(Meeting in Public) Monday 26Th September 2016 1.00Pm, Room 1 & 2, 1St Floor, the Curve

BOARD OF DIRECTORS (Meeting in Public) Monday 26th September 2016 1.00pm, Room 1 & 2, 1st Floor, The Curve

AGENDA – PART 1

ITEM ACTION PRESENTED BY TIME 01 Welcome and Apologies for Absence To Note Rupert Nichols, Chair 1.00pm 02 Service Presentation – Woodlands Centre: A To Note Lesley Jones 1.00pm Five Year Vision Advanced Practitioner Dementia Care

Gill Drummond Clinical Improvement Lead Nurse for Dementia, Older People and Carers Services

03 Declaration of Interests To Note 1.25pm 04 Minutes of the Previous Meeting held 25th To Approve Rupert Nichols, Chair 1.25pm July 2016 05 Matters Arising from the Previous Meeting To Note Rupert Nichols, Chair 06 Chair and Chief Executive Verbal Report To Note Rupert Nichols, Chair 1.30pm Bev Humphrey, Chief Executive

OPERATIONAL PERFORMANCE 07 Board Performance Report To Note Neil Thwaite, Deputy Chief 1.35pm Executive/Director of Development and Performance 08 NHS Improvement Q1 Feedback To Note Ismail Hafeji, Director of 1.45pm Finance, Capital and IM&T 09 Reporting Back, Looking Forward – To Note Neil Thwaite, Deputy Chief 1.50pm Summary Annual Report and Quality Executive/Director of Account for 2015/16 Development and Performance

GOVERNANCE AND QUALITY 10 Transaction and Transformation Committee – To Ratify Rupert Nichols, Chair 1.55pm Terms of Reference 11 Board Assurance Framework To Approve Andrew Maloney, Director of 2.00pm HR and Corporate Services 12 EPRR Core‐Standards Self‐Assessment To Note Andrew Maloney, Director of 2.15pm HR and Corporate Services 13 Quality Governance Committee: To Note Terry McDonnell, Non‐ 2.20pm Executive Director 13.1 – Minutes of the Meeting held 7th July 2016 (ratified) 13.2 ‐ Committee Chair’s Report of the Meeting held 1st September 2016 14 Minutes of the Charitable Funds Committee To Note Anthony Bell, Non‐Executive 2.25pm Meeting held 25th July 2016 (unratified) Director 15 Audit Committee Chair’s Report of Meeting To Note Malcolm Cowen, Non‐Executive 2.30pm held 5th September 2016 Director

HR AND ORGANISATIONAL DEVELOPMENT 16 Junior Doctor Industrial Action Autumn 2016 To Note Margaret Campbell, Acting 2.35pm Medical Director 17 Non‐Executive Director Appointments Process To Note Rupert Nichols, Chair 2.45pm Andrew Maloney, Director of HR and Corporate Services 18 Policy for the Reimbursement of Governor To Approve Rupert Nichols, Chair 2.55pm Expenses

ANY OTHER BUSINESS 19 Any Other Business To Note All 3.00pm

DATE AND TIME OF NEXT MEETING The next Board of Directors’ Meeting will take place on Thursday 13th October 2016 at 10.00am in Rooms 1 & 2, 1st Floor, The Curve

Board of Directors – Part 1

TITLE OF REPORT: Minutes of the Previous Meeting Held 25th July 2016 DATE OF MEETING: 26th September 2016 AGENDA ITEM: 04 PRESENTED BY: Rupert Nichols, Chair AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: The Board of Directors is asked to approve the minutes of the previous meeting held 25th July 2016.

LINKS TO OTHER KEY Minutes of the previous Board of Directors Meetings REPORTS/DECISIONS: LEGAL/REGULATORY IMPLICATIONS:

THIS REPORT SUPPORTS ACHIEVEMENT OF THE FOLLOWING CORPORATE OBJECTIVES: Objective 1 – Promote recovery by providing high x Objective 4 – Invest in our environments x quality care and delivering excellent outcomes Objective 2 – Work with service users and carers to x Objective 5 – Enable staff to reach their x achieve their goals potential and innovate Objective 3 – Engage in effective partnership x Objective 6 – Achieve financial strength and x working be well‐governed

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? No If ‘yes’: N/A DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: To Approve

UNRATIFIED

PUBLIC BOARD OF DIRECTORS MEETING, MONDAY 25th JULY 2016, 1.00 PM, CONFERENCE ROOM 7, GROUND FLOOR, THE CURVE

Present: Rupert Nichols ‐ Chair Anthony Bell ‐ Non‐Executive Director Malcolm Cowen ‐ Non‐Executive Director Kathy Doran ‐ Non‐Executive Director Gill Green ‐ Director of Nursing & Operations Ismail Hafeji ‐ Director of Finance, Capital and IM&T Bev Humphrey ‐ Chief Executive Julie Jarman ‐ Non‐Executive Director Andrew Maloney ‐ Director of HR & Corporate Services Terry McDonnell ‐ Non‐Executive Director Neil Thwaite ‐ Deputy Chief Executive/Director of Development & Performance

In Attendance: Chris Daly ‐ Deputy Clinical Director, Specialist Services Network and Medical Director w/e from 1st August 2016 Deborah Partington ‐ Interim Director of Manchester Services Kim Saville ‐ Company Secretary One member of the public

Action 162/16 Apologies for Absence Noted

Apologies for absence were received from Steve Colgan, Medical Director 163/16 Service Presentation – 7‐Day Community Care, Trafford Directorate Noted

The Board received a presentation on 7‐day community care from Emily Tuft, Team Manager, Trafford North CMHT and Donna Holt, Team Manager, Trafford South CMHT. Angela Thompson, Community Services Manager was in attendance during the presentation. Emily Tuft outlined the aims and objectives of the presentation and the background to the current 7‐day services which, following major redesign in 2014, are focused on community provision and prevention of referrals to home‐based treatment teams. She described how 7‐ day working operates in practice, including staffing, self‐rostering and management of ‘red zone’ clients.

In response to a query from Anthony Bell, Non‐Executive Director, Donna Holt summarised the out of hours support available and the crisis helpline. Donna

Holt also described the role of assertive outreach, describing the assertive outreach pathway as embedded in community mental health teams.

Emily Tuft outlined the benefits of 7‐day working. Kathy Doran, Non‐Executive Director, questioned whether there is evidence to show a reduction in A&E referrals to inpatient services and/or contacts with home‐based treatment teams (HBT) as a result of 7‐day community care. Bev Humphrey, Chief Executive, advised that the Trust completed an evaluation after 12 months, which demonstrated reduced contact with HBT. Inpatient admissions have also been analysed previously. Bev Humphrey reminded Board members that the Trust did not reduce bed numbers in Trafford as part of the acute care pathway redesign.

In response to a query from Neil Thwaite, Deputy Chief Executive/Director of Development and Performance, Donna Holt confirmed that CMHT care co‐ ordinators undertake weekly joint reviews with HBT teams to facilitate discharge back to CMHTs.

Emily Tuft concluded the presentation by highlighting a number of the challenges and lessons learned, and the positive feedback received from service users. The Board noted that service users felt more reassured and supportive and view services as more consistent. Neil Thwaite advised that the ‘raw’ community mental health survey results support these views. Kathy Doran questioned how staff felt about 7‐day working. Emily Tuft acknowledged some initial resistance but advised that self‐rostering and a shared understanding of the benefits has helped overcome this. She also described the role of social workers in response to a related query from Julie Jarman, Non‐Executive Director.

Rupert Nichols, Chair, thanked the presenters for an informative presentation. 164/16 Declaration of Interests

There were no declarations of interest. 165/16 Minutes of the Previous Meeting held 27th June 2016

The minutes of the previous meeting were accepted as a true record. 166/16 Matters Arising from the Previous Meeting

The Board considered the action log and confirmed that all matters arising had been actioned and/or were covered on the agenda. 167/16 Chair and Chief Executive Verbal Report Noted

Bev Humphrey thanked the Board for their additional support over the previous few weeks.

Rupert Nichols confirmed that, at their meeting on 5th July 2016, the Council of Governors approved the External Auditor Working Group recommendation to re‐ appoint KPMG as the Trust’s external auditors for a further 3 years with effect

from December 2016. 168/16 Board Performance Report Noted

Neil Thwaite presented the Performance Report for May 2016. He summarised the ‘quick view’ page, highlighting areas of positive performance and areas where further work is required. He also confirmed that actions agreed in the CQC action plan continue to be progressed and further updates will be brought to Board as required.

Neil Thwaite advised that the Trust has received the ‘raw’ results of the Community Mental Health Survey and the final report will be shared at the Action: NT September meeting of the Board of Directors.

With regard to Monitor’s Risk Assessment Framework, the Board noted that the Trust continues to be rated ‘green’ for governance and ‘4’ for finance. Neil Thwaite confirmed achievement of all Monitor mental health targets at May 2016 with the exception of IAPT, which is on track to be achieved by the end of Quarter 2. He also acknowledged the hard work of the Trust’s Early Intervention in Psychosis Teams in achieving the new 2‐week access target, referencing a recent HSJ analysis of EI performance.

Neil Thwaite drew the Board’s attention to the Trust‐wide sickness absence rate of 5.90% ‐ the lowest for nine months. He confirmed that management of sickness absence continues to be a challenge and the Board has previously received a more detailed paper on the management plan for this. Malcolm Cowen, Non‐Executive Director, highlighted Bolton’s positive performance and questioned whether learning could be shared. Andrew Maloney agreed, suggesting that recent staff engagement work in Bolton had likely impacted on sickness absence rates.

Andrew Maloney, Director of HR and Corporate Services, highlighted the staff Friends and Family feedback results for the last quarter of 2015/16. These demonstrate continuous improvement throughout the year, with 81% of staff recommending the Trust as a place to receive treatment and care.

Anthony Bell sought further information on the bed occupancy rates for Junction 17 and Gardener Unit. Neil Thwaite advised that the planned occupancy rates are as per the national block contract and that occupancy levels at adolescent forensic units are low across England. Gill Green, Director of Nursing and Operations, added that Gardener Unit has also been affected by the rapid change of Hindley from a young offender institute to a Category C prison. The Trust is now doing proactive in‐reach into Wetherby to establish a pathway into GMW.

Julie Jarman sought assurance on the significant differences in the proportionate use of seclusion and restraint at Recovery First and forensic mental health services (Edenfield). Gill Green outlined the work of the Trust‐wide ‘Positive and

Safe Group’ and advised that the differences relate to different service user profiles. Gill Green assured Board members that ‘positive and safe plans’ are in place, which ensure that if this level of care is required it is managed safely and reviewed regularly.

The Board noted the Performance Report. 169/16 Service User Engagement Strategy 2016 to 2019 Approved

Gill Green presented the Trust’s ‘Service User Engagement Strategy 2016 to 2019’ on behalf of the service users who have led its development. She described the approach taken in developing and designing the Strategy and accompanying leaflet, both of which are now ‘live’. The CARE Hub is responsible for monitoring the implementation of the Strategy, in particular the eight priority areas, with assurance provided up to Board via the Quality Governance Committee.

All members of the Board of Directors praised the Strategy. Kathy Doran sought further information on how the kite‐mark recognition scheme will work. Gill Green confirmed that teams led by service users will benchmarks services and award kite‐marks. She invited Board members to get involved. Kathy Doran suggested that services awarded ‘gold’ and ‘platinum’ be invited to present to Board.

Bev Humphrey asked that an email be sent via the CARE Hub, in the Chief Executive and Chair’s names, thanking all those involved in the development of Action: GG the Strategy and confirming the Board’s endorsement. Rupert Nichols also suggested that the kite‐mark scheme be shared with the HSJ once it is operational.

The Board noted the Service User Engagement Strategy. 170/16 Infection Prevention and Control Annual Report 2015/16 Noted

Gill Green presented the Infection Prevention and Control (IPC) Annual Report 2015/16, as previously been considered by the July meeting of the Quality Governance Committee. She confirmed that the Trust is currently meeting all requirements of the national Healthcare Associated Infections (HCAI) Assurance Framework and drew the Board’s attention to the key headlines of the Report, including:

 No major MRSA outbreaks in the last 12 months  Two cases of clostridium difficile during the reporting period – Gill Green confirmed that both cases had been reviewed  One outbreak of norovirus, which was managed with no direct impact on bed nights  Continuation of the link worker education and training programme  Continuation of the roll‐out of aseptic non touch technique (ANTT)

Gill Green summarised the outcomes of annual infection prevention and control audit. She confirmed that, overall, the audit demonstrated improvements compared to the previous year and advised that discussions are ongoing with Spectrum regarding their contractual obligation to manage the IPC audit action plan at HMP Styal.

Rupert Nichols challenged the 85% compliance threshold for the IPC audit. Gill Green advised that this threshold was set nationally with a local stretch target of 90% in place. In response to a further query, Gill Green also assured Board members that there were no concerns with regard to the Trust’s antimicrobial usage.

Chris Daly, Deputy Clinical Director, Specialist Services Network, sought information on actions to increase staff uptake of the influenza vaccination. Gill Green confirmed that the Trust’s approach has been bench‐marked against other local Trust and is comparable. In 2016/17, the number of nurses trained to administer the vaccine will increase to 50 and the Trust will record the numbers of individuals vaccinated at their GPs. Gil Green advised that it remained an individual decision, but confirmed that messages to staff emphasise the need to think of themselves and their service users. Neil Thwaite raised the 2016/17 CQUIN scheme relating to flu vaccine uptake, highlighting the target of 85% as a challenge. Bev Humphrey asked that further thought be given to the approaches taken to promote uptake. Board members suggested the encouragement of Action: GG ‘healthy competition’ between wards/services and the use of case studies.

The Board noted the activity and compliance for 2015/16.

171/16 Annual Complaints Report 2015/16 Noted

Gill Green presented the Annual Complaints Report, which has been prepared in accordance with the requirement of NHS statutory instrument 309 and considered at the July meeting of the Quality Governance Committee. Gill Green drew the Board’s attention to the Care Quality Commission’s assessment of the Trust’s approach to customer care. She advised that the total number of complaints decreased in 2015/16, with more complaints being resolved at a lower level.

Gill Green outlined the approach to learning from complaints and enabling this learning to be shared across the organisation. She confirmed that complaints action plans are monitored and followed‐up by the central Customer Care Team.

Anthony Bell questioned whether the Trust could do more to promote feedback, based on the number of complaints received per annum. Gill Green assured the Board that the Customer Care Team works closely with local services and that all understand the difference between complaints and queries.

Rupert Nichols drew the Board’s attention to the number of compliments received, particularly in substance misuse services. Bev Humphrey confirmed that this reflected the high level of service user engagement in those services.

The Board noted the Report. 172/16 Quality Governance Committee – Committee Chair’s Report and Minutes of the Noted Meeting held 5th May 2016

Terry McDonnell, Non‐Executive Director, presented the Committee Chair’s Report on the meeting held on 5th May 2016 and the associated minutes. He highlighted the key developments, including the review of the draft Quality Account 2015/16 and the receipt of the Annual Equality Report. He also drew the Board’s attention to identified risks and agreed actions, namely a legal clarification received in relation to DOLS, which will be circulated to all consultants, and the requirement to review the Trust’s Rapid Tranquilisation Policy.

Terry McDonnell also provided a verbal update on the meeting held on 7th July 2016. This meeting received an update on Recovery First and considered the potential acquisition of Manchester Mental Health and Social Care NHS Trust (MMHSC). Terry McDonnell advised that it was felt a meeting with MMHSC’s equivalent Committee would be beneficial post‐due diligence. He also confirmed that the Committee received the Annual Infection Prevention and Control and Annual Complaints Reports.

The Board noted the Committee Chair’s Report and minutes of the meeting held 5th May 2016. 173/16 Doctors in Training 2016 Contract Implementation Noted

Andrew Maloney presented a paper setting out the implications of the implementation of the new contract for doctors in training. He summarised the original aims of the new contract, including supporting 7‐day working and enabling better connections between work undertaken and payment. Board members noted that, following the rejection of a renegotiated contract offer by a ballot of BMA members in July 2016, the new contract will be imposed by the government going forward.

Andrew Maloney provided a briefing on the detailed work being undertaken with Pennine Acute, the Lead Employer, to prepare for the transition to the new contract. He confirmed that the Trust will be required to run two separate Terms and Conditions for up to five years and rotas that meet both requirements will also need to be designed. Consultation will be undertaken with Doctors in Training and the BMA with regard to rotas and the contract changes in general in August and September 2016.

Andrew Maloney summarised other key areas of action for GMW, including the

appointment of a Guardian of Safe Working. The Board noted that candidates were interviewed for this role on 25th July 2016 with Kenny Ross, who offers significant relevant experience, appointed. The Guardian of Safe Working will oversee the working practices of doctors in training, providing assurances to the Board that practices are compliant and safe This role will report to the Medical Director and reporting mechanisms to the Board are yet to be agreed.

Andrew Maloney advised that the contract was originally set as ‘cost neutral’, but raises the potential for ‘band drift’ and also incurs expenditure through the new Guardian role and opportunity for fines. The Board noted that further work is required to understand the full cost implications. Andrew Maloney will bring Action: an update on this to Board in the autumn. ACM

Bev Humphrey advised that the implications of the contract for mental health services has been raised with Royal College of Psychiatry. Bev Humphry also suggested that the Trust needs to be mindful of the significant additional work this transition will create for Pennine Acute and the associated potential risks for GMW.

The Board noted the report, the actions underway and the need for further financial analysis. 174/16 EU Workers in Health and Social Care Noted

Andrew Maloney briefed Board members on the background to the letter from NHS Employers regarding EU workers in health and social care. He confirmed that the Executive Management Team gave in principle agreement to support the letter, but that NHS Employers have delayed sending the letter due to changes at Prime Ministerial level. Andrew Maloney will notify Board members Action: should this position change. He also advised that the Trust currently employs ACM circa 80 EU national workers, so the risks associated with the outcome of the EU referendum are low.

The Board noted the letter. 175/16 Any Other Business Noted

There were no items of other business. 176/16 Date and Time of Next Meeting Noted

Monday 26th September at 1.00pm in Meeting Rooms 1 and 2, 1st Floor, The Curve 177/16 Resolution Adopted

The Board was invited to adopt the following:

“That representatives of the press and other members of the public be excluded from the remainder of this meeting, having regard to the confidential nature of

the business to be transacted, publicity on which would be prejudicial to the public interest” (Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960).”

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 June‐16 141/16 Corporate Submission of completed corporate governance 30/06/2016 ‐ Kim Saville, Governance statement and other self‐certifications to NHS Company Secretary Statement and Improvement Other Self‐ Certifications to NHS Improvement June‐16 142/16 Modern Slavery – Supplier Code of Conduct to be updated to 01/07/2016 ‐ Kim Saville, Risk Assessment and include expectation around Living Wage Company Secretary Statement June‐16 142/16 Modern Slavery – Slavery and Human Trafficking Policy Statement 01/07/2016 ‐ Kim Saville, Risk Assessment and to be uploaded onto Trust website Company Secretary Statement June‐16 144/16 Revalidation and Signed statement of compliance to be submitted 01/07/2016 ‐Steve Colgan, Appraisal 2015/16 to NHS England Medical Director /Kim Saville, Company Secretary June‐16 145/16 Board Performance Views to be fed‐back to Gill Green on 25/07/2016 ‐ All Report presentation of Positive and Safe data in Board Performance Report July‐16 168/16 Board Performance Final report of Community Mental Health Survey 26/09/2016 31/10/2016 Neil Thwaite, Deputy Report to be shared at September 2016 meeting of the Chief Executive/ Board of Directors Director of Development and Performance

Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion July‐16 169/16 Service User Email to be circulated from Chair and Chief 31/08/2016 Gill Green, Director Engagement Executive thanking all those involved in the of Nursing and Strategy 2016 to development of the Service User Engagement Operations 2019 Strategy and confirming the Board’s endorsement of the Strategy

July‐16 169/16 Service User Service user engagement kite‐mark scheme to be 31/12/2016 Gill Green, Director Engagement shared with the HSJ once operational of Nursing and Strategy 2016 to Operations 2019 July‐16 170/16 Infection Prevention New approaches to be taken to promote staff 26/09/2016 Gill Green, Director and Control Annual uptake of influenza vaccine of Nursing and Report 2015/16 Operations July‐16 173/16 Doctors in Training Update to be brought to Board of cost 31/10/2016 Andrew Maloney, 2016 Contract implications of new contract implementation Director of HR and Implementation Corporate Services July‐16 174/16 EU Workers in Notification to be given to Board members should Update to be Andrew Maloney, N/a Health and Social NHS Employers send letter regarding EU workers provided on Director of HR and Care in health and social care 26/09/2016 Corporate Services

Work in progress, not yet due Completed on time Incomplete and overdue

Board of Directors – Part 1

TITLE OF REPORT: Board Performance Report DATE OF MEETING: 28TH September 2016 AGENDA ITEM: 07 PRESENTED BY: Neil Thwaite, Deputy Chief Executive, Director of Business and Service Development AUTHOR(S): Neil Thwaite, Deputy Chief Executive, Director of Business and Service Development

EXECUTIVE SUMMARY: The report summarises the Trust’s performance against regulatory requirements from Monitor and the CQC as well as contractual quality requirements agreed with commissioners

LINKS TO OTHER KEY Previous Board Performance Reports REPORTS/DECISIONS: Operational Plan, Values into Action, Strategic Plan, Quality Account LEGAL/REGULATORY Compliance with Monitor targets, CQC standards and contractual KPIs IMPLICATIONS:

THIS REPORT SUPPORTS ACHIEVEMENT OF THE FOLLOWING CORPORATE OBJECTIVES: Objective 1 – Promote recovery by providing high x Objective 4 – Invest in our environments quality care and delivering excellent outcomes Objective 2 – Work with service users and carers to Objective 5 – Enable staff to reach their x achieve their goals potential and innovate Objective 3 – Engage in effective partnership Objective 6 – Achieve financial strength and x working be well‐governed

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? Yes If ‘yes’: N/A DATIX ID Strategic Objective Description (as per BAF) 1490 Achieve sustainable financial Risk of failure to meet national and/or local targets and strength and be well governed standards which may impact on patient care, Trust ratings and could lead to financial penalties and/or intervention from regulators.

RECOMMENDATIONS: To Note

Board Performance Report July 2016 Final Version

Context

The Board Performance Report is designed to provide assurance to the Trust Board on progress against a range of key performance indicators and highlight any areas of concern. The key performance indicators reported include both national targets and locally-agreed priorities. The Trust Board has delegated responsibility for monitoring and managing performance to nominated Executive Directors within the Executive Management Team (EMT). The Deputy Chief Executive / Director of Development & Performance has overall responsibility for the co-ordination of the performance agenda and provision of business intelligence support. The Director of Operations and Nursing and Medical Director are responsible for enabling the clinical workforce to deliver the key clinical performance indicators. The Directors of Finance, Capital and IM&T, and HR and Corporate Services, are responsible for progressing performance against their respec- tive targets (local and national). The Trust has systems and procedures in place to assure the quality of data reported to the Trust Board in the Board Performance Report. Within the Report, the dashboards provide an ‘at a glance’ summary of the Trust’s key performance indicators. Indicators are grouped by source or topic for ease of understanding. ‘Comments’ are used to highlight exceptions and areas of concern to the Trust Board. Details of corrective action required, or taken, in these areas is provided. The Board Performance Report is under-pinned by more detailed individual Directorate Performance reports. Directorate reports are used to focus action on improving performance and are reviewed in Network Board meetings and local management forums.

Perspective Area Page Perspective Area Page Indicators Linked to the 5 Domains Human Resources Sickness Rate 13 Quick View 3 of Quality Workforce Overview Financial Risk Ratings Ethnicity Human Resources 14 Monitor Compliance Framework - Governance Risk Ratings Mandatory Training 4 Overview Monitor Risk Ratings Turnover Membership Safe Staffing Levels Human Resources 15 Monitor Mental Health Indicators Summary 5 Staff, Friends and Family CPA 7 Day Follow Up Staff Costs Monitor Mental Health Indicators Access to CRHT 6 Agency Spend Summary Human Resources / Finance and Delayed Transfers of Care Financial Summary 16 Contracts Early Intervention in Psychosis Contract Income Monitor Mental Health Indicators CPA Formal Reviews 7 Mental Health Clustering MHSDS Data Completeness Bed Occupancy Young People Admitted to Adult Monitor Mental Health Indicators IAPT - Treated within 6 & 18 Weeks 8 Wards Locally Agreed Targets 17 CQC GMW Intelligent Monitoring Infection Control CQC Rating EMSA Breaches Care Quality Commission 9 CQC Visits PLACE Service Reviews Integrated Governance Incidents - Patient Safety 18 National CQUIN Integrated Governance Incidents - Staff Safety 19 CQUIN 10 CCG CQUIN - Local Integrated Governance Incidents - Positive and Safe 20 CCG CQUIN - Greater Manchester Integrated Governance Safeguarding Incidents 21 CQUIN 11 NHS England - Specialist Network Complaints and Concerns Complaints and Patient Feedback 22 Quality Account Quality Account 12 Patient Feedback - SU FFT

Board Performance Report - July 2016 Final Version 2

Quick View—CQC Domains

CQC Domains Responsiveness

Domain CQC RAG Area Indicator RAG GMW Overall Rating is GOOD Early Intervention - Effectiveness Good Monitor 4 treatment start within 2 G weeks Safety Requires Improvement IAPT - Treated within 6 Monitor 8 R Responsiveness Good weeks Caring Good IAPT - Treated within 18 Monitor 9 G Well Led Good weeks Cardio Metabolic National CQUIN N2a G Effectiveness Assessment IM&T & Mental Health CCG CQUIN GM2 G Area Indicator RAG Waiting Times Monitor 3 Delayed Discharges G Physical Health Early CCG CQUIN L3 G Monitor 6 MHSDS Identifiers G Intervention Monitor 7 MHSDS Outcomes G Monitor 10 Learning Disability G Well Led CCG CQUIN GM3 Crisis Concordat G CCG CQUIN GM4 Shared Care Protocols G Area Indicator RAG Older Adults Functional Sickness Rolling 12 CCG CQUIN L2 G HR 1 R Care Months NHS England MH.iv CAMHS Care Pathways G HR 2 Sickness In Month G Benchmarking MHD Staff, Friends and Family NHS England MH.v G HR 4 G Outcomes Test Monitor Risk Ratings Governance G Safety Monitor Risk Ratings Financial G Area Indicator RAG Monitor 1 7 Day Follow Up G Caring Monitor 2 Gatekeeping G Area Indicator RAG Monitor 5 CPA Reviews G IAPT - Recovery and CCG CQUIN GM 1 G CQC Registration G Reliable Improvement National CQUIN N2b Communication with GPs G NHS England MH.ii Recovery Colleges G CCG CQUIN L1 Suicide Prevention G Reducing Restrictive NHS England MH.iii G Practices HR 3 Staffing Levels G National CQUIN N1a NHS Staff Health G National CQUIN N1b Healthy Food G National CQUIN N1c Flu Vaccinations G

Board Performance Report - July 2016 Final Version 3

Monitor Risk Assessment Framework—Overview

Risk Ratings Overall Monitor 2015/16 Area Area of Risk Ratio Rating Risk Weighting Rating Plan Q1 Q2 Q3 Q4 Balance Sheet Sustainability Capital Servicing Capacity (No. of times) 2.93 25% 4 4 4 Continuity of Liquidity Liquidity Ratio (days) 28.18 25% 4 4 4 Services Weighted Average 50.00% 4 4 4 Underlying Performance I&E Margin (%) 1.70 25% 4 4 4 Financial Variance From Plan Variance in I&E Margin as a % of Income 0.03 25% 4 4 4 Efficiency Weighted Average 50.00% 4 4 4 2015/16 MEMBERSHIP as at Q1 2016-2017 Area Indicator Plan Q1 Q2 Q3 Q4 % of Total Required Over or Under Group No. of Members Performance against national Membership Representation Representation G G access and outcomes requirements PUBLIC Bolton Public 10.22% 285 819 Over Care Quality Commission G G Salford Public 8.81% 210 706 Over inspections and judgments Trafford Public 8.23% 294 659 Over Third party information G G Governance NW Public 16.70% 162 1,338 Over Organisational health indicators G G Sub Total 43.96% 951 3,522 Over Continuity of services and aspects SERVICE USER & CARER G G of financial governance Service User 16.45% 417 1,318 Over Overall G G Carer 2.93% 69 235 Over Sub Total 19.39% 486 1,553 Over 2015/16 STAFF Area Indicator Plan Q1 Q2 Q3 Q4 Health and Social 36.65% 795 2,936 Over Monitor Risk Governance G G Care Ratings Financial G G GMW TOTAL 100.00% 2,232 8,011 Over

Comments: GMW has achieved the maximum ratings of 4 for finance and Green for Governance; an achievement of only c.20% of Trusts in England. The Trust is planning to achieve a rating of 4 in the “Financial Sustainability Risk Ratings”. As at month 5 2016/17 a level 4 is being achieved by the Trust.

Board Performance Report - July 2016 Final Version 4

Monitor Mental Health Indicators

Monitor Mental Health Indicators—Summary

The monthly figure provides an indication of performance for the current quarter to date. The quarter figure is the actual performance from the Monitor submission unless otherwise stated. 2015/16 2016/17 Indicator Outturn Target Q1 Q2 Q3 Q4 Jul-16 YTD Comments 1. Receive follow-up contact within 7 days of 97.0% 95.0% 99.1% 98.2% 98.9% discharge 2. Admissions to Inpatient services had access to Crisis Resolution Home Treatment 99.3% 95.0% 99.6% 100.0% 99.7% teams. 3. Minimising MH delayed transfers of care. 0.3% 7.5% 0.8% 0.6% 0.7%

4. Early Intervention in Psychosis: first This is a new indicator for 2016/17. 2015/16 experience treated with a NICE-approved 73.0% 50.0% 78.6% 91.1% 81.5% Outturn is based on Q4 2015/16 submission. package within 2 weeks

5. Have formal review within 12 months. 97.2% 95.0% 97.9% 97.1% NA

6. Data Completeness - Identifiers:- • NHS Number • Date of Birth • Postcode (normal residence) • Current Gender 99.5% 97.0% 99.6% 99.6% NA • Registered General Medical Practice organisation code • Commissioner organisation code 7. Data Completeness - Outcomes:- (for patients on CPA) • Employment status recorded or confirmed in last 12 months 65.4% 50.0% 67.2% 70.9% NA • Accommodation status recorded or confirmed in last 12 months • HoNOS assessment in the last 12 Months This is a new indicator for 2016/17. Performance 8. IAPT Clients treated within 6 weeks of 76.9% 75.0% 71.2% 74.5% 72.1% is as anticipated at month 4. Plans are in place referral to achieve compliance by the end of Q2. This is a new indicator for 2016/17. The Trust 9. IAPT Clients treated within 18 weeks of 95.6% 95.0% 95.6% 96.9% 96.0% has improved performance during Q1 and is now referral compliant with the 18 week target. 10. Compliance with requirements regarding Compliance access to healthcare for people with a Green with all 6 Green NA NA Compliance is reported quarterly only. learning disability requirements Board Performance Report - July 2016 Final Version 5

Monitor Mental Health Indicators 1. CPA 7 Day Follow Up

Directorate 2015/16 Target Jul-16 YTD Comments: All services have performed well against this indicator in Month and have exceeded Total 97.9% 100.0% 98.8% the target. Bolton Functional 97.8% 100.0% 98.5% Organic 100.0% 100.0% 100.0% Total 96.6% 95.6% 99.0% Salford Functional 96.4% 95.1% 98.7% Organic 100.0% 95.0% 100.0% 100.0% Total 97.2% 100.0% 99.4% Trafford Functional 97.3% 100.0% 99.2% Organic 100.0% 100.0% 100.0% FMH 95.7% 100.0% 94.7% MHD 100.0% 100.0% 100.0% GMW (Functional Only) 97.0% 95.0% 98.2% 98.9% 2. Access to CRHT on Admission (Gatekeeping) Directorate 2015/16 Target Jul-16 YTD Comments Bolton 99.5% 100.0% 100.0% All services have performed well against this indicator in Month and have exceeded the target. Salford 99.0% 95.0% 100.0% 100.0% Trafford 98.9% 100.0% 99.1% MHD 100.0% - - GMW 99.3% 95.0% 100.0% 99.7%

3. Delayed Transfers of Care Directorate 2015/16 Target Jul-16 YTD Comments: Total 0.5% 0.0% 1.1% As anticipated, the situation in Trafford for functional inpatients has improved this month, drop- Bolton Functional 0.5% 0.0% 1.3% ping from 7.8% delayed in June 2016 down to 2.4% delayed in July 2016. Organic 0.0% 0.0% 0.0% The delay in the Mental Health and Deafness service was due to 1 client being delayed by 21 Total 0.3% 0.0% 0.0% days. Due to the low number of clients within the inpatient unit, this has had an adverse effect on Salford Functional 0.3% 0.0% 0.0% the calculation. The client is awaiting funding agreement for a nursing home placement. Organic 0.0% 0.0% 0.0% Total 1.2% 7.5% 3.0% 3.5% All other services have performed well against this indicator in Month and have exceeded the Trafford Functional 1.5% 2.4% 3.8% target. Organic 0.0% 6.2% 1.6%

Forensic Total 0.0% 0.0% 0.1% Mental LSS 0.0% 0.0% 0.0% Health Medium Secure 0.0% 0.0% 0.1% MHD 0.0% 9.3% 2.0% GMW (Exc. CAMHS) 0.3% 7.5% 0.6% 0.7% Board Performance Report - July 2016 Final Version 6

Monitor Mental Health Indicators

4. Early Intervention in Psychosis

Directorate 2015/16 Target Jul-16 YTD Comments Bolton 79.1% 100.0% 83.5% This is a new indicator introduced in Q4 2015/16. Salford 45.0% 87.5% 88.9% All services are within target for July 2016. 50.0% Trafford 82.6% 81.8% 67.4% Other 100.0% 100.0% 100.0% GMW 73.3% 50.0% 91.1% 81.5% 5. CPA Formal Review within 12 Months

2016/17 Comments: The monthly figure provides an indication of performance for the current quarter. Directorate 2015/16 Target Jul-16 Q1 All directorates are above target for Q1. Bolton 97.8% 97.5% 98.7% Salford 97.2% 97.8% 97.4% FMH and CJS are below target during July 2016 due to a recent issue of reviews not being flagged as overdue if they have no recorded care co-ordinator. The services are in the process of updating all care co- Trafford 97.6% 95.0% 96.7% 99.5% ordinator information to avoid this on future reports. FMH 96.7% 93.1% 96.7% CJS 95.7% 90.0% 96.9% MHD 96.9% 100.0% 100.0% CPTS 92.9% 100.0% 100.0% CAMHS 79.4% 95.0% 100.0% GMW 97.2% 95.0% 97.1% 97.9%

6. & 7. MHSDS—Data Completeness Identifiers Outcomes Comments: The monthly figure provides an indica- 2016/17 2016/17 tion of performance for the current quarter to date. The quarter figure is the actual performance from the quar- Directorate 2015/16 Target Jul-16 Q1 2015/16 Target Jul-16 Q1 terly Monitor submission. All directorates have exceeded the targets for Q1. Bolton 99.7% 99.77% 99.65% 66.2% 58.28% 60.46%

Salford 99.5% 99.61% 99.56% 73.5% 77.62% 70.30% Trafford 99.5% 99.70% 99.70% 70.0% 88.91% 84.42% Forensic Mental Health 98.8% 98.63% 98.56% 73.6% 64.09% 68.10% 97.0% 50.0% CJS 98.0% 98.48% 98.29% 74.4% 83.33% 83.90% MHD 98.6% 97.18% 97.69% 75.4% 80.73% 67.11% CPTS 99.5% 99.74% 99.67% 80.8% 87.27% 88.06% CAMHS 99.5% 99.36% 99.55% 82.7% 89.80% 95.59% GMW 99.5% 97.0% 99.60% 99.55% 65.4% 50.0% 70.88% 67.18%

Board Performance Report - July 2016 Final Version 7

Monitor Mental Health Indicators 8 & 9. IAPT—Clients Treated Within 6 and 18 Weeks of Referral (RTT) Bolton - IAPT Step 2/3 2015/16 Target Q1 Q2 Q3 Q4 Jul Aug Sep Referrals Received During Period 3463 1,569 471 % within <= 6 weeks 86.2% 75 87.3% 86.9% % within <= 18 weeks 100.0% 95 99.7% 99.2% Salford - IAPT Step 3 2015/16 Target Q1 Q2 Q3 Q4 Jul Aug Sep Referrals Received During Period 5476 1,098 366 % within <= 6 weeks 47.5% 75 52.4% 49.4% % within <= 18 weeks 89.3% 95 90.3% 93.5% Trafford - IAPT Step 2/3 2015/16 Target Q1 Q2 Q3 Q4 Jul Aug Sep Referrals Received During Period 8372 1,895 577 % within <= 6 weeks 75.8% 75 75.8% 87.2% % within <= 18 weeks 95.4% 95 96.9% 98.3% Military Veterans 2015/16 Target Q1 Q2 Q3 Q4 Jul Aug Sep Referrals Received During Period 27 9 0 % within <= 6 weeks 75.0% 75 33.3% 100.0% % within <= 18 weeks 100.0% 95 100.0% 100.0% Working Well 2015/16 Target Q1 Q2 Q3 Q4 Jul Aug Sep Referrals Received During Period - 7 75 % within <= 6 weeks - 75 - - % within <= 18 weeks - 95 - - GMW 2015/16 Target Q1 Q2 Q3 Q4 Jul Aug Sep % within <= 6 weeks 76.9% 75 71.2% 74.5% % within <= 18 weeks 95.6% 95 95.6% 96.9% Comments: Within 6 Weeks: Plans are in place to ensure compliance across the Trust (i.e. at GMW level) by the end of Q2. Month on Month progress contin uing with the July position showing an improvement on June. Within 18 Weeks: Compliance with the 18 week target has now been achieved at the end of Q1 and has been sustained during July.

Bolton: The service has continued to be compliant with both targets and manage the increase in referrals with the new service model Salford: Weekly performance monitoring is continuing to ensure improvements in current access times. At the end of Q1 the Directorat e remains under for both the 6 and 18 week targets, but is on schedule to meet both by the end of Q2. The July position has shown increased compliance with the 18 week target. Trafford: The service has achieved compliance with both the 6 and 18 week targets at the end of Q1 and this has been sustained in July.

Trust Position: At the end of Q1 The Trust is reporting 72.2% compliance with the 6 week target and has achieved compliance with the 18 week target. There has been significant improvement in overall performance during Q1 and the Trust remains on track to achieve compliance with both targets by the end of Q2.

Board Performance Report - July 2016 Final Version 8

Care Quality Commission

CQC GMW Intelligent Monitoring Report CQC Rating

Elevated No Risks Risk Number of Maximum Proportional Month Risks Band The trust has received an overall “Good” rating from CQC. Only 30% of Trusts have Risks Identified Score Indicators Risk Score Risk Score achieved this. Feb-16 1 7 64 9 72 143 6.29% 2 Jun-15 2 3 59 7 64 127 5.51% 2 CQC Visits Nov-14 3 0 54 6 57 114 5.26% 2 C = CQC M = Mental Health Act Risk Score Number of Risks + Number of Visits 2016/17 CQC Identified Risks (Number of Directorate Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 70

Elevated Risks x 2) 2015/16 C M C M C M C M C M C M C M C M C M C M C M C M 60 Maximum Number of Bolton 0 ------Woodlands 0 ------Risk Score indicators x 2 50 Salford 2 - - - 1 - - - - Proportional Risk Score / 40 BH 0 ------Risk Score Maximum Risk Trafford 2 ------30 64 59 54 Score FMH 11 - 1 - 1 - 1 - - Banding 6.5% and SMS 0 ------20 Band 1 7 Thresholds, above CAMHS 0 ------10 2 3 3 based on Betw een 4% R1 2 ------1 0 Band 2 0 proportional and 6.49% Mental Health Act Monitoring: risk score: Betw een 2% Feb-16 Jun-15 Nov-14 Band 3 There were no CQC visits for Mental Health Act Monitoring purposes during July and 3.99% 2016. Elevated Risks Risks No Risks Identified Band 4 Less than 2%

Comments: The February 2016 report identified 1 elevated risk and 7 risks – CQC Inspection: A detailed action plan has been developed to address issues in relation to areas for Elevated Risk improvement. This has been shared with partners at the Quality Summit and an up- Staff Appraised in last 12 month (staff survey ’14). The 2015 survey shows a date on progress will be brought to the Board in Autumn. marked improvement

Risks  2 risks in relation to sickness for last 12 months (nursing and non clinical staff, up to 09/16). Previously these had been elevated risks  Care records at MHA inspections showing evidence of discharge planning . This Service Reviews should improve as work has been undertaken in prep for CQC inspection  Patients discharged without recorded crisis plan – The community survey rates Community Patient Survey 2015: us well on this. Data capture should improve with Paris implementation The action plan to address the three key issues of :-  Deaths of patient detained under MHA (08/14-07/15) – There has been 1 death 1) Giving information to service users in relation to newly prescribed medicines.  Sampling error in 2013 Community survey – survey population was c.5,000 2) Improving awareness of the Out of Hours Crisis Helpline. compared to c.7,000 eligible population 3) Improving pathways which support services users to find or keep work. was reviewed by DMB and continues to be progressing well.  Delayed discharges data not available – Data has not been submitted on advice of NHSE, but will be resumed now CQC using this indicator The 2016 Patient Survey has now been received and is overall very positive. Ser- vices will consider individual results in October and develop appropriate action plans where indicated.

Board Performance Report - July 2016 Final Version 9

CQUIN

National CQUIN—5 indicators that are covered by both CCG and NHS England CQUIN schemes. These account for £780,000 towards CCG CQUIN scheme and £342,231 towards NHS England CQUIN Scheme. Greater Manchester CQUIN—4 indicators that are covered by CCG CQUIN Scheme and account for £585,000. Local CQUINs—3 indicators that are covered by CCG CQUIN Scheme and account for £585,000. Specialist Network CQUIN—4 indicators that are covered by NHS England Scheme and account for £771,000.

National CQUIN Scheme Indicators (£780,000 of CCG Contract and £342,231 of NHS England Contract) Indicator Financial Value 2016/17 Number Indicator CCG NHSE Target Q1 Q2 Q3 Q4 YTD Comments All data required to achieve Q1 Milestones have been met. The Trust has developed a Health and Wellbeing Action Plan which actively promotes the three initiatives; physical health, MSK and Introduction of health and Mental Health. The action plan has been subject to peer review N1a well being initiatives for £195,000 £85,583 G G from an external NHS Foundation Trust and via the Trusts Health staff and Wellbeing Steering Group comprising of senior manages and Lead experts. In addition the action plan is derived from the Trusts Health and Wellbeing Strategy which has been ratified by the Trust Board. All required data has been submitted for Q1. Significant progress Step-change in the health has been achieved in Q1 on banning the price promotions on N1b of the food offered on £195,000 £85,583 G G sugary drinks and foods high in fat sugar and salt on Trust provider premises premises for NHS staff, visitors and patients. No milestones to be achieved until Q3. During Q1 a robust Improving uptake of flu action plan has been developed and the Trust is well prepared for N1c vaccinations for frontline £195,000 £85,583 G G the seasonal flu vaccination programme. The plan for this year clinical staff includes staff incentives and accurate electronic recording.

Cardio metabolic To meet milestones the quarterly assessment and Continue to monitor by use of PHIT reporting. This is monitored N2a interventions for patients £156,000 £85,583 G G weekly via identified service leads. At the end of Q1 the Trust is with psychosis (EI, above target for interventions. inpatients and CMHT) Communication with N2b £39,000 - G G No Q1 milestone - work progressing on providing the audit in Q2. General Practicioners CCG CQUIN Scheme Local Indicators (£585,000 of CCG Contract)

Indicator Financial 2016/17 Number Indicator Value Target Q1 Q2 Q3 Q4 YTD Comments An external review benchmarking GMW against best practice has Implement best practice and L1 Suicide been completed. The outcomes from this review are informing the enhance current policies in £468,000 G G Prevention Action Plan which is also influenced by input from partner suicide prevention strategies. organisations e.g. Public Health. Level 1 and Level 2 training has continued to be rolled out to agreed staff. A Steering Group has been set up to drive forward the L2 Older Build on progress made last application for The Royal College of Psychiatrists AIMS (OP). The £68,250 G G Adults year. Trust has made a formal application for accreditation and has agreed that peer review visits will take place in early December 2016.

Local Local CQUINS L3 Continue provision of cardio A review of technological options has been completed the outcome Physical metabolic screening in EI being a decision to develop a specific app to support young people Health - and build an innovative £48,750 G G with psychosis in managing their own physical health choices.

To To meet milestones the quarterly Early solution to improve Milestones for Q2, Q3 and Q4 have been proposed and we await Intervention engagement. agreement of commissioners. Board Performance Report - July 2016 Final Version 10

CQUIN CCG CQUIN Scheme Greater Manchester Indicators (£585,000 of CCG Contract) Indicator Financial 2016/17 Number Indicator Value Target Q1 Q2 Q3 Q4 YTD Comments Development of indicator to The end codes associated with planned and unplanned endings GM1 IAPT measure the effectiveness of £117,000 G G have been established and we are able to describe both measures psychological interventions. of effectiveness by Step and ending type. Development of robust Leads appointed and systems to support waiting time standards GM2 IM&T waiting list management for £117,000 G G are in place and the Trust is meeting all statutory reporting IAPT and EI pathways. requirements. Crisis Concordat - further Action plan developed to address areas identified during the development across the evaluation. Training continues and we have been exploring ideas to GM3 partnership to deliver £117,000 G G ensure that training is sustainable, within current resources. Partnership improved outcomes for Additional leads have been identified within service areas new to patients. the Crisis Concordat. GM4 Review of shared care GM wide pharmacist has been appointed. Scoping work continues Greater Manchester CQUINS Greater Shared protocols to deliver improved to understand current commissioning arrangements and to identify £234,000 To meet milestones the quarterly G G Care outcomes for patients barriers to effective shared care. A formal progress report was Protocols receiving oral antipsychotics. presented at the May GMMMG. NHS England CQUIN Scheme Specialist Network Indicators (£771,000 of NHS England Contract) Indicator Financial 2016/17 Number Indicator Value Target Q1 Q2 Q3 Q4 YTD Comments A plan of milestones has been prepared for the rest of the year. The recruitment of Peer Mentors and Volunteers is in progress. A Recovery Colleges for working group has been established. A half day workshop inclusive MH.ii Medium and Low Secure £414,000 G G of service users took place on 3/6/16 in developing a strategy for Patients AFS and developing a prospectus. Communications team is working alongside service users in the design of the prospectus.

FMH The recruitment of service user Volunteers is in progress. A working group has been agreed and a half day workshop inclusive Reducing Restrictive of service users took place on 6/6/16 in identifying restrictive MH.iii Practices within Adult £262,000 G G practices and blanket rules. An action plan has been produced Secure Services outlining the development of a framework. A scoping exercise on data flow, collection of baseline data and monitoring outcomes. Improving CAMHS Care Recruitment of a Carers Support Worker. Audit completed against Pathway Journeys by the standards stated within the CQUIN and an action plan has been MH.iv £55,000 G G Enhancing the Experience produced. A family/carer satisfaction survey is established in CAMHS of Family/Carer preparation for roll out in Q2. To To meet milestones the quarterly The first National meeting was held on 21/6/16 in Birmingham. A set Benchmarking Deaf Adult of standards were highlighted from the MHSDS incorporating the MH Services and measuring scale from ‘All About Me’ recovery package. Regional MH.v Developing Outcome £40,000 G G

MHD training days for sharing of good practice will involve GMW, Performance Plans and Cygnet(Bury) & St Georges(Warrington). The deadline for Q1 has Standards been extended for all participating services to end of July 2016. Board Performance Report - July 2016 Final Version 11

Quality Account Highlights

The Quality Account 2015/16 was approved Priority One: Listening to and Learning Priority Two: improving Outcomes Priority Three: Enhancing the Quality of at the Trust Board in May 2016 following ex- from Service User Feedback - Q1 Update through the Delivery of Recovery- Life of People with Dementia and Older tensive consultation and engagement. KPMG Focussed Services - Q1 Update People with Functional Illness - Q1 Update External Assurance gave GMW the highest rating in terms of the contents and accuracy Progress on all improvement measures is This is an exciting opportunity to develop Both Level One and Level Two Training have of data. underway through the GMW CAREhub and meaningful quality outcomes for GMW and it continued to be rolled out during Q1 to the For 2016/17, there are only 7 Improvement related activities. is excellent to see that our initiative is syner- agreed staff within the services. Priorities. Psychological Therapies, Carers A Service User Engagement Policy has been gistic with the latest document jointly pub- The Trust has made a formal application for Involvement/Engagement and Dual Diagno- developed, and the Service User Engage- lished by NHSE and NHSI which discusses accreditation and has agreed to peer review sis have been removed due to assurances ment Strategy for 2016-2019 is due to be the development of quality and outcomes visits in early December 2016. these can be effectively managed separately. launched. measures associated with the Five Year For- GMW continue to work with partners to de- Staffing has been added following suggestion ‘You Said, We Did’ posters developed to ward View. velop the Dementia Friendly Communities. In by the Council of Governors and supported communicate improvement stories based on Progress is being made to determine what Dementia Awareness Week facilitated a full by governors, service user and carer repre- feedback. tools will be used for different teams / health programme of events. GMW are active mem- sentatives. CAMHS has also been added During Q1 service user participation has conditions to capture the quality Outcomes bers of Dementia Action Alliances across following recent CQC feedback and from been widened including: 10 have been re- on the individual’s recovery rates. This re- Bolton, Salford and Trafford. Service User Surveys. cruited to take part in the annual PLACE in- quires both consideration and engagement An End of Life Task and Finish Group has The Quality Governance Committee will con- spections; 20 are involved in developing and with people who use our services in order to been set up to look at effective end of life and tinue as in previous years to monitor pro- delivering the Recovery Academy Prospec- ensure meaningful outcome measures are bereavement support across GMW. gress against the 7 priorities each quarter. tus; 2 are included in the Trust Welcome constructed and utilised. We continue to aim Work has commenced in relation to the Pain Day. to have 80% of our services reporting on and Dementia project funded by The Drag- GMW celebrated National Volunteer Week their recovery rates over the next 2 years and ons Den. and the Festival of Learning with an event careful consideration is being given to when 80% people referred to MATS had an initial during Q1 attended by 97 people. a measure is both clinically and practically appointment within 6 weeks and 79% waited appropriate. no more than 12 weeks for a diagnosis. Priority Four: Physical Health - Q1 Update Priority Five: Positive and Safe - Reduce Priority Six: Staffing - Improving Individu- Priority Seven: CAMHS - Safe, Effective Conflict in Inpatient Settings - Q1 Update al and Organisation Well Being to En- and Collaborative Treatment - Q1 Update hance Patient Care - Q1 Update

Significant work in relation to ensure screen- Progress on all improvement measures is Staff Health and Wellbeing is key to deliver- The process of the CAMHS Review and a ing and intervention are priority across the underway through the Positive and Safe net- ing high quality care by a motivated and series of Visioning events has helped to fo- services with Lester Positive Cardiometabolic work and related Task and Finish groups. We healthy workforce. During Q1 staff have been cus and develop meaningful quality out- health resource embedded within PARIS. We are tracking the impact of our interventions to engaged to identify key areas in the promo- comes for GMW CAMHS. The process has can demonstrate regular monitoring against reduce restrictive practices through a dash- tion of health and wellbeing activities. Staff provided a framework for the organisational target. Delivery of Higher education led train- board showing organisational levels of physi- Health and Wellbeing Network established in structure and clarity of roles and responsibili- ing in wound care and chronic disease man- cal restraint, seclusion and intra-muscular close partnership with staff side colleagues. ties. agement has demonstrated high demand (IM) medication. In quarter 1 there has been Approx. 100 staff have volunteered to act as The visioning events have given rise to the and requirement to review available training a reduction in physical restraint with prone Health and Wellbeing Champions. GMW CAMHS service development opportu- in relation to this. Successfully established restraint as the least used method. However, An enhanced Occupational Health service nities and the framework with which to recog- SLT in some areas, this to be extended. Die- there has been a slight increase in the use of commenced in Q1. The new service offers nise these ambitions. tetics services to be back to full establish- IM medication and seclusion and the Positive fast track physiotherapy and access to psy- There are challenges when moving forward ment in August 2016 following period of ma- and Safe group have taken steps to ensure chological therapies. An online employee which include the national tender process for ternity leave. that this is not a restrictive interventions dis- assistance programme is available to support CAMHS services and developing a cohesion placement effect. staff with advice, guidance and raising with our local colleagues in the GM Partner- awareness of wellbeing issues. ship. The new PICU service will offer an at- A range of initiatives to promote the Five tractive package of care which we expect to Ways to Wellbeing have taken place during develop into a fully functional model of care. Q1and the Trust has linked with other partners to address public health challenges.

Board Performance Report - July 2016 Final Version 12

Human Resources

Sickness Rate

10.00 Directorate In Month Sickness Rates (%) - July 2016 GMW Sickness Rate (%) - In Month 7.00 9.00 8.60 6.56 6.60 6.64 6.39 6.23 6.19 6.09 6.04 5.90 8.00 6.00 5.79 5.64 5.79 5.61 6.69 7.00 6.52 5.00

6.00 5.61 5.55 5.61

3.99 4.18

4.97 4.31 4.43

4.88 4.00 3.84 3.98

5.00 6.53 4.50

3.40

4.66 4.07 3.72 3.94

4.38 3.80

2.83 % 4.44 3.40 4.27 4.00 2.07 3.35 3.00 2.91 3.00 2.87 2.00 2.00 2.97 2.91

2.78 2.57 2.42

1.00 2.33

2.25 2.21

1.00 2.20 2.21 2.06

2.07 1.97 2.06 1.96

1.85

1.84 1.82

1.51 1.73

1.53 1.52

0.00 0.00

FMH

SMS GMW

Bolton 2015/16 2016/17

Salford

Other

Trafford

CAMHS Specialist Sickness Absence - Short Term Sickness Absence - Long Term Directorate Target Corporate Corporate Target GMW - Short term GMW - Long term Target

9.00 Directorate Rolling 12 Month Sickness Rates (%) - July 2016 GMW Sickness Rate (%) - Rolling 12 months 7.00 8.00 8.34 7.24 6.13 6.11 6.08 6.11 6.12 6.09 6.19 6.13 6.17 6.19 6.20 6.12 6.08 6.00 7.00 6.43 6.06 6.35 6.08 6.00 5.81 5.51 5.00

5.00 5.49 4.40

7.01 4.00

4.43

4.40

4.58

4.41

4.57

4.44

4.39

4.62

4.54

4.62

4.47

4.50 4.56

4.47 % 4.00 4.70 4.38 4.52 4.27 3.92 3.00 3.00 3.21 2.00 2.00 1.00 1.00

1.73 1.68 1.82 1.75 1.59 1.61

1.71

1.70 1.70

1.54 1.69

1.68

1.62

1.61

1.59

1.57 1.56 1.33 1.19 1.55

0.00 0.00

J J

A S

N D

FMH

SMS GMW

Bolton 2015/16 2016/17

Salford

Other

Trafford

CAMHS Specialist

Corporate GMW - Short term GMW - Long term Target Sickness Absence - Short Term Sickness Absence - Long Term Directorate Target Corporate Target Sickness: Please note that in smaller Directorates relatively small changes in absolute values can appear as marked fluctuations when expressed as percentages. At 6.08% the total sickness rate for the 12 months ending July 2016 was 0.04% less than the previous month. The sickness rate comprised 4.47% due to long-term sickness and 1.61% arising from short term absences. The July in-month total for the Trust was 0.18% lower than the previous month and at 5.61% was below the target rate of 5.75%. Sickness rates have fallen for four con- secutive months. Long Term Sickness continues to make up the majority of the time lost to sickness absence. The new OH service became operational in April and referrals for physiotherapy and psychological therapy support have been made. CAMHS (a small Directorate) had the highest sickness absence rate (8.6%); the lowest sickness absence rate in the month of July was recorded in Corporate Services (4.38%). The average sickness rate for Mental Health/Learning Disability Trusts in the NW for the month of June was 5.1% (latest available data); 0.69% lower than the GMW rate at that time.

Board Performance Report - July 2016 Final Version 13

Human Resources Workforce Overview Ethnicity Month Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Staff in Post FTE 2,786 2,815 2,844 2,856 Greater +/- change Staff in Post Headcount 3,024 3,055 3,092 3,103 Staff % Manchester from previous Difference between Population %* month contracted and budgeted FTE 486 467 439 413 Ethnicity as at month end White 87.31 88.63 0.14 Difference between Mixed 1.61 1.60 0.03 contracted and budgeted FTE 15 14 13 13 Asian 4.45 6.77 -0.01 as a percent of budgeted FTE Black 4.70 1.66 -0.05 Chinese/Other Mandatory Training 0.90 1.33 0.00 Ethnic group Percentage of staff with valid completed mandatory training as at end of the month Course Name Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Not Stated 1.03 - -0.10 Basic Life Support - 1 Year 69 85 86 82 *Source: ONS PEEG Estimates for 2009 Equality & Diversity - 3 Year 92 93 93 91 Fire Safety - 1 Year 63 70 72 55 Fire Safety - 3 Years 87 90 91 N/A Health and Safety 69 76 79 80 Turnover Intermediate Life Support - 1 Year 56 54 53 50 Infection Prevention - Level 1 - 2 Year 86 87 87 88 1.80

Infection Prevention - Level 2 - 1 Year 75 79 35 62 1.63 1.60

Infection Prevention - Level 3 - 1 Year 65 73 76 75 1.60 1.53

1.41

1.42 1.35

Information Governance - 1 Year 93 94 94 93 1.40 1.50

1.28

1.40

1.18 1.36

Mental Capacity Act 58 68 71 74 1.20 1.21

1.41

1.35 1.03 Mental Health Act Code of Practice 66 88 89 88 1.05

1.00 1.14

0.84

1.18

1.15 0.77 Moving & Handling Inanimate Objects - 3 Year 81 84 85 85 0.79

0.80 1.03 PMVA 65 73 67 66

0.60 0.84 0.65 PMVA Later Life 54 48 43 41 0.74 Prevent Awareness 84 87 88 87 0.40

Safeguarding Adults Level 1 - 3 Years 90 90 92 91 0.20

0.20

0.17

0.30

0.03

0.13

0.03

0.13

0.13 0.06

Safeguarding Children Level 1 - 3 Years 91 92 93 92

O M Safeguarding Children Level 2 71 78 80 81 M 2015/16 Trust Target 85 85 85 85 Wastage Rate (%) 2016/17 Total Compliance 79 84 85 82 Fixed term Contracts & TUPE Transfers All Other Leavers IPDR 68 63 68 75 Workforce Overview: The Trust employs 3103 people who work a total of 2856 Full-Time Equivalent. In July the budgeted FTE exceeded the contracted FTE by 413, a reduction of 73 when compared to the start of the financial year. Mandatory Training and IPDR: Overall, the compliance rate is 82%. Highest levels of compliance are in Information Governance, Safeguarding Children Leve l 1, Safeguarding Adults and Equality and Diversity where all exceeded 90%. The reduction in compliance for Fire Safety is due to a change in training requirements whereby all staff now have to complete some element of fire training on an annual basis. Recently, local managers and the L&D team have focussed on BLS training; next to be prioritised will be ILS and Fire training. As at the end of July 75% of staff had completed IPDRs. A new process for IPDR recording and scheduling is being developed with a view to improving compliance. Ethnicity: The majority of GMW staff describe themselves as being of White origin. When compared with the ethnicity of Greater Manchester, the Trust had a slightly smaller proportion of white employees. GMW has a greater percentage of staff of Black origin but is under-represented in the “Asian” and “Chinese/Other” category. The proportion of staff describing their ethnic origin as “Mixed” was very similar to the NW population. 1.03% of staff chose not to state their ethnic origin. Turnover: During July a total of 49 staff left the Trust. Reasons for leaving included voluntary resignation (32) and retirement (8), 9 left for various other reasons.

Board Performance Report - July 2016 Final Version 14

Human Resources Safe Staffing Levels Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Directorate Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night SMS 100.00% 100.00% 100.0% 100.0% 100.0% 100.0% 103.9% 104.8% FMH 106.94% 105.53% 105.8% 101.9% 108.3% 103.3% 107.3% 103.7% CAMHS 100.26% 100.00% 100.0% 99.7% 100.4% 99.4% 100.4% 99.6% MHD 109.89% 112.00% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Bolton 98.19% 99.67% 105.9% 105.1% 102.5% 103.7% 101.7% 103.9% Salford 96.96% 103.41% 108.2% 117.4% 105.3% 110.6% 103.9% 115.2% Trafford 97.83% 100.00% 100.0% 100.0% 99.9% 100.0% 99.7% 100.0% GMW 102.44% 103.55% 104.7% 104.3% 105.0% 103.7% 104.3% 104.8% Comments: Where percentages are in excess of 100% this is because the number of hours worked is greater than the number of hours planned. This is usually on account of enhanced observations of service users. Where staffing falls short of 100% an escalation procedure is in place which is reviewed by matrons, senior operations managers and heads of operations.

Staff, Friends and Family Test—Quarter 1 (2016/17)

Question 1. How likely are you to recommend this organisation to friends Question 2. How likely are you to recommend this organisation to friends and family if they needed care or treatment? and family as a place to work? 2% 3% 6% 6% 13%

Extremely Likely 32% 34% Extremely Likely 15% Likely Likely

Neither likely nor unlikely Neither likely nor unlikely

Unlikely Unlikely

Extremely Unlikely Extremely Unlikely

48% 41%

Comments:899 staff responded to the latest staff FFT; GMW invites all staff to participate and has consistently high numbers of staff engaging with the process. 81% said they would recommend the Trust as a place to receive care or treatment (sum of pie charts is 1% higher due to rounding). 73% said they would recommend GMW as a place to work. Both indicators are at their highest levels since the test began in June 2014.

Board Performance Report - July 2016 Final Version 15

Human Resources / Finance and Contracts Staff Costs—Rolling 12 Months Agency Spend Summary

Salary Costs (000s) Agency Costs (000s) Bank Costs (000s) Staff Plan Budget Actual to 10000 800 800 Group 1617 to Aug-16 Aug-16 Variance 700 700 8000 Medical 2,149,353 895,564 1,261,329 -365,765 600 600 Nursing 1,303,146 542,978 848,097 -305,120 6000 500 500 Professional992,362 & Technical413,484 517,573 -104,089 4000 400 400 Admin & Clerical601,286 250,536 338,723 -88,187 300 300 Ancillary 211,471 88,113 91,984 -3,871 2000

200 200 Total all5,257,618 agency 2,190,674 3,057,706 -867,032

472

459

464

538

457

619

466

386

486

398

381

526

419

469

706

626

683

660

900

761

735

588

661

760

724

9417

9342

9351

9087

9319

8387 1053

9162

9010

8951

8751

8815

8719 8613 100 100 Med = Medical; Nurs = Nursing; P&T = Profes- A S O N D J F M A M J J A A S O N D J F M A M J J A A S O N D J F M A M J J A sional & Technical; A&C = Admin and Clerical; Anc = Ancillary 2015/16 2016/17 2015/16 2016/17 2015/16 2016/17 Financial Summary Financial Aug-16 YTD FY Summary £m Plan Actual Var Plan Actual Var Plan Comments: The Trust is reporting a surplus on income and Total Income 13.97 13.83 -0.14 69.84 69.81 -0.03 168.70 expenditure of £1,097k as at month 5 16/17. This is £71k Pay Costs -10.58 -10.36 0.22 -52.83 -52.05 0.78 -126.78 behind the planned surplus. Drug Costs -0.27 -0.33 -0.05 -1.37 -1.48 -0.11 -3.28 Directorate financial positions compared to budget can be Other Costs -2.23 -2.26 -0.03 -11.01 -11.64 -0.63 -26.74 found in section 5 of the Finance Board Report. EBITDA 0.88 0.89 0.00 4.64 4.64 0.01 11.89 Depreciation -0.38 -0.38 -0.01 -1.88 -1.91 -0.03 -4.52 Interest Receivable 0.02 0.01 -0.01 0.07 0.06 -0.01 0.18 Interest Payable - unwinding of discount -0.02 -0.01 0.01 -0.09 -0.04 0.05 -0.21 Profit/Loss on Asset Disposal 0.00 0.00 0.00 0.00 -0.00 -0.00 0.00 PDC Dividend -0.31 -0.31 0.00 -1.57 -1.57 0.00 -3.77 Mental Health Clustering Net Surplus/(Deficit) 0.19 0.20 0.01 1.17 1.19 0.02 3.57 Percent Clustered Percent with Valid Cluster Non Operating Expenses 0.00 0.00 0.00 0.00 (0.09) -0.09 (0.53) Surplus/(Deficit) after Non-Operating Exps 0.19 0.20 0.01 1.17 1.10 -0.07 3.04 Comments Elements of Comprehensive Income -0.00 -0.00 0.00 -0.01 -0.01 0.00 (0.02) Percent Clustered is the total number of clients clustered to Total Comprehensive Income 0.19 0.20 0.01 1.16 1.09 -0.07 3.03 date, and is an increase of 0.6% EBITDA % Income 6.3% 6.4% 0.1% 6.6% 6.7% 0.0% 7.0% from the June 2016 position. Percent with a Valid Cluster is the Contract Income number of clustered clients for Aug-16 YTD FY whom the clustering review is not Income £m Plan Actual Var Plan Actual Var Plan yet due, and is a decrease of 0.3% from the June 2016 position. Cost & Volume contract income 0.1 0.1 0.0 0.5 0.2 -0.3 1.2 The drop in performance is due to Block contract income 5.7 5.7 0.0 36.0 36.0 0.0 77.2 the change in clinical information Secondary commissioning income 2.5 2.4 0.0 4.9 4.9 -0.1 22.2 system. As the new process em- Other Clinical MS income 2.9 2.9 0.0 14.6 14.5 0.0 35.4 beds data quality issues will be Private patient income 0.0 0.0 0.0 0.0 0.0 0.0 0.0 addressed. Non mandatory clinical income 1.7 1.8 0.1 8.5 9.2 0.7 20.4 1224 clients remain unclustered. Other income 1.1 0.8 -0.2 5.4 4.9 -0.4 12.3 Total income 14.0 13.8 -0.1 69.8 69.8 0.0 168.7 Board Performance Report - July 2016 Final Version 16

Locally Agreed Targets Bed Occupancy By Contract 2015/16 2016/17 Comment: % Occupancy Outturn Plan Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD NHS England have confirmed a nationwide Bolton 92 85 84 94 94 96 92 drop in demand for secure young people’s Salford 98 85 98 93 95 95 95 beds. The service continues to be challenged for referrals following the transfer of young Trafford 96 85 96 99 103 100 99 offenders to Wetherby. This coincided with a Medium Secure 95 95 99 96 96 98 97 reduction in the number of referrals to the LSS 97 95 95 98 96 100 97 Gardener Unit. Improved links with Wetherby JDU 89 78 84 77 62 60 71 have been established, and an outreach ap- CBU 87 87 89 97 99 93 94 proach to ensure referrals are received has RADAR 67 66 66 59 77 67 commenced. J17 101 95 80 70 74 74 75 Infection Control Gardener 62 90 38 40 40 40 40 Bramley Street 87 100 86 73 67 82 There were no outbreaks of infection during Braeburn House 38 56 72 78 76 71 July 2016. By Specialty 2015/16 2016/17 EMSA Breaches % Occupancy Outturn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Functional 97 92 97 97 96 95 There have been no breaches of Single Sex Organic 93 95 93 117 122 107 Accommodation during July 2016 PICU 98 100 98 99 97 98 Rehab 91 81 84 84 82 83 PLACE Medium Secure 95 99 96 96 98 97 The annual PLACE inspections were under- LSS 97 95 98 96 100 97 taken in Q1 2016/17 and the National results Mental Health & 89 84 77 62 60 71 have since been published by NHS England. Deafness GMW scored higher than the National aver- SMS 83 82 87 88 89 87 age across all domains with an overall com- Young Persons 87 66 60 63 63 63 pliance level of 99.87% across the organisation. GMW 94 93 93 93 94 93 Young People Admitted to Adult Wards 2015/16 2016/17 Indicator Outturn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD No. Young People Admitted 9 1 2 0 1 4 to Adult Wards Bed Nights 12 3 0 0 4 7 Comment: There was 1 under 18 clients admitted to an adult ward in Salford for 4 nights. The client was 17 years old on admission. The client had presented at A&E due to a deterioration in their mental state and an increase in suicidal ideation. They had never had an inpatient admission prior to this and were being seen in the community by Salford EIT. Due to them turning 18 in a matter of weeks and the fact that they were under EI the decision was made to nurse them on Eagleton for this admission. The service user was discharged on 21/7/16.

Board Performance Report - July 2016 Final Version 17

Safety

Incidents—Patient Safety

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Comments 1 6 5 1 All RCAs investigations continue to be managed as per Na- RCA 1 tional SUI Framework (2015), Trust Incident Policy, and rele- RCA 2 6 4 4 9 vant Health & Safety/HR Policies. 0 0 0 0 All data was extracted from DATIX on 22/08/2016. Never Events Regulation 28: None received during July 2016. Regulation 28's 1 0 0 0

1. Moderate & Major Incidents Reported on Datix Moderate & Major Incidents Comments: 60 2. Total Moderate & Major Incidents Reported on 20 YTD to July 2016 During July 2016 there were 24 incidents resulting in moder- Datix - Rolling 12 months with Trend ate harm: Accident x 8, Self-Harm x 11, Medication x 1, Pa- 50 Moderate Major tient Care x 2, Missing Patient x 1, and Security Incident x 1. 15 40 There were no major incidents resulting in harm during July 10 2016. 30

18 16 16 The security incident was an alarm failure, the two patient

13 20

No.Incidents No.Incidents

5 11 care incidents relate to a service user suffering from a seizure

7 6

6 on the ward and a service user admitted from a non-trust 10 1 1 location to the acute trust with intoxication following illicit sub-

stance use. The medication incident was an incorrect pre- 0

R1 FMH

SMS scription record, prescription cancelled when service user

Bolton

Salford

Jul-15

Jul-16

Oct-15

Apr-16

Trafford Jan-16

failed to attend x3 for prescription. Jun-16

CAMHS

Feb-16

Mar-16

Aug-15

Sep-15

Nov-15

Dec-15

May-16 SSN Other

3. Catastrophic Incidents Resulting in Death Catastrophic Incidents Comments: 4. Total Catastrophic Incidents Resulting in Death Reported on Datix YTD to July 2016 During the last 12 months there has been an increase in the 30 35 Reported on Datix - Rolling 12 months with Trend number of incidents reported as Catastrophic as demonstrat- 30 ed in Chart 4. In accordance with governance procedures all 25 25 deaths are robustly investigated. 20 20 The figures include both Expected and Unexpected deaths. 15

15 30

The in month position for July 2016 is as follows: 10

No.Incidents No.Incidents

10 22 There were 19 deaths, all outpatient, including: 5 expected 12

5 5 5 deaths; 14 unexpected deaths, of these 1 occurred in the

2 Criminal Justice Service, 6 in Substance Misuse Services. 1 The other 7 deaths include: cause of death unknown x 4 0

R1 (awaiting inquest verdict), 1 road traffic accident and 2 sus-

FMH

SMS

SSN

Other

Jul-15 Jul-16 Apr-16

pected suicides. Oct-15

Bolton

Jan-16 Jun-16

Feb-16 Mar-16

Aug-15 Sep-15 Nov-15 Dec-15

May-16

Salford

Trafford CAMHS

Statutory Duty of Candour: Being Open involves acknowledging, apologising and explaining to service users/carers (face to face) when harm categorised as moderate/severe has occurred following a patient safety incident during their care. There have been 5 recorded Being Open discussions in July 2016, bringing the YTD total to 7.

Board Performance Report - July 2016 Final Version 18

Safety

Incidents—Staff Safety

5. Violence and Aggression Incidents Causing Violence and Aggression Incidents Causing Injury to 6. Total V&A Incidents Causing Injury to Staff - Injury to Staff (Including RIDDOR) YTD to July 2016 Staff Comments: 100 Rolling 12 months with Trend 100 The number of incidents recorded during July 2016 was 70, 90 of which one was RIDDOR reportable. 80 Minor harm, may require aid/support 80 70 Moderate harm requiring treatment The number of V&A incidents reported causing injury to staff 60 60 Major permanent or long-term harm increased from 46 in June to 70 incidents in July 2016. 50 40

40 84 There was a significant increase in incidents reported at No.Incidents 30

No.Incidents Woodlands Unit from 8 in June to 31 incidents in July 2016. 20 20 18 incidents were reported on Delamere Ward involving 3

38 10

1 11 12 patients and 13 incidents were reported on Holly Ward involv-

6 0 3 3 ing 7 patients.

FMH

SMS

Jul-15

Jul-16

SSN

Oct-15

Apr-16

Other

Jan-16

Jun-16

Mar-16

Feb-16

Nov-15

Dec-15 Aug-15

Incidents reported across the remaining services averaged 2 Sep-15

May-16

Bolton

Salford Trafford CAMHS incidents per service in July 2016.

YTD there have been 176 incidents recorded, of which 4 have been RIDDOR reportable.

The rolling 12 months data suggests that incidents are reducing.

Positive initiatives, including Positive and Safe, Safe Working, ‘Respect Us’ poster campaign, NLB approval of PMVA training, issuing of sanctions, and strengthening of police liaison relationships were implemented in 2015/16 which may have influenced the downward trend in V&A incidents resulting in harm. Further initiatives are planned for 2016/17 in order to identify and manage the causes of V&A and provide a safe working environment for patients and staff. The 2015/16 Reported Physical Assaults report is due to be submitted to NHS Protect in June 2016.

7. Accident Incidents Causing Injury to Staff Accident Incidents Causing Injury to Staff Comments: 8. Total Accident Incidents Causing Injury to Staff - (Including RIDDOR) YTD to July 2016 The number of incidents recorded during July 2016 was 14, 18 Rolling 12 months with Trend 15 of which 1 was RIDDOR reportable. Accidents include: burn/ 16 Minor harm, may require aid/support scald x1, collision with object x1, cut with object (non-medical 14 Moderate harm requiring treatment sharps) x2, slip/trip/ fall x3, fall walking down stairs (Riddor 12 Major permanent or long term harm 10 reported) x1, injured by animal (staff bitten by dog during home visit) x1, moving & handling (non- patient) x1, needle 10

stick x1, staff illness at work (cause unknown required A&E 8 13

5 attendance) x 2 and staff injury during PMVA x1. 6

No.Incidents

9 No.Incidents

7 4 3

3 YTD there have been 45 incidents recorded, of which 2 have

2 2 2

2 2 1 1 been RIDDOR reportable. Accidents include: 11 x trips/falls, 0

R1 5 x moving & handling (non-patient), 2 x moving and handling SMS

FMH (patient), 3 x burn, 1 x trap, 5 x needle stick injuries, 3 x colli-

Bolton

Salford

Jul-15 Jul-16

Trafford

CAMHS

Oct-15 Apr-16

Jan-16 Jun-16

Feb-16 Mar-16

Aug-15 Sep-15 Nov-15 Dec-15

sion with object, 1 x stretching, 1 x slip/trip, 4 x cut with sharp May-16 Corporate SSN Other object (non-medical sharp), 1 x hit by moving object, 1 x cut with medical equipment (non-needle stick), 3 x staff injury PMVA, 1 x fall walking down stairs, 1 x injured by animal, 2 x staff illness at work.

The rolling 12 month data suggests that incidents are increasing.

Board Performance Report - July 2016 Final Version 19

Positive and Safe Incidents—Positive and Safe (Positive Management of Violence and Aggression)

The DoH’s Positive & Safe Programme (2014) outlines requirements for promoting development of therapeutic environments and minimising restrictive practices, including prone restraint.

9. V&A Incidents where Restaint Techniques V&A Incidents where Restraint Techniques were used 10. V&A Incidents where Restraint Techniques 450 were used YTD to July 2016 500 were used - Rolling 12 months with Trend 400 Face Down (Medication) Comments: 450 Face Down (Patient) Both the YTD and Rolling 12 months charts show the total 400

350 63 number of times a restraint technique was used. Multiple tech- 350

Other 14

300 41 31 300

5 niques can be recorded against one incident. 250 250 8 200 13 200

15 The data indicates that prone restraint is the least used. 150

No.Incidents 12

150 4

No.Incidents The rolling 12 month, trend suggests an increase in the num- 100

281

22 272

100 235 ber of incidents resulting in restraint. 50

6 165

50 152 0

Jul-15

Jul-16

Oct-15

Apr-16

Jan-16

Jun-16

Mar-16

Feb-16

Nov-15

Dec-15

Aug-15

Sep-15

May-16

FMH

SMS

SSN

Other

Bolton

Salford

Trafford CAMHS

11. Incidents that Required the Use of Rapid Incidents that Required the use of Rapid Tranquilisation 12. Incidents that Required the Use of Rapid 70 Tranquilisation YTD to July 2016 Comments: 80 Tranquilisation - Rolling 12 months with Trend 70 60 During July 2016 there were 65 incidents involving 28 service 60 50 users. 50 40 YTD there have been 164 incidents involving 74 service us- 40

30 63 ers. 30

20 No.Incidents 20

No. Incidents No. 30

25 The rolling 12 months trend suggests an increase in the use 10

10 20

18 1

7 of Rapid Tranquilisation. 0

FMH

SMS

Jul-15

Jul-16

Oct-15

Apr-16

Jan-16

Jun-16

Feb-16

Mar-16

Aug-15

Sep-15

Nov-15

Dec-15

Bolton

May-16

Salford

Trafford

CAMHS SSN Other

14. Incidents Resulting inUse of Seclusion - Rolling 13. Incidents Resulting in Use of Seclusion YTD to Incidents Resulting in Use of Seclusion Comments: 12 months with Trend 90 July 2016 During July 2016 there were 46 incidents involving 29 service 70 80 users: Medium Secure Service (FMH) x20, Low Secure Ser- 60 70 vice (FMH) x3, Gardener Unit (CAMHS) x3, Maple House- 50 60 PICU (Bolton) x4, Meadowbrook Unit (Salford) x 3,Chaucer 50 40 83 Ward - PICU (Salford) x10, Moorside Unit (Trafford) x1, Re- 40 covery First x1, SMS x1. 30 30

No.Incidents 20 50

No. Incidents No.

20 38

10 YTD there have been 205 incidents involving 139 service us- 10

16 13

4 ers. 1 0

FMH SMS Jul-15

The rolling 12 months trend suggests an increase in the use of Jul-16

Oct-15 Apr-16

Jan-16 Jun-16

Mar-16 Feb-16

Aug-15 Nov-15 Dec-15 Sep-15

May-16

Bolton

Salford Trafford CAMHS Seclusion. This is monitored by the Positive and Safe Group

SSN Other SSN which is strengthening ward level reporting and local improvement plans.

Board Performance Report - July 2016 Final Version 20

Safeguarding

Incidents—Safeguarding (Quarter 1 2016)

Safeguarding data will be reported on a quarterly basis. The next data set will be available in the September 2016 report. Staff report in DATIX when they have initiated a Safeguarding Referral as a consequence of information/observation/disclosures pertaining to the welfare and safety of children, young people and adults from any setting, i.e. Trust and Non Trust locations. The safeguarding incidents are reviewed by the safeguarding Leads and any queries escalated to the Safeguarding Chil- dren’s Practitioner, Named Nurse (Children), Named Doctor (Children), Named Doctor (Adults) and Safeguarding Lead (Adults) to ensure that the safeguarding incident is managed as per safeguarding policies and that those reaching the threshold of multiagency procedures are appropriately referred.

15. Number of Incidents Leading to a Child Safeguarding Comments: 16. Type of Action Taken for Child Safeguarding Safeguarding Children’s Action Q1 2016-17 The main categories for raising a child safeguarding incident 30 50 Incidents Q1 2016-17 during Q1 include; V&A, self-harm and patient care. The patient 25 care incidents are not as a consequence of any care delivery/ 40

20 care omissions. There was one allegation of abuse against a 20

30 28

15 staff member, this is being managed through local authority 1

2 safeguarding procedures and was reported to the LADO. 20 2

10 3

No. Incidents No.

5 4

The death reported incident relates to an unexpected death of 4 1

5 10

No. Incidents No.

4 1

5 1

1 1

3 an adult service user from a cardiac arrest. The service user

1 1 1 had guardianship responsibilities for a child in need, the clinical team made contact with children’s services to ensure and seek 1. Initiation of a 2. Referral to 3. Other Action 4. Contacted 5. Local Death Common Children's Taken the police / Authority

Accident Assessment Social Care PPIU (Public Designated V&A Staff V&A

Self Harm Self confirmation that they were aware of the death.

Information

V&A Others V&A Governance

Patient Care Patient Framework Services Protection Officer (LADO)

V&A Patients V&A Environmental

Missing PatientMissing (CAF) Invest Unit)

Security Incident Security IllicitSubstances

140 17. Number of Incidents Leading to a Adult Safeguarding Comments: 18. Type of Action Taken for Adult Safeguarding 120 Safeguarding Adults Action Q1 2016-17 The main categories for raising an adult safeguarding incident Incidents Q1 2016-17

7 90 2 during Q1 include; V&A, self-harm and patient care. The patient 1

80 6

100 3 35 70 2

care incidents were low level incidents, categorised as inappro- 5 1 80 1 priate behaviour patient on patient, vulnerable patient, suicidal 60 5

60 50 34 34 thoughts, inadequate supervision. The V&A included disclo- 40 29

40 sures of abuse, patient admitted from another provider with a 30 4

14 No. Incidents No.

20 2

No. Incidents No.

3 2

20 2 pressure ulcer, 4 incidents of financial abuse and 4 allegations

1 18

1 10

2 4

1 of inappropriate communication staff on patient. The incidents of

1 2 1 financial abuse and staff allegations were reported and man-

Death aged through local authority safeguarding procedures.

Accident

taken

Service

V&A Staff V&A

Self HarmSelf Medication

Information…

Smoking on… Smoking

V&A Others V&A

Patient Care Patient

2. Managed in 2.Managed

V&A Patients V&A

Invest Invest Unit)

3. Other action 3.Other

police/ PPIU police/

4. Referral 4.Referral to

1.Contacted

Environmental

V&A PrisonersV&A

Contract/Fraud

Missing Patient Missing

Communication

safeguarding unit safeguarding

(Public (Public Protection

Security Incident Security IllicitSubstances

19. Total Incidents Leading to a Safeguarding Rolling 12 Months Comments: Number of hospital-acquired pressure ulcers: Action - Rolling 8 Quarters with Trends The trend shows that there is consistent reporting of safeguard- There have been no hospital - acquired pressure ulcers 250 ing across the Trust. recorded during July 2016. 200 150

100 No. Incidents No.

Q1 Q1 15-16 Q2 15-16 Q1 16-17 Q2 16-17 Q3 16-17 Q4 16-17 Q3 15-16 Q4 15-16 Child Adult

Board Performance Report - July 2016 Final Version 21

Complaints and Patient Feedback

Complaints and Concerns

40 District Services - 12 Months to July 2016 25 Specialist Services - 12 Months to July 2016 60 Trust Wide by Level - 12 Months to July 2016

20 50 30 40 15 20 30 10 20 10 5 10

0 0 0 Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul SMS FMH SSN Other Level 1 Level 2 Level 3 Level 4 Bolton Salford Trafford Totals: Trend Recovery First Totals: Trend Level 5 Totals: Trend

Comments: 35 complaints and concerns were recorded across the Trust in July representing a 29% decrease from the number of complaints and concerns recorded in June (49). The level trend for complaints and concerns has changed to an upwards trend over the past twelve months.

During July 2016, 31 complaints at level 2 and above were closed, of which 15 (48%) were either upheld or partially upheld.

During July 2016 one level 4 complaint was closed. The complaint was about Salford services and was partially upheld. The partially upheld complaint from Salford related to the lack of involvement of a relative in meetings and clinical decisions about their mother. Senior managers in Sal- ford have taken steps to ensure that all care coordinators are instructed to involve relatives and carers in meetings and clinical decisions where deemed appropriate.

Patient Feedback—Service User Friends and Family Test

Question. How likely are you to recommend this organisation to Comment: The Friends and Family Test (FFT) for service users has been fully implemented in all 2.6% friends and family if they needed care or treatment? GMW services. There are a variety of ways in which the FFT is asked and embedded in current 2.9% YTD Period: July 2016 service user experience surveys i.e. electronic surveys, SMS text messaging and postcards. The 2.9% FFT results provide invaluable feedback on what service users think of the care and treatment they have receive, this feedback helps us to make improvements and scope how we deliver services in the future. For the month of July 2016, of the 137 service users asked, 91.2% said they 7.3% 1 - Extremely Likely would recommend our services to friends and family bringing the YTD total to 84.1%. 2 - Likely 3 - Neither likely nor unlikely 4 - Unlikely 25.8% 58.3% 5 - Extremely unlikely 6 - Don't Know

Board Performance Report - July 2016 Final Version 22

Board of Directors – Part 1 TITLE OF REPORT: NHSI Quarter 1 Feedback Report

DATE OF MEETING: 26th September 2016 AGENDA ITEM: 08 PRESENTED BY: Ismail Hafeji, Director of Finance, Capital and IM&T AUTHOR(S): Ismail Hafeji, Director of Finance, Capital and IM&T

EXECUTIVE SUMMARY: The Board Directors is asked to receive and note the Quarter 1 NHSI return feedback

LINKS TO OTHER KEY Trust’s 2016/17 Operational Plan REPORTS/DECISIONS: LEGAL/REGULATORY Compliance with Monitor’s Risk Assessment Framework (RAF) IMPLICATIONS:

THIS REPORT SUPPORTS ACHIEVEMENT OF THE FOLLOWING CORPORATE OBJECTIVES: Objective 1 – Promote recovery by providing high Objective 4 – Invest in our environments quality care and delivering excellent outcomes Objective 2 – Work with service users and carers to Objective 5 – Enable staff to reach their achieve their goals potential and innovate Objective 3 – Engage in effective partnership Objective 6 – Achieve financial strength and x working be well‐governed

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: To Note the Quarter 1 feedback

31 August 2016

Ms Beverley Humphrey Chief Executive Greater Manchester West Mental Health NHS Foundation Wellington House Trust 133-155 Waterloo Road London SE1 8UG Prestwich Hospital Bury New Road T: 020 3747 0000 Manchester E: [email protected] W: improvement.nhs.uk M25 3BL

Dear Beverley,

Q1 2016/17 monitoring of NHS foundation trusts

Our analysis of your Q1 submissions is now complete. Based on this work, the trust’s current ratings are:

 Financial sustainability risk rating: 4  Governance rating: Green

These ratings will be published on NHS Improvement’s website in September.

NHS Improvement is the operational name for the organisation which brings together Monitor and the NHS Trust Development Authority. In this letter, “NHS Improvement” means Monitor exercising functions under chapter 3 of Part 3 of the Health and Social Care Act 2012 (licensing), unless otherwise indicated.

The trust has been assigned a ‘Green’ governance rating but has failed to meet the IAPT six week standard.

NHS Improvement uses the above targets (amongst others) as indicators to assess the quality of governance at foundation trusts. A failure by a foundation trust to achieve the targets applicable to it could indicate that the trust is providing health care services in breach of its licence, which could lead to consideration of enforcement action1.

We expect the trust to address the issues leading to the target failures and achieve sustainable compliance with the targets promptly. NHS Improvement does not intend to take any further formal action at this stage, however should these issues not be addressed promptly and effectively, or should any other relevant circumstances arise, we will consider what, if any, further regulatory action may be appropriate.

1 Under the Health and Social Care Act 2012, taking into account, as appropriate, our published guidance on the licence and enforcement action including our Enforcement Guidance (www.monitor-nhsft.gov.uk/node/2622) and the Risk Assessment Framework (www.monitor.gov.uk/raf). A report on the aggregate performance of all NHS providers (Foundation and NHS trusts) from Q1 2016/17 is available on our website (in the Resources section), which I hope you will find of interest.

For your information, we have issued a press release setting out a summary of the report’s key findings.

If you have any queries relating to the above, please contact me by telephone on 0203 747 0232 or by email ([email protected]).

Yours sincerely,

Mark Demain Senior Regional Manager cc: Mr Rupert Nichols, Chair Mr Ismail Hafeji, Director of Finance, Contracting and IM&T

Board of Directors – Part 1

TITLE OF REPORT: Reporting Back, Looking Forward – Summary Annual Report and Quality Account for 2015/16 DATE OF MEETING: 26th September 2016 AGENDA ITEM: 09 PRESENTED BY: Neil Thwaite, Deputy Chief Executive/Director of Development and Performance AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: ‘Reporting Back, Looking Forward’ provides a high‐level summary of the Trust’s Annual Report and Accounts 2015/16 and Quality Account 2015/16. An overview of the Trust’s key achievements during the period is included, in addition to the quality priorities and key strategic plans for 2016/17.

‘Reporting Back, Looking Forward’ will be shared with members and other key stakeholders at the Trust’s Annual Members’ Meeting and is also available via the Trust’s website.

LINKS TO OTHER KEY Board of Directors 16th May 2016: REPORTS/DECISIONS:  Final Operational Plan 16/17  Draft Annual Report and Accounts 2015/16  Draft Quality Account 2015/16 LEGAL/REGULATORY N/a IMPLICATIONS:

THIS REPORT SUPPORTS ACHIEVEMENT OF THE FOLLOWING CORPORATE OBJECTIVES: Objective 1 – Promote recovery by providing high X Objective 4 – Invest in our environments X quality care and delivering excellent outcomes Objective 2 – Work with service users and carers to X Objective 5 – Enable staff to reach their X achieve their goals potential and innovate Objective 3 – Engage in effective partnership X Objective 6 – Achieve financial strength and X working be well‐governed

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: The Board of Directors are asked to note the contents of the ‘Reporting Back, Looking Forward’ document.

Our Summary Annual Report and Quality Account for 2015/16

gmw.nhs.uk

Reporting back, Looking Forward 3

Reporting Back

2015/16 has continued to see significant challenge facing the NHS nationally, and the groundworks laid for significant change in Greater Manchester through devolution. At Greater Manchester West Mental Health NHS Foundation Trust (GMW), this has been another demanding but successful year. We have delivered our key strategic plans and performance targets, maintained and improved the quality of care we provide, and continued to ensure that we use our resources as effectively as possible.

Our Care Quality Committee (CQC) inspection took place in February 2016 and we were delighted to receive notification of our overall rating of ‘good’ in June 2016. In reaching this conclusion, the CQC found many areas of good practice and described our staff as caring, professional and supportive of the people who use our services.

We have taken action during the year to ready ourselves for achievement of the new access targets for Early Intervention in Psychosis and Improving Access to Psychological Therapies (IAPT) in 2016/17. We have also continue to be an important partner in Salford’s Integrated Care Organisation, which went live in July 2016. We delivered a positive financial position at year-end, having maintained low levels of financial risk throughout the period and delivered the efficiencies required for future sustainability. As a result we have been able to make significant investment in a number of our physical environments for the benefit of our service users.

This summary of our Annual Report and Quality Account for 2015/16 celebrates these, and a number of our other key achievements over the last twelve months. A key priority for 2016/17 and onwards will be the acquisition of Manchester Mental Health and Social Care NHS Trust. We are delighted to have been selected as preferred acquirer and are confident that, in bringing together the best of both our organisations, we can make sustainable and positive impacts on the City’s health and wellbeing. We will also continue to work closely with other providers across the region to deliver the wider priorities set out in the ‘Greater Manchester Mental Health and Wellbeing Strategy’.

You can find a copy of our full Annual Report and Accounts, and Quality Account, for 2015/16 on our website + www.gmw.nhs.uk

Bev Humphrey Chief Executive Reporting back, Looking Forward 5

£ £ About Us

We provide inpatient and community-based mental health care and treatment for adults and older people living within the North West. Our inpatient bed numbers currently stand at over 580 beds. Our adult district inpatient services on the Royal Bolton, Trafford General and Salford Royal hospital sites include psychiatric intensive care, whilst our later life services are located at Woodlands Hospital in Salford and Trafford General. Our community services are wide-ranging and focused on supporting people to maintain their mental health and stay out of hospital. They include community mental health teams, crisis care, home-based treatment, early intervention in psychosis, Improving Access to Psychological Therapies (IAPT) services and memory clinics.

We also provide a wide range of more specialised, or tertiary, services across Greater Manchester, the North West of England and beyond. These include substance misuse services (inpatient and community-based), forensic mental health services for adults and adolescents, child and adolescent mental health services, mental health and deafness services, health and justice services and community psychological therapies.

We employ over 3,000 members of staff, who deliver our services from more than 60 sites. In a 12-month period, we see over 40,000 patients.

Our main commissioners are:

Bolton Clinical Commissioning Group NHS England

Salford Clinical Commissioning Group Local authorities in Cumbria, Central Lancashire, Salford, Wigan and Leigh and Trafford Clinical Commissioning Group Trafford Reporting back, Looking Forward 7 Our Achievements 2015/16

High Quality Care + Working With Service Effective Partnership Excellent Outcomes Users and Carers Working

Achievement of an overall Release of a new GMW voice heard ‘good’ rating in our CQC ‘Service User and Carer throughout the ‘Greater inspection Engagement Policy’ with Manchester Mental Health focus on ensuring equality, and Wellbeing Strategy’ Redesign of our substance fairness and transparency misuse services in Working with Salford Royal Cumbria - introducing Improved performance in NHs Foundation Trust more innovation around 2015 Community Mental and Salford City Council prevention, access, shared Health Survey, with GMW to deliver the ‘Salford recovery and employment scoring higher than any Together’ programme other mental health trust in Launch of our new the country on the question Launch of a new specialist ‘GMW Nursing Strategy ‘do staff help you with mental heath service 2016/2021 what is important to you?’ ‘Veterans in Mind’ in Cheshire and Merseyside Positive CQC inspection Friends and Family Test report on mental health - During 2015/16, 1,879 Expanding our provision crisis care in Salford service users participated in of mental health and the test with 84% stating substance misuse services Provision of a new Working they would recommend our in prisons and secure Well Talking Therapies services children’s centres across service across Greater the North West Manchester Investing in our Staff Reach Potential Sustainable + Environments and Innovate Governed Strength

Opening of The Curve, our Positive 2015 staff survey Achievement of a level 4 £5million education and results and ‘Staff Friends Financial Sustainability Risk training facility and Family’ feedback - Rating from Monitor, now indicating improvements in NHS Improvement, and Opening of a brand new a number of key areas ‘green’ governance rating ward at our Woodlands - these are the highest Hospital in Salford, which ‘Being Outstanding’ ratings available cost over £4 million and workshops celebrated offers a contemporary our success and shared Delivery of a normal dementia-friendly examples of outstanding operating surplus for the environment practice across staff groups period of £3.3 million

Achievement of Monitor Re-location of our male Development of a ‘Staff Mental Health Targets and low-secure wards to a Engagement Action Plan’, CQUIN (Commissioning brand new unit on our setting out our key staff For Quality and Innovation) Prestwich site. The Lowry engagement priorities for schemes. Unit enables care to be the next 12 months provided in the least restrictive environment Looking Forward

Our Quality Priorities

We have worked with our staff, service users and carers, governors and other partners to identify our future quality priorities. In 2016/17, we have committed to delivering a range of quality improvements in the following seven areas:

Service User Experience - Listening to and Physical Health - Improving the assessment learning from service user feedback and treatment of physical health conditions and to promote health improvement Recovery - Improving outcomes through messages/approaches and sign-post service the delivery of recovery-focused services users to relevant services

Enhancing the quality of life for people Positive and Safe - Reducing conflict in with dementia and older people with inpatient settings functional illness Staffing - Improving individual and CAMHS - Delivering safe, effective and organisational well-being to enhance collaborative treatment patient care

A number of these priorities build on progress made in previous years. Others are new (staffing and CAMHS), and reflect feedback received from stakeholders and learning from, for example, our CQC Inspection preparation programme and the Inspection itself.

Progress against these priorities will be overseen by the Quality Governance Committee of our Board of Directors. Reporting back, Looking Forward 11

Capital Investment

In 2016/17, we will continue to use our strong financial performance to improve the quality of our buildings and estate. We will invest in the region of £10million to provide a new inpatient wing at our young people’s unit (Junction 17), build a new bedroom suite at our Gardener Unit, redesign Beech and Oak Wards at Royal Bolton Hospital, and provide a larger central pharmacy on our Prestwich site to improve services for our service users.

Service Transformation

We will be focused on planning for our acquisition of Manchester Mental Health and Social Care NHS Trust over the coming weeks and months. The acquisition is not scheduled to complete until 1st January 2017. Between now and then, we will be working hard to better understand the organisation, and to listen to and engage with staff, service users and carers, and other key stakeholders in the City. We are viewing this transaction as a challenge, but also an opportunity to share learning and best practice, enable innovation, develop staff in both organisations and ultimately achieve a brighter future for all of our service users and carers.

During the year, we will also continue to respond to opportunities to grow our business, particularly in our more specialist services, and improve our existing services. We are taking forward a programme of redesign for ‘Discover’, our substance misuse service in Central Lancashire, and will work with commissioners across the region to develop rehabilitation and recovery services and pathways. Get Involved

If you are interested in becoming a member of GMW, please contact Steph Neville, Stakeholder Development Manager, + [email protected].

Volunteer

If you are interested in becoming a volunteer or would like to find out what volunteering opportunities are available please visit + www.gmw.nhs.uk/Volunteering or contact + [email protected].

For more information about GMW, please contact us on + [email protected], follow us on Twitter + @GMW_NHS or like us on Facebook + facebook.com/GreaterManchesterWestNHS.

Greater Manchester West Mental Health NHS Foundation Trust Trust Headquarters The Curve Bury New Road Prestwich Greater Manchester M25 3BL 0161 773 9121 gmw.nhs.uk

Board of Directors – Part 1

TITLE OF REPORT: Transaction and Transformation Committee – Terms of Reference DATE OF MEETING: 26th September 2016 AGENDA ITEM: 10 PRESENTED BY: Rupert Nichols, Chair of the Committee AUTHOR(S): Neil Thwaite, Deputy CEO/Director of Development and Performance Lewis Standring, Acquisition and Transition Project Manager

EXECUTIVE SUMMARY Following the evaluation of the proposals submitted by both bidders and further to an NHS Improvement (NHSI) Board meeting on Thursday 28th July 2016, GMW was identified as the Preferred Acquirer of Manchester Mental Health and Social Care Trust.

A new sub‐committee of the Board of Directors has been established which will provide strategic leadership for, and oversight of, the transaction and all associated future transformation. The Board of Directors has previously approved the proposed establishment of the Transaction and Transformation Committee as part of its review of the Acquisition Proposal.

The ‘Transaction and Transformation Committee’ is chaired by our existing Chair and representatives from the Board of Directors, select members of Manchester Acquisition Group and Lead Governors attend. Due to the establishment of the NHS Improvement Transaction Board that provides transaction governance, there will be no external members of this group however external members will be invited to attend if required.

Along with providing the strategic leadership, the committee will track progress against agreed objectives and milestones, including financial, operational and service quality, and will provide monthly assurances to Board. The committee meets on a monthly basis, reporting directly to the Trust Board.

The proposed terms of reference for the Transaction and Transformation Committee are attached for approval.

LINKS TO OTHER KEY Monthly reports/presentations to the Board of Directors/Council of Governors: REPORTS/DECISIONS: LEGAL/REGULATORY NHSI licence and CQC registration IMPLICATIONS:

THIS REPORT SUPPORTS ACHIEVEMENT OF THE FOLLOWING CORPORATE OBJECTIVES:

Objective 1 – Promote recovery by providing high x Objective 4 – Invest in our environments quality care and delivering excellent outcomes

Objective 2 – Work with service users and carers to Objective 5 – Enable staff to reach their achieve their goals potential and innovate

Objective 3 – Engage in effective partnership Objective 6 – Achieve financial strength and x working be well‐governed

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? Yes If ‘yes’: DATIX ID Strategic Objective Description (as per BAF) 2189 Achieve sustainable financial Future delivery of Mental Health Services currently provided strength and be well‐governed by MMHSCT – proposed timetable and process on the future configuration of services is imminent and may provide a potential acquisition opportunity for the Trust along with risks as a consequence of an acquisition process

RECOMMENDATIONS: The Board are asked to:

 Note the content of the terms of reference and advise of any further amendments/points for consideration

 Note the content of the terms of reference and ratify

Draft V3 for approval

Acquisition of Manchester Mental Health and Social Care Trust Programme

Transaction and Transformation Committee Terms of Reference

1 Purpose

To provide strategic leadership and oversight of the transaction and all associated future service transformation and to ensure effective assurance and governance arrangements throughout phases 2 to 4 of the Manchester acquisition programme.

2 Membership

Chair: Chair of GMW Vice Chair: Non Executive Director, GMW Members: Chief Executive, GMW Deputy CEO/Director of Development and Performance, GMW Director of Finance, Capital and IM&T, GMW Director of Manchester Services, GMW Non‐executive Director, GMW x 2 Company Secretary Programme Manager, GMW In attendance: Lead Governor, GMW

3 Quorum

For the committee to be quorate, the Chair or Vice Chair must be present and at least one Executive Director from GMW. On occasions when the Chair is not present a Non‐Executive Director from GMW must also be present for the committee to be quorate.

4 Frequency of meetings

The meetings will take place monthly between 11am – 12pm on the same day as the Board of Directors meetings. The dates for 2016 are as follows:

- 26th September 2016 - 31st October 2016 - 28th November 2016 - 19th December 2016

Draft V3 for approval

5 Accountability and Reporting Arrangement The Transaction and Transformation Committee reports to the Trust Board of Directors and all minutes will be received formally at the Trust Board. The Transaction and Transformation Committee will also provide monthly Board briefings (verbal and written).

It is envisaged that the terms of reference and membership of this Committee will be reviewed at the point the transaction is executed.

6 Sub‐Groups

The Transaction and Transformation Committee will oversee the work of the Manchester Acquisition Group (MAG) and will receive monthly briefings (verbal and written) from the MAG.

7 Duties

7.1 Agree and oversee the Transition Plan to ensure a successful acquisition and delivery of the programme objectives. 7.2 Regularly track progress against the agreed objectives and milestones, including financial, operational, service quality, communications and transaction requirements and ensure that plans are put in place to mitigate any potential areas of slippage or risk as identified 7.3 Ensure that there is clear, effective governance structures and processes in place to lead and support the transaction and acquisition of MMHSC. 7.4 Ensure GMW and MMHSC meets all requirements and timescales in a way that meets regulatory requirements. 7.5 Ensure appropriate representation on, and direct links with the NHSI Transaction Board and sub‐committees: ‐ HR Working Group - Communication Working Group - Quality Oversight Group - Finance Working Group 7.6 Ensure effective coordination and communications between GMW and MMHSC to support the delivery of the Transition Plan. 7.7 Ensure there is ongoing and effective medical and clinical engagement in the programme. 7.8 Review the Due Diligence reports and agree actions in relation to findings. 7.9 Review and approve the Full Business Case (FBC) and other required submissions prior to submission to Board and NHSI. 7.10 Ensure the Board of Directors and the NHSI Transaction Board receive appropriate assurance during the transition and transformation period. 7.11 Receive and review reports from the executive director members of the NHSI Transaction board to ensure that the requirements of that Board are consistent with the Trust’s objectives, the terms of the bid documents and the Full Business Case (when completed). 7.12 Review the programme mandate and governance arrangements for all phases of this transaction, including the development of a Post Transaction Implementation Plan. 2

Board of Directors – Part 1

TITLE OF REPORT: Board Assurance Framework DATE OF MEETING: 26th September 2016 AGENDA ITEM: 11 PRESENTED BY: Andrew Maloney, Director of HR and Corporate Services AUTHOR(S): Andrew Maloney, Director of HR and Corporate Services

EXECUTIVE SUMMARY: The Board Assurance Framework has been revised and updated to reflect the key risks facing the Trust Board in the delivery of its strategic objectives.

LINKS TO OTHER KEY The key reports that link to the strategic risks in the Board Assurance Framework are REPORTS/DECISIONS: identified in the Controls and Assurance columns in the report. LEGAL/REGULATORY The Board Assurance Framework is a key assurance document relevant to the IMPLICATIONS: Trust’s ongoing compliance regime with its two external regulators, Monitor and the CQC.

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: Board members are asked to review the risks and determine whether they are an accurate representation of the risks to the delivery of the trust’s strategic objectives.

Board members are also asked to determine whether the target risk score once achieved can be withstood.

Greater Manchester West Mental Health NHS Foundation Trust

Board Assurance Framework 2016 - 17

Private and Confidential

OPERATIONAL PLAN – KEY PRIORITIES FOR 2016/17

Improved Lives and Optimistic Futures for People Affected by Mental Health and Substance Misuse Problems VISION VISION

‘Delivering the Forward ‘Devo National and local Closing Crisis care CQC Monitor’s Risk View 2016/17-2020/21’ the Gap Manc’ commissioning Concordat Inspection Assessment Strategic intentions Regime Framework Plan

Mental Health Winterbourne, Berwick, Everyone Counts: ‘Choice’ and No Health Financial Climate: Efficiencies competition & PBR for Mental Health CONTEXT CONTEXT Taskforce Francis and Keogh Planning for Patients Without Mental

STRATEGIC STRATEGIC Report Inquiries and Reports 2014/15 – 2018/19 Health

Promote recovery by Work with service Engage in effective Invest in our Enable staff to reach Achieve sustainable providing high quality care users and carers to partnership working environments their potential and financial strength and be and delivering excellent achieve their goals innovate well-governed outcomes STRATEGIC STRATEGIC OBJECTIVES

Engage in Devo Supporting the Manc Redesign of mental health Competition - Responding to Developing and Reviewing and Continuous services in tender opportunities (new strengthening improving existing improvement –acting Manchester and existing business) partnerships clinical services on patient experience feedback Embed Paris System Promoting and delivering Achieve Quality Promoting recovery quality and performance Account through education – Proactive workforce planning, Delivering the financial plan, agendas Priorities Recovery College development and management including efficiencies TRUST-WIDE PRIORITIES CLINICAL SERVICE DEVELOPMENT PRIORITIES

 Introducing new expanded teams to achieve the new Early Intervention targets – more than 50% of people seen within two weeks and offered NICE approved packages  Improving the psychological therapies offer by taking the lead provider role for Bolton and developing the Working Well Talking Therapies service across Greater Manchester  Improving access to psychological therapies – achieving 75% 6 week and 95% 18 week maximum wait targets  Open Braeburn House, a new 28 bedded male recovery service, and work with commissioners across Bolton, Salford, Trafford and Manchester to develop Rehab and Recovery Services to return out of area placements and further improve pathways  Support the implementation of the Salford Integrated Care Organisation  Capital project to improve in patient and community properties in Bolton

DISTRICT NETWORK  Implement the lead provider RAID model at South Manchester A&E  Continue to develop better pathways and closer working relationships with GP’s, Substance Misuse Services, Housing and CAMHS  Further Development of Woodlands as a centre of excellence for MATs and Older Adults

 Implement capital projects including a new bedroom suite at Gardener Unit and expansion of Junction 17  To respond to tenders for Lancashire prisons, Bolton SMS, CAMHS and adult secure services (may also be some tenders to retain other contracts in SMS)  Implement the new mental health service at HMP Risley and HMP Thorn Cross  Opening of 4th Ward at Recovery First  Use expertise to reduce restrictive practice across services  Continue to develop pathways and closer working relationships with district and specialist services across Greater Manchester  Extended the provision of Tier 4 inpatient detoxification services to meet the contracting requirements for St Helens and Knowsley  Central Lancashire Substance Misuse Service service re-design

SPECIALIST SERVICES NETWORK

Board Assurance Framework September 2016 Executive Summary:

The following document sets out the key strategic risks that have been identified which could affect the delivery of the Trust’s key strategic objectives and priorities. The diagram on the previous page sets out the Trust’s priorities for 2016/17 and an assessment of risks against the delivery of these six strategic objectives forms the structure of this document.

For each strategic objective, specific risks to delivery have been identified along with the control measures that have been established to manage them. Each risk is then graded using the following methodology:

A list of assurances relied upon to provide evidence that the controls are effective is identified against each of the risks with any gaps in controls and assurances being highlighted.

The risks that have been identified are based on a collective assessment by the Trust Board of the operating environment. They are also informed by the identification of risks at Directorate level which are managed via the Directorate risk registers and reviewed at the Risk Management Committee. Key Directorate risks are reviewed by the relevant Director and are escalated to the Board Assurance Framework where it is agreed they could significantly impact upon the delivery of strategic objectives.

A summary of the key strategic risks identified in the following report are:-

DATIX Title Risk level (current) Risk Subtype Opened Risk Treatment Next Review Date ID Status

Extreme 15 2363 Devolution Greater Manchester Board Level Risks 03/12/2015 Reduce 31/12/2016

2189 Mental Health Services in Manchester Extreme 15 Board Level Risks 16/01/2015 Reduce 31/12/2016

2252 Safe Staffing Levels High 12 Board Level Risks 17/09/2015 Reduce 31/12/2016

2128 Implementation of PARIS High 8 Board Level Risks 19/06/2014 Close 30/09/2016

773 Sickness Absence High 12 Board Level Risks 19/09/2013 Reduce 31/12/2016

1804 Mandatory Training High 12 Board Level Risks 19/09/2013 Reduce 31/12/2016

1490 Compliance with targets High 12 Board Level Risks 01/04/2011 Reduce 31/12/2016

High 12 2521 CAMHS Review Board Level Risks 06/05/2016 Reduce 31/12/2016

2572 Agency staff costs High 12 Board Level Risks 15/09/2016 Reduce 31/12/2016

Exec Lead Description Controls Gaps in controls Assurance Gaps in assurance Action Required Progress Due (Likelihood x Consequence) = Risk Level Risk Status Review Current Opened DATIX ID Action ID Initial Risk Treatment Action Due Target Risk Principal objectives: OBJ 1 ‐ Promote recovery by providing high quality care and delivering excellent outcomes Safe staffing levels ‐ risk that unless staffing levels are defined ‐Staffing levels defined via shift system review. ‐National and regional supply ‐Exec Lead ‐ Director of Operations and Nursing. N/A ‐Detailed recruitment activity plan agreed for Activity plan being and resourced to an appropriate level the Trust is unable to ‐Review of levels undertaken and benchmarked nationally. shortages of professional staff. ‐Board paper and minutes April 2015. 2016. implemented. provide safe and effective inpatient care. ‐Investment agreed in ward staffing by Trust Board in April 2015. ‐Board Performance Report. Gill Green ‐Monitoring of fill rates via Trust Board. ‐Board Paper December 2015. 2252

‐Ward staffing investment implemented. ‐Directorate Workforce Plans 2016/17. Reduce 31/12/2016 17/09/2015 31/12/2016 High Risk 9 (3x3) High Risk 12 (4x3) Extreme Risk 16 (4x4) Address the concerns identified during the CQC inspection ‐Mitigating actions agreed and implemented during inspection. ‐Actions are being implemented ‐Exec Lead ‐ Director of Operations and Nursing. Completion and ‐Final agreed model and strategy to be Steering Group regarding the CAMHS service to ensure safe and effective care ‐Actions agreed and implemented post inspection. and require time to embed. ‐Letters to CQC from Trust setting out actions to be taken. embedding of presented to Trust Board – December 2016 leading the 12559 is being delivered. ‐Terms of Reference agreed for review of service. ‐Terms of Reference agreed at EMT with key objectives actions. implementation of Gill Green ‐External CAMHS and OD support to review. and timescales. the review. Plan on 2521

‐Assurance update provided to QGC ‐ September 2016. track. Reduce 31/12/2016 31/12/2016 06/15/2016 High Risk 8 (2x4) High Risk 12 (3x4) Extreme Risk 16 (4x4) Principal objectives: OBJ 2 – Work with service users and carers to achieve their goals Risk of failure to implement the new PARIS clinical ‐ Board Approved Business Case. ‐Gaps in knowledge of system at ‐Exec Lead ‐ Director of Finance. ‐Evidence that staff ‐PARIS Management Group to have ongoing Ongoing. information system effectively which may impact upon ‐Implementation overseen by Project Board. frontline require further support ‐Project Board minutes and progress to EMT for are competent in oversight. clinical safety and delivery. ‐ Resources agreed and committed. and development. assurance. the utilisation of the Ismail ‐Director level engagement in Project Board inc clinicians. ‐Update paper to Trust Board in July 2015 system. 9956 2128 Hafeji Close ‐Post implementation resources agreed. ‐Post implementation paper to Board November 2015. 30/09/2016 30/09/2016 20/06/2014 ‐Paris Project Board sign off ‐ September 2016. High Risk 8 (2x4) High Risk 8 (2x4) Extreme Risk 16 (4x4) Principal objectives: OBJ 5 ‐ Enable staff to reach their potential and innovate Higher than planned sickness absence rates lead to impact on ‐Sickness Management ‐Directorate sickness absence reports – monthly. N/A ‐ Exec Lead Director of HR and Corporate Services. N/A ‐Embed actions implemented via deep dive ‐Actions clinical delivery and higher bank and agency costs. ‐Designated HR officer and Health and Wellbeing Lead support to ‐ Monthly meetings with Directorates. action plan. implemented require Directorates. ‐ HR Director meetings with Heads of Operations. ongoing support. ‐ Training on absence management for line managers. ‐ Monthly Board Performance Report. Andrew ‐New Occupational Health and Counselling Service support for staff. ‐Trust Board paper ‐ February 2015. 10791 11521 773 Maloney

‐Monthly monitoring and assurance meetings with Directorates. ‐Deep Dive Action Plan ‐ July 2015. Reduce 31/12/2016 01/09/2008 ‐Deep dive action plan in place. ‐MIAA audit report ‐ significant assurance.

‐Trust Board paper ‐ January 2016. High Risk 12 (3x4) Extreme Risk 16 (4x4) Moderate Risk 6 (3x2)

Lower than agreed compliance with mandatory training leads ‐Lower than adequate ‐ Exec Lead Director of HR and Corporate Services. ‐Not all services ‐Continued monitoring and performance On‐going monitoring to risk that staff are not adequately trained. ‐Induction and Mandatory Training Policy. compliance levels for certain ‐ Workforce Development Committee minutes. above the 85% Management of Directorates via Workforce being undertaken. ‐Directorate Lead monitoring via monthly reports at WDC and DMB. services and bank staff. ‐Directorate Management Board minutes. target standard. Development Committee to reach 85%. ‐Adequate classroom and e‐learning provision in place. ‐ Compliance reports. 9138 Andrew ‐Establishments have resources built in to enable release of staff. ‐Monthly Board Performance Report. ‐MIAA Audit Report ‐ Limited Assurance. 1804 Maloney ‐Requirement to attend mandatory training a requirement for annual pay High Risk 12 (4x3) Reduce 31/12/2016 31/12/2016 31/12/2016 22/05/2012 progression. ‐Ward level data provided monthly. Extreme Risk 15 (5x3) ‐New web based elearning portal implemented. Moderate Risk 6 (3x2)

Principal objectives: OBJ 6 ‐ Achieve sustainable financial strength and be well‐governed Risk of failure to meet national and/or local targets and ‐ Board performance reports. N/A ‐ Exec Lead Director of Development and Performance / N/A ‐Plan to deliver targets on track ‐ continued Ongoing. standards which may impact on patient care, Trust ratings ‐ Directorate Performance Reports. Director of Operations and Nursing. implementation. and could lead to financial penalties and or Intervention from ‐ Data Quality Reports and operating guidance. ‐ Directorate Management Board and Trust Board regulators. ‐ Directorate Management Board. minutes. Gill Green ‐ Performance measures meetings. ‐ Executive Management Team minutes. ‐ Contract meetings ‐ MIAA assurance report on data integrity of performance 1490 11856 ‐ Quality accounts priorities are monitored via the Quality Governance report. Reduce 31/12/2016 31/12/2016 01/04/2011 Committee. ‐ KPMG Quality Account Opinion 15/16. High Risk 8 (2x4) High Risk 12 (3x4)

Extreme Risk 16 (4x4) ‐ Plan agreed to deliver new IAPT targets at Board. ‐Operational Plan 16/17 ‐Plan agreed to deliver EI targets at Board. ‐ IAPT Board Paper November 2015. ‐EI Board Paper January 2015. Future delivery of Mental Health Services currently provided ‐Contingency plan in place to back fill roles and project team resourced. ‐Significant financial, ‐Exec Lead ‐ Chief Executive Due diligence ‐Transition plan actions require by MMHSCT. GMW identified as preferred acquirer ‐ risks to ‐Intelligence gathering undertaken on current services provided by organisational and clinical risks ‐Trust Board paper and minutes. process identifies implementation. operational, financial and clinical performance inherent in MMHSCT. require further detailed work as ‐Trust Board briefing paper ‐ July 2015. risks that require ‐Full Business Case required to be completed Bev acquisition process. ‐Governors and Board engaged and benefits realisation identified. part of acquisition process. ‐Trust Board paper ‐ Feb 2016 mitigation. and approved.

2189 Humphrey ‐Detailed program structure in place. ‐Trust Board paper ‐ April 2016 12560 ‐Bid document ‐Trust Board paper ‐ May 2016 Reduce 31/12/2016 31/12/2016 16/01/2015

‐Trust Board paper ‐ June 2016 High Risk 12 (3x4) Extreme Risk 15 (3x5) Extreme Risk 20 (4x5) ‐Trust Board paper ‐ July 2016 Devolution Greater Manchester and local integration ‐CEO, Chair and Exec Director involved in governance arrangements ‐Controls related to mitigation of ‐Exec Lead ‐ Chief Executive ‐Further assurance ‐Exec Director involvement in local Ongoing. programs ‐ the current process of devolution presents across GM. risks identified in business case ‐Trust Board paper and minutes i.e. Salford ICO ‐ required regarding development and divisions. opportunities for expansion for the trust across GM along ‐CEO involvement in shaping MH strategy for GM and specialist require time to embed. December 2015. the future shape of Bev with risks related to service configuration at a local level e.g. commissioning arrangements. ‐Trust Board paper April 2016. integration in

2363 Humphrey Development of Salford ICO. ‐Salford ICO business case and exec involvement in development. ‐Trust Board paper May 2016. Bolton, Trafford and 11855 Reduce 31/12/2016 31/12/2016 03/12/2015 ‐Subcontract for GMW in Salford ICO. Manchester.

‐ICO Governance proposals. High Risk 12 (3x4) Extreme Risk 15 (3x5) Extreme Risk 20 (4x5)

Risk that staff agency costs are not controlled and kept within ‐Agency mitigation action plan agreed at June 16 Trust Board. ‐National staff supply shortages ‐Exec Lead ‐ Director of HR & Corporate Services. ‐Current agency ‐Implementation of actions agreed at June 16 Actions on track. the limit set by NHSI. ‐Agency staff procured via approved frameworks. result in increased need for ‐Trust Board paper June 16. spend above NHSI. Board. ‐Escalation process in place to authorise breaches of capped rates. agency staff. ‐Board Performance Report. Andrew ‐Recruitment Strategy ‐ 2016.

2572 Maloney 11855 Reduce 31/10/2016 31/10/2016 15/09/2016 High Risk 8 (2x4) High Risk 12 (3x4) Extreme Risk 16 (4x4)

Principal objectives: OBJ 6 - Achieve sustainable financial strength and be and well-governed financial 6 OBJ strength sustainable Principal- Achieve objectives: 5 OBJ EnablePrincipaltheir- to reach objectives: staff potential innovate and 2 OBJ Principaltheir– Work to achieve withobjectives: carers and goals users service 1 OBJ providing delivering by high and Promote care quality recovery Principal- objectives: excellent outcomes 2572 2363 2189 1490 1804 773 2128 2521 2252 DATIX ID

15/09/2016 03/12/2015 16/01/2015 01/04/2011 22/05/2012 01/09/2008 20/06/2014 06/15/2016 17/09/2015 Opened Ismail Hafeji Humphrey Humphrey Exec Lead Gill Green Gill Green Gill Green Maloney Maloney Maloney Andrew Andrew Andrew Bev Bev limit set by NHSI. Risk that staff agency costs notare controlled and kept within the ICO. service configuration at a local level Developmente.g. of Salford expansion for the trust across GM along with risks related to the current process of devolution presents opportunities for Devolution ManchesterGreater and local integration programs - acquisition process. operational, financial and clinical performance inherent in MMHSCT. GMW identified as preferred acquirer risks - to Future delivery of Mental Health Services currently provided by financial penalties and or Intervention from regulators. which may impact on patient care, Trust ratings and could lead to Risk of failure to meet national and/or local targets and standards risk that staff notare adequately trained. thanLower agreed compliance with mandatory training leads to clinical delivery and higher bank and agency costs. Higher than planned sickness absence rates lead to impact on delivery. system effectively which may impact upon clinical safety and Risk of failure to implement the new PARIS clinical information being delivered. regarding the CAMHS service to ensure safe and effective is care Address the concerns identified during the CQC inspection safe and effective inpatient care. resourced to an appropriate level the Trust is unable to provide Safe staffing levels risk - that unless staffing levels definedare and Description

Extreme Risk 16 Extreme Risk 16 Extreme Risk 16 (4x4) Extreme Risk 20 (4x5) Extreme Risk 20 (4x5) Extreme Risk 16 (4x4) Extreme Risk 15 (5x3) Extreme Risk 16 (4x4) Extreme Risk 16 (4x4) Initial Risk (4x4) (4x4) -Induction and Mandatory Training Policy. -Deep dive action plan in place. -Monthly monitoring and assurance meetings with Directorates. Occupational-New Health and Counselling Service support for staff. Training- on absence management for line managers. -Designated HR officer and Health and Wellbeing Lead support to Directorates. Management-Sickness -Directorate sickness absence reports – monthly. -Post implementation resources agreed. -Director level engagement in Project Board inc clinicians. Resources- agreed and committed. -Implementation overseen by Project Board. Board- Approved Business Case. -External CAMHS and OD support to review. -Terms of Reference agreed for review of service. -Actions agreed and implemented post inspection. -Mitigating actions agreed and implemented during inspection. staffing-Ward investment implemented. -Monitoring of fill rates via Trust Board. -Investment agreed in ward staffing by Trust Board in April 2015. -Review of levels undertaken and benchmarked nationally. -Staffing levels defined via shift system review. (Likelihood =Risk Level x Consequence) Controls -Recruitment Strategy 2016.- -Escalation process in place to authorise breaches of capped rates. -Agency staff procured via approved frameworks. -Agency mitigation action plan agreed at June 16 Trust Board. Governance-ICO proposals. -Subcontract for GMW in Salford ICO. -Salford business ICO case and exec involvement in development. arrangements. involvement-CEO in shaping MH strategy for GM and specialist commissioning -CEO, Chair and Exec Director involved in governance arrangements across GM. -Bid document -Detailed program structure in place. -Governors and Board engaged and benefits realisation identified. -Intelligence gathering undertaken on current services provided by MMHSCT. -Contingency plan in place to fillback roles and project team resourced. -Plan agreed to deliver EI targets at Board. Plan- agreed to deliver new IAPT targets at Board. Committee. Quality- accounts priorities monitoredare via the Quality Governance Contract- meetings Performance- measures meetings. Directorate- Management Board. Data - Quality Reports and operating guidance. Directorate- Performance Reports. Board- performance reports. web based -New elearning portal implemented. level-Ward data provided monthly. progression. -Requirement to attend mandatory training a requirement for annual pay -Establishments have resources built in to enable release of staff. -Adequate classroom and e-learning provision in place. -Directorate Lead monitoring via monthly reports at WDC and DMB. staff. result in increased need for agency -National staff supply shortages require time to embed. risks identified in business case -Controls related to mitigation of process. detailed as partwork of acquisition and clinical risks require further -Significant financial, organisational N/A staff. levels for certain services and bank than-Lower adequate compliance N/A and development. frontline require further support -Gaps in knowledge of system at require time to embed. -Actions beingare implemented and shortages of professional staff. -National and regional supply inGaps controls -EI Board-EI Paper January 2015. IAPT - Board Paper November 2015. -Operational Plan 16/17 KPMG - Quality Account Opinion 15/16. report. MIAA- assurance report on data integrity of performance Executive- Management Team minutes. Directorate- Management Board and Trust Board minutes. Director of Operations and Nursing. Exec- Lead Director of Development and Performance / -MIAA Audit Report Limited - Assurance. -Monthly Board Performance Report. Compliance- reports. -Directorate Management Board minutes. Workforce- Development Committee minutes. Exec- Lead Director of HR and Corporate Services. -Trust Board paper January- 2016. -MIAA audit report significant - assurance. -Deep Dive Action Plan July- 2015. -Trust Board paper February- 2015. Monthly- Board Performance Report. HR - Director meetings with Heads of Operations. Monthly- meetings with Directorates. Exec- Lead Director of HR and Corporate Services. -Paris Project Board sign off September- 2016. -Post implementation paper to Board November 2015. paper-Update to Trust Board in July 2015 Board-Project minutes and progress to EMT for assurance. -Exec DirectorLead - of Finance. -Assurance update provided to QGCSeptember - 2016. timescales. -Terms of Reference agreed at EMT with key objectives and to-Letters CQC from Trust setting out actions to be taken. -Exec DirectorLead - of Operations and Nursing. -Directorate Workforce Plans 2016/17. -Board Paper December 2015. -Board Performance Report. -Board paper and minutes April 2015. -Exec DirectorLead - of Operations and Nursing. Assurance -Board Performance Report. -Trust Board paper June 16. -Exec DirectorLead - of HR & Corporate Services. -Trust Board paper May 2016. -Trust Board paper April 2016. 2015. -Trust Board paper and minutes Salfordi.e. December - ICO -Exec ChiefLead - Executive -Trust Board paper July- 2016 -Trust Board paper June- 2016 -Trust Board paper May- 2016 -Trust Board paper April- 2016 -Trust Board paper Feb - 2016 -Trust Board briefing paper July- 2015. -Trust Board paper and minutes. -Exec ChiefLead - Executive spend above NHSI. agency-Current Manchester. Trafford and integration in Bolton, the future shape of required regarding -Further assurance require mitigation. identifies risks that Due diligence process N/A standard. above the 85% target -Not all services N/A system. utilisation of the competentare in the -Evidence that staff embedding of actions. Completion and N/A inGaps assurance

Current High Risk 12 (3x4) Extreme Risk 15 (3x5) Extreme Risk 15 (3x5) High Risk 12 (3x4) High Risk 12 (4x3) High Risk 12 (3x4) High Risk 8 (2x4) High Risk 12 (3x4) High Risk 12 (4x3) Risk 11855 11855 12560 11856 9138 10791 9956 12559 11521 Action ID Board. -Implementation of actions agreed at June 16 and divisions. -Exec Director involvement in local development approved. -Full Business requiredCase to be completed and -Transition plan actions require implementation. implementation. -Plan to deliver targets on continued- track Development Committee to reach 85%. Management of Directorates via Workforce -Continued monitoring and performance plan. -Embed actions implemented via deep dive action oversight. Management-PARIS Group to have ongoing to Trust Board – December 2016 -Final agreed model and strategy to be presented 2016. -Detailed recruitment activity plan agreed for RequiredAction Actions on track. Ongoing. Ongoing. being undertaken. On-going monitoring support. require ongoing -Actions implemented Ongoing. track. the review. Plan on the implementation of Steering Group leading implemented. Activity plan being Progress

31/10/2016 31/12/2016 31/12/2016 31/12/2016 31/12/2016 31/12/2016 30/09/2016 31/12/2016 31/12/2016 Action Due

High Risk 8 (2x4) High Risk 12 (3x4) High Risk 12 (3x4) High Risk 8 (2x4) Moderate Risk 6 (3x2) Moderate Risk 6 (3x2) High Risk 8 (2x4) High Risk 8 (2x4) High Risk 9 (3x3) Target Risk Treatment Reduce Reduce Reduce Reduce Reduce Reduce Close Reduce Reduce Status Review 31/10/2016 31/12/2016 31/12/2016 31/12/2016 31/12/2016 31/12/2016 30/09/2016 31/12/2016 31/12/2016 Due

Board of Directors – Part 1

TITLE OF REPORT: EPRR Core Standards Self‐Assessment DATE OF MEETING: 26th September 2016 AGENDA ITEM: 12 PRESENTED BY: John Harrop, Head of Risk, Safety and Resilience AUTHOR(S): Andrew Maloney, Director of HR and Corporate Services

EXECUTIVE SUMMARY: The NHS England Core Standards for Emergency Preparedness, resilience and Response (EPRR) are the minim standards which NHS organisations and providers of NHS funded care must meet.

This paper provides a statement of substantial compliance against the 2016‐17 EPRR core standards. It is a requirement of the EPRR assurance process that this paper is presented to the Board.

The EPRR Policy and supporting procedures have been updated to reflect revised NHS England guidance. The documents have been approved by the Network Command and Control Team (NCCT) and Risk Management Committee (RMC) as appropriate.

LINKS TO OTHER KEY N/A REPORTS/DECISIONS: LEGAL/REGULATORY NHS Standard Contract requirement IMPLICATIONS:

THIS REPORT SUPPORTS ACHIEVEMENT OF THE FOLLOWING CORPORATE OBJECTIVES: Objective 1 – Promote recovery by providing high x Objective 4 – Invest in our environments quality care and delivering excellent outcomes Objective 2 – Work with service users and carers to Objective 5 – Enable staff to reach their achieve their goals potential and innovate Objective 3 – Engage in effective partnership x Objective 6 – Achieve financial strength and x working be well‐governed

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: The Board are asked to note the report

Emergency Preparedness, Resilience & Response (EPRR) Core Standards Self‐Assessment 2016‐17

1. Introduction

This paper provides a statement of compliance against the 2016‐17 EPRR core standards.

2. Background

Organisations who receive NHS funding are required to carry out a self‐assessment against the NHS England Core Standards for EPRR and present the papers to their Boards. The Local Health Resilience Partnerships (LHRP) will consider submissions as an agenda item at the meeting on 5th December 2016.

NHS England published a revised EPRR Framework in Nov 2015 and an updated Business Continuity Toolkit in February 2016. Mersey Internal Audit Agency (MIAA) undertook an audit of Business Continuity arrangements within the Trust in 2016; significant assurance was achieved.

3. Statement of Compliance

The Statement of Compliance (Appendix 1) is due to be submitted to CCGs by 31st October 2016 together with the EPRR core standards action plan (Appendix 2) as part of the assurance process. The action plan incorporates the actions from the MIAA audit. The organisation has been self‐ assessed as demonstrating substantial compliance against the core standards.

4. EPRR Policy and Business Continuity Procedure

The EPRR Policy and supporting procedures have been updated to reflect the revised NHS England guidance and recommendations from the MIAA Audit. These documents have been through staff consultation via share point and approved by the NCCT and RMC as appropriate.

5. Recommendation

It is recommended that the: ‐

 EPRR Statement of Compliance is noted by the board.  Network Command & Control Team (NCCT) meeting is assigned to monitor compliance against the EPRR Core Standards Action Plan.  EPRR Policy revision is noted by the Board.

Appendix 1

Appendix 2

Board of Directors – Part 1

TITLE OF REPORT: Quality Governance Committee DATE OF MEETING: 26th September 2016 AGENDA ITEM: 13 PRESENTED BY: Terry McDonnell, Non Executive Director AUTHOR(S):

EXECUTIVE SUMMARY: 13.01 Minutes of the Meeting Held 7th July 2016 13.02 Quality Governance Committee Chair’s Report for the meeting Held 1st September 2016

LINKS TO OTHER KEY n/a REPORTS/DECISIONS: LEGAL/REGULATORY n/a IMPLICATIONS:

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? Yes/No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: The Board of Directors is asked to note the minutes of the meeting held 7th July 2016 and the Chairs Report for the meeting held 1st September 2016.

RATIFIED MINUTES OF THE QUALITY GOVERNANCE COMMITTEE HELD ON THURSDAY 7th JULY 2016, 9.00 AM SEMINAR ROOM 2, TRUST HEADQUARTERS

Present: Terry McDonnell ‐ Non Executive Director (Chair) Julie Jarman ‐ Non Executive Director Kathy Doran ‐ Non Executive Director Andrew Maloney ‐ Director of HR and Corporate Services Steve Colgan ‐ Medical Director Gill Green ‐ Director of Operations and Nursing Neil Thwaite ‐ Deputy CE/Director of Performance and Development Sodi Mann ‐ Consultant, Specialist Services Network Jonathan Dewhurst ‐ Consultant, Specialist Services Network David Hughes ‐ Consultant, Salford Directorate Andrew Haddock ‐ Consultant, Specialist Services Alice Seabourne ‐ Consultant, Bolton Directorate Gail Johnson ‐ Assistant Director of Nursing/Physical Healthcare Richard Backhouse ‐ Deputy Director, Integrated Governance Karen Clancy ‐ Deputy Director, Clinical Governance Aidan Bucknall ‐ Trust Professional Lead – Psychological Therapies Jonathan Dewhurst ‐ Consultant, Specialist Services Network Tim McDougall ‐ Deputy Director of Nursing/Director of IPC Lear Rothwell ‐ Deputy Director, Service & Business Development Paul Roper ‐ Network Operational Manager, CAMHS Chris Daly ‐ Consultant, Specialist Services Samir Shah ‐ Consultant, Salford Directorate

In Attendance:

Imelda Barrington ‐ PA to Chair and CEO (Minutes) Shirley Wheeler ‐ Head of Service (Rehab) – for agenda item 46/16 John McCoy ‐ Hospital Director, Priory – for agenda item 46/16

40/16 Apologies for Absence

Apologies for absence were received from:

Bev Humphrey ‐ Chief Executive Boben Benjamin ‐ Consultant, Trafford Directorate Shermin Imran ‐ Consultant, Specialist Services Network

41/16 Minutes of the Previous Meeting Held 5th May 2016

The minutes of the previous meeting held 5th May 2016 were approved as a correct record subject to the addition of Kathy Doran to the attendance list. 42/16 Matters Arising

42/01/16 (31/16) Rapid Tranquilisation Policy Andrew Maloney, Director of HR and Corporate Services asked for this to be brought back to the September meeting. Action: TMcD 42/02/16 Equality Annual Report Richard Backhouse, Deputy Director of Integrated Governance advised that he had been told that it was not possible to drill down into the report by Directorate.

43/16 Care Quality Commission Outcome

Neil Thwaite, Deputy CEO/Director of Development and Performance advised the Committee that the CQC had published its inspection reports which gave an overall rating of “good” which was the highest overall rating awarded to any Mental Health Trust in England. He said that 70% of Mental Health Trusts had received a “requires improvement” or “inadequate” rating.

Neil highlighted areas which required improvement and explained that action plans were being worked through.

In relation to the issues with CAMHS, Julie Jarman asked what improvements had been made.

Paul Roper, Operational Manager for Junction 17 advised that a substantial piece of work had been undertaken at the service with regards to the inspection outcome. Bev Worthington who had reviewed the service highlighted a number of areas that required improvement.

A CAMHS Steering Group was established which involved both Junction 17 and the Gardener Unit which analysed the current culture, practice, models of care and service user profile across the CAMHS Service.

Staffing – there had been a number of retirements and with HR support a robust recruitment process had been undertaken. Four Nurses were seconded to Gardener Unit with experience of working in CAMHS.

Workforce Development – a focus had been taken staff mandatory training and developing CAMHs specific training.

Following the incident in February temporary grills had been immediately replaced and also a review of furniture had been undertaken. It was noted that a “graffiti” wall, decorative grills and natural landscaping would be installed.

Terry McDonnell thanked Paul Roper for the comprehensive update and advised the Committee that Sherman Imran would be presenting an update at the September meeting.

Neil Thwaite advised that if the Trust was successful in the Manchester procurement a further deep dive inspection could be undertaken with 12‐18 months.

The Committee noted the report.

44/16 Manchester Health and Social Care Trust Overview of Acquisition Process

Neil Thwaite reported that following the submission of the tender the Board had met with NHSI, TDA and Commissioners for a formal interview. The outcome of the procurement would be discussed at the NHSI Board meeting on 28th July with the result being issued a few days after. If successful this would trigger a period of due diligence.

Neil reported that going forward benchmarking of staff would be undertaken as Mental Health Nursing was a difficult area to recruit into but with the development of a strategy the trust would be in good stead to become an employer of choice and expert mental health provider.

Further work would have to be done with stakeholders, CCGS, 3rd sector and voluntary sector organisations in Manchester.

He reported that whilst GMW’s finances were rated as 4 there could be difficulties going forward as the Trust was already lean but there was scope to reduce corporate/back office functions.

A transformation plan would be developed and lead by a new Transaction and Transformation Committee.

Andrew Maloney reported that the planning process was already being undertaken led by Deborah Partington with engagement events over the coming months for new and existing staff to keep them informed. These would run from August and are intended to be communication and listening events before any changes take place.

Steve Colgan suggested learning from previous acquisitions and gave the example of Mental Health Services of Salford taking on Bolton Directorate and that lessons could be learnt from the experiences and difficulties that were raised. It was important that the Manchester staff felt part of the new organisation. Chris Daly added that it was important that the transaction process was well led.

Andrew Maloney advise that due diligence would take place in August, September and October and suggested that the Committee was put on hold after it’s November meeting when an agreed board and sub‐committee schedule could be developed.

The Committee noted the update

45/16 Update on Recovery 1st

Shirley Wheeler, Head of Service (Rehab) introduced Joh McCoy, the new Hospital Director at Priory. She explained that a number of actions had been undertaken since her last presentation to the Committee in November 2015.

She reported that the recruitment of mental health nurses, which had been difficult, was well on track.

Following a cluster of complaints (which was the same issued raised by a number of service users) the number of complaints had significantly reduced. She reported that one young man’s mother had thanked the service explain that if it was not for recovery 1st, her son would not be getting the care and support he required.

Terry McDonnell advised the Committee that Recovery 1st take patients with very complex needs.

Concerns around PMVA were now being addressed with GMW trainers.

Medication errors – these had now been addressed with weekly audits by Ashton’s pharmacy.

Observations – the observation policy had been reviewed and agreed with the Priory.

Kathy Doran reported that she had attended a hospital managers hearing at Recovery 1st and one of the issues raised was access to Psychology Services. Shirley Wheeler advised that there was now dedicated psychology services provided.

Terry McDonnell thanked Shirley for the update.

The Committee noted the update

46/16 NRLS Data

Karen Clancy, Deputy Director of Clinical Governance presented the updated report to the committee explaining it was the most up to date data available. He explained that the data identified 6 months reporting and highlighted that GMW was identified as low harm.

The Committee noted the report.

47/16 Annual Complaints Report

Richard Backhouse, Deputy Director, Integrated Governance presented that report to the Committee. He highlighted:‐

 The number of complaints received had decreased by 4.3 % during 2015/16  Salford Directorate received the most complaints and it was noted that AFS had had a reduction of 30%. A 200% increase in complaints had been noted for specialist services but this related to the complaints made a Recovery 1st.

He reported that form the complaints 65 actions had resulted from upheld complaints and these were monitored by the Customer Care Team.

Following investigations by the parliamentary Ombudsman two complaints had been upheld and required financial recompense.

He reported that Substance Misuse Service had received the most compliments, and he reminded services that compliments can be logged onto datix.

Richard Backhouse wanted the Committee to note his thanks to Jonathan Roberts for leading the Customer Care Team.

The Committee noted the report

48/16 Infection Prevention and Control Annual Report

Tim McDougall, Deputy Director of Nursing/Director of IPC presented the report to the Committee. He explained it had been compiled to advise of the developments and activities in infection prevention and control during the period April 2015 to March 2016.

He advised the Committee that Rebecca McCarren was now on maternity leave and Gail Johnson would be covering Rebecca’s role.

49/16 PIR Summary Report

Karen Clancy presented the summary to the Committee and advised that the reports gave an overview of the following incidents:‐

100205 Criminal Justice Service 100343 CAMHS 99569 Bolton 97168 Salford

The Committee noted the Report.

50/16 Sub Group Assurance

50/01/16 Infection Prevention & Control Committee

Tim McDougall updated the Committee on the condemned mattresses that had been reprovided. Discussions were ongoing on clinical quality and procurement of mattresses for the Trust.

51/02/16 Joint Safeguarding Steering Group

The Committee noted the report.

51/03/16 Mental Health & Mental Capacity Compliance Committee

Richard Backhouse reported that there had been no meeting.

51/04/16 Post Incident Review Panel

The Committee noted the report.

51/05/16 Research Readiness Group

The Committee noted the report

51/06/16 Medicines Management Group

The Committee noted the report

51/07/16 Physical Healthcare Group

The Committee noted the report.

51/08/16 Mortality Group

The Committee noted the report

52/16 Any other Business

Terry McDonnell thanked Steve Colgan Medical Director for the work he had undertaken for the Committee and wished him well in his retirement.

53/16 Date and Time of Next Meeting

The next meeting will take place on 1st September 2016, 9.00 am, Seminar Room 3, Ground Floor, The Curve

Committee Chair’s Report to the Board of Directors

QUALITY GOVERNANCE COMMITTEE

Date of Board Meeting: 26th September 2016 Date of Committee Meeting: 1st September 2016 Committee Chair: Terry McDonnell Date of Chair’s Report: 1st September 2016 Date of Next Committee Meeting: 3rd November 2016

Key Developments  Update on developments with Recovery 1sst in Widnes in the context of the change in ownership of Priory.

 Updates provided on Quality Account priorities regarding service user experience and positive and safe. All progress on track.

 Presentation received on the new Service User Engagement Strategy.

 Presentation received on the development plan for CAMHS following the CQC inspection.

Any Risks Identified  Action regarding the CAMHS development to continue with final and Agreed Actions report to Trust Board in December 2016.

 Positive feedback from Salford CCG following visit to Woodlands with local actions agreed.

Other Items for the N/A Board’s Attention

Board of Directors – Part 1

TITLE OF REPORT: Minutes of the Charitable Funds Committee held 25th July 2016 (Unratified) DATE OF MEETING: 26th September 2016 AGENDA ITEM: 14 PRESENTED BY: Anthony Bell, Non‐Executive Director (Charitable Funds Committee Chair) AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: The Board of Directors is asked to note the unratified minutes of the Charitable Funds Committee held 25th July 2016

LINKS TO OTHER KEY N/A REPORTS/DECISIONS: LEGAL/REGULATORY N/A IMPLICATIONS:

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: To Note

Greater Manchester West Mental Health NHS Foundation Trust UNRATIFIED CHARITABLE FUNDS COMMITTEE 25TH JULY 2016 at 11.30AM ROOM 1, 1ST FLOOR, THE CURVE

PRESENT: Anthony Bell, Non‐Executive Director, Chair Malcolm Cowen, Non‐Executive Director

IN ATTENDANCE: Ismail Hafeji, Director of Finance, Capital and IM&T Gill Green, Director of Nursing and Operations Caroline Ryan, Deputy Director of Finance Kim Saville, Company Secretary Finance Trainee

No. Notes Action 11/16 APOLOGIES Noted

There were no apologies for absence 12/16 MINUTES OF PREVIOUS MEETING Approved

The minutes of the previous meeting held on 29th February 2016 were agreed as an accurate record subject to the noting of apologies from Gill Green, Director of Operations and Nursing. 13/16 MATTERS ARISING Noted

 03/16 (11/15) – Ismail Hafeji, Director of Finance, Capital and IM&T confirmed that the due diligence policy for donations over £10k had been rolled‐out across the Trust

 06/16 – Ismail Hafeji confirmed that Peter Syddall’s offer (free of charge) has been questioned and accepted on the grounds that it is a good will gesture. Caroline Ryan, Deputy Director of Finance, stated that it is unlikely an independent examination will be required in future and, if it was, is covered in the External Auditor contract

 09/16 (Dragons Den) – Kim Saville, Company Secretary, briefed the Committee on the current thinking in relation to this year’s Dragons Den initiative. She confirmed that £150k had been set aside for GMW and £250k in the MMHSC acquisition proposal. No set plans/timescales for Dragons Den, whilst the MMHSC outcome is awaited. Neil Thwaite, Deputy Chief Executive/Director of Development and Performance has indicated that, if GMW is the preferred acquirer, a joint programme may be considered in the New Year. Members of the Committee noted this and suggested that, when the Den convenes, an additional notional amount could be allocated from Charitable Funds to support bids that are consistent with donor wishes but are not funded by the Dragon’s Den. The Committee considered the potential funds available under Any Other Business.

 09/16 (Edenfield Cash Machine) – Caroline Ryan confirmed that this development has been temporarily halted. She will keep the Committee briefed on any changes to this.

14/16 FINANCE REPORTS: Noted

 FOR THE 12 MONTHS ENDED 31ST MARCH 2016  FOR THE 3 MONTHS ENDED 30TH JUNE 2016

Caroline Ryan summarised the two finance reports, highlighting the areas of income and expenditure. In response to a query from Anthony Bell, Non‐Executive Director and Committee Chair, Caroline Ryan confirmed that both income received and investment income are to be treated as total income in the context of the Charity Commission’s thresholds for independent examination of funds.

The Committee noted the movement of the Charitable Funds during the two periods.

15/16 INVESTMENT REPORTS: Noted

 FOR THE 12 MONTHS ENDED 31ST MARCH 2016  FOR THE 3 MONTHS ENDED 30TH JUNE 2016

The Committee considered the benefits of crystallising the funds. In response to a query from Malcolm Cowen, Non‐Executive Director, Caroline Ryan confirmed that the funds had not been crystallised in the past due to concerns regarding volatility. Ismail Hafeji recommended that the Committee consider crystallising the funds on an annual basis and moving the crystallised funds to a separate ‘investment income’ account. The Committee agreed to take this decision annually at the February/March meeting of the Charitable Action: IH Funds Committee.

The Committee noted the investment income of the Charitable Funds during the periods.

16/16 ANNUAL ACCOUNTS/ANNUAL REPORT 2015/16 Approved

Caroline Ryan presented the timetable for the Annual Accounts and Annual Report 2015/16. The Committee agreed that, given the size of the funds, there was no requirement for Peter Syddall to attend the November 2016 meeting. A written report would be acceptable. IH to discuss findings/certification in advance of the report to the Action: IH Charitable Funds Committee.

The Committee approved the timetable and assigned responsibilities. ONLINE DONATIONS Noted

The Committee noted that an online fundraising account has been reopened (Virgin Money Giving), following a query from a prospective fundraiser and with Ismail Hafeji’s approval. 17/16 STAFF HEALTH AND WELLBEING FUNDING REQUEST Noted

Caroline Ryan presented a paper outlining a request for funding from the General Staff Amenities Fund for health and wellbeing activities. The Committee noted that the Fund currently stands at £18,628 and the request is for £10,950. In response to a query from Anthony Bell, Caroline Ryan confirmed that the General Staff Amenities Fund covers donations made specifically for staff. The Committee noted the benefits of the planned initiatives for both clinical and non‐clinical staff and supported. 18/16 ANY OTHER BUSINESS Noted

 Pooling of Funds ‐ Caroline Ryan circulated a paper on potential pooling of fund balances in response to minute 09/16 from the previous meeting. Section A of the paper outlined the funds deemed appropriate for pooling and Section B the funds deemed inappropriate for pooling. Caroline Ryan advised that pooling funds would require local directorate/service approval. Ismail Hafeji suggested that funds could be bundled up at a Directorate level, rather than Trust‐wide, to maintain locality and increase ability to spend. Gill Green agreed and suggested that a letter should be sent Action: from Gill Green and Ismail Hafeji seeking agreement for pooling from the Heads of IH/CR Operations. The Committee agreed this approach and that the General Fund should Action: be flagged to the Dragons Den. IH/GG

 Request for Funding – Caroline Ryan advised that a request to access the General Fund had been received from Aidan Bucknall. There is currently no formal process for people to follow to access the funds, or form to use. Caroline Ryan circulated a proposed draft form for the Committee’s approval. The Committee considered how this form would be used. The Committee approved the form for use to access funds within a budget holder’s entitlement but suggested that requests to access other funds (such as Aidan Bucknall’s request) should first be considered by Gill Green and Ismail Hafeji. Caroline Ryan to update form accordingly. The Committee agreed that Action: CR GG should respond to Aidan Bucknall’s request. Action: GG

In response to a query from Malcolm Cowen, Caroline Ryan outlined the current approvals process. The Committee confirmed that their role was to be notified of funding requests and approvals, not to approve. The previous agenda item (Staff Health and Wellbeing Funding Request) was re‐considered in this context and the Action: IH, Committee agreed that approval should be granted by Gill Green and Ismail Hafeji. GG 19/16 DATE AND TIME OF NEXT MEETING Noted 28th November 2016 at 11.30am in Room 1, 1st Floor, The Curve CHARITABLE FUNDS COMMITTEE ACTION LOG

Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion Feb‐16 06/16 Appointment of Rationale to be sought for Peter Syddall’s fee 31/03/2016 ‐ Ismail Hafeji/Janine Independent Taylor Examiner Feb‐16 08/16 Terms of Reference Nominated Deputies section of the Terms of 04/03/2016 ‐ Kim Saville Reference to be amended July‐16 15/16 Investment Reports Committee to take decision regarding 31/03/2017 Ismail Hafeji crystallisation annually at the February/March meeting July‐16 16/16 Annual IH to discuss findings/certification of 28/11/2016 Ismail Hafeji Accounts/Annual Independent Examination in advance of report Report 2015/16 to the Charitable Funds Committee.

July‐16 18/16 Any Other Business Letter to be sent from Gill Green and Ismail 30/09/2016 Ismail Hafeji, – Pooling of Funds Hafeji seeking agreement for pooling of funds Caroline Ryan from the Heads of Operations. July‐16 18/16 Any Other Business Funds available in General Fund to be flagged to 31/12/2016 Ismail Hafeji, Gill – Pooling of Funds Dragon’s Den initiative Green July‐16 18/16 Any Other Business Funding request form to be updated to 31/08/2016 Caroline Ryan – Request for incorporate requirement for Ismail Hafeji and Funding Gill Green to review requests for access to funds outside of a budget holder’s entitlement Meeting Minute Item Action Agreed Forecast Owner Status No. Timescale Completion July‐16 Any Other Business Gill Green to respond to Aidan Bucknall’s 31/08/2016 Gill Green – Request for funding request Funding July‐16 Any Other Business Approval for funding of Health and Wellbeing 30/09/2016 Ismail Hafeji, Gill – Request for initiatives from the General Staff Amenities Green Funding Fund to be granted by Ismail Hafeji and Gill Green

Work in progress, not yet due Completed on time Incomplete and overdue

Board of Directors – Part 1

TITLE OF REPORT: Audit Committee Chair’s Report of Meeting held 5th September 2016 DATE OF MEETING: 26th September 2016 AGENDA ITEM: 15 PRESENTED BY: Malcolm Cowen, Non‐Executive Director AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: The Board of Directors is asked to receive and note the Audit Committee Chair’s Report on the meeting held on 5th September 2016.

LINKS TO OTHER KEY N/a REPORTS/DECISIONS: LEGAL/REGULATORY N/a IMPLICATIONS:

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: To Note

Committee Chair’s Report to the Board of Directors

AUDIT COMMITTEE

Date of Board Meeting: 26th September 2016

Date of Committee Meeting: 5th September 2016

Committee Chair: Malcolm Cowen, Non‐Executive Director

Date of Chair’s Report: 5th September 2016

Date of Next Committee Meeting: 5th December 2016

Key Internal Audit: Developments Significant assurances received from Mersey Internal Audit Agency (MIAA) following reviews of the Trust’s controls and processes for business continuity planning and the management and monitoring of nurse staffing levels at Trust‐ and ward‐level. One high priority recommendation in the business continuity audit report relating to monitoring of assurances received from Royal Bolton Hospital on fire/generator testing, with a deadline of December 2016 for action.

MIAA are considering the impact the acquisition of MMHSC will have on the risk profile and Internal Audit Plan of both organisations and will

present a consolidated plan to the Audit Committee in December 2016.

Quality Review of 2015/16 FT Audits:

KPMG have been selected for review of their audit of the Trust’s accounts by NHS Improvement. The Trust will be informed of the outcomes of this review, with KPMG outlining any resultant changes to the audit approach going forward in December 2016. Any Risks The Committee considered a report on breaches of the Trust’s Standing Identified and Financial Instructions (SFIs) for the period 01/04/2016 to 31/07/2016. Agreed Actions Work is ongoing to reduce the number of breaches relating to the lapse or exceeding of call off orders. Assurance received that this is not a material issue in the context of the total numbers of orders processed. Other Items for The Committee was not quorate and, as such, decisions to approve the the Board’s following were deferred to the December 2016 meeting: Attention

 Minutes of the previous meetings  Internal Audit Plan changes  Anti‐fraud and Bribery Corruption Policy – the current policy will continue to operate in the interim  Draft Programme of Meetings for 2017  Draft Audit Committee Work‐plan 2017  Audit Committee Terms of Reference

Board of Directors – Part 1

TITLE OF REPORT: Junior Doctor Industrial Action Autumn 2016 DATE OF MEETING: 26th September 2016 AGENDA ITEM: 16 PRESENTED BY: Margaret Campbell, Interim Medical Director AUTHOR(S): Margaret Campbell

EXECUTIVE SUMMARY: The BMA have announced a series of industrial action dates for Autumn 2016, each involving a full withdrawal of junior doctor’s service for 5 days between 8am and 5pm. Services have developed local action plans for the period of industrial action, reflecting services needs and priorities. Senior Leadership Teams will review, daily, the impact on services of the industrial action. National returns data to NHS England will be submitted both before and during the industrial action period.

LINKS TO OTHER KEY REPORTS/DECISIONS: LEGAL/REGULATORY IMPLICATIONS:

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? Yes/No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: The Board to note the emergency planning in place to ensure the safe delivery of core services during the periods of action.

Board of Directors 26th September 2016

Junior Doctor Industrial Action Autumn 2016

1. Introduction

The purpose of this report is to provide the Board with assurance of the measures which have been put in place to ensure delivery of safe, effective services during proposed periods of Junior Doctor industrial action. The BMA have confirmed their intention to undertake industrial action involving a full withdrawal of Junior Doctors between 8am and 5pm on the following dates:

5th October to 11th October 2016 (normal weekend cover) 14th November to 18th November 2016 (inclusive) 5th December to 9th December 2016 (inclusive)

The Academy of Medical Royal Colleges, the Royal College of Psychiatrists and the GMC have each individually requested Junior Doctors reconsider prolonged industrial action. In response, the BMA cancelled the first planned week of industrial action, September 2016, but has stated that they will continue a programme of industrial action throughout the Autumn.

2. Background

The BMA entered into negotiations with the Department of Health and NHS Employers, on reforming the Junior Doctor contract for England in 2013. Original negotiations in 2013 aimed to modernise Junior Doctor’s terms and conditions of work focusing on safe working practice and review of remuneration. Negotiations halted on a number of occasions. Subsequently Junior Doctors’ undertook industrial action on 5 occasions in early 2016.

In May 2016, an agreement was reached between the BMA, NHS Employers and The Secretary of State for Health; subject to BMA referendum of Junior Doctor members.

In July 2016, it was announced that the Junior Doctors had rejected the contract offer. The following day, The Secretary of State confirmed the Government intention to impose the Junior Doctor contract in a statement to Parliament. The BMA released further industrial action dates outlining the main areas of dispute; discrimination against women and disabled workers, impact of the contract on difficult to recruit specialities and weekend pay.

3. Action Planning for Services at GMW

 All services have developed local service action plans for the periods of industrial action, which reflect the local service needs and priorities.  Consultant and non‐training grade Doctors will deliver services at all sites during period of industrial action. They will be supported by Advanced Nurse Practitioners, Physical Healthcare Nurses and prescribing Pharmacists.  Action plans prioritise inpatient wards, Home Based Treatment, Liaison and Emergency cover (8am – 9am periods)  The Chapman Barker Unit will have a reduced number of planned admissions in the week of the industrial action.  All Junior Doctor clinics have been cancelled. Medical clinics delivered by Consultants and non‐training Doctors in the community will continue; unless staff need to be redeployed locally to cover priority services.  External study leave has been cancelled during the period of industrial action. Internal training sessions are being reviewed by Organisational Development to release front line staff.  Contact has been made with acute trust services to confirm provision of resus response and the pathway for referral for acute physically unwell admissions to acute services.  The Chair of the Local Negotiating Committee (LNC) has been updated on service planning and he has offered his full support to maintain safe services within the Trust.  Human Resources to collate Assurance template for first week of action, to submit to NHS England September 2016.

4. Training

 Consultants attended a physical healthcare training day in July 2016  Extra educational resources on prescribing will be accessible on the Trust intranet.  Further training on physical healthcare will be provided to maintain consultant’s competency in this area.

5. Monitoring

 Each senior leadership team will review daily any impact on services of the industrial action.  Collation of cancelled clinics and planned admissions by HR through the national returns data.  Human Resources will collate daily monitoring for National Situation Reporting (SITrep). We are required to report twice daily to NHS England during the Industrial Action period.. Data will be reviewed by the Director of Operations, Director of Human Resources and Acting Medical Director.

6. Risk Issues

 Cancellation of planned clinics and admissions will impact on service delivery; cancellations have been minimised. However, there will be an impact of repeated industrial action throughout the autumn months to December.  The Government is committed to implementing the contract in October. Imposing the contract at the time of industrial action will inevitably affect Junior Doctor morale. There will be planned communication sessions through Medical Staffing to ensure that all Junior Doctors are aware of national and local plans in relation to the Junior Doctor contract.

Margaret Campbell Interim Medical Director 12 September 2016

Board of Directors – Part 1

TITLE OF REPORT: Non‐Executive Director Appointments Process DATE OF MEETING: 26th September 2016 AGENDA ITEM: 17 PRESENTED BY: Rupert Nichols, Chair AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: At the Board of Directors meeting in July 2016, the Chair briefed Board members on plans to appoint three new Non‐Executive Directors with effect from 1st January 2017. This position reflects the terms of office of two of the Trust’s existing Non‐ Executive Directors expiring at the end of December 2016, and an additional Non‐ Executive Director required to balance the Board following the appointment of the Director of Manchester Services.

An overview of the Non‐Executive Director Recruitment Process is attached for the Board’s noting and comment. Gatenby Sanderson, specialist providers of executive search recruitment services, have been commissioned to support the Nominations Committee of the Council of Governors in this work. The process covers three phases – preparation, generation of the candidate pool and selection. A recruitment timetable is outlined, which concludes with a decision at the 6th December 2016 meeting of the Council of Governors.

Also attached is a draft role description and person specification, setting out the main duties and responsibilities of a Non‐Executive Director, plus eligibility criteria, terms of office, skills and experience.

The Council of Governors approved the recruitment process, role description and person specification at its meeting on 13th September 2016. This followed a recommendation from the Nominations Committee, who are responsible for identifying suitable candidates for Non‐Executive Director positions and presenting recommendations for appointment to the Council of Governors.

LINKS TO OTHER KEY N/a REPORTS/DECISIONS: LEGAL/REGULATORY N/a IMPLICATIONS:

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: The Board of Directors are asked to note and comment on the Non‐Executive Director appointments process.

Greater Manchester West Mental Health NHS Foundation Trust 3 x Non‐Executive Directors 2016 Outline of the recruitment process

The recruitment for your new Non‐Executive Directors will form three stages.  Preparation;  Generating the Candidate Pool; and  Selection. These are outlined in more detail below.

1. Preparation GatenbySanderson have already spent some time understanding the demands of these roles but recognise that the context for your Trust is evolving. We look forward to meeting with the Nominations Committee on the 23 August to build a broader perspective on the challenges for the Trust and the priorities for the experience and skills that you seek in your Non‐Executive Directors. We will offer support to the Nominations Committee throughout the process. We understand that you will be seeking one Non‐Executive Director with a Financial background and that for the other two positions you are keen to keep an open mind to the backgrounds of individuals however potential areas of interest may include commercial, legal or local authority backgrounds.

Benchmarking remuneration levels Below is a summary of data we have in relation to 17 Mental Health, Community Services or other Specialist Trusts in the North of England. From our discussion about your remuneration levels it appears that you are aligned to market practice although there is variation as you see. We don’t anticipate your intended remuneration levels being a barrier to attraction here.

Region Median Average Min Max Sample size

North of England £12,361 £12,824 £12,000 £16,835 17

Job Description and Person Specification Another key output of the preparation stage is to finalise the job description and person specification for the roles. These should reflect the criteria that are agreed to be essential for the roles.

Timetable A draft timetable is included below. This works towards your Council of Governors meeting on 6 December. It will be important to get key dates fixed in the diary as soon as this is appropriate.

Activity Dates Microsite update, candidate paperwork (including JD/PS) Drafted by 23 August and and advertisement prepared for sign off. finalised by 2 September following feedback at the meeting on 23 August Meeting with the Nominations Committee to understand Tuesday 23 August at 11am more about their requirements and to agree the timetable and key dates for the process. Council of Governors meeting for approval of the Tuesday 13 September recruitment process Advertising w/c 19 September Search commences with weekly updates from w/c 19 September GatenbySanderson Closing date Friday 14 October Sift of applications provided Early w/c 17 October Longlisting meeting Late w/c 17 October Preliminary interviews with GatenbySanderson w/c 24 and 31 October Short List Meeting w/c 7 November Shortlisted candidates informal access to the Trust and w/c 14 November opportunity to meet with the Chairman, Lead Governor and other key stakeholders.

Behavioural assessment for shortlisted candidates if required (can be undertaken remotely) Final interviews and informal stakeholder panels Monday 21 and Tuesday 22 November Papers to be ready for the Council of Governors Friday 25 November Ratification of the decision by the Council of Governors Tuesday 6 December 2016

Microsite A bespoke recruitment microsite has been developed for the Trust and for these roles. Candidates will be directed to the microsite from the search calls or an advertisement and it is here that they will be able to access further information about the roles and the Trust. Applications are submitted via the site. We would recommend candidates apply with a CV and a supporting statement addressing the person specification.

Greater Manchester West Mental Health NHS Foundation Trust Non‐Executive Directors recruitment process 2

2. Generating the Candidate Pool Search (headhunting) will play an important role in developing a strong and diverse pool of candidates for these positions. We also recommend this is supported by an advertisement in the Sunday Times (costs outlined below). Our initial discussions with Rupert and Kim were very helpful in starting to shape our thinking about the search geography for the roles and we look forward to developing these further in discussion with the Nominations Committee. Whilst you have a requirement for individuals with some specific skill sets, for all candidates the focus should be on individuals who bring strong leadership experience at Board level and with evidence of developing organisations through changing environments as well as identifying those who share your values and ambition. Non‐ Executive Directors will need to provide support and challenge to a strong and experienced Board, as you transform services to meet your population’s needs.

We recognise the underlying requirements for all NEDs to maintain an independent perspective, have a strong understanding of good governance and to provide a strategic oversight across the organisation. We’d be seeking to ensure that individuals are capable of demonstrating a clear awareness of governance, management and the boundaries between them. We’d also be seeking to establish the motivation and values of individuals to fit with your organisation; you will need to ensure a strong team fit and alignment with your ambition and organisational culture. Critical to any candidates’ suitability will be their ability to demonstrate the values of your organisation and bring a strong service user focus.

Geographically your constitution allows you to appoint from any area of the North West however we will restrict our search to ensure that candidates are within a reasonable commuting distance to the Trust (say, up to an hours’ drive).

3. Selection Post‐closing date a copy of all the applications will be submitted to you. We will sift the applications and provide comments, assessment and recommendation of these candidates’ propositions. We would then meet with you to agree the longlist of applicants to be invited to a preliminary interview with us. Those candidates not being selected will be informed of the outcome of their application and we will offer feedback to all.

Preliminary interviews Externally run, robust and objective preliminary interviews would benefit this process. We would expect to interview candidates (on an equal footing) for 1 – 1 ½ hours where we would explore their background and achievements, their style and their overall suitability for the role. We also cover issues such as eligibility time commitment, conflicts of interest, reputation and remuneration.

Interviews are conducted in person and 1‐2‐1 – we can conduct them on your premises if there is room available so that candidates also have the opportunity to see your impressive facilities. We report back to you on the suitability, eligibility and credibility of candidates – we make

Greater Manchester West Mental Health NHS Foundation Trust Non‐Executive Directors recruitment process 3

recommendations to the Nominations Committee based on the person specification. These would then be discussed with the Nominations Committee at a shortlisting meeting.

Informal Meetings In addition to the formal parts of the process, it will be crucial to ensure that the personal fit and chemistry of the candidates is right. Informal meetings with the Chair and Lead Governor are one of the ways in which these issues can be explored in a less pressurised and formalised way. We would advise and co‐ordinate this part of the process as necessary (usually after shortlisting).

NED Role‐Fit Assessment (optional additional service) Over the last couple of years we have developed a psychometric assessment offering for Non‐ Executive Director appointments. This has been particularly valuable for Chairs in considering the team fit of candidates with the Board and the preferences that individuals are likely to exhibit. Some further information is provided at Appendix 1 and we would be happy to discuss this with you further. Final Stages We would work with you to structure and organise the final interview process, advising on the structure and the panel composition. We can give suggested options on presentation topics, wider stakeholder engagement exercises, advice on interview questions and areas of the candidates’ applications to be explored in greater depth. We will endeavour to secure a verbal sounding from referees prior to final interview (preferably the candidates’ current line manager). We would also attend the final interviews to support and advise the panel and also to be in a position to give unsuccessful candidates meaningful feedback.

The team Emma Pickup, Senior Consultant

Emma joined GatenbySanderson in July 2013 and has over seven years’ experience of Executive recruitment in the health sector. She has recruited to a wide range of executive and non‐executive Board positions within Acute and Mental Health providers, Commissioning organisations, Regulators and Special Health Authorities. Relevant recent assignments include 2 NEDs with 5 Boroughs Partnership, 3 NEDs with South Staffordshire and Shropshire Partnership NHS FT, 2 NEDs with Calderstones Partnership, 4 NEDs with Central Manchester University Hospitals NHS FT, the Chair for Lancashire Care and 3 NEDs for Derbyshire Healthcare NHS FT (ongoing). Emma is a member of the Chartered Institute of Personnel and Development and prior to her recruitment career was a Manager in PricewaterhouseCoopers’ Human Resource Services business advising organisations in the public and private sector in respect of innovative and efficient reward structures. Emma would be your first point of contact for the appointments.

Greater Manchester West Mental Health NHS Foundation Trust Non‐Executive Directors recruitment process 4

Robin Staveley MBE, Health Partner

Robin is GatenbySanderson’s Northern based Health Partner and he would work closely with Emma on these roles. His healthcare track record includes executive and non‐executive appointments across the sector and in every NHS region within the last 3 years. He is currently working with Bolton NHS FT to recruit their Audit Chair and with Alder Hey to recruit a Non‐Executive Director. Robin also led our NHS England national sole supplier contract during the set up phase of the organisation. Prior to GatenbySanderson, Robin has 8 years’ experience as a UK public sector headhunter and 5 years as a private sector headhunter. His first career was as an Army officer. He was awarded the MBE in 1996. He has an MBA and a BA (Hons).

Greater Manchester West Mental Health NHS Foundation Trust Non‐Executive Directors recruitment process 5

Appendix 1: Non‐Executive Role‐Fit Assessment Our non‐executive role fit assessment delivers a robust process that measures key attributes critical for success in the NHS NED role but reduces the time commitment for candidates and the investment for NHS trusts. The diagram below shows how the assessment fits into the overall NED search assignment.

NED candidates will undergo an online psychometric assessment (45 mins) which produces an overall profile of the candidate’s preferred working styles, behaviours and attitudes as well as an indication of role fit. This is followed up by a verbal interview session with a qualified business psychologist (30 mins). This interview explores areas of risk highlighted by the profile, considering in particular the fit within your Board makeup and also with the behaviours that will differentiate delivery of accountabilities of a NED in an FT environment. These are broadly; values alignment with NHS purpose, exercising accountability to stakeholders, reviewing and evaluating strategic options; advanced impact and influencing, holding others to account; conceptual and analytical thinking, monitoring performance. After this interview, the business psychologist produces a short report with summary notes on the key strengths and development areas for each candidate. We can also provide a business psychologist to give a verbal briefing to the panel prior to the final interviews.

Greater Manchester West Mental Health NHS Foundation Trust Non‐Executive Directors recruitment process 6

ROLE DESCRIPTION

Post Title: Non‐Executive Director

Reports to: Chair of the Trust

Accountable to: Chair of the Trust and the Council of Governors

Main Location: Trust Headquarters, The Curve, Prestwich, Greater Manchester

Salary: £12,524 per annum – commitment of 3‐4 days per month (inclusive of reading/preparation time) ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ROLE SUMMARY

Non‐Executive Directors are full and equal members of the Board of Directors. They bring an independent perspective to the Board and offer specific knowledge and skills that benefit the Trust, its stakeholders and its wider community. Non‐Executive Directors hold Executive Directors to account for delivery of strategy and offer constructive scrutiny and challenge of performance.

Non‐Executive Directors may Chair, or participate in, key Committees of the Board of Directors.

Non‐Executive Directors have a duty to uphold the highest standards of probity, integrity and governance and act as an ambassador for the Trust. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ KEY WORKING RELATIONSHIPS

Non‐Executive Directors will work alongside other Non‐Executive Directors, the Chair of the Trust and the Executive Directors as a unitary Board. Non‐Executive Directors will also be expected to forge strong links with the Council of Governors to enable them to hold the Non‐Executive Directors individually and collectively to account for the performance of the Board of Directors.

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ORGANISATIONAL CHART

Medical Director

Director of Nursing and Operations

Deputy Chief Executive/Director of Development and Performance Chief Executive

Chair Director of Finance, Non‐Executive Capital and IM&T Directors

Council of Director of HR and Corporate Services Governors

Director of Manchester Services

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ MAIN DUTIES AND RESPONSIBILITIES

1. Strategy

 Ensure that a compelling vision for the Trust’s future is clearly articulated  Contribute to the setting of the Trust’s strategic aims and objectives, ensuring that the necessary financial, quality, commercial, service and workforce plans are in place for the Trust to meet its objectives and that performance is effectively monitored and reviewed  Hold Executive Directors to account for the effective management and delivery of the Trust’s strategic aims and objectives  Ensure the effective implementation of the Board of Directors’ decisions by the Chief Executive and Senior Management Team  Provide independent judgement and advice to the Board of Directors and offer constructive scrutiny and challenge  Participate in constructive debate on the strategic development of the Trust, and any other significant issues facing the Trust, and ensure appropriate consultation with key stakeholders

 Ensure that Governors are enabled and have opportunity to influence the Trust’s strategic direction  Ensure the long‐term sustainability of the Trust

2. Governance

 Work to the highest standards of probity, integrity and governance  Contribute to ensuring that the Trust’s governance arrangements conform with best practice and all statutory requirements for NHS Foundation Trusts  Obtain assurance that financial and other performance information is accurate and timely and that financial and other controls, and systems of risk management, are robust  Obtain assurance that that the Trust has appropriate processes and procedures in place to deliver high standards of professional and personal conduct across the Trust  Provide assurance to the Council of Governors as to how the Non‐Executive Directors have held the Executive Directors to account for the performance of the Board  Ensure that the Trust meets its commitments to service users and carers with regard to service delivery and quality of care  Challenge discrimination, promote equality of opportunity and respect and protect human rights

3. Board Activities

 Participate fully in the work of the Board, ensuring the corporate responsibility of the Board of Directors  Chair, or participate in, Committees established by the Board of Directors to exercise delegated responsibility  Liaise and co‐operate with the Council of Governors to ensure that the views of Governors on key strategic and performance issues are understood and taken into account  Appoint the Chief Executive, with the approval of the Council of Governors, and other Executive Directors  Where necessary, remove the Chief Executive and other Executive Directors  Participate in any Board induction, training/development and evaluation, as an individual and as part of the Board or a Board Committee  Participate in the annual appraisal of Executive Directors, fellow Non‐Executive Directors and the Chair  Participate in an annual individual appraisal process and commit to taking action to address any identified personal development needs

4. Organisational Culture

 Uphold the Trust’s values and work with fellow Directors to provide strong and clear leadership  Support a positive culture throughout the Trust and adopt behaviours in the Boardroom and elsewhere that exemplify that culture  Adhere to the seven principles of public life (the ‘Nolan Principles’) – selflessness, integrity, objectivity, accountability, openness, honesty and leadership

 Adhere to the Board of Directors’ Code of Conduct  Challenge discrimination, promote equality of opportunity and respect and protect human rights  Act as an ambassador for the Trust, safeguarding and promoting its good name and reputation

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ELIGIBILITY

To be eligible for appointment as a Non‐Executive Director, an individual must be a member of one of the Trust’s Public Constituencies (Bolton, Salford, Trafford, Manchester and Other England with effect from 1st January 2017) or be a member of the Trust’s Service User and Carer Constituency.

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ TERMS OF OFFICE

Tenure – the tenure of appointment for a Non‐Executive Director will initially be for a three‐year period. Re‐appointment for a further three‐year period will be subject to satisfactory appraisal and agreement by the Council of Governors.

Remuneration and Time Commitment – remuneration will be £12,524 per annum for an average commitment of 3‐4 days per month (inclusive of preparation time). (Enhancements will be paid dependent on any additional responsibilities). Non‐Executive Director remuneration is reviewed and set by the Council of Governors. Appropriate allowances for travel and subsistence will also be paid.

Disqualification – an individual may not serve as a Non‐Executive Director if he/she is disqualified for any of the reasons set out in the Trust’s constitution, Monitor’s Provider Licence or the Fit and Proper Persons Regulations.

Termination ‐ a Non‐Executive Director may be removed from appointment in accordance with the procedure set out in the constitution and the approval of the Council of Governors.

Other – this post is a public appointment and is not subject to the provisions of employment law. To ensure that public service values are maintained, all Directors are required, on appointment, to agree to abide by the Board of Directors’ ‘Code of Conduct’

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

PERSON SPECIFICATION

Post Title: Non‐Executive Director ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ The Trust is looking to appoint 3 Non‐Executive Directors, one of whom offers significant and recent financial expertise and, ideally, a relevant financial qualification.

In addition, the Trust has identified the following criteria for all appointments. which candidates will be required to demonstrate through application and at interview:

Knowledge and  Experience of operating at, or near, Board level in a large, complex and Experience changing organisation  Experience of leading transformational change  Evidence of strategic thinking  Track record of success  Understanding of, and commitment to, NHS values of accountability, probity and equality of opportunity  Understanding of the role, legal duties, responsibilities and liabilities of a Non‐Executive Director and the relationship with Governors  Understanding of the needs and expectations of service users, carers and the wider community  Experience of working productively with a wide range of internal and external partners at a strategic level  Sound knowledge of corporate governance and risk systems  Experience and understanding of strategic planning, financial control, performance management and assurance Skills and Abilities  Excellent communication and interpersonal skills  Commercial and political astuteness  Ability to understand complex issues and information in order to make pragmatic decisions  Ability to champion the service user and carer, and wider public, voice in the Trust’s financial and strategic context Personal Qualities  Prepared and able to make difficult decisions and challenge constructively  A strong commitment to the Trust and its values  Commitment to continuous improvement and delivery of high quality services  Team player  Prepared to undertake varied roles and Chair meetings  Sufficient time and commitment to fulfil the requirements of the role  Meets the Trust’s eligibility criteria for a Non‐Executive Director  Ideally, able to demonstrate local knowledge

Board of Directors – Part 1

TITLE OF REPORT: Policy for the Reimbursement of Governor Expenses DATE OF MEETING: 26th September 2016 AGENDA ITEM: 18 PRESENTED BY: Rupert Nichols, Chair AUTHOR(S): Kim Saville, Company Secretary

EXECUTIVE SUMMARY: The Trust is committed to providing fair and appropriate reimbursement for reasonable expenses incurred by Governors in undertaking their duties and participating in activities and events arranged by or through the Trust.

The Trust’s current ‘Policy for the Reimbursement of Governor Expenses’ dates back to 2008. This Policy has been reviewed and re‐drafted in August 2016 to reflect an agreed change to governor mileage rates and incorporate changes to the process for reimbursement. See attached. It is proposed that, for consistency, the reimbursement process is via payroll going forward and Governors will be required to complete an ‘Electronic Staff Record’ booklet to facilitate this.

The Council of Governors considered and supported the updated Policy at their meeting on 13th September 2016. The Board of Directors are now asked to approve the ‘Policy for the Reimbursement of Governor Expenses’.

LINKS TO OTHER KEY N/a REPORTS/DECISIONS: LEGAL/REGULATORY N/a IMPLICATIONS:

DOES THIS REPORT ADDRESS A RISK ON THE BOARD ASSURANCE FRAMEWORK (BAF)? No If ‘yes’: DATIX ID Strategic Objective Description (as per BAF)

RECOMMENDATIONS: The Board of Directors are asked to approve the ‘Policy for the Reimbursement of Governor Expenses’

POLICY FOR THE REIMBURSEMENT OF GOVERNOR EXPENSES

Responsible Director: Director of HR and Corporate Services

Document Author: Kim Saville, Company Secretary

Document Type: Policy and procedure

Target Audience: Council of Governors The Trust will provide fair and appropriate reimbursement for Document reasonable expenses incurred by Governors in undertaking their duties Purpose/Scope: and participating in activities and events arranged by or through the Trust.

This Policy defines what the Trust considers to be claimable Governor expenses and sets out the framework within which expenses will be reviewed, authorised and processed.

Date Approved: TBC

Approved by: TBC

Implementation Date: TBC

Review Date: TBC ‐ 3‐year review period

Date of Equality Impact 22nd August 2016 Assessment:

Version: 2.0 Replaces Version 1.0 (December 2007) Review Date: TBC

POLICY FOR THE REIMBURSEMENT OF GOVERNOR EXPENSES

Contents Page No.

1. Introduction 3

2. Aims and Objectives 3

3. Scope 3

4. Duties 4

5. Claimable Expenses 4

6. Process for Reimbursement 6

7. Training and Support 6

8. Monitoring 7

Appendix 1 – Governor Expenses Claim Form 8

POLICY FOR THE REIMBURSEMENT OF GOVERNOR EXPENSES

1. Introduction

1.1 The statutory roles and responsibilities of Governors are set out in the National Health Service Act 2006 and the Health and Social Care Act 2012. The over‐riding role of Governors is to hold the non‐executive directors to account for the performance of the Board of Directors and to represent the interests of the Trust’s membership and of the public. Governors do not undertake operational management of NHS Foundation Trusts.

1.2 This post of Governor of an NHS Foundation Trust is voluntary, and it is a fundamental principle that no Governor shall receive any form of salary for being a Governor.

1.3 The Trust will provide fair and appropriate reimbursement for reasonable expenses incurred by Governors in undertaking their duties and participating in activities and events arranged by or through the Trust.

2. Aims and Objectives

2.1 This Policy:

2.1.1 Sets the framework within which claims for expenses incurred by Governors will be processed

2.1.2 Sets out responsibilities for ensuring that claims are subject to an appropriate level of scrutiny and authorisation

2.1.3 Encourages equal opportunities by facilitating participation of all governors by ensuring that individuals contributing their views or time are not excluded due to financial restraints

2.1.4 Promotes an ethos of fairness and delivering value for money by making clear the appropriate nature and level of expenses to be incurred

3. Scope

3.1 This Policy applies to all members of the Council of Governors equally, with the exception of the Chair. For the avoidance of doubt, members of the Council of Governors include public governors, service user and carer governors, staff governors and appointed governors.

POLICY FOR THE REIMBURSEMENT OF GOVERNOR EXPENSES

4. Duties

4.1 The Board of Directors:

4.1.1 The Board of Directors is responsible for approving this Policy

4.2 Company Secretary:

4.2.1 The Company Secretary is responsible for:

4.2.1.1 Interpreting this Policy on a day to day basis 4.2.1.2 Reviewing and authorising expenses claims in accordance with this Policy 4.2.1.3 Bringing the content of this Policy to the attention of new Governors as part of the induction process 4.2.1.4 Ensuring that this Policy is subject to periodic review 4.2.1.5 Providing advice and guidance on the general nature and level of appropriate expenditure prior to expenses being incurred

4.3 Chief Executive Office Manager/Executive PA:

4.3.1 The Chief Executive Office Manager/Executive PA is responsible for the onward processing of Governors’ expenses claims in accordance with this Policy.

4.4 Governors:

4.4.1 Individual Governors are responsible for:

4.4.1.1 Ensuring adherence with this Policy 4.4.1.2 Submitting claims in a timely and accurate manner 4.4.1.3 Only incurring expenditure that is appropriate and consistent with their role and the needs of the Council of Governors

5. Claimable Expenses

5.1 Governors participating in Trust events such as meetings of the Council of Governors, committees or working groups as agreed or invited by the Trust, and whose expenses are not paid by another organisation, are entitled to claim expenses.

5.2 Governors participating in external events without specific invitation, or prior written agreement with the Trust, will not receive reimbursement.

POLICY FOR THE REIMBURSEMENT OF GOVERNOR EXPENSES

5.3 Expenses for Governors will only be reimbursed for the following expenditure:

5.3.1 Travel expenses by the most reasonable means, including car mileage at 56p per mile, motorcycle mileage at 28p per mile and pedal cycle mileage at 20p per mile

5.3.2 Public transport expenses (standard class only) on provision of a receipt or ticket

5.3.3 Parking expenses on provision of a receipt or ticket

5.3.4 Payment for taxis or other alternative travel arrangements (for example, in the event that illness of disability prevents a Governor from travelling by car or accessing public transport, or where a Governor’s involvement is outside of public transport hours), only by prior agreement with the Company Secretary

5.3.5 Passenger payments allowance for passengers being transported as a direct result of Governor duties (currently 5p per mile)

5.3.6 Subsistence allowance where the Governor is away from home for longer than five hours for the purpose of attending a designated meeting and where no refreshment is provided at the Trust’s expense. Reimbursement of receipted expenses can be claimed up to a maximum rate of £5.00. (For more than ten hours, reimbursement of receipted expenses can be claimed up to a maximum of £15.00). Periods away from home are calculated from the time of leaving to the time of returning home. Except in exceptional circumstances, overnight expenses will not be paid

5.3.7 Reasonable receipted costs for caring arrangements, only by prior agreement with the Company Secretary who will consider such claims on a case by case basis

5.3.8 Reasonable expenses of a companion to enable a Governor to participate, only by prior agreement with the Company Secretary

5.3.9 Reasonable receipted costs for use of an interpreter, only by prior agreement with the Company Secretary

5.3.10 Expenses associated with agreed attendance at conferences or external meetings by Governors on behalf of the Trust. The Trust will aim to arrange prepaid travel, accommodation and meals where required and possible to keep out of pocket expenses low for Governors.

5.3.11 Additional reimbursement such as an individual being requested to undertake specific work such as a presentation or training, including preparation and administration, only by prior agreement with the Company Secretary

POLICY FOR THE REIMBURSEMENT OF GOVERNOR EXPENSES

6. Process for Reimbursement

6.1 An expenses claim form is attached as Appendix 1 to this Policy. Claim forms are available on request from the Company Secretary or Chief Executive Office Manager/Executive PA.

6.2 Completed claim forms should be sent to the Company Secretary at the following address for review and authorisation:

Company Secretary Trust Headquarters 1st Floor, The Curve Bury New Road Prestwich Greater Manchester M25 3BL

6.3 Authorised claims will be sent to Payroll, via the approved courier service, by the Chief Executive Office Manager/Executive PA.

6.4 Claims will normally be reimbursed direct to a nominated bank or building society on the first available payment run following receipt of an authorised claim. Payment dates fall on the 26th of the month, unless the 26th falls on a weekend or bank holiday in which case the payment date would be the preceding working day.

6.5 All expenses except mileage claims should be submitted with valid tickets or receipts attached.

6.6 All claims must be retrospective and should be submitted within three months of the expenses being incurred.

6.7 If a Governor is in receipt of benefits, it is their responsibility to check with their local benefit agency whether the receipt of expenses might affect their entitlements.

7. Training and Support

7.1 There is no formal training requirement associated with this Policy.

7.2 The content of this Policy will be brought to the attention of new Governors as part of the Induction Process.

7.3 The Company Secretary will be available to provide advice to members of the Council of Governors in relation to expenses claims and the application of this Policy.

POLICY FOR THE REIMBURSEMENT OF GOVERNOR EXPENSES

8. Monitoring

8.1 This Policy will be monitored on an ongoing basis by the Company Secretary.

8.2 Any expenses claims suspected to be fraudulent will be referred to the Trust’s Local Anti‐ Fraud Specialist for consideration of formal investigation in line with the Trust’s ‘Anti‐Fraud and Corruption Policy’.

POLICY FOR THE REIMBURSEMENT OF GOVERNOR EXPENSES

Appendix 1 GOVERNOR EXPENSES CLAIM FORM

Return completed forms to COMPANY SECRETARY

Name of Claimant:

Address of Claimant:

Assignment Number (must be completed):

Other Expenses Date Reason for Journey Travel Mileage Mode of e.g. covered Transport * parking **

From To

Total mileage covered

Total other expenses

POLICY FOR THE REIMBURSEMENT OF GOVERNOR EXPENSES

* please state motor vehicle, motor cycle, pedal cycle or public transport

** please attach original receipts

CLAIMANT CERTIFICATION I certify and declare that:

1- The travelling expenses and any other expenses claimed are in accordance with the Trust Policy for the Reimbursement of Governors’ Expenses and are in respect of expenses actually and necessarily incurred whilst engaged on the business stated. 2- No other claim has been or will be made by me on any public body for expenses or allowances in connection with the business stated. 3- The motor vehicle/cycle in respect of which mileage allowance is claimed is covered for full third party insurance cover against risk of injury or death of passengers and damage to property and the policy is maintained at the date of this claim (Please note that the Trust cannot accept responsibility in respect of any risks not covered by the claimant’s insurance policy). The insurance also includes cover for business use. 4- The motor vehicle/cycle in respect of which mileage allowance is claimed is covered by a valid MOT certificate (as appropriate to the vehicle). 5- I hold a current, valid, full driving licence (for motor vehicle and motorcycles).

I certify that the above mileage and expenses claimed have been incurred as claimed.

Print Name: ______Signature:

______Date: ______

COMPANY SECRETARY CERTIFICATION

I certify that the above mileage and expenses claimed have been incurred as claimed and confirm that I have the authority to countersign these claims.

Print Name: ______Signature:

______Date: ______

Fully certified forms need to be sent to ELFS Payroll via the approved courier service, which collects mail every Monday (Tuesday if Bank Holiday Monday) from the GMW post room at Prestwich.