair to approve any changes to the membership of the Nominations Committee

Committee and Working Group Membership

1. Introduction

1.1 This paper seeks expressions of interest from governors in contributing to the work of the Council of Governors’ Nominations Committee and the Membership Engagement Working Group. Expressions of interest are, in particular, welcomed from newly elected governors who may be able to bring fresh thinking and new ideas.

2. Nominations Committee:

2.1 The Nominations Committee is chaired by Rupert Nichols, Chair, except where a conflict of interest arises. The Committee’s main responsibilities include:

• Identifying and nominating suitable candidates for all Non-Executive Director positions (including the Chair) on the Board of Directors, for appointment by the Council of Governors; and • Making recommendations to the Council of Governors with regard to the remuneration and other terms and conditions of services of the Chair and other Non-Executive Directors.

2.2 As per the Committee’s Terms of Reference, membership of the Committee shall consist of a minimum of three elected Governors, one of whom shall be the Lead Governor.

2.3 Current governor membership of the Nominations Committee is as follows:

• Maureen Burke, Public Governor (Salford) / Lead Governor • Angela Beadsworth, Public Governor (Other England and Wales) • Iris Nickson, Public Governor (Trafford) • Nathan Prescott, Service User and Carer Governor • Dan Stears, Service User and Carer Governor • Margaret Willis, Service User and Carer Governor • Stuart Edmondson, Staff Governor (Nursing)

2.4 Though the Committee is currently well-resourced in terms of members and operating effectively, expressions of interest are welcomed from any other/new governors who feel they have a particular skill set or perspective to bring. Expressions of interest should be shared at the full Council of Governors meeting on 13 July 2020 or sent via email to Kim Saville, Company Secretary ([email protected]).

2.5 With the Council of Governors’ approval, and on the basis of the Committee being a formal Committee of the Council of Governors, the Chair will approve any new members of the Nominations Committee on behalf of the Council of Governors.

3 Membership Engagement Working Group

3.1 The Council of Governors’ Membership Engagement Working Group is responsible for leading the development, implementation and review of the Trust’s Membership Engagement Strategy. Key priorities for the Working Group include:

• Membership Community – upholding the membership community, addressing natural attrition and any shortcomings in the membership profile • Membership Engagement – developing and implementing best practice engagement methods • Governor Development – supporting the developing and evolving role of Governors

3.2 As per the Working Group’s Terms of Reference, the Working Group will comprise representatives from each of the Trust’s elected constituencies, with a quorum being three governors in attendance. The Working Group is currently chaired by one of the Trust’s Service User and Carer Governors (Dan Stears) and includes the Lead Governor within its membership as Vice Chair.

3.3 The Membership Engagement Working Group is relatively well-established with seven/eight governors regularly attending meetings prior to COVID-19. Expressions of interest are, however, sought from newly elected governors in particular who are interested in supporting the Trust to progress this agenda. Expressions of interest should be shared at the full Council of Governors meeting on 13 July 2020 or sent via email to Steph Neville, Head of Corporate Affairs ([email protected]).

4 Recommendations

4.1 Governors are invited to:

• Note and express interest in the opportunity to become a member of the Council of Governors’ Nominations Committee or Membership Engagement Working Group. • Delegate authority to the Chair to approve any changes to the membership of the Nominations Committee.

Council of Governors

TITLE OF REPORT: Board of Directors: • Ratified Minutes of the Board of Directors Meeting Held in Public on 21 May 2020 • Chair’s Report on Part 2 Items • Governor Feedback on Board of Directors Meetings DATE OF MEETING: Monday 13 July 2020 AGENDA ITEM: 14.01 – 14.03 PRESENTED BY: Rupert Nichols, Chair AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: Under the Health and Social Care Act 2012, the Board of Directors is required to share a copy of the minutes of a meeting of the Board of Directors with the Council of Governors as soon as is practicable after a meeting.

The most recent ratified minutes, provided here, contain a summary of the Board discussion on each agenda item and a record of any agreed actions. They include evidence of questioning and challenge from the Non-Executive Directors, which is one way in which the Non-Executive Directors hold the Executive Directors to account for performance and delivery of strategy. Minutes of previous Board of Directors meetings are available via the Trust’s website.

The minutes are presented to the Council of Governors for information. The Chair will provide a verbal report on items discussed recently under the private part (Part 2) of the Board agenda.

RECOMMENDATIONS: The Council of Governors are invited to note the ratified minutes of the Board of Directors meeting held in public (via Microsoft Teams) on 21 May 2020 and the Chair’s verbal report on items discussed recently in the private part (Part 2) of the Board meeting.

Governors who have taken the opportunity to observe recent Board meetings are invited to share their views and experience with the wider Council of Governors.

RATIFIED

IN PUBLIC BOARD OF DIRECTORS MEETING – THURSDAY 21 MAY 2020 AT 1.00PM VIA MICROSOFT TEAMS

PRESENT:

Board of Directors:

Rupert Nichols - Chair Anthony Bell - Non-Executive Director Liz Calder - Director of Performance and Strategic Development Helen Dabbs - Non-Executive Director Stephen Dalton - Non-Executive Director (via Skype) Gill Green - Director of Nursing & Governance Andrea Harrison - Non-Executive Director Julie Jarman - Non-Executive Director Pauleen Lane - Non-Executive Director Andrew Maloney - Director of HR and Deputy CEO Deborah Partington - Director of Operations Alice Seabourne - Medical Director Janine Taylor - Acting Director of Finance Neil Thwaite - Chief Executive

IN ATTENDANCE:

Les Allen - Public Governor (Bolton) Avril Clarke - Service User and Carer Governor Terry Corbett - Public Governor (City of Manchester) Sharon Mason - Public Governor (Other England and Wales) Lesley O’Neill - Staff Governor (Nursing) Arif Patel - Staff Governor (Non-Clinical) Diomidis Psomas - Staff Governor (Psychological Therapies) Kim Saville - Company Secretary (Minutes) Dan Stears - Service User and Carer Governor

No. Item Action 104/20 Welcome and Introduction Noted

Rupert Nichols, Chair thanked those governors in attendance for joining the meeting. He established the ground rules, noting that governors would have the opportunity to ask questions at the end of Part 1. 1

No. Item Action 105/20 Apologies for Absence Noted

There were no apologies for absence. 106/20 Declarations of Interest Noted

There were no declarations of interest in agenda items. 107/20 Extract from the Minutes of the Board of Directors Meeting held 30 March 2020 Approved

The extract from the minutes of the Board of Directors meeting held in private on 30 March 2020, in light of the COVID-19 pandemic, were agreed as a true and correct record. The minutes evidenced discussion of the papers that would normally have been considered in the ‘in public’ part of the Board of Directors meeting. 108/20 Matters Arising and Action Log Noted

The Board of Directors reviewed the action log, noting the progress made and the in progress items of work. Kim Saville, Company Secretary advised that the action log updates reflect the impact of COVID-19. In response to a question from Andrea Harrison, Non-Executive Director regarding digital strategy progress reports, Kim Saville clarified that implementation of the new strategic performance management framework has been deferred during COVID-19 and will be revisited during Quarter 2 2020/21. The new framework was planned to include progress reports to Board against the individual strategic objectives and associated strategies as well as over-arching six-monthly updates. Updates on digital developments will be incorporated into the monthly COVID-19 Oversight Report in the interim.

With regard to the action arising from minute 179/19, Neil Thwaite, Chief Executive, advised that options for a virtual Board development session focused on equality, diversity and inclusion are being explored to coincide with the date of the next Board meeting. He reflected on the importance of this session in the current context. 109/20 Chair and Chief Executive’s Report Noted

Rupert Nichols, Chair noted that all Board members have been kept up to date on the local, regional and national position via the daily briefings, the weekly Non-Executive Director call and other ad hoc sharing of information.

Neil Thwaite advised that Janine Taylor, Acting Director of Finance is revising the Trust’s financial plan for 2020/21 to reflect the new COVID-19 financial regime and the associated risks and opportunities. A revised financial plan will be shared Action: JT at the Board of Directors meeting in June 2020. 110/20 COVID-19 Briefing – Oversight Report May 2020 Noted

Neil Thwaite summarised the key headlines from the COVID-19 Oversight Report, an earlier iteration of which had been discussed by the COVID-19 Board 2

No. Item Action Assurance Committee. Neil Thwaite drew the Board’s attention to the updates provided in relation to daily national and local Situation Reporting (SitReps), Personal Protective Equipment (PPE), oxygen supply and equipment, testing, research and innovation, the 24/7 helpline for all service users and carers and the ongoing work with the Trust’s BAME (Black, Asian and Minority Ethnic Network). Board members acknowledged the significant number of changes made to services during a short period of time.

Neil Thwaite also outlined the guidance issued in a letter from Simon Stevens and Amanda Pritchard on 29 April 2020 regarding the next steps and action needed in the second phase of the NHS response to COVID-19. He summarised the eight high priority actions for mental health providers during the second phase and the action taken to date in terms of each (as per Appendix 2 of the paper).

The Board discussed the following in detail:

• Capacity planning – Neil Thwaite briefed the Board on the Phase 2 bed- based capacity planning exercise underway at a regional level, which is being co-ordinated through the GM COVID-19 Hospital Cell, Out of Hospital Cell and Gold Command arrangements. He advised that the capacity planning work is focused on opportunities to reduce Delayed Transfers of Care (DTOCs), flexible use of independent sector capacity and robust financial planning from both a revenue and capital perspective. The outcomes of this exercise will be shared with the Board of Directors in June 2020. The Board reviewed the outcomes of the Trust’s review of current levels of demand for urgent/acute services, which has informed the capacity planning. Neil Thwaite advised that the Trust is currently planning on the basis of 80% occupancy for single room inpatient areas, and 50% occupancy for dormitory accommodation, from an infection prevention and control perspective. This is based on guidance received from the NHS England and NHS Improvement (NHSEI) Regional Team, which may be subject to change. The Board discussed the potential implications of this, taking account of the expected increase in demand for services. Neil Thwaite advised that a further capacity planning exercise, focused on Phase 3 and also covering community services, is scheduled to complete in late June 2020.

• Capital – Neil Thwaite advised that an expectation has been placed on providers to reduce their current capital investment programmes to support a 42% reduction at a Greater Manchester level. Providers do, however, have opportunity to bid for COVID-19 related capital investment. The Trust is working up capital proposals to strengthen the temporary arrangements put in place for delivery of mental health urgent care centres during COVID and also improve the environment at North Manchester.

No. Item Action • Recovery Planning – Neil Thwaite advised that the Trust has established a new Recovery Planning Group, operating alongside Gold Command, to co-ordinate the Trust’s recovery plan. An overview of the priority areas of work and how these are being progressed will be provided in the June Oversight Report to Board.

Stephen Dalton, Non-Executive Director highlighted the significant number of staff working from home and sought understanding of the Trust’s current thinking in terms of a return to normal working environments. Neil Thwaite outlined the pressures social distancing requirements place on work space capacity and the opportunity to think more flexibly about working arrangements going forward. Andrew Maloney, Deputy Chief Executive and Director of Human Resources confirmed that the current message remains that if staff can work from home they should work from home. He advised that a Task and Finish Group has been established to review and take action on the recently published government guidance on working safely during COVID-19. A survey has also been issued to all staff working from home to understand people’s experiences, their views on home working and any adaptations or support required. Andrew Maloney confirmed that risk assessments are being completed as a priority with home workers in high risk groups to establish plans for the medium and longer term. He also recognised the need to factor clinical priorities in workplace assessment and workforce planning, as well as digital/IT support, and confirmed that these workstreams will be aligned through the Recovery Planning Group.

Anthony Bell, Non-Executive Director, sought further information on the current levels of COVID-19 related sickness absence including how these compare to the regional and national picture. Andrew Maloney advised the reported COVID- related sickness figure represents the number of staff tested and confirmed positive. He advised that, in addition, there is a high number of staff self-isolating with suspected symptoms. The Trust’s current position is broadly in line with other Greater Manchester providers. In response to a further question, Andrew Maloney confirmed that early data analysis shows a disproportionate number of BAME staff self-isolating due to COVID-19 symptoms and in high risk groups. He noted that it is not clear currently whether this has translated into higher numbers of COVID-19 positive test results.

Referencing the information provided on COVID-19 testing, Pauleen Lane, Non- Executive Director questioned whether testing is widely enough available and the impact of delays in turnaround times. Alice Seabourne, Medical Director provided assurance that the Trust is monitoring turnaround times closely. Andrew Maloney that the Trust has facilitated 400 staff to access testing to date, which equates to approximately 8% of the workforce. He added that the actual number is likely to be higher as staff have been able to self-refer via the government portal. He provided assurance that the Trust has sufficient testing capacity in place to meet current need and that work is underway to review how mass testing and testing of asymptomatic staff will be enabled.

No. Item Action

Anthony Bell noted the changes made to the delivery of healthcare support in prisons and sought further understanding of the impact of COVID-19 on day to day service delivery in these environments. Deborah Partington, Director of Operations advised that activity has been pared back in accordance with individual prison’s lockdown arrangements. She noted that staff have responded well to the new regime and have taken opportunity to introduce changes, such as telemedicine, which the Trust hopes to retain post-COVID. Discussions are underway with NHS EI on this issue. Neil Thwaite reminded Board members that health and justice services previously provided by Bridgewater transferred successfully to the Trust on 1 April 2020 and that the Trust has also taken over provision of all healthcare services in HMPs Garth and Wymott from that date. He advised that, in this context, he has written to the Trust’s health and justice staff, thanking them for their efforts during this particularly challenging time.

Helen Dabbs, Non-Executive Director requested the inclusion of information of the Trust’s enhanced support offer for BAME service users and communities in Action: GG the next COVID-19 Oversight Report.

The Board of Directors noted the Trust’s comprehensive work and planning response to COVID-19 to date and the priorities going forward.

COVID-19 Board Assurance Committee Terms of Reference: Ratified

The Board of Directors reviewed and ratified the Terms of Reference for the COVID-19 Board Assurance Committee. 111/20 COVID-19 Board Assurance Committee Chair’s Assurance Report on the Noted Meeting held 14 May 2020

Julie Jarman, Non-Executive Director and Chair of the COVID-19 Board Assurance Committee briefed the Board of Directors on the key matters considered at the first meeting of the COVID-19 Board Assurance Committee on 14 May 2020. She advised that the meeting provided a helpful opportunity to probe and ask questions on the COVID-19 Oversight Report, the Quarter 4 Quality Report and the most recent mortality data. She confirmed that the next meeting will include focus on recovery and capacity planning.

Referencing the scope of the Committee’s duties, Julie Jarman advised that the Terms of Reference and Committee effectiveness will be reviewed every three months.

At Julie Jarman’s request, Alice Seabourne briefed the Board on the decision taken by the Trust to facilitate friend and family visits to individuals on end of life care pathways. She advised that this has been one of a number of ethical issues considered by the Clinical Ethics Group, as constituted with Pennine Care NHS Foundation Trust early in the crisis. 5

No. Item Action

The Board of Directors noted the Committee Chair’s Assurance Report on the first meeting of the COVID-19 Board Assurance Committee held on 14 May 2020. 112/20 GMMH Learning from Deaths - Quarter 4 2019/20 Noted

Alice Seabourne presented the Quarter 4 2019/20 Learning from Deaths Dashboard. She advised that the report demonstrates no significant change in the number of inpatient or community deaths when compared to the same period in 2018/19S. She also advised that COVID-19 did not impact on the number of inpatient deaths during the reporting period and, although the prevalence of COVID-19 was increasing in the community at the end of the financial year, there is no evident impact on numbers of community deaths. Board members recognised that the impact of COVID-19 will be manifest in the next quarterly report and in the monthly mortality reports to the COVID1-9 Board Assurance Committee.

Alice Seabourne advised that the number of deaths in substance misuse services remains relatively high and management are continuing to maintain oversight of this. She noted that some of the reported differences in mortality rates at a divisional level, when compared to the 2018/19 position, can be attributed to service or structural changes.

Alice Seabourne confirmed that she has discussed changes to the format of the Learning from Deaths report with Helen Dabbs, Non-Executive Director. Due to capacity limitations during COVID-19, action on this will be deferred to a future date.

The Board of Directors noted the Learning from Deaths Report for Quarter 4 2019/20. 113/20 Self-Certification on Compliance with the Requirements of the NHS Provider Approved Licence

Neil Thwaite presented the summary of evidence to support the Trust’s self- certification against Conditions G6, CoS7 and FT4 of the NHS Provider Licence. The Board of Directors reviewed the requirements of the individual Licence Conditions and confirmed:

• With regard to Condition G6 of the Provider Licence, that the Directors of the Licensee are satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS Acts and have had regard to the NHS Constitution

• With regard to Condition CoS7 that, after making reasonable enquiries, the Directors of the Licensee have a reasonable expectation that the Licensee will have the Required Resources available to it over the next 6

No. Item Action financial year (2020/21) after taking account of distributions which might reasonably be expected to be declared or paid

• With regard to Condition FT4 of the Provider Licence, compliance with the required governance arrangements

• Compliance with the requirements regarding training of governors 114/20 Board Performance Report (March 2020 Performance) Noted

Liz Calder, Director of Performance and Strategic Development presented the Board Performance Report on March 2020 performance. She advised that the Trust ended the year in a strong position. She highlighted the ‘Green’ rating against four of the five NHSI Oversight Framework indicators as at the end of Quarter 4 2019/20, including the improved position against the Operational Performance and Finance and Use of Resources metrics. She advised that the ‘Amber’ rating against the fifth indicator (Leadership and Improvement Capability) is unchanged as this metric is derived from the annual Staff Survey. She also drew the Board’s attention to the continued progress of the Trust’s IAPT service with both the 6- and 18-week Referral to Treatment (RTT) targets achieved at Trust-level in March 2020, with Salford meeting the 6-week target and only narrowly missing the 18-week target. All Board members acknowledged this significant achievement. Liz Calder advised that the recovery target, which is a CCG target to which all providers in the pathway contribute, remains a challenge.

Liz Calder highlighted the continued strong performance of the Trust’s early intervention in psychosis services in Month 12 2019/20 and the achievement of the OAPs (Out of Area Placements) reduction target at year-end. The Trust delivered an 86% reduction on 2017/18 OAPs bed nights compared to a 66% target. Liz Calder noted that the Care Programme Approach (CPA) 7-day follow up target was narrowly missed in month and for Quarter 4, with the position impacted by the opening of Birch Ward and the inclusion of admissions from Pennine Care. If these admissions had been excluded from the data, the Trust would have achieved the 95% target.

Liz Calder advised that the Trust total expenditure on agency staffing was £11.62million at year-end, which represents a favourable variance when compared to the agency cap of £11.64million.

Liz Calder confirmed that the new format Board report will be introduced from the June 2020 Board of Directors meeting.

With reference to the Service User Friends and Family Test results for February 2020, Rupert Nichols noted that the proportion who would recommend our services to friends and family is higher than that reported (79.6% rather than 76.9%). 7

No. Item Action

Neil Thwaite welcomed the strong year-end performance. He advised that the upcoming virtual Senior Leaders meeting on 27 May 2020 will provide opportunity to thank staff, on the Board’s behalf, for their hard work and achievements in 2019/20.

The Board of Directors noted the Board Performance Report (March 2020 performance). 115/20 Board Performance Report (Quality) – Quarter 4 2019/20 Noted

Gill Green presented the Board Performance Report (Quality) for Quarter 4 2019/20, which was also reviewed by the COVID-19 Board Assurance Committee on 14 May 2020. She advised that the use of Statistical Process Control (SPC) charts has continued to increase and be refined to support understanding of performance variation over time.

Gill Green confirmed that performance against the key quality indicators has remained relatively steady during Quarter 4 2019/20, with minimal impact from COVID-19 on quality performance at year-end. She noted that a number of national data collections, including the Friends and Family Test and the Mental Health Safety Thermometer, have been suspended as part of the COVID-19 response.

Gill Green briefed the Board on a number of key headlines from the report. She advised that the Trust achieved the 80% target for the uptake of seasonal flu vaccinations by February 2020 and is now planning its flu vaccination programme for the coming winter in the context of COVID-19. She highlighted the Trust-wide increase in violence and aggression over recent months, providing assurance that further work is underway to explore the correlating factors. She advised that initial analysis indicates that an increase in acuity of a small number of services users on several wards, including two PICUs, may have impacted on the position.

Gill Green confirmed that she is working with Liz Calder to refine the Board Quality Report in the context of the new format Board Performance Report.

The Board of Directors noted the Board Performance Report (Quality) for Quarter 4 2019/20. 116/20 Guardian of Safe Working Report – Nov. 2019 to Jan. 2020 Noted

The Board of Directors noted the Guardian of Safe Working Hours report for the period November 2019 to January 2020. Alice Seabourne briefed the Board on the changes to the junior doctor contract during the period, advising that a number of rotas are being reviewed in light of this. She provided assurance that all on-call shifts were covered during the period despite junior doctor vacancies at all levels. 117/20 Audit Committee: Noted 8

No. Item Action

• Minutes of the Meeting held 17 February 2020 (Ratified) • Committee Chair’s Assurance Report on the Meeting held 27 April 2020

The Board of Directors noted the minutes of the Audit Committee meeting held on 17 February 2020 and the Committee Chair’s Assurance Report on the meeting held 27 April 2020. Andrea Harrison highlighted the receipt of a ‘Substantial’ Head of Internal Audit Opinion on the Trust’s system of internal control during 2019/20. She advised that the deferment of a number of audits at the end of Quarter 4, due to COVID-19, did not impact on the evidence available to support the Head of Internal Audit Opinion. She confirmed that the Audit Committee reviewed the pre-audit Annual Report and Accounts 2019/20, noting that the review was enabled by a helpful commentary from the Finance Team. She noted the receipt of KPMG’s final audit opinion has been deferred to June 2020 in line with the revised year-end arrangements under COVID-19. An extraordinary meeting of the Audit Committee has been convened for 22 June 2020 to approve the post-audit Annual Report and Accounts on the Board’s behalf. 118/20 Any Other Business Noted

There were no items of other business. 119/20 Questions from the Public Noted

There were no questions or comments from the public. 120/20 Date and Time of Next Meeting Noted

The next Board of Directors meeting in public will take place on Monday 29 June 2020 at 1.00pm via Microsoft Teams. 121/20 Resolution Adopted

The Board of Directors adopted the resolution ‘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’.

Certified as a true record of the meeting

………………………………………………………… …………………………………………………………… Chair – Rupert Nichols Date

Action Log – Part 1

The following action log has been updated to reflect any progress reported and actions agreed by the Board on 21 May 2020. Where COVID-19 has impacted on the ability to progress actions agreed prior to the pandemic this is noted. Actions will be deferred to either a new date (identified below) or date to be agreed. A record of deferred actions will be retained by the Company Secretary.

Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion Feb-19 47/19 Matters Arising Review of workforce data presented in 20/05/19 29/06/20 Andrew Outcomes of review of and Action Log Board Performance Report to be Maloney, workforce data reflected completed by Workforce Strategy Director of HR in new format Programme Board and Deputy CEO Performance Report to Board from June 2020 June-19 179/19 Annual Equality Neil Thwaite and Gill Green to discuss 30/09/19 29/06/20 Neil Thwaite, Remote development and Diversity options for external support in Chief Executive session on equality and Report progressing the Trust’s equality, and Gill Green, diversity scheduled for diversity and inclusion agenda, including Director of 29/06/20 as part of the Board’s Development Nursing and Programme. Governance July-19 214/19 Infection Gill Green to include more comparative 27/07/20 29/06/20 Gill Green, Brought forward and on Prevention and data against the previous year’s Director of agenda for June 2020 Control Annual performance in future reports. Nursing and Report 2018/19 Governance July-19 215/19 Customer Care Gill Green to provide a more detailed 27/07/20 Gill Green, Development of Annual Report breakdown of complaints data in future Director of Customer Care Annual 2018/19 reports (by level and location) Nursing and Report 2019/20 on track Governance for review in July 2020. To be reviewed by the

Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion new COVID-19 Board Assurance Committee in advance of Board. July-19 216/19 Learning from Helen Dabbs to advise on how best to 28/10/19 Defer Alice Seabourne, Limited capacity to revise Deaths – Quarterly include data on variations outside of the Medical Director Mortality Review Mortality Review expected range and time series analyses and Helen Dashboard to address Dashboard in future reports Dabbs, Non- previous Board Executive recommendations during Director COVID-19. Separate monthly report on COVID-19 deaths prepared from April 2020 for review by the COVID- 19 Board Assurance Committee. Nov-19 315/19 Matters Arising Ismail Hafeji to provide an update on the 27/01/20 28/09/20 Janine Taylor, Planned progress and Action Log Digital Strategy following discussion at Acting Director reporting against new October’s Board meeting of Finance strategic performance framework deferred during COVID-19. Six- monthly progress reports to Board on all objectives and enabling strategies (including digital) to commence from Sept. 2020. Updates on digital

Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion development also included in COVID-19 Oversight Reports. Nov-19 319/19 Workforce and Reconciliation against the original NHS 21/05/2020 28/09/2020 Andrew Deferred until September Organisational Professionals business case to be shared Maloney, 2020 in context of COVID- Development with the Board in May 2020 Director of HR / 19 Strategy Update Deputy CEO Nov-19 326/19 Freedom to Speak Benchmarking data on proportion of 21/05/20 29/06/20 Andrew Six-monthly FTSU report Up Guardian Six- concerns raised anonymously via the Maloney, on agenda for June 2020 Monthly Report FTSU Guardian to be sought Director of HR / Deputy CEO Jan-20 15/20 GMMH Learning Future reports to include information on 21/05/20 Defer Alice Seabourne, Limited capacity to revise from Deaths – Q3 lessons learnt and changes made to Medical Director Mortality Review 2019/20 clinical practice following reviews. Dashboard to address previous Board recommendations during COVID-19. Separate monthly report on COVID-19 deaths to be prepared from April 2020 for review by the COVID- 19 Board Assurance Committee. Feb-20 47/20 Board Feedback from the recent NHS 21/05/20 28/09/20 Andrew Planned progress Performance Improvement visit (Emma Wadey) to be Maloney, reporting against new Report (Dec. 2019) incorporated in the next Workforce Director of HR / strategic performance

Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion Strategy update to Board Deputy CEO framework deferred during COVID-19. Six- monthly progress reports to Board on all objectives and enabling strategies (including workforce) to commence from Sept. 2020. Feb-20 55/20 NHS Staff Survey Quality Improvement Committee to 14/05/20 Defer Andrew Quality Improvement 2019 receive and review performance against Maloney, Committee stood down Staff Survey quality of care questions Director of HR / during period of Deputy CEO operation of new COVID- 19 Board Assurance Committee. Only business critical items that would otherwise have been reviewed by the QIC to flow through to new COVID Committee. Mar-20 86/20 Board Assurance Controls identified for the Digital 29/06/20 Andrew On agenda for June 2020 Framework Strategy risk to be strengthened to Maloney, (March 2020) include learning from exemplars and Director of HR / new and emerging innovations Deputy CEO & Kim Saville, Company Secretary

Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion Jun-20 109/20 Chair and Chief Revised financial plan for 2020/21 to be 29/06/20 Janine Taylor, On agenda for June 2020. Executive’s Report shared at the Board of Directors meeting Acting Director Reviewed by COVID-19 in June 2020 of Finance Board Assurance Committee in advance Jun-20 110/20 COVID-19 Briefing Next Oversight Report to include 29/06/20 Gill Green, On agenda for June 2020. – Oversight Report information on the Trust’s enhanced Director of Reviewed by COVID-19 (May 2020) support offer for BAME service users Nursing and Board Assurance and communities during COVID-19 Governance Committee in advance

Not yet due Completed In progress Incomplete and overdue