Council of Governors 16th October 2017 Public
COUNCIL OF GOVERNORS MEETING IN PUBLIC
To be held on Monday 16 October 2017 at 11:00am In the Roebuck Suite, Hellingly, East Sussex, BN27 4ER AGENDA INTRODUCTION ACTION
11:00 CG 26/17 Introductions and apologies for absence
11:01 CG 27/17 To receive any declaration of interests
11:02 CG 28/17 Questions from members of the public
Minutes of the meeting held on 17th July 2017 and For 11:05 CG 29/17 Matters Arising A approval (Richard Bayley, Interim Chair)
CG 30/17 CURRENT PRIORITIES
Chief Executive’s Report For CG 30.1/17 B 11:10 (Sam Allen, Chief Executive) information
Lead Governor Report For CG 30.2/17 C 11:15 (Amy Herring, Lead Governor) information
Sustainability and Transformation Plan For CG 30.3/17 Verbal 11:20 (Sam Allen, Chief Executive) information
CG 31/17 ASSURANCE
CQC Compliance and Strategic Assurance For 11:30 CG 31.1/17 D (Diane Hull, Chief Nurse) assurance
To receive a report on Serious Incidents For 11:40 CG 31.2/17 E (Diane Hull, Chief Nurse) assurance
CG 32/17 HOLDING TO ACCOUNT
For 11:50 CG 32.1/17 Issues from the Council of Governors Assurance Verbal
Quality Committee Summary (Gordon Ferns, Non-Executive Director) For 12:00 CG32.2/17 F Feedback from Governor Observers information (Amy Dickinson, Service User Governor Mark Hughes, Carer Governor)
Finance & Investment Committee Summary (Finance Report) For 12:10 CG 32.3/17 (Richard Bayley, Non-Executive Director) information Verbal
Feedback from Governor Observers (Karen Braysher, Service User Governor Michael Decker, Service User Governor)
Audit Committee Summary For 12:20 CG 32.4/17 (Lewis Doyle, Non-Executive Director) information G Feedback from Governor Observers
Mental Health Act Committee Summary (Martin Richards, Non-Executive Director) For 12:30 CG 32.5/17 H Feedback from Governor Observers information (Sarah Gates, Public Governor)
CG 33/17 GOVERNANCE
Governor Committees and Working Groups:
For a) To receive an update from the Membership information Committee I (Mark Hughes, Carer Governor) b) To receive an update from the Nomination For J and Remuneration Committee information
12:40 CG 33.1/17 (Richard Bayley, Interim Chair)
c) To review and approve the Council For Committee’s Terms of Reference approval K (Adam Churcher, Head of Corporate Governance) d) To receive an update from the Governors For Verbal Development Day (6th October 2017) information (Amy Herring, Lead Governor)
To receive the Council of Governors Declaration 13:00 CG 33.2/17 of Interest Register To receive L (Adam Churcher, Head of Corporate Governance)
To agree the Frequency and Council of Governors For 13:05 CG 33.3/17 Meetings dates for 2018 approval M (Adam Churcher, Head of Corporate Governance)
13:10 CG 34/17 ANY OTHER BUSINESS
Date and Venue of the next Council of Governors Meeting TBC 2018
Sussex Partnership NHS Foundation Trust Council of Governors: 16th October 2017 - Public Agenda Item CG 29/17 Attachment: A For: Decision By: Michelle Jasilek, Corporate Governance Administrator SUSSEX PARTNERSHIP NHS FOUNDATION TRUST
Minutes of the Council of Governors held in public on Monday 17th July 2017 at 11:00 in the Lecture Theatre, Sussex Education Centre, Mill View, Hove
Present Diana Marsland, Non-Executive Director (DM, Chair) Sam Allen, Chief Executive (SA) Scott Hunt, Public Governor (SH) Amy Herring, Service User Governor (AH) Giles Adams, Appointed Governor (GA) Phyllida De Salis, Public Governor (PDS) Sarah Gates, Appointed Governor (SG) Elizabeth Hall, Service User Governor (EH) Louise Patmore, Staff Governor (LP) Mark Hughes, Carer Governor (MH) Karen Braysher, Service User Governor (KB) Jayne Bruce, Staff Governor (JB) Dr Jose Belda, Staff Governor ( JoB) Gabrielle Gardner, Service User Governor (GG) Fiona McClay, Service User Governor (FM) Rachel Brett, Appointed Governor (RB) Bryan Goodenough, Carer Governor (BG) Claire Quigley, Public Governor (CQ) John Holmstrom, Appointed Governor (JH) Paul Burris, Service User Governor (PB) Amy Dickinson, Service User Governor (AD) Martin Richards, Non-Executive Director (MR) Lewis Doyle, Non-Executive Director (LD) Anne Beales, Non-Executive Director (AB) Gordon Ferns, Non-Executive Director (GF)
In Attendance Michelle Jasilek, Corporate Governance Administrator (Minutes) Natalie Hennings, Corporate Governance Manager (NH) John Child, Chief Operating Officer – Brighton & Hove CCG (JC, for item CG 20.1/17) Diane Hull, Chief Nurse (DH, for item CG 21.1/17) Sally Flint, Chief Finance Officer (SF, for item CG 25.1/17) Satinder Jas, External Auditor KPMG (SJ, for item CG 25.2/17) Lou Morgan, Deputy Director of People Participation (LM, for item CG 25.4/17)
Observers 1x Member of the public
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ITEM NO ITEM
INTRODUCTION
CG 17/17 Introductions and Apologies for absence
1 DM welcomed all present to the meeting. 2 DM noted apologies from: 3 Caroline Armitage, Chair Andrew Voyce, Service User Governor Simon Street, Staff Governor Michael Decker, Service User Governor Katie Glover, Appointed Governor Richard Bayley, Non-Executive Director Adam Churcher, Head of Corporate Governance Diana Byrne, Service User Governor Sarah Reynolds, Staff Governor Bryan Doughty, Appointed Governor Debbie Kennard, Appointed Governor David Fowler, Appointed Governor Sue Esser, Director of HR & OD
CG 18/17 To receive any declarations of interest
4 PB advised the Council that he has taken on a role as an Occupational Therapy Course Representative for Brighton University. 5 LP advised the Council that she is on the Committee for STP.
CG 19/17 Questions from members of the public
6 DM advised that there were no questions submitted by members of the public prior to the meeting.
CG 20/17 CURRENT PRIORITIES
CG 20.1/17 Sustainability and Transformation Plan (STP)
7 The STP slides were taken as read. 8 JC advised that the STP has recently changed to Sustainability and Transformation Partnership from Sustainability and Transformation Plan. There are a significant
number of organisations working together in partnership to make system improvements. 9 There is a STP work stream for mental health, SA is the Senior Responsible Officer and JC is working as a Commissioner. There is a 17 week project underway to review mental health across Sussex and East Surrey. There will be a significant overlap with the STP and the Trust’s Clinical Strategy. 10 PDS asked how this will be different and what it is going to achieve. JC advised that this is a unique opportunity for all organisations to work together, mental health is being recognised as a priority, which hasn’t happened before. SA added that it is a time consuming process, however feels it is worthwhile, and it is a real opportunity for the Trust to engage with partners and create shared priorities across 23
organisations. We are currently in the process of pulling data together, a delivery Page 2 of 11
plan with a clear set of priorities and outcomes will be brought to the Council of Governors in October.
11 Action: An update on STP to be brought to the October Council of Governors, to include the delivery plan with a clear set of priorities and outcomes
AD felt that the communication of what is taking place needs to improve, as at the 12 moment people don’t know the time line and when they should start seeing the outcomes. AD is also concerned around funding. 13 CQ wished to understand the vision and what is expected to be different for patients in 5 years’ time. SH felt that this is a prime opportunity for mental health to have a voice in every sector and we should see great change. KB highlighted the importance of the relationship between the patient and GP. LP advised that she represents service users in the STP and Clinical Strategy, and there has been a lot of service user engagement across the Trust. The STP is looking at putting more services in the community. Mental health training is also starting to be delivered in A&E units, and more partnership linking is starting to happen. There are positives taking place that haven’t been seen before.
JC recognised that communication across STP hasn’t been good; however a lot of 14 attention is going in to how we now get this right. Regarding finance, there is a plan
in place for the STP process to bridge the gap; the £900m figure is the “do nothing
differently” scenario. The STP process allows mental health to articulate the offer it
will bring to the mental health system; it is about what mental health can do to
support acute services in a better way. It will also give emphasis for great integrated
care.
15 SA advised that from a Trust perspective, the biggest difference this time is the Clinical Strategy, it is currently on its second iteration and should be finalised by September. Regarding what will look differently in 5 years’ time, for example, if you have diabetes you will also have access to cognitive therapy. We will also see more peer support workers across the workforce, people in A&E will be trained in mental health and we will have open youth access services, along with many other positives.
CG 20.2/17 Chief Executive’s Report
16 SA wished to highlight National Carers Week which took place the week commencing 12th June 2017during which a lot of positive work happened across the
Trust over this period.
The second Chief Executive Briefing is taking place on 19th 17 July; the focus will be on team development, health and wellbeing - which continues to be extremely important as services continue to operate under real pressure, and The introduction of our Freedom to Speak Up Guardian and the importance to continue promoting the cultural work encouraging staff to speak up.
18 The Council discussed mandatory and statutory training; it continues to be a challenge, however good progress is being made. There are still difficulties with connecting My Learning and ESR systems which is causing problems in validating data. The Golden Source Project will be starting, which will involve linking all systems and databases across the Trust. Following the incident at Grenfell Tower, we were asked to check our buildings for any cladding. We were able to provide assurance on this, and we have no emerging fire risks in our inpatient buildings. There has also been a real push on fire safety training. 19 SA advised that there is an internal clinically lead review on Older Peoples and Page 3 of 11
Dementia Services which will be undertaken over the next 4 months, as the Board feels that these services are a priority. There will be opportunities for contributions from Governors, staff and members of the public. This work will be overseen by the Steering Group.
CG 20.3/17 Lead Governor Report
20 The Lead Governor report was taken as read, and EH had nothing new to add. 21 AH wished to thank EH on behalf of the Council for all she has done as Lead Governor. DM thanked EH and SH for their leadership and hard work during their tenure as Lead and Deputy Lead Governor.
CG 20.4/17 Recruitment & Retention Update
22 SA advised that SE was unable to attend the Council meeting and proposed that any comments or questions relating to the presentation slides be fed back to SE to provide answers on Alfresco or at the next Council meeting in October. 23 PDS requested that a view on the picture over 2-3 years would be helpful, rather than just 12 months. 24 GF advised that the way in which the retention figures were presented at above 100% was not very clear. 25 SA advised that we are one of 23 NHS organisations working with NHSI on the second phase of the Lord Carter Review. A 90 day Rapid Improvement Project started last week. It gives us a good opportunity to look at rostering, and other learning for recruitment and retention. It was agreed that an update on the Lord Carter work will be brought to the Council of Governors in October. 26 Action: Update on the Lord Carter review to be brought to the Council of Governors in October 27 AD felt that it is very positive to see information in the Clinical Strategy in upskilling our workforce, and also using apprenticeships. 28 CQ noted that the exit survey data was interesting, however would like to see specific actions that are taken around the identified areas in future papers. GA also asked how the reasons in the exit survey data were numbered, and felt that they should be numbered in order of top priority for addressing first. 29 Action: For future Recruitment and Retention papers to include specific actions that are being taken around the identified areas 30 GG highlighted that although it shows staff retention figures, there are no dates on the activity and would like to see this in future. 31 Action: Dates for activity to be provided in the next paper on Recruitment and Retention 32 AH asked that with regards to the “Broaden Experience” reason in the exit survey data whether the leavers are given the opportunity to say what this experience is that they are leaving for. SA advised that the exit survey data is helpful, however it has highlighted that we have missed opportunities in asking specific questions, and these are really important, as we need to be acting sooner.
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CG 21/17 ASSURANCE
CG 21.1/17 Annual Mortality & Serious Incidents Report
33 DH advised that with regards to 3.3 in the paper, East Sussex has seen a gradual increase in the number of SI’s. The action plan following the Thematic Review continues to be reviewed and looks as themes and patient profile, to gain a better understanding of what is happening in East Sussex. 34 3.9 of the report shows a reduction in slips trips and falls, and there is a dual review with the CCG’s taking place to look into deaths relating to substance misuse over the past 3 years. 35 There are currently 139 SI actions that need to be closed down, and Justine Rosser is working with the CDS’s to help with this. 36 AH asked whether this is an action plan in place to reduce the number of self-harm SI’s. DH advised that each SI has its own action plan, we are working closely with CCG’s in order to reduce the number of actions, to make the ones we do have more meaningful. There is also an SI Mortality Scrutiny Group which is chaired by SA which looks at SI reports in detail, to see whether we need to change our approach, what the themes and critical points are, and what we can do differently. 37 In section 4.5.3, Figure 8 shows the total number of fatalities reported as a SI by cause in 2016/17 compared to 2015/16, KB asked with regards to 25 Ligature deaths, whether this in or outside of hospital. DH confirmed that this is outside of hospital. KB feels that there needs to be a half-way house between being discharged from hospital and returning home, as there is a gap here. SA advised that we haven’t yet been able to benchmark the number of deaths against other organisations; however we are now capturing more data. We have changed the 7 day follow up to 48 hours for the Trust to work towards as a standard. In terms of a half-way house, there is the Sanctuary in Sussex, and through the STP model of care we will be advocating this, as it could be an alternative to someone going home. RF is also leading on a piece of work through the Suicide Prevention Strategy. KB is happy to help in any way towards this, if needed. 38 SH felt concerned with the number of incidents happening in East Sussex, and asked whether this is due to staff shortages and training levels. DH advised that this is why a review is being carried out, and we will need to think about making changes in the service following this, the details and plans following the review will be brought to the Council of Governors in October. 39 Action: A more detailed report on incidents, and information/actions on the review being carried out to be brought to the Council of Governors in October 40 AD feels that from a service user perspective, there is a lot of work that needs to be done with primary and secondary care for suicidal ideation, the crisis helplines are not always helpful. There has also been an issue with capacity for the Mental Health Rapid Response Service (MHRRS). Further training needs to be carried out in services on what to do if people are expressing suicide ideation. People need to feel heard, and this is as important as treatment that is given. 41 JB advised that there is a lot of work underway with safeguarding adults and children looking at self-harm and self-neglect. 4 new posts are being recruited to, and we are working closely with our safeguarding boards. 42 DH advised that it is about how we use participation, buddy systems and how we do things differently. AD confirmed that she is happy to help with this, and will discuss
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further with DH. 43 SH added that there is a lot more work to do around access, demand and capacity is an ongoing issue. There are a lot of positive stories as well; however we are not getting the consistency. SA confirmed that she will pick up the issue with MHRRS.
CG 22/17 HOLDING TO ACCOUNT
CG 22.1/17 Issues from the Council of Governors
44 There were no issues from the Council of Governors raised.
CG 22.2/17 Quality Committee Summary
45 The paper summarises the meeting which took place in May, there was a recent meeting held on 12th July 2017. GF provided the Council with updates and information on discussion points as followed; 46 The new sub-committee structure has now been established, and Chairs have been identified for these. The importance of including service users and carers as part of the membership to the sub-committees was discussed. 47 A leaflet is being developed for care planning, which is now called “personal support planning”. 48 Teams with low compliance levels for mandatory and statutory training are being contacted individually. 49 A new Participation Lead has been appointed and will be starting at the end of August. 50 A Recruitment Task and Finish Group has been established, as recruitment and retention continues to be an issue. DH advised that the group will be targeting newly qualified students. DM added that the New Roles Working Group gave an update at the Committee, and the Quality Committee will be looking at the new roles and recruitment for them. 51 Following serious incidents at Woodlands and Caburn Ward, action plans have been put in place, and the observation policy has been circulated to staff.
CG 23.2/17 Feedback from Governor Observers
52 MH welcomed how well GF and DM lead the Committee. 53 SH felt that the Trust/Governors need to be aware that there has been a 10% drop in the number of people completing nurse training, there has also been a huge drop in the number of people coming out of medical school and staying in the country. Teams are under huge pressure. DM added that working on new roles is part of helping with this issue, however in some areas the staff aren’t there to actually recruit. SH noted that it is important that we aren’t taking staff from other teams to fill the new roles. 54 SA advised that it has a lot to do with leadership and culture, and being positive in where you work. Langley Green Hospital has made considerable improvements in the last year, and we need to have the same focus on other sites where there are issues. We need to create a culture where people want to come to work. As a Trust we need to be speaking positively about our organisation, and request the help from Governors to do this as well.
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CG 23.3/17 Finance & Investment Committee Summary
55 SF advised that the paper shows the position at Month 2, the Finance & Investment Committee meet formally and informally bi-monthly. 56 Month 2 showed a deficit of £102k, through contract negotiations we have closed the £1.3m gap. The challenges are the high use of agency, and delivering Service Improvement Plans. There was an overspend in inpatient units as a consequence of the amount of vacancies resulting in the use of agency staff. There has been a real pressure on inpatient beds and we have had a number of out of area admissions. We are working closely with Commissioners on joint recovery plans in order to address the problems and want to set up a Joint Delivery Service Board. 57 It has emerged through the mental health work stream that there is a huge variation in the CCG’s investment in mental health. The ways of addressing this will be the outcome of the STP work and Clinical Strategy. 58 MR asked whether the expectation is still a breakeven position at year end and also what the rating numbers mean. SF confirmed that it is, and explained that NHSI ratings are 1 is good and 4 is low: we currently have a rating of 3. We have good cash reserves, however agency spend is the main issue and we will be rating our CDS’s in order to address the agency problem. 59 KB asked whether the Trust could pay graduate nurse’s tuition fees over a period of time as this would help attract and retain candidates thereby helping to reduce agency spend. SF advised that the department would need to do a study on this, but agreed that it would help with retention. LD added that he has seen this done elsewhere and it has worked with mixed results. 60 SA advised that NHSI set the agency cap and we are spending 50% over this. Incentives that we have been offering Golden Hellos, offering to pay for nurse accommodation for the first 3 months and increasing bank pay rates. DH added that we are also running a project in East Sussex where we will pay students band 3 in the second year and offer them intensive support in order to attract them to the Trust. Discussions have taken place with Brighton and Surrey Universities regarding increasing the number of nurses on courses. Portsmouth University is also interested in working in partnership with us to become a school of nursing. We want to start interviewing students in their second year and then giving them dedicated coaching in their final year.
CG 23.3/17 Feedback from Governor Observers
61 Discussed above.
CG 22.4/17 Audit Committee Summary
62 The Audit Committee last met in May. LD advised that the focus was on year end and counter fraud. There have been many changes with the Executive Team and we had to make sure that previous recommendations haven’t been lost. Both sets of auditors have performed well and have given good insight.
CG 22.4/17 Feedback from Governor Observers
63 CQ advised that the report highlights things that are completely within the Trust’s control. The agency review was only given a red/amber rating so the Board is unable
to take full assurance on this, however the focus on this is helpful and needs to continue.
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64 DM added that the Audit Committee could have chosen easy options for internal audit but selected areas thought to have difficulties in order to see improvements that can be made.
CG 22.5/17 Mental Health Act Committee Summary
65 MR advised that patient care is at the heart of the Mental Health Act Committee work, and it is also about following the law, which the CQC visits are making sure we do. Good practice has been identified, Associate Hospital Managers attend, which plays an important role in gaining feedback. 66 Regarding ligatures, the CQC have given positive feedback on the ligature footprint maps.
CG 22.5/17 Feedback from Governor Observers
67 SG noted that there has been an improvement in attendance levels, and thanked MR for this. 68 JH asked whether there is an adequate supply of legal aid Mental Health Practitioners and whether the legal aid lawyers feedback. MR advised this hasn’t
been considered in the last 12 months, however is a good suggestion. PDS noted
that the use of advocates also don’t seem to be used.
69 LP asked whether there is service user and carer attendance. MR advised that they are not currently on the circulation list. LP also noted that with regards to the nearest relative, it is not always straight forward in identifying this, and also may be that the patient doesn’t want their nearest relative to be included due to various reasons. SA advised that we will look into this, to check the process. MR added that he will also liaise with Ellen Lim, Associate Director of Legal Affairs and Governance EPRR Lead 70 Action: MR to liaise with Ellen Lim and discuss the process regards ‘nearest relative’ 71 PDS added that originally it was Associate Hospital Managers who would review papers, and would have more knowledge regarding the nearest relative and asked what the process is now. JoB advised that section papers are now allocated to Consultants who are on a rota for scrutiny. 72 DM confirmed that these have been helpful comments that the Committee can look at for the future. 73 Comfort break 12:38 74 JoB left the meeting.
CG 23/17 GOVERNANCE
CG 23.1/17 Governor Committees and Working Groups
To receive an update from the Membership Committee 75 MH advised that we have been moving people from post to email in order to cut down on costs; there has been some success in this area. For people that have not responded we have closed their membership. We need to be clear of what the benefits of membership are and work on engaging with members. We are also looking at how this links with participation, and what we can offer through
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participation activity. 76 AB we need to guarantee the principal, that if you get involved it will help improve your wellbeing, and there is a real commitment to looking at this. 77 DM understood that the need to move to email, however asked whether members have received reminders about the change to email. MH confirmed that reminders have gone out. 78 DM noted that the last issue of Partnership Matters was really good and informative, and thanked the Committee.
CG 23.2/17 Minutes of the meeting held on 24th April 2017 and Matters Arising
79 The minutes of the meeting held on 24th April 2017 were approved as an accurate record. 80 PDS noted that a previous action was for a presentation on Spirituality to be at this meeting, and asked why this has not happened. SH advised that Shakil Malik is liaising with other staff first as further work needs to be done. NH confirmed that it is tentatively scheduled for the October meeting. 81 Action CG 06.1/17 “Buddy System update to be brought to the Council of Governors in July” 82 DH provided the below update;
the ENRICH project is an academic study that has been trialled in another
Trust that trains people with lived experience to support people transferring
from mental health hospital setting to home
we are signed up to trial this at both Langley Green and Mill View, Capital are
the leading agency, and SPFT have to be led by them re: start dates etc.
a recent update from Capital advised that they are still recruiting/about to train and therefore have had to put back the start date, and are looking at Autumn now the People Participation Team and AB are working with leads/other organisations to develop a new Peer Strategy which is closely aligned to the Clinical Strategy commitments to develop more peer support roles also there are lots of other opportunities for people with lived experience to support the Trust, from interview panels to Quality Visits and we are delivering training to support them to do this. 83 KB asked whether we could have the details of what is involved for the model we’re following. DH confirmed that she would need to liaise with Bryan Lynch, Deputy Director of Social Work. AB advised that the Enrich Project is a national project, which Sussex Partnership are signed up to, it is being evaluated to see how effective it is in supporting people. There is also a Capital Project which we are recruiting to this week and advised that training taking place next week if any Governors would like to be involved. 84 KB advised that Bipolar UK have support groups across the country and feels that they would be a good model to use. KB runs the Lewes branch which meets once a month. AB agreed that Bipolar UK is a model that we should adopt. 85 SH asked what needs to be done in order to make sure everyone is on the same page. AB advised that a lot of hard work needs to take place, and it is about revisiting research that has taken place, and doing additional new research. We need to go back to the principal of peer worthiness. 86 SA advised that it is a good opportunity to reflect on what we have done, and look at Page 9 of 11
how we accelerate this and take this forward. An update will be brought back in October in order for Governors help with the development. 87 Action: An updated paper on the Buddy System to be brought back to the Council of Governors in October so that Governors can have input
CG 24/17 Any Other Business
Team Development Days 88 AH noted that team development days are now being rolled out across the Trust, and asked whether this is something that can be extended to the Governors as well. SA confirmed that yes the Council of Governors should be included in this, and we can work with the Governors in order to look at team development leads. NH confirmed that this can be added as an item on the agenda for the next Training and Development Committee in August. 89 Action: Team Development Day to be an item on the agenda of the Training and Development Committee in August
7 Day Follow Up
90 GA said that he was concerned to see a drop in follow ups within 7 days and asked to have assurance performance was moving in the right direction. SA advised the drop coincides with how the criteria and measuring of audits is set. KPMG
highlighted that there were changes and confirmed that there was no harm to patients as a result of this. It is something that we are currently really focusing on. SF advised that we are changing our target to follow up within 48 hours and the Trust is working towards this as a standard. As part of the performance review, we look at every patient that wasn’t followed up with the correct timescale.
CG 25/17 ANNUAL GENERAL MEETING / ANNUAL REPORTS
CG 25.1/17 Annual Report and Annual Accounts 2016/17
91 Governors were given a copy at the meeting. SF advised that it sets out what was prescribed by NHSI, it is a requirement for the Trust to prepare a set of Annual
Accounts and to include a Quality Report.
92 The report sets out the key work and themes for the Trust for 2016/17 and gives a forward look at what we are doing this coming year. The Quality Report produced by Jonathan Beder includes the quality indicators for the year and how we have performed. The Annual Accounts shows the financial position for the year, and the cover sheet 93 highlights the issues. There will be a more user-friendly version summary available at the Annual Members Meeting in October.
94 PDS noted that in future it would be helpful to have a more detailed contents page. 95 Action: Annual Report to have a more detailed contents page going forward
The Council of Governors confirmed that they were happy to receive the Annual 96 Report and Annual Accounts for 2016/17.
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CG 25.2/17 External Auditor (KPMG) Update
97 SJ summarised the main points from the presentation slides which were included within the papers.
98 DM asked for a clarification on what NAO stood for and JS advised that this is the National Audit Office. CQ asked what work KPMG did on statutory and mandatory training and what the 99 outcomes were. SJ advised that their process was to review all training recorded on the system and to compare this with actual records. When the review was carried out, discrepancies were found. SF advised that this year, staff who change teams will be recorded as this was one of the reasons for the discrepancies. Systems need to be linked in order to know whether each individual is compliant with their training. MH asked what the timescale is for the Golden Source project and SF advised that it should be finalised by the end of the financial year.
100 SG asked whether the data for the 7 day follow up was inaccurate. SJ advised that some of the data was incorrectly recorded, therefore the Trust decided to go back and look at the data again. With the indicators if the Trust decide not to choose the same indicators again for this year, KPMG will still look at whether anything was actioned from the recommendations. 101 DM noted that on last year’s Quality Account had a qualified opinion and we have an unqualified opinion this year.
CG 25.3/17 Proceedings of Council meetings/Changes to Governors
102 NH advised that it is a requirement for Governors to receive this report at the Annual General Meeting. The paper also provides detail on Governors’ election with
nominations closing at 17:00pm today, 17th July 2017. 103 DM thanked CQ for her support as a Governor, as she is now stepping down. 104 AD asked whether we have contacted Sophie Campbell, NH advised that we have tried contacting her on a number of occasions by all methods, and to date we have not had a response, therefore she is no long a member of the Council from the end of this month. 105 The Council of Governors confirmed that they were happy to receive the paper.
CG 25.4/17 An update on progress against the Membership Strategy
106 The paper was taken as read.
Date and Venue of the next Council of Governors Monday 16th October, time TBC Roebuck Suite, Hellingly
Signed………………………………………………………. Date………………….. Diana Marsland, Non-Executive Director Sussex Partnership NHS Foundation Trust
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Sussex Partnership NHS Foundation Trust Council of Governors: 16th October 2017 – Public Agenda Item: CG 29/17 Attachment: A For: Approval By: Michelle Jasilek, Corporate Governance Administrator
MATTERS ARISING: ACTION POINTS FROM THE COUNCIL OF GOVERNORS HELD IN PUBLIC ON 17th July 2017
Action Minute Action Points Lead Action Required Date Reference 16/01/2017 GC 03/17 The Quality Committee to investigate and provide a Diane Hull In Progress: being paragraph 7 response to the member of the publics submitted question investigated by the
regarding impact assessments on patients following PALS and incidents Complaints Manager
16/01/2017 CG 06.3/17 Serious Incident Reporting Gordon Ferns/ In Progress: being paragraph 85 A member of the public had submitted a question prior to Diane Hull investigated by the
the meeting. The Chair asked that this was picked up by PALS and the Quality Committee and a response provided. Complaints Manager
24/04/2017 CG 13.3/17 The Council requested an update on Smoke Free in Diane Hull Complete: An October update has been circulated to governors prior to the meeting
Page 1 of 3 Action Minute Action Points Lead Action Required Date Reference 17/07/2017 CG 20.1/17 An update on STP to be brought to the October Council of John Child/Sam Complete: Governors, to include the delivery plan with a clear set of Allen Scheduled on the priorities and outcomes agenda as a verbal update – item CG 30.3/17.
To note: The delivery plan and timescales not due to be approved until 30th October 2017.
17/07/2017 CG 20.4/17 Update on the Lord Carter review to be brought to the Sam Allen Complete: An Council of Governors in October update has been circulated to governors prior to the meeting
17/07/2017 CG 20.4/17 For future Recruitment and Retention papers to include Sue Esser To be included in specific actions that are being taken around the identified future papers areas.
17/07/2017 CG 20.4/17 Dates for activity to be provided in the next paper on Sue Esser To be included in
Recruitment and Retention future papers
17/07/2017 CG 21.1/17 A more detailed report on incidents, and Diane Hull Complete: Item on information/actions on the review being carried out to be the October agenda brought to the Council of Governors in October
17/07/2017 CG 23.2/17 An updated paper on the Buddy System to be brought Diane Hull In progress: Update back to the Council of Governors in October, in order for to be provided at the Governors to have an input into the development meeting
Page 2 of 3 Action Minute Action Points Lead Action Required Date Reference 17/07/2017 CG 24/17 Team Development Day to be an item on the agenda of Natalie Hennings Complete: Being the Training and Development Committee discussed at the Council Development Day on 6th October 2017
17/07/2017 CG 25.1/17 Annual Report to have a more detailed contents page Sally Flint Complete: Noted for
going forward future Annual reports
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Report to Council of Governors Agenda item CG 30.1/17 Attachment B EHRIA N/A code Date of meeting 16th October 2017 Format of Paper Title of paper Chief Executive Report Written Author Sam Allen, Chief Executive Oral ☐ Presenter Sam Allen, Chief Executive Presentation ☐ Committees/meetings where this item has been N/A considered Purpose of report (tick all that apply) To provide assurance ☐ For decision ☐ Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information To highlight patient, carer or staff experience ☐ Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report
In this report the Chief Executive will update the Council of Governors on a number of areas relating to local, regional and national issues.
Recommendation For the Council of Governors to note the report and ask any questions of the Chief Executive.
1. INTRODUCTION The purpose of this report is to provide a summary from the Chief Executive of information relating to Sussex Partnership colleagues and clinical services along with an overview of relevant regional and national items of interest. 2. REPORT 2.1 Introduction 2.1.1 Our inpatient and community teams continue to work hard to deliver a high quality, safe service operating under significant pressures. As an Executive Team we are supporting our Care Delivery Services to focus on reducing the number of people whose discharge is delayed. There are a variety of reasons why delays occur and some of them are complex and not all within our control however we are raising our level of ambition for those we serve to reduce the number of days people are in hospital when they should be in another setting. We are working closely with our health and care partners across the system on this as all services are under pressure, particularly as Winter draws closer.
2.1.2 The Care Quality Commissioner has started their most recent inspection of our services. The inspection process has changed and we are one of the first mental health trusts to receive a ‘Well-Led’ Inspection. The CQC will be inspecting a number of core services over the next couple of months, unannounced and we expect to receive feedback on the inspection in the New Year. 2.2 Sussex Partnership Colleagues 2.2.2 I am delighted to report the Trust has been shortlisted in three HSJ Awards and also the National Positive Practice Awards for Time for Dementia (shortlisted in both awards), i-Rock Youth Service and East Sussex Better Together (shortlisted in HSJ Awards). This demonstrates the Trust commitment to research, partnerships and innovative clinical service models co-produced with people who have lived experience.
2.2.3 On the 9th November we will have our own Positive Practice Awards and this year we have exceeded the record number of applications made last year with a total of 330 nominations. This will be an opportunity to value and celebrate the outstanding work of our colleagues.
2.2.4 This month I have met with the Chief Constable for Sussex Police and our joint group that oversees Operational Cavell. This is part of our focus on prevention of violence and aggression in the workplace – our highest reporting incident. Attached at Appendix 1 is a poster we have recently produced going in to our team and clinical bases. Wherever possible we want to reduce the likelihood of violence and harassment of staff and service users. This links with work our Chief Nurse is leading on reducing the use of restrictive practices. Where violence, harm of harassment does occur I want us to be an organisation that provides the best support to our staff and service users.
2.2.5 The Trust is testing the ‘ImproveWell’ App as a way of gathering and sharing ideas from people about improvement the services we provide and the way we work. One of our values is about being ‘future focused’, which means we are optimistic, we learn and always try to improve. Eight weeks in to testing the App we have had 53 people register and 32 improvement ideas shared. Our next step will be to do further communications on the sharing of the ideas and how others can get involved.
2.3 Sussex Partnership Clinical Teams & Networks 2.3.1 The Trust Board received an update on our Suicide Prevention Strategy this month. I specifically want to highlight the SAFE Campaign, which stands for Suicide Awareness for Everyone, run by our Hampshire CAMHS Team. This is an excellent piece of work and the evaluation is attached at appendix 2 for your information.
2.3.2 The Trust continues to progress work on Wave 2 of the New Care Models as the lead with partners across Surrey, Sussex and Kent, for Secure and Forensic Care. This month we will interview for a Programme Director to support the work. We have agreed with NHS England to slip the implementation timescale to April 2018 to enable further work to be undertaken on partnerships and infrastructure to support effective mobilisation.
2.3.3 A huge thank you to all our staff, Governors and peers who volunteered to support on the day at Brighton Pride on Saturday 5 August. It is reported that LGBTQ+ people have much higher rates of mental health problems and also detrimental coping strategies, which can lead to poor physical health and generally a decreased quality of life.
2.3.4 Walking in the Brighton Pride Parade with colleagues and friends of Sussex Partnership was a brilliant experience. I felt very proud to promote the importance of taking Pride in our Mental Health and the support from the community for the NHS was amazing! I also took pride in promoting the equality and diversity of our staff, the LGBTQ community and the work we do at Sussex Partnership to support each other to be ourselves and recognise the value this brings to our work.
2.4 Thematic Review 2.4.1 In October 2016 we published a thematic, independent review of homicides involving people known to our services. We commissioned this review jointly with NHS England.
2.3.2 The first phase of work in response to the thematic review has been completed over the last year. But the work will continue beyond that point because it’s about sustaining improvements on issues like listening to and supporting families. In the meantime, we’ve made lots of changes such as creating new family liaison roles and improving our electronic patient record system. We have also signed up to the Triangle of Care programme as a mechanism for measuring, monitoring and continuing to improve the support we have in place for carers within our local services. A more detailed update and progress against the action plan can be seen on our public website using the following link:
https://www.sussexpartnership.nhs.uk/our-thematic-review-1
2.5 Regional and National Highlights 2.5.1 The Executive Team met with representatives of the East Sussex, Brighton and Hove and West Sussex Health Overview Scrutiny Committees in August to update members on work with our Clinical Strategy, Thematic Review and other items of interest to the Committees. This is now established as a bi-annual meeting with attendance at local Committees.
2.5.2 I recently attended my first NHS Employers National Policy Board and had the opportunity to highlight the workforce planning and delivery requirements for the recently published mental health workforce plan. The plan sets out the commitment of the government to have:
• 2,000 additional nurses, consultants and therapist posts created in child and adolescent mental health services • 2,900 additional therapists and other allied health professionals supporting expanded access to adult talking therapies • 4,800 additional posts for nurses and therapists working in crisis care settings, with the majority of these (4,600) being nursing positions • Perinatal mental health support, liaison and diversion teams and early intervention teams working with people at risk
2.5.3 In common with many mental health and learning disability organisations across the country, we face significant challenges recruiting qualified nurses and doctors and other specialist mental health professionals. This is why we are focusing on developing new roles as part of our Clinical Strategy alongside recruitment and retention work targeting nursing and medical staff. Our teams do a fantastic job and are very flexible to meet the demands and open to exploring new roles we face in spite of these challenges.
2.5.4 I also wanted to take this opportunity to let you know that I have been meeting with a number of MPs across Sussex to discuss the services Sussex Partnership provides/ Whilst I have not met every MP yet I have met the following:
Amber Rudd MP Hugh Merriman MP Sir Peter Bottomley MP Peter Kyle MP Caroline Lucas MP Nick Gibb MP Sir Nicholas Soames MP Gillian Keegan MP Tim Loughton MP
I also have a meeting with the Hampshire MPs in Westminster on 17 November to discuss children and young people’s mental health services in Hampshire.
2.6 Sussex and East Surrey STP 2.6.1 The final workshop for the development of the strategic framework for mental health being developed across the STP will have taken place by the time of the Board meeting. The strategic framework will set out the priorities, opportunities to address these for the STP. I will provide an update on progress at the Board meeting. Alongside this we have been working closely with Clinical Commissioning Groups on the opportunities identified through the case for change and the financial plan. There has also been a further submission of the delivery plan for the Five Year Forward View to NHS England.
3. Recommendation For the Council of Governors to note the report and ask any questions of the Chief Executive.
HELP US HELP YOU
Our staff are here for you Please treat them and other visitors with respect It isn’t ok to be aggressive or abusive And it may lead to police prosecution
At Sussex Partnership we value, appreciate and respect each other. It’s an offence under the law to cause a nuisance or disturbance on NHS premises. Sam Allen, Chief Executive
Operation Cavell Working together to tackle violence and anti-social behaviour against NHS staff
SAFE (Suicide Awareness For Everyone) Campaign
Evaulation Report
September 10th 2016- Septmeber 10th 2017
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Index
1) SAFE Campaign Aims and Objectives p. 3 2) SAFE Campaign initiatives; summary and evaluation p. 3 2.1 Launch p. 3 2.2 SAFE Campaign Cards p. 4 2.3 SAFE Information Stands p. 5 2.4 Cycle 145 p. 7 2.5 Starfish Installation p. 8 2.6 Faces Of You p. 10 2.7 Teaching for NCS p. 11 3) SAFE Campaign Anniversary Week p. 14 3.1 Monday 4th September 2017 p. 19 3.2 Tuesday 5th September 2017 p. 21 3.3 Wednesday 6th September 2017 p. 23 3.4 Thursday 7th September 2017 p. 25 3.5 Friday 8th September 2017 p. 35 4) Next Steps for the SAFE Campaign p. 46
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1) SAFE Campaign Aims and Objectives
The objectives of the campaign;
Raise awareness of youth suicide and self-harm; the prevalence, contributing factors, impact on others and how to help and support Reduce stigma of mental health (specifically suicide) Improve confidence, knowledge and awareness of how and where to seek help and support Improve knowledge to all of the potential warning signs and of prevention/ risk reduction strategies Increase young people’s resilience/compassion/self-compassion Improve the emotional and psychological well-being of young people in Hampshire Enhance skills and confidence of parents/carers to manage and support a young person and know where to seek further support if required Continue and enhance opportunities for professionals within health/education/youth services to understand and support young people who engage in self-harm behaviour Work closely and collaborate with other relevant organisations to enhance joint working for the best outcomes for young people.
2) SAFE Campaign Initiatives; Summary and Evaluation
2.1 Launch
CAMHS staff held an information stand in Central Winchester on Saturday 10th September 2016, World Suicide Awareness Day. The information stand had a display board citing key statistics and figures relating to self-harm, suicide and suicidal behaviour prevalence in high risk/ vulnerable groups of young people. The information stand provided free resources about CAMHS and other relevant services available to support young people in crisis and their families. Clinicians engaged in discussion with the public about the campaign and CAMHS services.
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Additionally, within most of the 8 CAMHS clinics, an information presentation was installed onto TV screens within the reception/ waiting room areas. Where TV screens were unavailable, clinics had information stands displaying the same information. The information presentation highlighted key statistics about the prevalence of crisis in young people as well as information, advice, top tips and resources for young people, parents and carers and professionals who may be seeking to access additional support.
2.2 SAFE Campaign Cards
SAFE Campaign cards were designed by a CAMHS clinician and were widely disseminated across Hampshire. These were credit card sized cards detailing helpline numbers, websites and apps that young people, parents and carers can access for information and guidance when in crisis.
Front: Back:
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Over 17,000 cards have been distributed across many services and organisations across Hampshire.
Below is a distribution list of where SAFE cards have been provided:
Every Hampshire CAMHS Clinic
Every secondary school, college and pupil referent unit in Hampshire
Every GP surgery in Hampshire
Every Early Help Hub base in Hampshire
Every Children’s Care home, hostel and homeless centre in Hampshire
Every school nursing team in Hampshire
A&E and Children’s wards of; Southampton General Hospital, Royal Hampshire County Hospital, Frimley Park Hospital, Queen Alexandra Hospital, Basingstoke Hospital
A number of Hampshire Constabulary bases and custody suites
Hampshire Scouts and Girl Guides
Person Best Education: National Citizen Scheme
A number of libraries and art centres across Hampshire
Winchester and Portsmouth Street Pastors
Police Crime Commissioner for Youth
A number of train stations: Winchester, Eastleigh, Basingstoke, Andover, Havant and Petersfield, Fareham, Cosham, Fratton
2.3 SAFE Information Stands
SAFE display boards have been circulating between public venues, schools and youth organisations throughout Hampshire over the course of the year. The boards highlight key statistics relating to youth suicide along with top tips for how to cope in times of crisis and information on where and how to access support. Resources were also provided alongside the boards which included an A-Z leaflet of coping strategies, instructions for how to make a self-soothe coping box and SAFE cards.
Locations of the SAFE display boards were Hampshire wide and included; a number of secondary schools, a number of libraries, a number of arts centres and youth group centres. Of note, some boards were displayed in very rural parts of Hampshire which helped information reach those who may not normally have access to the information or resources.
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All venues that hosted a SAFE board were sent a brief evaluation form. Of the 18 venues that have so far hosted the boards, 11 completed evaluation forms were returned. Results are presented below.
Usefulness of the boards
The pie chart below represents how useful people found the SAFE boards to be. Of the 11 respondents, 81% (n=9) reported they felt the boards were “extremely” “very” or “quite” useful.
A pie chart to illustrate how useful participants felt the SAFE boards to be
Extremely Useful Very Useful Quite Useful Neutral Not very useful Not useful
The table below reflects the qualitative positive feedback about the SAFE boards.
Theme Number of Responses Boards enable conversations with young people about suicide 2 (and signposting where to go for help) Observed many people looking at the boards 6 Eye catching and visible 5 Helped to support local campaigns around Mental Health Week 4 and general education for local community about mental health Clear information and advice 1
The table below reflects the qualitative feedback about improvements or recommendations for the boards/ campaign
Theme Number of Responses Have someone there to talk through material 1 Pop up banner for ease of mobility 1 Different colour boards 2 Make resources more eye catching/ use more images 2
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According to the National Confidential Inquiry into Suicide and Homicide (2016), approximately 145 young people every year end their lives by suicide. This was a key statistic that SAFE Campaign events and initiatives sought to highlight through various activities and mediums.
2.4 Cycle 145
This initiative involved staff from Hampshire Child and Adolescent Mental Health Service (CAMHS) and Hampshire Constabulary cycling a combined distance of 145miles on two static bikes.
Hampshire CAMHS also had a stand providing information, advice and guidance to the general public about the services they provide, where and how young people and families can access support and practical strategies and resources to help young people who may experience episodes of crisis or distress.
Two events were run on different dates in different areas of the county. The first event was held on Wednesday 12th April 2017 at Fareham Shopping Centre and the second, Friday 11th August 2017 at Totton Precinct. Both dates were chosen as they were during the school holidays and as such it was hoped that teams would be able to engage with more young people and families.
Outcomes
- Over 145 miles were cycled at both events. - Staff engaged with over 200 young people, families and members of the general public across both events. Conversations were had about; the project’s purpose and aims, people’s own experiences of mental health, young people’s mental health and CAMHs services. - Self-help resources, signposting and the role of CAMHs were shared with the public. - Staff from both organisations reported the events were a useful collaboration and networking opportunity in order to present a united positive stance on the importance of young people’s mental health and wellbeing and working together to reduce youth suicide. - At the event in Fareham, money was raised for Red Lipstick Foundation (a charity that supports those bereaved by suicide).
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Starfish Installation Project
The Project
The project involved young people across Hampshire accessing a half hour interactive and engaging workshop focused on; young people exploring issues that impact on emotional health, wellbeing and functioning, discussions on how to cope when in crisis and where to access help and support. Following this, young people completed an hour long pottery/ ceramic workshop to make a starfish. Four installations each made up of 145 ceramic starfish; each one representing and in memory of a young person who ended their life by suicide, were displayed in public venue across Hampshire.
Rationale
The Starfish Story (adapted from The Star Thrower, by Loren Eiseley) was used as the basis for introducing the concepts of kindness, compassion and working together. The message delivered in workshops is that mental health and wellbeing is everyone’s business and that if collectively people demonstrate kindness and empathy, there could be a significant positive impact in reducing stigma about mental health difficulties which would enable more people to talk about their experiences and access help and support if needed.
The Starfish Story:
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Participants
Over 600 young people engaged with the project; engaging in the mental health and wellbeing workshop and making a starfish. Below is a list of the schools and organisations that participated in the project:
All in the Mind Festival (Mental Health Arts Festival)
Amery Hill Secondary School
Burgate Secondary School
Crestwood Secondary School
General Public
Hampshire CAMHS
Henry Beaufort Secondary School
King’s Secondary School
Perins Secondary School
Samaritans (Charity)
Hampshire School Nursing Team
Simon Says (Charity)
Survivors of Bereavement by Suicide (Charity)
The Key, Pupil Referral Unit
Westagte Secondary School
Wilden Secondary School
Winchester Young Carers (Charity)
Youth in Romsey (Charity)
Outcome
The starfish were temporarily displayed in four public art installations in; Winchester, Romsey, Fareham and Basingstoke between Monday 4th September- Friday 22nd September. For more information and pictures of the installations, please refer to page 19-22 of this report.
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2.5 Faces Of You
Faces Of You; an exhibition of photographic portraits of those who have been affected by suicide. The photographs were taken by a professional photographer, and the completed works printed and displayed to a professional standard, in public venues in Hampshire. Thirteen individuals from a range of demographic backgrounds (ages, gender, ethnicities, professions, experiences) volunteered to be photographed.
The project sought to encourage conversations that lead to better understanding and greater compassion for those who take their own lives as well as the impact of suicide on others.
People shouldn’t be afraid of talking about suicide; they should hear, see, and be aware of what’s around them
The Faces Of You Exhibition launched on Monday 4th September and was displayed at Romsey Abbey until Friday 22nd September 2017. For more information about the launch event of the exhibition please refer to page 20 of this report.
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2.7 Training for National Citizen Service Programme
Hampshire Child and Adolescent Mental Health Service (CAMHS) were asked to provide two specific workshops (Coping in crisis and How to support a young person with an eating difficulty) by the National Citizen Service for staff supporting young people enrolled on the 2017 programme. This training took place as part of a wider NCS staff induction programme held at Marwell Activity Centre on 13.05.2017.
Each workshop, 45minutes in length aimed to:
1) Provide key information about the topic; signs and symptoms, prevalence and relevance to the programme staff 2) Top tips and advice on how to support a young person who may be presenting with a difficulty 3) Information on how and where to access more information, advice and guidance for both programme staff and the young person who may be presenting with a difficulty
It was estimated that approximately 100 programme staff attended both workshops with 86 attendees completing feedback evaluation forms. The results of which are presented below. Please note for qualitative responses, totals may exceed 86 as respondents could provide more than one response.
How useful/ informative did you find the information presented?
The majority of attendees (97%, n=83) reported that they found the information presented to be useful .
A pie chart to illustrate how useful/ informative attendees found the information presented
Very Useful (n=66) Useful (n=17) A little useful (n=1) Neutral (n=1) Not useful (n=1)
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How useful were the resources provided?
The majority of attendees (97%, n=84) reported that they found the information presented to be useful.
A pie chart to illustrate how useful the resources provided were
Very Useful (n=55) Useful (n=29) A little useful (n=4) Neutral (n=1) Not useful (n=1)
What did you find most useful about the workshops?
The table below illustrates the themes of responses and number of respondents.
Themes Number of respondents Clear concrete advice and top tips 37 Useful/ relevant information that increased awareness 41 Resources provided 20 Opportunities for Q&A/ discussion with facilitator 3 Everything 2 Clear delivery, good presentation 6
How could the workshops be improved?
The table below illustrates the themes of responses and number of respondents.
Themes Number of respondents Smaller workshops 4 Increased opportunities for interactivity/ Q&A 16 More time/ longer workshops 13 Having the NCS safeguarding leads present so they are 1 identifiable More detail/ scenario specifics/ case examples 10 Resources in one booklet for ease 3 Information could have been provided online 1 Bigger screen for better visibility 4
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Any other comments/ feedback?
The table below illustrates the themes of responses and number of respondents.
Theme Number of respondents Interesting, informative & worthwhile workshops 19 Well-presented/ knowledgeable speaker 12 Information presented was ‘common knowledge’ 2 Thank you 5 Would like a workshop on managing anxiety in young 1 people
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3.0 SAFE Campaign Anniversary Week
Alongside World Suicide Prevention and Awareness Month in September 2017 and specifically World Suicide Prevention Day on September 10th 2017, a weeklong series of events to commemorate the first anniversary SAFE Campaign were held. Events involved young people, members of the public, professionals working with young people and Hampshire CAMHs staff.
The schedule of events:
MONDAY 4TH SEPT
A public art installation of 145 ceramic starfish , made A photography exhibition which depicts portraits by young people in Hampshire and to represent the taken of those who have been directly impacted by statistic that on average 145 young people each year suicide. end their lives by suicide. For who? The launch of the exhibition is by invitation For Who? A free open exhibition to the public. The only with an initial private viewing. The exhibition will installations will be in situ for approximately 3 weeks. be in situ for approximately 3 weeks and open to the
Where? Exhibits will be installed: public for viewing
9am Basingstoke, Alencon Link Where? Romsey Abbey
12pm Winchester Cathedral, West Door, Winchester Opening night: 4pm, Monday 4th September.
TUESDAY 5TH SEPT
A public art installation of 145 ceramic starfish , made by young people in Hampshire and to represent the statistic that on average 145 young people each year end their lives by suicide.
For Who? A free open exhibition to the public. The installations will be in situ for approximately 3 weeks. Where? Exhibitions will be installed:
9am Romsey, King John’s Gardens
14pm Fareham, Fernham Hall
WEDNESDAY 6TH SEPT
HAMPSHIRE CAMHS STAFF WELLBEING DAY
For who? For Hampshire CAMHS (Child and Adolescent Mental Health Service) staff
Where? St John’s House, The Broadway, Winchester 14
THURSDAY 7TH SEPT
PROFESSIONAL’S EVENT
For who? Professionals who have direct contact with young people and those with strategic influence.
Where? St John’s House, The Broadway, Winchester
Cost? £50.00 (includes lunch and refreshments) By
invita tion FRIDAY 8TH SEPT only YOUNG PERSON’S EVENT: “13 REASONS WHY NOT”
For Who? Young people representing secondary schools and colleges across Hampshire
Where? St John’s House, The Broadway, Winchester
Please note lunch and refreshments will be provided
St John’s House, the venue for the several events (CAMHS staff wellbeing day, the Professional’s Event and the Young Person’s Event) also hosted a SAFE Campaign exhibition space. This included; conference style posters which outlined the various projects and events of the SAFE Campaign, an example metal signage used for the Starfish Installation along with a few examples of ceramic starfish made and banners displaying the signatures of all those who participated in the project by making a starfish.
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The events were well publicised and were featured across a number of local media platforms.
Additionally, young person Georgia (18years old), a previous CAMHs service user, was interviewed for Radio Solent about her experiences of having difficulties with her mental health and her involvement with CAMHs. Radio Solent also covered the Faces Of You exhibition in a separate radio interveiw with Helen Dove (Lead for Innovations and Participation).
The projects of the SAFE Campaign were also publicised across various other media domains and written publications including;
- That’s TV: https://www.youtube.com/watch?v=MIN6EjzP-hE&feature=youtu.be - Winchester City Council Art News September 2017 - BBC South Today’s Instagram Account https://www.instagram.com/p/BY6TgQhHNXa/?taken-by=bbcsouthtoday - Daily Echo
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- Hampshire Chronical - Romsey Advertiser
Other Media
The events of the SAFE Campaign Anniversary Week were well publicised and documented on various social media platforms with an approximate audience reach of over 12,000 views during the period 1st September- 10th September 2017.
Hampshire CAMHs innovation team have both Facebook (Fit Fest Hampshre) and Twitter (@HANTS_CAMHS) accounts. Here are some example Facebook posts with associated statistical data related to public engagement.
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3.1 Monday 4th September 2017
08.00am; First Starfish Installation at Alencon Link- Between Basingstoke Train Station and the Shopping Centre.
Staff members from the Basingstoke CAMHS team held a stand, handing out SAFE Campaign resources (SAFE cards, A-Z coping strategy leaflets) and spoke to many members of the public about the purpose and aim of the installation as well as provided information about CAMHs services.
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12.00pm; Second Starfish Installation at the West Door, Winchester Cathedral
Staff members from the Test Valley CAMHS team held a stand, handing out SAFE Campaign resources (SAFE cards, A-Z coping strategy leaflets) and spoke to many members of the public about the purpose and aim of the installation as well as provided information about CAMHs services. Two young people who had previously received a CAMHs service were also invited and joined the team to engage with the public and support the installation.
Reverend Roly of Winchester Cathedral offered and conducted a blessing of the installation; offering words of comfort and hope to the families of the 145 young people who ended their lives by suicide as well as encouraging empathy and compassion to all.
4pm; Launch of Faces Of You Photographic Exhibition at Romsey Abbey
A number of people were invited to a private launch of the exhibition; volunteers who had been photographed, the photographer, managers within Hampshire CAMHs and Sussex Partnership, NHS Commissioners, representatives from relevant organisations that offer support to those in crisis and the local MP.
Speeches were delivered by Helen Dove (Lead for Innovations and Participation, Hampshire CAMHS), Xavier Fiddes (Photographer), Colin (volunteer participant), Barbara (volunteer participant), Fran (volunteer participant), Sue Fowler (Samaritans) and Reverend Canon Tim Sledge (Romsey Abbey). Following speeches, invitees spent time looking around the exhibition.
As part of the exhibition and in order to gather feedback from those viewing the exhibition, a comments book was left.
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3.2. Tuesday 5th September 2017
9am; Third Starfish Installation at King John’s Walk, Romsey
3pm; Civic Gardens, Fareham
Staff members from Fareham CAMHS team held a stand, handing out SAFE Campaign resources (SAFE cards, A-Z coping strategy leaflets) and spoke to many members of the public about the purpose and aim of the installation as well as provided information about CAMHs services.
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Alongside the main installations, ceramicist Pauline Bradbury (Crank Pots Ceramics) handmade 145 limited edition starfish magnets and brooches. These were sold for a suggestion donation price of £3.50 each with all proceeds raised going to the charity Survivors Of those Bereaved by Suicide (SOBS). A significant amount of money has been raised and this will be given to SOBS in October 2017.
Additionally, all those who participated in the project were asked to sign a banner. Signatures represent a pledge by all participants to be more compassionate towards themselves and others in line with the messages of the Starfish Story.
(Black signatures are those of young people, Red by teachers/ professionals and Green by the general public).
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3.3. Wednesday 6th September 2017; CAMHS Staff Wellbeing Day
Hampshire CAMHs took over temporary occupancy of St John’s House, Winchester for several events during the SAFE Campaign Anniversary week including a whole service Hampshire CAMHs staff wellbeing day. A number of engaging creative workshops were available for Hampshire CAMHs staff to select including; song writing, willow weaving, card making through screen printing, yoga with giant bubbles, drama and improvisation and Clue Capers (escape rooms). Several of these workshops were kindly sourced and funded by Hampshire Cultural Trust.
Staff could participate in two different workshops during the morning then enjoyed a selection of lunch options. The afternoon saw the inaugural Hampshire CAMHs Reward Ceremony. Teams and disciplines were honoured and rewarded for their hard work, dedication and commitment.
I have been with the trust since 2012 and in my opinion today definitely was the best well- being day so far. We were so fortunate to have the individuals from outside agencies give up their time to offer their skills to us. The food and drink was very innovate too!. I just ” “ want to say thank you for that without any hidden agenda. Today made me feel valued which I think will go some way to help to retain staff. Staff feeling valued, respected and heard is so crucial for moral.
I never experienced any staff well-being days on any level at the previous NHS trust I worked for, which has made me wonder how other NHS trusts invest in staff well-being and demonstrate they genuinely value their staff. Today's well-being day was a huge investment in staff well-being. “ ”
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I feel the trust do genuinely invest in their staff “ ”
It was absolutely brilliant and I felt very privileged to attend
“ ”
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3.3. Thursday 7th September 2017; Professionals’ Event
On Thursday 7th September 2017, Hampshire Child and Adolescent Mental Health Service held a professionals’ conference as part of a weeklong series of events and initiatives to commemorate the first anniversary of the SAFE (Suicide Awareness For Everyone) Campaign. The aims of the conference were to; increase knowledge, awareness and skills in identifying and managing episodes of crisis for professionals working with young people, increase compassion and empathy for those that experience mental health difficulties and to provide information and advice about services and organisations available to support young people and their families in crisis.
Delegates paid a nominal fee of £50.00 per head although some discounted and free tickets were honoured for those working within the voluntary sector on a first come first served basis. Based on the number of bookings and delegate information packs given out, it was estimated that 115 delegates attended the event of which 86 completed and returned feedback forms.
Please note that for qualitative feedback questions, number of responses may exceed the actual number of participants as delegates could make multiple suggestions in their feedback.
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Outline of the day
9.00 Coffee and Registration
9.15 Introduction to the day, overview of the SAFE Campaign and context setting (key statistics) by Helen Dove and Dr Emily David
9: 40 am- Keynote Speaker; Stephen Habgood, Chairman of Papyrus (National Charity for Young People Affected by Self-Harm and Suicide)
10:30 break
10:50 Workshop 1- Early Signs and Prevention; how to spot early warning signs that someone may be presenting in distress, confidentiality limitations, how to communicate worries and concerns with a young person and where to go for additional help and support by Helen Masters and Nadine McIntosh
11:40 Workshop 2- Coping in Crisis; psychoeducation about crisis in young people, practical skills and strategies to help support a young person in crisis by Dr Kim Freeman and Dr Emily David
12:30 Lunch
14:00 Autobiographical presentation with a twist; Performance of Every Brilliant Thing, a play which tells the true story of a young boy who lives with a mother who experiences suicidal thoughts and feelings and who later goes on to end her own life. The play encourages reflection about the impact of suicide.
15:00 Break
15:20 Workshop 3- After a serious incident; brief presentations from organisations that are available to help support young people and families experiencing crisis or who have been bereaved through suicide.
16:20 Q&A, Plenary and Close
“For the first time I understood the impact of suicide on people on an
emotional level”
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Demographic Data
The tables below represent which organisation delegates were representing
Overall
Organisation Number of responses Education 23 Hampshire & IOW Educational Psychology Service 2 Hampshire Constabulary 4 Hampshire County Council Children’s Services 13 Hampshire Futures 4 Hart District Council 1 Hospital 2 Primary Behaviour Service 2 Southern Health School Nursing Team 4 Sussex Partnership 1 Voluntary Sector Organisation / Youth 26 Organisation/ Youth Counselling Youth Offending Team 2
Education Institutes
School/ College Location Number of responses Barton Pevril College Eastleigh 2 Bay House Fareham & Gosport 1 Bridgemary Fareham & Gosport 1 Cams HIll Fareham & Gosport 1 Henry Beaufort Test Valley 2 Henry Cort Community College Fareham & Gosport 2 Lakeside Eastleigh 2 Norman Gate School Test Valley 1 Peter Symonds College Test Valley 1 Ropley Primary Test Valley 1 St Vincent College Fareham & Gosport 2 Swanmore College Test Valley 2 The Pilgrim’s School Test Valley 1 The Romsey School Test Valley 2 The Westgate School Test Valley 1 Warblington Havant 1 Wildern Eastliegh 2 Wyvern Eastleigh 1 Did not specify n/a 1
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Hospitals
Hospital Number of responses Frimley Park Hospital 1 University Hospital Southampton 1
Voluntary Organisations/ Youth Organisations
Voluntary/ Youth Organisations Number of Responses Yellow Door Rape Crisis 1 Street Pastors 1 Personal Best Education- National Citizen Service 2 Solent Mind 2 Crisis Support Centre 1 Cruse Bereavement 2 No Limits 1 Catch 22 1 Autism Hampshire 1 Eastleigh Youth Counselling Service 1 Motiv8 2 KIDS 2 Community First 2 Two Saints Community Support 2 Hampshire Cultural Trust 3 Little Art Haven 1
How delegates heard about the event
Method Number of responses Indirectly (through manager) 27 Indirectly (not specified/ other) 11 Direct correspondence with CAMHS- email 39 Direct correspondence with CAMHS- face to face 9
What delegates found most useful about the event
Theme Number of responses Workshop on practical strategies and techniques to use with young 30 people in crisis Powerful personal testimony of keynote speaker Stephen Habgood 26 Workshop on where to go and question and answer opportunities 3 Variety of presentation styles and formats; useful information to take 18 away (info packs) Networking opportunity, information stands and increased 25 knowledge of other agencies to support young people Workshop on early warning signs 5 Every Brilliant Thing drama production; encouraging reflection 27 Passion and knowledge of workshop presenters was inspiring, 19
28 motivating and thought provoking Improved understanding and confidence in talking with young people 12 about suicide; reassurance that current practice is in line with CAMHS advice
Suggested improvements by delegates
Theme Number of responses Shorter lunch break 19 More water available 1 More details about the content of the day prior to the event 3 Larger more visible screen 2 List of delegates and contact details to aid further networking 1 Time for group discussions/ more interactivity around sharing 6 practice Include male presenters 1 Provide decaffeinated coffee 2 More detailed workshops on risk management 2 Personal testimony from young people 1 “More drama” 1 Better acoustics 2 More organisations to speak about the services they offer 1 Better food/ more choice of food 2 Softer chairs to sit on 1 Venue based on ground floor or with lift access for people with 1 mobility difficulties A greater presence by children’s services 1 Greater emphasis on self-care when managing a young person in 2 crisis Provide a booklet with helpful contacts 1 A greater presence by different Police teams e.g., neighbourhood 1 police teams Provide information on public transport links and car parks 1
Other feedback and comments
Theme Number of Responses Best training event ever been on/ excellent and useful event 27 Thank you for providing the event; appreciate the effort CAMHS 19 make Well organised and thoughtful planning 7 Powerful, emotive, thought provoking and inspiring event; 15 fantastic for raising awareness of suicide and informative Please provide other similar days/ training on other issues e.g., 3 anxiety & exam stress Good venue and refreshments/ lunch 4 Would recommend the event to other professionals 1 Good refresher of knowledge and skills 2 Inspired to find ways of collaborating with CAMHS to support 2
29 wellbeing of CYPs Useful opportunity to reflect on a very ‘real’ issue 3 Friendly facilitators and organisers 1
Knowledge and Awareness
The pie chart below represents how much delegates felt the event had helped to improve their knowledge and awareness of how to support a young person in crisis. 86% respondents (n=74) reported the event has helped ‘very much’ or ‘quite a lot’.
A pie chart to illustrate how much delegates felt the event had helped to improve their knowledge and awareness of how to support a young person in crisis
Very Much (n=42) Quite A Lot (n=32) A Little (n=9) Neutral (n=2) Not Much (n=1) Not at all (n=0)
Development of skills and strategies
The pie chart below represents how much delegates felt the event had helped to improve their skills and strategies that could be used in their professional work with young people in crisis. 84% respondents (n=72) reported the event has helped ‘very much’ or ‘quite a lot’.
A pie chart to illustrate how much delegates felt the event improved skills and strategies that could be used within their professional role
Very Much (n=41) Quite A Lot (n=31) A Little (n=12) Neutral (n=1) Not Much (n=2) Not at all (n=0)
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Networking Opportunities
The pie chart below represents how much delegates felt the event had provided networking opportunities and increased awareness of organisations available to support young people in crisis. 87% respondents (n=75) reported the event has helped provide opportunities ‘very much’ or ‘quite a lot’.
A pie chart to illustrate how much delegates felt the event provided them with networking opportunities and increased awareness of organisations available to support young people and their families in crisis
Very Much (n=51) Quite A Lot (n=24) A Little (n=11) Neutral (n=1) Not much (n=0) Not at all (n=0)
Refreshments
The pie chart below represents how much delegates enjoyed the lunch and refreshments provided. 81% respondents (n=70) reported they enjoyed refreshments ‘very much’ or ‘quite a lot’.
A pie chart to illustrate how much delegates enjoyed the lunch and refreshments provided
Very Much (n=40) Quite A Lot (n=30) A Little (n=9) Neutral (n=6) Not much (n=1) Not at all (n=0)
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Venue
The pie chart below represents how comfortable delegates found the venue. 91% respondents (n=78) rated the venue as comfortable either ‘very much’ or ‘quite a lot’.
A pie chart to illustrate how comfortable delegates found the venue
Very Much (n=48) Quite A Lot (n=30) A Little (n=7) Neutral (n=2) Not much (n=1) Not at all (n=0)
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Examples of comments provided on feedback forms:
Probably the best conference I have attended- well done CAMHS! Really found the workshops helpful & I’m inspired to take these back to my work place
The whole thing has helped to build my confidence in having conversations with young people and professionals on topics relating to suicide and crisis. Feeling very I think this event has been very well inspired! thought out- well done to everyone in the team. Thank you for an energetic event that was fresh and professionally presented Really clear ways of helping young people (and adults) in crisis- some very practical advice. Great range of workshops. Keep hosting these important events so we can recommend them Being able to talk with CAMHS colleagues and get contacts with a view to future joined work/ closer liaison has been the most useful outcome So powerful and moving. A real unique innovative way of addressing such sensitive issues. It was wonderful! Well done and thank you
The autobiographical play was outstanding. The variety of organisations represented really promoted a ‘joint’ way of working. It was a bold and Lots of practical ideas to use with young innovative event which reached across people. The speakers were fantastic, sectors informative and very thought provoking. Thank you for a fantastic day, I would definitely recommend to other professionals
Very useful for networking and finding out details of support available for families which I was previously unaware of
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Summary
Objective and subjective feedback from both delegates and facilitators at the event experienced this professional’s event as powerful, impactful and a thought provoking opportunity to acquire knowledge skills and professional contacts in order to help support young people and families in crisis. The variety of presentations and formats of delivering materials struck a balance between information provision and space for reflection. The wide range of delegates that attended the event provides hope that the key messages will filter back to a wider audience; schools, statutory and voluntary sector agencies for the benefit of Hampshire’s young people.
Hampshire CAMHs are thankful to all those contributed and attended this innovative and informative event.
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3.5 Friday 8th September 2017; Young Person’s Event
On Friday 8th September 2017, Hampshire Child and Adolescent Mental Health Service held a young people’s event, titled “13 Reasons Why Not” as part of a weeklong series of events and initiatives to commemorate the first anniversary of the SAFE (Suicide Awareness For Everyone) Campaign. The event aimed to be an inspiring, useful and proactive opportunity for young people to learn more about young people’s mental health, to explore in a safe and informative way the issues of youth self-harm and youth suicide, how to look after themselves and support others who may be experiencing a difficult time and contribute towards improved mental health and wellbeing for young people in Hampshire. The day had an emphasis on hope, resilience and recovery; supporting and encouraging young people to take responsibility for their life choices in relation to health and wellbeing.
Secondary Schools from across Hampshire were invited to bring student ambassadors to this free event, hosted and facilitated by Hampshire CAMHS in partnership with facilitators from other organisations including but not limited to; Winchester Young Carers, Catch 22, Life Education Wessex and No Limits. Although every secondary school and college in Hampshire were invited to the event, 22 schools (equating to 84 young people plus staff) booked onto the event and 11 attended the event along with a group of young people who volunteer for the Police Youth Crime Commissioner. A total number of 37 young people attended the event. Disappointingly, a number of apologies/ cancellations were submitted in the days preceding the event as well as there being a number of schools that did not attend without notice.
Please note that for qualitative feedback questions, number of responses may exceed the actual number of participants as delegates could make multiple suggestions in their feedback.
A fantastic couple of days. I learnt so much as did the students who we took along. You worked so hard and
everything about the two days was perfect. I learnt more than I ever have, going to various courses where we have spent a fortune!
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Overview of the day
9.00 am- Welcome; overview of the SAFE Campaign and the day
9.30 am- Warm Up; “The Box” A collective exercise in helping young people to see that first impressions can lead to judgements and assumptions around difference or inclusivity. This exercise sought to demonstrate that sometimes you can have things in common with people that you had initially assumed to have nothing in common with. The exercise also sought to encourage young people to be reflective on how different life experiences may shape our thoughts, feelings and beliefs about others and the world around us.
10.00 am- Round Table Debates; an opportunity to debate some of the 13 reasons why young people experience crisis and poor mental health. These discussions were facilitated by experts in the field; a mix of CAMHs clinicians and external facilitators. The 13 debate questions were:
1) How do you stop hateful messages/ comments on social media impacting on self-esteem? 2) How do people cope and manage if you are being bullied? 3) How much does academic success matter to you? 4) What impact does the social pressure to have a sexual relationship with a boyfriend/ girlfriend have? 5) What kind of support/ services do young people need and want? 6) How can adults take young people and their worries seriously? 7) Will people only like and accept you if you are happy and outgoing? 8) Why do young people take drugs and drink alcohol when the risks are so well known? 9) What kind of pressure is there to look/ be a certain way and where does it come from? 10) Does the way the media reports world affairs create worry? 11) Does thinking about the future and making life choices feel overwhelming? 12) How does playing video games impact on mood and behaviour? 13) Do you agree with the phrase ‘Money can’t buy you happiness’?
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11.30- Break
12.00- Personal testimony; Georgia (18years old) a young person talked about her experiences of struggling with self-harm and suicide ideation, her journey to recovery and her experience of attending CAMHS for therapy and support.
13.00- Lunch
14.00- 16.00 Pods; there were a series of fun, creative, thoughtful and inspiring pods (activities) for young people to experience. These interactive activities aimed to help express and communicate thoughts and feelings about mental and emotional health as well as help young people to think about their role in promoting health and wellbeing in their schools. The pods also offered opportunities to learn new skills and techniques to help themselves and others cope in times of crisis as well as find out where to go for more information and support.
1). Make your school a coping in crisis/ self-soothe box; each school was provided a large box and a number of items to begin a self-soothe resource for their school. CAMHs clinicians supported young people by explaining when and how to use the box and the items within the box and supported young people to make the box. Items included; instructions on how to use and what to include; bubbles, lavender bags, glitter jars, peacock feathers, skipping rope, pack of cards, bubble wrap, stress balls, Play Doh, tissues, mindful colouring books and crayons, sensory materials, marbles in a coloured jar, A-Z of coping strategies, SAFE cards.
2). Information stands from youth organisations; an opportunity find out what support and advice is available from organisations in Hampshire. Stands included; Catch 22, National Autistic Society, Hampshire School Nursing, Support 4SEND, Southern Domestic Abuse Service, Barnardos and CAMHS (including Hampshire CAMHs’ Eating Disorder Team).
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3). Digital Graffiti Wall; an opportunity to express the things in life that make it fun and worthwhile. We asked young people to think about the messages they would want to give others who may be struggling and use their artistic skills to communicate these using a novel and youth friendly medium. Young people received print outs of their artwork and a digital copy of the artwork produced was given to CAMHS in order to electronically distribute to those who participated.
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As part of this pod experience, young people were also given the opportunity to take part in two poster initiatives. The first of which was a SAFE Campaign ‘100 Reasons to live’; young people were encouraged to write and draw the things that bring meaning and joy to their lives. The results generated may later be used as part of an initiative to further raise awareness of youth mental health and of the SAFE Campaign.
Some of the posters drawn by young people:
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The second poster initiative involved young people voting on their favourite design of a poster designed to provide signposting advice for young people experiencing emotional and mental health difficulties. Hampshire Child and Adolescent Mental Health Service in collaboration with Hampshire Police Crime Commissioner had designed three posters in order to provide information and advice to young people of secondary school age where and how to access help and support. Results of the vote and qualitative feedback from young people will help to further the development of the posters and identify the chosen design to be used for the project.
The three designs of the posters:
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Demographic Data
Age of Participants
The bar chart below illustrates the ages of participants
25
20
15 Number of participants 10
5
0 14years 15years 16-18years 18-25years Age of participants
Gender of Participants
The pie chart below illustrates the gender variation of participants
Male Female
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Schools Attending
The table below illustrates the schools that participants attend.
School Area Number of Participants Applemore New Forest 2 Arnewood New Forest 2 Burgate New Forest 2 Cams Hill Fareham & Gosport 2 Harrow Way Test Valley 2 Henry Beaufort Test Valley 3 Henry Cort Fareham & Gosport 3 Mill Chase Fareham & Gosport 4 Park Community Havant 1 Testbourne Test Valley 4 Westgate Test Valley 6 Police Crime Commissioner Hampshire Wide 2 Young People’s Participation group
How will you feedback to your school what you have learnt from the event
Theme Number of responses Share information in a school assembly 11 Offer to help/ mentor students who need help 6 Share information with the school council 7 Talk about what I have learnt in my tutor group 4 Make posters, artwork and leaflets 6 Use/ make more coping boxes 6 Run workshops for other people to share what I have learnt 3 Write in our weekly newsletter/ bulletin 2
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Enjoyment
The pie chart below illustrates how much participants enjoyed the event. Of the 37 respondents, 85% (n=29) reported they enjoyed the event ‘very much’ or ‘quite a lot’,
Very Much Quite A Lot A Little Neutral Not Much Not At All
Knowledge
The pie chart below illustrates how much participants felt they learnt something new front attending the event. Of the 37 respondents, 85% (n=29) responded ‘very much’ or ‘quite a lot’.
Very Much Quite A Lot A Little Neutral Not Much Not At All
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Feedback and Comments by Young People and Teaching Staff
Both my students and I came
away buzzing with excitement about how we can move
“mental health” at school forward!
I felt welcomed. I have learnt that
other people are thinking the same as me, but it just takes a person to open up. I definitely want to pass on what I’ve learnt to others.
I want to try and organise a session that different year
groups can attend to raise awareness of mental health
If someone comes to me for help, I will now be able to help them. I’ll show them the coping box.
It has reignited my passions for
what I do and made me realise how important the role of teachers are for students.
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Summary
Objective and subjective feedback from young people, teachers and facilitators at the event experienced this young people’s event as an inspiring, creative and thought provoking opportunity to discuss key issues that impact on young people and engage in creative practical activities in order to help young people express themselves and gain information and skills to take back to their schools. The variety of activities and formats of delivering materials struck a balance between information provision and personal expression and innovation to the topic of mental health (and specifically crisis, self-harm and suicide). The number of schools that attended the event provides hope that the key messages will filter back to a wider audience at their schools for the benefit of more young people.
Hampshire CAMHs are thankful to all those contributed and attended this innovative and informative event.
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4) Next Steps for the SAFE Campaign
Given the success of the first year, it is important for the Campaign to continue to develop and continue reinforcing the messaging and work already having been completed.
The following plans have been made to ensure the campaigns longevity:
- The Faces Of You exhibition will tour around Hampshire, occupying public spaces which will help to raise awareness of the project and the wider SAFE Campaign - A poster campaign using the drawing and descriptions form the Young Person’s Event is being developed - There are plans being made to have SAFE cards available in every Hampshire pharmacy - ICE Project; The ICE Project has been developed and led by Hampshire Cultural Trust’s Better Life Chances team and Hampshire CAMHS, and has received match funding between the Arts council and Hampshire CAMHS commissioners. The three key aims: to have a positive impact on the Health & Wellbeing, particularly mental health, of children & young people in Hampshire. ICE: Inspire // Create // Exchange aims to address and explore important mental health issues with young people using high-quality arts and culture. There will be core target groups of young people directly engaged in project work, p of young people across Hampshire who will be reached and affected by the messages and artwork shared through the ‘Exchange’ phase. Using arts and culture we aim to promote positive mental health, build young people’s emotional resilience and more specifically bring to the attention of all, the issue and impact of youth suicide and self-harm.
References
Suicide by Young People and Children in England. (2016). National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Manchester: University of Manchester, 2016
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Report to Council of Governors Agenda item CG 30.2/17 Attachment C EHRIA N/A code Date of meeting 16 October 2017 Format of Paper Title of paper Lead Governors Report Written Author Amy Herring, Interim Lead Oral ☐ Governor Presenter Amy Herring, Interim Lead Presentation ☐ Governor Committees/meetings where this item has been N/A considered Purpose of report To provide assurance ☐ For decision ☐ Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information To highlight patient, carer or staff experience ☐ Strategic Goals 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice ☐ 4. Be the provider, employer and partner of choice 5. Living within our means ☐ Summary of Report The Lead Governor gives an update of the last three months of governor activities.
Recommendation To note the content of the report.
1. INTRODUCTION I would like to welcome the new governors to their first of many Council of Governors meetings. I hope you find them useful and informative; but most importantly for these meetings if you do not understand something or would like further information on the item, please do not hesitate to ask or question. These meetings are also a helpful format of engaging with our Non-Executive Directors. 2. REPORT I would like to elaborate from my last report the departure of Sue Esser as this will be her final Council of Governors. Whenever we have had a question or asked for something to be looked into at the Council of Governors, Sue has always came back to us with much detail and provided us with assurance. Sue, thank you for all your hard-work and commitment you have provided the Council of Governors over the years, you will be missed by all team. Richard Bayley and I have been down to Hampshire to see our Hampshire CAMHS team who have been very busy with their Suicide Awareness For Everyone (SAFE) campaign. Their innovation and creativity managed to engage a lot with young people, the public and other professional organisations to raise awareness of young suicide. A few of us governors took part in Brighton Pride in August. It was really positive to see in the parade the different NHS organisations and also the turnout of people watching and supporting the parade. A couple of governors also attended a TEDxNHS conference in London in August. The second part of the conference which focused on mental health did not only highlight how important it is to have these on-going public conversations to raise awareness, but that mental health does not discriminate against anyone. When these events come up I would definitely recommend governors taking the opportunity to take part. It is not only a great opportunity at getting to know your colleagues, but is also a way to make positive memories to look back on. By the time of the Council of Governors, Karen Braysher will have visited HM Lewes Prison with Martin Richards. I hope this was a beneficial visit and we look forward to hearing feedback at a later point. Mark Hughes has also been busy by really engaging with our carers and how we as a Trust make sure we support our carers. We have our Annual Members Meeting shortly on Thursday 19th October at CityCoast Centre in Portslade. I encourage governors to attend if possible as this will be a good opportunity to engage with our service users, carers, public and staff, but also a way to find out further about how the Trust’s provision of local mental health services are being transformed. As an idea of what to expect, if anyone would like to see the presentations and the presenters speak from last year; these can be found on the Trust’s website and include speakers such as Professor David Fowler, Dr Rick Fraser and more. 3. RECOMMENDATION To note the content of the report.
Report to Council of Governors Agenda item CG 31.1/17 Attachment D EHRIA N/A code Date of meeting 16 October 2017 Format of Paper Title of paper CQC Compliance & Strategic Written Assurance Author John Rosser, Director of Oral ☐ Improvement and Innovation Presenter Diane Hull, Chief Nurse Presentation ☐ Committees/meetings where this item has been N/A considered Purpose of report To provide assurance For decision ☐ Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information To highlight patient, carer or staff experience ☐ Strategic Goals 1. Safe, effective, quality patient care 2. Local, joined up care ☐ 3. Put research, innovation and learning into practice ☐ 4. Be the provider, employer and partner of choice ☐ 5. Living within our means ☐ Summary of Report The following report provides an update on progress with the CQC Improvement Programme. It includes key elements; CQC Well Led Inspection Programme CQC RPIR Data Submission CDS Well Led Self Assessments Developmental Review Quality and Safety Reviews Roadshows/Exec Visits Comms Recommendation The Council of Governors is asked to note the progresses made, and raise any issues requiring additional assurance.
1. INTRODUCTION The following report provides an update on progress with the CQC Improvement Programme. 2. REPORT 1. CQC Well Led Inspection Programme The CQC consulted upon a revised inspection regime between November 2016 and February 2017. This included a revised set of regulatory standards or Key Lines of Enquiry (KLOEs). Whereas previously organisations received infrequent large scale “Wave Inspections”, the emphasis has now shifted to more frequent focused unannounced inspections and an annual Well Led Inspection. The process commences with a large scale data request – Routine Provider Information Return (RPIR). This along with the previous inspection rating informs the inspection programme which builds over a period of 6 to 8 weeks up to the Well Led Inspection. It should be noted that the CQC are still developing the programme which will vary between organisations. We understand that our Well Led Inspection will commence in early December which might suggest the focussed inspections are due to commence imminently. 2. CQC RPIR Data Submission The CQC RPIR data submission was delivered in two parts on 11 and 14 August 2017. Following a request, the Trust was given an additional 4 working days for part 1 and 5 days for part 2. Part 1 of the submission was far smaller than part 2 and comprised Mental Health specific reports and documents. Part 2 comprised generic/core documents and reports. Upon receipt of the request, a meeting was held where each of the items were allocated to director level leads and a return date agreed. Over the next three weeks, Soni Gaffney coordinated the returns with the CQC Project Group. Additional staff were co-opted to assist with data collection and a Quality Assurance exercise was completed for each return. Prior to submission, the CQC Project Group spent a day reviewing each of the returns. Compared with previous submissions, the quality of data has improved. Whilst services are better prepared to gather and report the information requests, where the format is different, the energy and resource required to generate the reports is enormous. A conservative estimate suggests the full submission took 600+ hours to complete. We are aiming to better mainstream CQC intelligence; site list, Q&S reviews and reporting. We were invited to complete an evaluation where we suggested that we submit the Trust’s existing reports in the first instance and then address any additional questions posed by the CQC. Also, where possible, we agree essential data items with CQC and build these into our routine reports. 3. CDS - Well Led Self Assessments As mentioned, the CQC undertook a detailed review of the quality domains which were previously referred to as the Fundamental Standards of Care. There have been some changes which have been shared and discussed throughout operational and support services. Despite an awareness of the KLOEs, each CDS is being encouraged to complete a review against the revised Well Led domain and the KLOEs, and associated prompts. The Children and Young Peoples CDS pioneered a Well Led Self-Assessment. A similar exercise was undertaken by representatives of the Board of Directors. Each CDS has been asked to complete a similar exercise. Brighton and Hove have partially completed the review but they have also held a service wide workshop. Similarly, Learning Disability Services have partially completed their self-assessment which they are due to complete on 4 October. East Sussex have developed a local action plan from their self-assessment which is being administered by the CDS Leadership Team. Arrangements for West Sussex and PCW are being explored with the Service Directors. 4. Developmental Review Sue Holden (an external consultant) has been commissioned to assist with the Developmental Review of Leadership and Governance. This follows the format advised by NHSI and previous completed by KPMG. A series of interviews took place with a mix of Executive Directors and senior managers with key responsibilities on Wednesday 13 September. Feedback to each person interviewed was provided on the day and discussed by the Executive Team. A further 2 days are being arranged for an additional cohort of staff to be interviewed which will further support our preparation for the inspection. 5. Quality and Safety Reviews With the impending inspection, we have amended the Quality and Safety Review programme. We have focused upon the Older Peoples and Adult Inpatient Wards using a smaller group of senior staff to undertake the reviews to add rigor and reduce variation. A service user inspection complements the peer review which take an “action oriented” approach where the review team work with senior clinical staff to address any issues picked up. Key issues highlighted in the reviews so far include; grounds and gardens, provision of white goods, maintaining the buildings, the entrance and first impressions of the services, clinical risk assessment and care planning, service user and carer participation, medication management, physical health assessment and monitoring. 6. Roadshows The Chief Operating Officer, Chief Nurse and Chief Medical Officer are undertaking a series of visits to our wards and community teams. They have a checklist of areas they aim to cover with front line staff. These visits have been well received. 7. CQC Masterclasses A series of Masterclasses have taken place with invitation extended to all staff. Each session covers a single quality domain; Safe, Caring, Responsive, Effective and Well Led (which we are running twice). A formal presentation on the content of the quality domain is followed by an exercise where the participants are helped to explore the KLOEs and present evidence of how they are meeting the standards, or how they mitigate the risk when the standards cannot be met. 8. Comms The approach we are taking tries to avoid branding the improvement programme under the CQC preferring to mainstream this work as part of the “day job”. Building upon the previous preparation programme, we have published “Top Tips” for inpatient wards and community teams and “Time to Shine” encouraging staff to present what they are most proud of. We have a series of posters covering each of the quality domains and are in the process of reviewing the staff handbook. 3. RECOMMENDATION The Council of Governors is asked to note the progresses made, and raise any issues requiring additional assurance.
Report to Council of Governors Agenda item CG 31.2/17 Attachment E EHRIA code Date of meeting 16 October 2017 Format of Paper Title of paper Serious Incident Assurance Written Report Author Justine Rosser, Deputy Chief Oral ☐ Nurse Presenter Diane Hull, Chief Nurse Presentation ☐ Committees/meetings where this item has been considered Purpose of report (tick all that apply) To provide assurance For decision ☐ Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information To highlight patient, carer or staff experience ☐ Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care ☐ 3. Put research, innovation and learning into practice ☐ 4. Be the provider, employer and partner of choice 5. Living within our means ☐ Summary of Report This paper provides an overview of the Serious Incidents reported by the Trust during August 2017. The report also outlines the Trust’s performance regarding the completion of Serious Incident Investigation Reports within the appropriate deadlines. The report outlines the Serious Incident Investigations that were completed and submitted to the Commissioners in this period, to provide assurance to the Committee that the root causes have been identified, and lessons learned. The report also updates the committee on progress regarding the governance processes surrounding the management of Serious Incidents in the Trust.
Recommendation The Council of Governors is asked to note the details of the information provided and actions being taken as a response to serious incidents and Prevention of Future Death reports (PFDs) to prevent reoccurrence within a limited timeframe.
1. INTRODUCTION The purpose of this paper is to enable the Council of Governors to obtain assurance as to the efficacy of the management of Serious Incidents across the organisation. This report concerns Serious Incidents that were reported in August 2017 and those Serious Incident Reports that were submitted to our commissioners in the same period. 2. REPORT
2. Serious Incidents reported to Commissioners during August 2017 2.1 The table below indicates the numbers of Serious Incidents reported aligned to the cause group. Cause Group Total Fall, Slip, Trip 1 Security & Information Governance 1 Self-Harm 1 Unexpected Death 8 Total 11
2.2 The Chart below contextualises the numbers of Serious Incidents reported by the Trust each month during 2017 and compares this to the numbers reported each month during 2016.
3. Serious Incident investigations submitted to Commissioners during August 2017 3.1 The table below indicates the numbers of Serious Incident Reports submitted to our Commissioners in August 2017. 11 out of the 19 Serious Incident Reports submitted were within deadline (59%).
Date Submitted reported on SI Reference CDS Type Of Incident Within STEIS Deadline? 15/03/2017 130104/16-17 North West Sussex Unexpected Death No
22/03/2017 129256/16-17 North West Sussex Unexpected Death No
18/04/2017 130654/17-18 Brighton & Hove Unexpected Death No
10/05/2017 131975/17-18 East Sussex Unexpected Death Yes
17/05/2017 132086/17-18 North West Sussex Unexpected Death No
18/05/2017 132195/17-18 North West Sussex Unexpected Death No
22/05/2017 132321/17-18 Brighton & Hove Unexpected Death No
23/05/2017 132332/17-18 Brighton & Hove Unexpected Death Yes
26/05/2017 132395/17-18 Brighton & Hove Unexpected Death Yes
31/05/2017 131753/17-18 Brighton & Hove Unexpected Death Yes
05/06/2017 132771/17-18 CAMHS Unexpected Death Yes
07/06/2017 132891/17-18 North West Sussex Unexpected Death Yes
08/06/2017 132926/17-18 North West Sussex Unexpected Death Yes
09/06/2017 132866/17-18 Coastal West Sussex Violent Incident Yes
21/06/2017 133225/17-18 East Sussex Unexpected Death Yes Coastal West Sussex 13/07/2017 134015/17-18 Fall, Slip, Trip Yes & Dementia Security & Info 12/04/2017 130642/17-18 East Sussex No Governance 02/05/2017 131668/17-18 East Sussex Unexpected Death Yes
30/03/2017 130400/16-17 East Sussex Accidental Event No
3.2 The Trust currently has a target of submitting 90% of Serious Incidents (SIs) within the designated timescale. This is valid for all reports due for submission from April 1st 2016.
SI Reports Proportion of SI Total SI SI Reports % submitted Reports submitted Reports due submitted submitted Target % late/not yet on time in quarter on time on time submitted
Q2 (July – September) 90 38 52 42% 90% 2016/17 Q3 (October - 82 39 43 48% 90% December) 2016/17 Q4 (January – March) 55 29 26 53% 90% 2016/17 Q1 (April – June) 41 26 15 63% 90% 2017/18 Q2 (July – September) 50 TBC TBC TBC 90% 2017/18 3.3 The table below provides the number of overdue Serious Incidents Reports with the CCG as of 04/09/2017. Total open Total open reports Division Reports overdue Total overdue Service Director L1 L2/L3 L1 L2/L3 East Sussex 0 6 0 0 0 Neil Waterhouse Primary Care & Wellbeing 1 3 0 1 1 Claire Newman Brighton & Hove 1 3 0 0 0 Dr Gurprit Pannu Coastal West Sussex & Dementia 2 10 0 2 2 Jo Scott North West Sussex 2 5 0 1 1 Jo Scott CAMHS 2 2 0 0 0 Ruth Hillman Forensic Healthcare Service 2 1 1 0 1 Rebecca Hills Specialist Adult LD 0 1 0 0 0 Viki Baker Corporate Directorate 0 0 0 0 0 Interim Adam Churcher Nursing Home Services 3 0 3 0 3 Sue Turner TOTAL 13 31 4 4 8
4. Learning from Serious Incidents Action plans that are developed in response to the findings of serious incident investigations are uploaded to the Ulysses system, in order to ensure that the implementation of the actions
can be monitored. The table below shows the number of SI action plans that have been closed for each CDS and the number of actions that were completed from 12.08.17 – 06.09.17. Number of SI action plans Number of actions closed completed East Sussex CDS 5 6 Brighton & Hove CDS 9 15 Coastal Sussex CDS 0 1 North West Sussex CDS 1 0 CAMHS CDS 2 0 Learning Disability CDS 0 0 Forensic Healthcare CDS 1 3 Primary Care CDS 0 0 Nursing Home CDS 3 5 Total 21 30 The table below shows the number of open SI action plans for each CDS, the number of open actions and action implementation rate. No. of SI No. of No. of open Actions action plans actions actions overdue open open overdue rate Brighton & Hove CDS 3 7 1 14% Coastal Sussex CDS 11 29 26 90% East Sussex CDS 27 58 43 74% North West Sussex CDS 8 17 11 65% CAMHS CDS 5 14 14 100% Forensic Healthcare CDS 0 0 0 - Primary Care CDS 3 13 11 85% Learning Disability CDS 2 8 8 100% Nursing Home CDS 0 0 0 - Totals: 59 146 114 78%
NB. This report is calculated based on open SI action plans as of end 06.09.17. Where all actions on an SI action plan are completed, the record is closed and subsequently will be omitted from the calculation of the overdue open actions rate. To support services in reviewing/ auditing and closing SI actions in a timely manner, automatic reminders are emailed to open SI Action Plan Owners. A monthly Open SI Action report is also sent automatically sent to Chief Operating Officer, Deputy Chief Operating Officer, Service and Clinical Directors to inform discussions at CDS clinical Governance meetings. In addition the Quality and Safety Assurance Manager has been meeting with clinical services to assist in closing actions where there is evidence to support completion.
5. Duty of Candour Compliance Report There were 12 SIs that potentially met the Duty of Candour regulation criteria in August 2017. Of these 1 potentially breached Duty of Candour as there were no NoK as both of the patient’s parents were deceased.
Details of potential below: Incident CDS Incident Why relevant person Patient CCG No. Type not contacted within timescale
134933 B&H Fatality No DOC possible as no Sussex - NHS NoK. Both patient’s Brighton and Hove parents deceased CCG
6. Prevention of Future Deaths Report
Date of Date PFD Coroner Response Trust Brief details Coroner’s concerns death received area due improvements
09/04/2017 17/08/2017 Brighton 23/10/2017 SI 131063/17-18 No local in-patient Maintaining & Hove CDS B&H detox facility such as ongoing used to exist at Mill collaborative Patient had been found View Hospital. Local working with deceased at their private people have to travel partner address on the to Islington away from agencies. 09/04/2017; the final family and friends. cause of death:- 1a Serious toxicity of A collaborative Venlafaxine in the approach to dual diagnosis treatment presence of left is needed. ventricular hypertrophy Inappropriate to and recent blood loss separate each from self-inflicted wound component and only to ankle agree to 1b - treat/assess one 2 Bipolar Affective component when the other is dealt disorder, alcohol with. dependency, presence of alcohol, high BMI, mixed anxiety and depressive disorder. 3. RECOMMENDATION(S) The Council of Governors is asked to note the details of the information provided and actions being taken as a response to serious incidents and Prevention of Future Death report (PFDs) to prevent reoccurrence within a limited timeframe.
4. NEXT STEPS
Improvements will continue to be monitored through the Quality report and through the Quality meeting, Safety Committee and the Serious Incident Review Group.
Report to Council of Governors Agenda item CG 32.3/17 Attachment F EHRIA N/A code Date of meeting 16 October 2017 Format of Paper Title of paper Quality Committee Summary Written Author Glen Woolgar, Head of Oral ☐ Incident Management and Safety Presenter Professor Gordon Ferns, Presentation ☐ Non-Executive Director Committees/meetings where this item has been Quality Committee & Board of considered Directors Purpose of report (tick all that apply) To provide assurance For decision ☐ Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information To highlight patient, carer or staff experience ☐ Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice ☐ 4. Be the provider, employer and partner of choice ☐ 5. Living within our means ☐ Summary of Report The Quality Committee last met on 5 September 2017, chaired by Professor Gordon Ferns, Non-Executive Director. In summary, the meeting considered reports from the newly formed sub committees: Effective Care & Treatment Committee Positive Experience Committee Safety Committee Well Led Committee, Workforce The committee also considered the Quality Improvement Programme and Quality Assurance Report. Recommendation The Council of Governors is asked to note the content of this report and raise any issues for clarification
1. INTRODUCTION The purpose of the Quality Committee is to enable the board to obtain assurance that high standards of care are provided by the trust and, in particular, that adequate and appropriate governance structures, processes and controls are in place throughout the trust to: Promote safety and excellence in patient care; Identify, prioritise and manage risk arising from clinical care; Ensure the effective and efficient use of resources through evidence-based clinical practice; Protect the health and safety of trust employees; Ensure compliance with legal, regulatory and other obligations. 2. REPORT
Summary of the Quality Committee held on the 5 September 2017. Effective Care & Treatment Committee The first meeting of the ECAT Committee had taken place. A key feature is that all work will be in partnership between CDS leads, carers and service users and Trust functions Education & Training and the annual audit plan will now come under this committee The Committee will now agree the national and local mandatory and discretionary standards to which it intends to work by the end of October 2017, for presentation to the November Quality Committee
Positive Experience Committee The first meeting of the Positive Experience Committee had taken place and the Terms of Reference written and submitted to this committee The committee noted it had been a productive meeting looking at ensuring that carer and patient involvement was meaningful and agreeing future items for discussion, complaints, FFT, etc. It was agreed that the meeting would meet bi-monthly and report to the Quality Committee by exception. Once the meeting was quorate, others may be invited as applicable It was noted by the committee that safeguarding needs for adults and children had not previously been met, so a new team has been formed and an additional post will be recruited to in October 2017 The physical health people with mental health has been well publicised and generated a lot of positive interest by staff
Safety Committee A work plan has been agreed for the year The Health & Safety Committee and the Safeguarding Committee both report into this committee The Ligature Risk Reduction Committee will also report to the Safety Committee The supporting training for smoking cessation has gone well with over 400 staff trained to Level 1 and meetings of the smoke free steering group will continue The no smoking policy is being reviewed and work is in hand with community teams to encourage service users to go smoke free or to be aware that they will not be able to smoke if admitted to an inpatient facility The Quality and Safety report showed improvement in baseline figures with a reported increase in incident numbers
The committee noted an increase in prone restraint incidents reported. However if a patient is restrained and part of that restraint required prone, regardless of length of time, this would be reported on the system as a prone restraint It was noted that the PMVA (Prevention and Management of Violence and Aggression) team will now come under the remit of the Associate Director of Nursing, to look at ways of reducing the use of restraints It was noted that medication incidents had increased, however this is due to increased reporting and the actual issues were considered small Key issues from the Prevention of Future Deaths report (PFD) centered around the quality of documentation and family involvement. The trust is making enquiries with regards to CCTV following a recent inquest and PFD report
Well Led Committee Workforce Report All NMC nurse revalidations due in July had been completed. A programme is in place to remind Trust nurses three months in advance of their revalidation date A number of completed appraisals had yet to be uploaded on MyLearning and asked colleagues to encourage staff to do this An analysis of reasons for leaving the Trust was undertaken. The main reasons highlighted were the lack of perceived career progression and also not feeling appreciated. These will continue to be monitored
Quality Improvement Update Exploratory work is being carried out in order to create a work programme and action plan Next steps are to engage with a strategic partner and this will be going out to tender within the next couple of weeks, and to define the metrics to be used.
Quality Assurance Report Figures shown in the last Quality Assurance report showed significant improvement. Concerns were noted regarding 7 day follow ups where performance is inconsistent across the CDS’s (Care Delivery Service). Work is in hand to review trends within this area 3. NEXT STEPS The next Quality Committee is scheduled for the 15 November 2017, Main Meeting Room, Mill View.
4. RECOMMENDATION
The Council of Governors is asked to note the content of the report.
Report to Council of Governors Agenda item CG 32.4/17 Attachment G EHRIA code Date of meeting 16th October 2017 Format of Paper Title of paper Audit Committee Report Written Summary Author Sally Flint, Oral ☐ Chief Finance Officer Presenter Lewis Doyle, Non-executive Presentation ☐ Director Committees/meetings where this item has been Audit Committee considered Purpose of report (tick all that apply) To provide assurance For decision ☐ Regulatory requirement To highlight an emerging risk or issue To canvas opinion ☐ For information To provide assurance To highlight patient, carer or staff experience ☐ Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report This report provides a summary of the papers and discussions from the Audit Committee meeting held on the 13th September 2017. The agenda for the meeting in September covered a number of areas across internal controls and risk management (including both operational and financial risks), accountability and assurance.
The Committee has highlighted the following areas for attention of the Board:- For Executive Directors to have an oversight of the implementation of audit recommendations. All recommendations arising from the agency timesheet audit at Langley Green Hospital had been implemented and that the Committee has requested a follow up audit in a year’s time to ensure that the improvement has been sustained To note the reduction in salary overpayments and the use of Single Tender Waivers and the request that compliance with financial controls is picked up through the regular performance meetings with Care Delivery and Support services. To note the improvements found on the re-audit of letters to GPs, patients and families. Recommendation The Council of Governors is asked to note this report.
1. INTRODUCTION The Audit Committee is responsible for monitoring and reviewing matters such as the integrity of financial statements, internal controls and overseeing the internal audit function. It is also focused on providing assurance to the Board that the systems and processes are functioning effectively (so that the Board is discharging its duty) and that those committees that are reviewing quality information in more detail are doing so effectively. The Audit Committee’s annual work plan is designed to cover these responsibilities and sets the agenda for each meeting, which is built around the following areas:-
• Internal Audit and Counter Fraud • Financial Controls and External Audit • Internal Controls and Risk Management • Corporate Governance • Accountability and Other Matters
Minutes of the meeting are circulated to all Board members. 2. REPORT The agenda for the meeting in September covered a number of areas across internal controls and risk management (including both operational and financial risks), accountability and assurance and included discussion of the following reports.
Internal Audit Update Report on progress being made to deliver the internal audit plan – the Trust’s Internal Auditors presented an update on the progress being made to deliver the Internal Audit Plan for 2017/18. The report highlighted 33% of the audit plan had either been completed or in draft and 67% of assignments were planned across the remainder of the financial year. There were no final reports for the Committee to review at the meeting. However, it was reported that good progress was being made on delivering the plan and that there would be a number of final reports for review at the November Committee meeting.
The Committee also reviewed the progress being made on the implementation of the recommendations arising from previous audit reports. The Committee noted the progress that has been made, but requested that this is reviewed regularly by the Executive Sponsors for each audit. The two main areas of concern were the actions relating to backlog maintenance and location visits.
The Internal Auditors also shared a number of information briefings that they have recently released, including briefings on Cyber Security in the NHS and their regular Health Matters Briefing that featured articles on Contract Compliance Audits, Demand & Capacity Modelling, Building Change Management and Person Centred Case Management. The auditors also shared a report that provided an Analysis of 2016/17 Internal Audit High Priority Management actions across the NHS, with the top three areas focused on Human Resources and Staffing Issues, Financial Management and Data Quality.
Local Counter Fraud Service (LCFS) – The Committee received an update from the Trust’s LCFS manager that set out the progress being made to deliver the annual LCFS plan for 2017/18 including the following areas.
The proactive work that has been undertaken in the period since the last Audit Committee meeting, which included bespoke training for the recruitment team on fraud and bribery and identification of fraudulent identification documents and exaggerated CVs, together with the on-going review of compliance against the bribery act across the Trust. Completion of the local proactive exercise to review agency timesheets, which has made recommendations to improve both the booking and invoice reconciliation process, both of which have been taken forward by the Trust
The 2016 Counter Fraud Benchmarking Report of all Trust’s across the RSM LCFS client base. The report showed that the Trust, with 11 referrals, had slightly more than the average, but the overall range was between 3 and 15 referrals. The report also showed that the Trust’s main source of referrals was from managers and senior staff. In terms of referral type the highest percentage of referrals in the Trust were for allegations of staff undertaking private work in NHS time, this differed from the peer group, were the high percentage of referrals were for allegations of payroll timesheet fraud.
Completion of the local proactive exercise to review agency staff timesheets at Langley Green Hospital - The Committee were reminded of the context of this work when the LCFS service were requested to review the use of agency staff at Langley Green Hospital in October 2016. The initial work had raised a number of concerns and a number of recommendations were made. A follow up review in July 2017 showed that all the recommendations from the review had been implemented. The Audit Committee acknowledged the achievements of the new senior management team at the unit, but requested a further review in a year’s time to ensure that the improvements have been sustained.
The Committee also received an update on current reactive cases, noting that there have been 5 referrals year to date, with two cases still on-going.
Financial Statements, Annual Report and External Audit - the Committee received two papers under this heading as follows:-
External Audit Update – the Committee received a short update report from KMPG that set out the work that had been undertaken since the year end, including a debrief of the 2016/17 audit with Trust management and presentation of the findings of the audit to the Council of Governors. Before the next Committee meeting the external auditors plan to complete their initial planning work for the 2017/18, agree the start date for the on-site interim audit and provide management with a draft audit plan for 2017/18.
Review of Losses and Special Payments and Schedule of Aged Debtors & Creditors over 6 months old – the Committee noted this report and were assured that the outstanding debtors and creditors are discussed at the monthly Finance meeting. The Committee requested a deep dive into specific debtor and creditor balances. It was agreed to review this at a future meeting, however the external auditors gave their assurance that this work is undertaken as part of the audit of the financial statements. .
Internal Controls and Risk Management – the Committee received a number of papers under this heading, as follows:-
Compliance and Financial Controls - the Committee reviewed the paper on compliance with financial controls, noting the improvement in salary overpayments and use of Single Tender Waivers. However, it was recognised that there is a significant piece of work to be undertaken to increase compliance with the use of purchase orders. Currently the project plan is being developed and all suppliers will be written to in due course to inform them that payment will only be make for goods and services if a purchase order is in place. The Committee supported this approach. It was also agreed that compliance with financial controls would be picked up at the monthly performance meetings with the Care Delivery and Support services.
Review of Standing Financial Instructions - the Committee received the updated Standing Financial Instructions (SFIs), summarising the main changes and noting the new section on joint ventures. The Committee also welcomed the Policy on Page summarising the key elements of the SFIs. The Committee approved the updated SFIs, subject to any changes that may come out of the Trust’s Governance Review and review of the Board sub-committees.
Update on GP Letters – the Committee received an update on the actions that have been taken within Adult and Children and Young People’s services to improve the quality and timeliness of letters sent to GPs, patients and families since the last clinical audit. Although, there is still wide variation in practice across the Trust the report highlighted that there had been an overall improvement in the numbers of letter sent and that this had been evidenced on Carenotes, the Trust’s clinical information system. The Committee noted that targeted actions have been identified to focus on further improvement in specific areas. The Committee welcomed this update and were supportive of further work in this area.
Accountability and Other Matters – the Committee received a number of papers under this heading including:-
Audit Committee Terms of Reference – the Committee undertook its annual review of its terms of reference and they were agreed subject to any changes that may come out of the Trust’s Governance Review and review of the Board sub-committees.
Quality Committee Update – the Committee received a report from the Quality Committee that provided the rationale for the restructuring of the Quality Committee, setting out the background and national and local context for the changes. The report outlined the new Governance structure for the Quality Committee, the sub-committees their directorship and terms of reference. The Audit Committee discussed the report and agreed that now the new Quality Committee was in place the Audit Committee no longer required a specific update from the Quality Committee. However, it was proposed that future agendas include a standing item that allows issues to be raised from other sub-committees that are relevant to the Audit Committee.
Action Log and Forward Look – the Committee also reviewed the action log and asked that it is reviewed regularly by the Executive Assurance Committee to ensure that recommendations from audits are implemented in a timely manner. The Committee also discussed the length and frequency of future meetings. It was agreed to keep to the agreed number of meetings for the remainder of 2017/18 until the Board sub-committee review is complete and Committee work plan is aligned to the meeting structure for 2018/19.
4. RECOMMENDATION(S) The Council of Governors is asked to note this report. 5. NEXT STEPS The next meeting of the Audit Committee is due to be held on 8th November 2017.
Report to the Council of Governors Agenda item CG 32.5/17 Attachment H EHRIA N/A code Date of meeting 16 October 2017 Format of Paper Title of paper Mental Health Act Committee Written Summary Author Alison Naylor, Mental Health Oral ☐ Act Information and Quality Manager Presenter Martin Richards, Non- Presentation ☐ Executive Director Committees/meetings where this item has been Mental Health Act Committee considered Purpose of report To provide assurance For decision ☐ Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information To highlight patient, carer or staff experience ☐ Strategic Goals 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report This report summarises the discussions and papers presented at the quarterly Mental Health Act (MHA) Committee held on Thursday 7th September 2017. The MHA Committee monitors Trust compliance with the Mental Health Act 1983, the Code of Practice 2015 and associated legislation and examines practice around the use of the MHA and investigates how the Trust is responding to identified issues. Good governance requires the Board to be sighted of MHA activity and performance. This report is for information. The Committee received and discussed: A summary report of feedback from CQC reviewers following unannounced MHA-related inspections carried out between 1st April and 30th June 2017 (“Q1” 2017-18) A summary of themes emerging from data relating to the use of the MHA in Q1 2017-18. A summary of feedback from Tribunal and Associate Hospital Managers’ hearing panels convened during Q1. Recommendation The Council of Governors is asked to note the contents of this report and raise any issues for clarification.
1. INTRODUCTION This report informs the Council of Governors of MHA-related activity and areas where there are challenges, as well as good practice, across the Trust. 2. REPORT MHA Committee Purpose Martin Richards, Non-Executive Director and Chair of MHA Committee, confirmed that the aim of MHA Committee is to examine practice around the use of the MHA and to investigate how the Trust is responding to identified issues. Particularly useful to this process is the continued attendance and the expertise of representatives from Clinical Delivery Services in talking about pinch points and sharing areas of good practice.
Matters arising from previous meeting The Committee heard updates from attendees on: Progress on s136 provision ahead of changes brought in by the Policing and Crime Act 2017. Emergency access to Carenotes for late notice staff cover. Recruitment of clinical staff. HMP Lewes. Reviews of, and training provided in, older people’s wards. Feeding comments and plaudits from Associate Hospital Managers back to Consultants via their appraisal mechanism.
CQC MHA monitoring visits Seven MHA monitoring visits were carried out by the CQC during Quarter 1. As was the case in the previous quarter, a significant amount of good practice was identified. Areas of good practice and ‘pinch points’ were identified and discussed as follows: S132 rights and how staff are encouraged to repeat them to patients on time and evidence this. Patient autonomy: how independent access to bedrooms can is being achieved for older people. Carer involvement and the Trust’s acceptance onto the Triangle of Care programme. Advance statements and decisions, which is an issue raised by the CQC following most MHA visits. Section 17 leave and the completion and auditing of forms. The increasing cost of conveyance of detained patients.
Themes emerging from the use of the MHA The following themes were discussed, having been identified from MHA-related data: The increase in the use of section 2, which is reflected nationwide, and possible reasons for this. The increase in the use of active CTOs, particularly in Coastal West Sussex.
Update on ligatures Clear guidelines have been produced for community teams around ligatures.
Tribunal and Managers’ hearings An update was provided on recruitment and training of clinical and nursing staff in East Sussex Adult Services.
MHA Committee Terms of Reference These were circulated and agreed.
Any other business Martin Richards introduced Dominic Ford, Director of Corporate Affairs, who will be taking over responsibility for the MHA within the Trust. 3. RECOMMENDATION To note the content of the report.
Report to Council of Governors Agenda item CG 33.1.17 Attachment I EHRIA N/A code Date of meeting 16/10/2017 Format of Paper Title of paper Membership Committee Written Update Author Membership & Voluntary Oral ☐ Services Coordinator Presenter Mark Hughes, Membership Presentation ☐ Committee Chair/ Carer Governor Committees/meetings where this item has been N/A considered Purpose of report (tick all that apply) To provide assurance ☐ For decision ☐ Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information To highlight patient, carer or staff experience ☐ Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care ☐ 2. Local, joined up care ☐ 3. Put research, innovation and learning into practice ☐ 4. Be the provider, employer and partner of choice 5. Living within our means ☐ Summary of Report This paper is to summarise the proceedings of the most recent Membership Committee and highlights the main points from the 4 primary agenda items.
Recommendation For the councils information and discussion.
1. INTRODUCTION The Membership Committee last met on 7th September 2017. Its purpose is to oversee all membership related areas of the Trust and to look at ways of promoting greater involvement of members. The following report highlights some of the topics considered at this latest meeting. 2. REPORT The Committee discussed: Partnership Matters Magazine: The Committee agreed that they would like Partnership Matters to be closer linked with the work of the Council of Governors, and wished to continue working closely with communications to ensure articles featured stories from people that have used Trust services. It was agreed that the Communications team will advise the Committee of the article submission deadline and publication dates, at least four weeks in advance. The Committee also discussed the possibility of sharing unpublished articles with the members electronically if they suitable but had not made the publication. Membership Report: The Committee requested that future reports were clearer on the steps the Trust had taken to engage with its members during the database improvement project which the council has been advised of previously. The focus in the past 6 months has been on ensuring our members are active and that we have recorded their preferred method of communication as we look develop our online and electronic presence.
The committee viewed the report as being a true reflection of the membership but wanted to see more granular details on the number of carer members which was not reflected in the report. Governor Elections: The Committee were informed that the election was delayed due to Purdah, and that the results were finalised on 4th September 2017. Out of the 13 positions that were part of the election, 12 were successfully filled, which means we now have a total of 30 Governors in post. The Trust currently has 2 vacant governor positions, 1 position was unfilled in the recent election and the other became vacant during the election campaign. We are currently considering whether a By-election should be called to fill these remaining 2 positions.
Membership Development: The Committee suggested that the Membership Development Strategy should be revised to align to the Trust 2020 vision, the Trust objectives and the Clinical Strategy. The Committee has been advised that the version taken in September was not the most current. Therefore a review of the comments will be made against the correct version of the strategy to assess whether the comments still need addressing. Annual Members Meeting: The Committee were informed that the summary of the Annual Account and Quality Report was being designed by the Communications department and a copy would be distributed to all steering group members once complete. A theme for the event had yet to emerge from the steering group, and a committee member suggested “You, you’re mental health & wellbeing”. There was general agreement that a celebrity booking was not viable for this year’s Annual Members Meeting but Heads-On would look into it for next year. Members of the committee suggested the following: All 8 CDS should be encouraged to have stall at the event. A Governor be present on the Membership and Governor stall with Governor pictures displayed. A live Twitter wall. With Questions and answers for on the day to be thought about and actioned with the Communications department and IT. Four people stationed at registration desks in the main stairwell, each having a list of the same attendees to tick off, give them a goodie bag and a name badge with their chosen workshop on and one by the lift. It was agreed that the steering group would take the suggestions forward. 3. NEXT STEPS Any comments and agreed suggestions will be taken forward by the Committee.
Report to Council of Governors Agenda item CG 33.1/17 Attachment J EHRIA N/A code Date of meeting 16th October 2017 Format of Paper Title of paper Nomination and Written Remuneration Committee Author Dominic Ford, Director of Oral ☐ Corporate Affairs Presenter Richard Bayley, Interim Chair Presentation ☐ Committees/meetings where this item has been N/A considered Purpose of report (tick all that apply) To provide assurance ☐ For decision ☐ Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information To highlight patient, carer or staff experience ☐ Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care ☐ 2. Local, joined up care ☐ 3. Put research, innovation and learning into practice ☐ 4. Be the provider, employer and partner of choice 5. Living within our means ☐ Summary of Report This report summarises the proceedings of the Nomination and Remuneration Committee on 18th September 2017.
Recommendation The Council is asked to note the report.
1. INTRODUCTION The Nomination and Remuneration Committee met on 18th September 2017. Its purpose is to consider proposals regarding the appointment of the Chair and Non-Executive Directors and their terms and conditions; and the appointment of the Deputy Chair; and make recommendations to the Council. 2. REPORT The Committee discussed: Chair and Non-Executive Director recruitment process: The Committee discussed a draft proposal for the staged recruitment of the substantive Chair and Non-Executive Directors. The Committee discussed the timescale for recruitment; the skills required in the Chair and Non-Executive Directors; and the value of external agency support in the recruitment process. No changes to the remuneration of the Chair or Non-Executive Directors were proposed. The Committee recommended the proposed process to the Council. Interim Deputy Chair: The Committee noted that following Richard Bayley’s appointment as Interim Chair, a replacement Interim Deputy Chair would be required. A proposal is submitted to the Council for approval. Terms and Conditions for Chair and Non-Executive Directors: The terms and conditions for the Chair and Non-Executive Directors were reviewed to incorporate the Fit and Proper Persons Regulations and are recommended to the Council for approval. Terms of Reference: The Committee reviewed its Terms of Reference which are submitted to the Council for approval, together with the membership of the Committee 3. NEXT STEPS The Council is asked to note the report.
Report to Council of Governors Agenda item CG 33.1/17 Attachment K EHRIA N/A code Date of meeting 16 October 2017 Format of Paper Title of paper To review and approve the Written COG Terms of Reference Author Adam Churcher, Head of Oral ☐ Corporate Governance Presenter Adam Churcher, Head of Presentation ☐ Corporate Governance Committees/meetings where this item has been considered Purpose of report (tick all that apply) To provide assurance For decision Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information ☐ To highlight patient, carer or staff experience ☐ Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care ☐ 3. Put research, innovation and learning into practice ☐ 4. Be the provider, employer and partner of choice 5. Living within our means ☐ Summary of Report
The Constitution (SO 5.1) provides for the Council of Governors to establish a Committee to assist it in the proper performance of its functions. The Council has established three Committees:
1. Nominations & Remuneration Committee – Appendix 1 2. Membership Committee – Appendix 2 3. Training & Development Committee – Appendix 3
SO 5.5 states that the Council cannot delegate to any Committee any powers or responsibilities which are to be exercised by the Council at a formal meeting.
Recommendation The Council is asked to: Approve the Terms of Reference of the three committees.
Nomination & Remuneration Committee Terms of Reference Constitution
The Nominations and Remunerations Committee is a Committee constituted by the Council of Governors subject to Standing Order 5.1
The Committee is responsible for making recommendations to the Council of Governors relating to: The evaluation of the performance of the Chair and Non-Executive Directors The remuneration, allowances and other terms and conditions of office for the Trust Chair and Non- Executive Directors The recruitment process for the selection of candidates for the office of Chair or other Non-Executive Directors
Duties
The duties of the Nominations and Remunerations Committee are categorised as follows:
To consider the reappointment of the Chair or Non-Executive Directors at the end of each three year term of office, taking into account the latest annual appraisal and in line with the requirements of the Constitution, and to make recommendations to the Council of Governors To regularly review skills, knowledge and experience required of the Chair and Non-Executive Directors, taking into account the challenges and opportunities facing the Trust, and make recommendations with regard to whether these are being met. To consider any matters relating to the continuation of appointment of any Non-Executive Director at any time, including the suspension or termination of office, and make recommendations to the Council of Governors, in accordance with the constitution and any relevant guidance. To develop the job description, person specification and advertisement for any new appointment of the Chair or a Non-Executive Director, taking into account the views of the Board of Directors on the skills and experience required and the leadership needs of the Trust, for approval of the Council. To engage external support for the search and selection of candidates as required, subject to the advanced agreement of the Board of Directors (SO 5.7) To advertise the vacancy in at least one appropriate publication, shortlist suitable candidates (not more than 5 for each vacancy), convene an interview panel, conduct interviews and recommend a candidate to the Council of Governors for approval. To ensure that all Non-Executive Directors undergo an appropriate induction, training and development programme. To regularly review the time required from and provided by Non-Executive Directors. To consider the remuneration and terms of service of the Chair and Non-Executive Directors to ensure they are fairly rewarded, having proper regard to the financial circumstances of the Trust and any relevant national arrangements, and make recommendations regarding the same to the Council of Governors. To establish the selection criteria, selecting, appointing and setting of terms of reference for any external consultants who advise the Committee or the Council of Governors To evaluate its own membership and performance on a regular basis. To ensure that the Committee membership is refreshed and that undue reliance is not placed on particular individuals when undertaking the responsibilities of the Committee To review and update annually these Terms of Reference, recommending any changes to the Council of Governors.
Authority
The Committee is authorised by the Council of Governors to carry out any activity within its Terms of Reference.
Members Quorum
Trust Chair The Chair (or agreed Chair in their absence) plus two 2 Governors from the Service User constituency, i.e. members, to include at least one Governor from the one service user governor and one carer governor Service User or Public constituencies. 1 Governor from the Public constituency 1 Governor from the Staff constituency 1 Appointed Governor
Membership will be by self-nomination and Governors will serve a 1 year term with the option of self- nomination for one additional term.
All appointments to the Committee will be approved by the Council of Governors and will be reviewed annually
The Committee will be chaired by the Chair (except when considering the terms and conditions or appointment of the Chair).
When considering the appointment of the Chair, the Senior Independent Director or a Governor, agreed by members of the Committee, shall chair the meeting.
When evaluating the performance of the Chair or considering the Chair’s terms and conditions, the Governors shall appoint a chair from one of their number.
Only members of the Committee have the right to attend meetings of the Committee.
The Committee may ask the Chief Executive, Director of Human Resources and/or the Head of Corporate Governance to be in attendance for all or part of a meeting to advise the Committee.
The Head of Corporate Governance or their nominee will be in attendance to minute the meeting.
The Committee may also seek the advice of external advisors as appropriate when exercising the functions set out in 1.2 and 7.0 , subject to the advance agreement of the Board of Directors (as directed by Standing Order 5.7).
Frequency Calling Meetings
Meetings will take place as frequently as it may Meetings will be called at the request of the Chair. determine to be necessary to undertake its duties but as a minimum at least once a year. Notice of each meeting, including an agenda and supporting papers will be sent to the members of the All meetings are in accessible venues, taking into Committee 5 clear days before the date of the meeting. account the needs of all attendees.
Reporting Communication
The Committee reports to the Council of Governors and will present an update to the next meeting of the The Committee will agree key messages for Council of Governors. Such reports will be given in communication to the Council of Governors at the end private whenever the names of individuals are being of each meeting discussed All papers, minutes and documents are available in A statement regarding the Committee’s activities, alternative formats, if requested including the process used for appointments, will be included in the Annual Report. All members of the Committee are required to observe the strictest confidence regarding the information The Chair will present a report to the annual members presented to the Committee and must not disclose any meeting and take any questions that arise at that confidential information either during or after their term meeting. of membership. Failure to comply with these requirements could result in the termination of The notes of the meeting will be agreed by the Chair membership of the Committee and/or could be deemed within 5 working days of the meeting. Action points will a breach of the Governor Code of Conduct be circulated to members within 10 working days of the meeting.
Review
These terms of reference will be reviewed annually.
Membership Committee Terms of Reference Constitution
The Membership Committee is a Committee constituted by the Council of Governors subject to Standing Order 5.1
The Committee is responsible for making recommendations to the Council of Governors relating to: Membership recruitment and development Member retention and engagement with the Trust Member engagement with the Governors Member communication and feedback
Duties
The duties of Membership Committee are categorised as follows:
To monitor and review the Membership Development Strategy and revise it as necessary making recommendations to the Council of Governors. To monitor membership targets and build a representative and engaged membership. To devise and implement two-way communications channels between the Governors and members To develop other mechanisms for members to pass on their comments, opinions and suggestions to the Council of Governors. To work with the Membership Office and Trust managers to devise a programme of member involvement and interesting events. To provide ideas for, and contribute to, member recruitment activities. To identify links with the Membership Office for the production and development of the members’ newsletter and other means of communication. To receive regular reports on the current membership.
Authority
The Committee is authorised by the Council of Governors to carry out any activity within its Terms of Reference.
Members Quorum
Not less than three Governors (Any constituency) The Chair (or agreed Chair in their absence) plus a minimum of two governors. Membership will be by self-nomination and Governors will serve a 1 year term with the option of self- nomination for one additional term.
All appointments to the Committee will be approved by the Council of Governors and will be reviewed annually.
The Committee may ask the Chair, Head of Corporate Governance and/or the Director of Communications to be in attendance to advise the Committee for all or part
of a meeting.
The Committee will elect one of its members as Chair
The Corporate Governance Office will provide administrative support for the Committee, including producing the agenda and papers and taking notes at the meetings.
The Head of Corporate Governance or their nominee will be in attendance to provide an essential link to the Governance support office
Frequency Calling Meetings
Meetings will take place as frequently as it may Meetings will be called at the request of the Chair. determine to be necessary to undertake its duties but as a minimum at least twice a year. Notice of each meeting, including an agenda and supporting papers will be sent to the members of the All meetings are in accessible venues, taking into Committee 5 clear days before the date of the meeting. account the needs of all attendees.
Reporting Communication
The Committee will agree key messages for The Committee reports to the Council of Governors and communication to the Council of Governors at the end will present an update to the next meeting of the of each meeting Council of Governors.
All papers, minutes and documents are available in A statement regarding the Committee’s activities will be alternative formats, if requested included in the Annual Report.
All members of the Committee are required to observe The notes of the meeting will be agreed by the Chair the strictest confidence regarding the information within 5 working days of the meeting. Action points will presented to the Committee and must not disclose any be circulated to members within 10 working days of the confidential information either during or after their term meeting. of membership. Failure to comply with these
requirements could result in the termination of membership of the Committee and/or could be deemed a breach of the Governor Code of Conduct
Review
These terms of reference will be reviewed annually.
Training & Development Committee Terms of Reference Constitution
The Training & Development Committee is a Committee constituted by the Council of Governors subject to Standing Order 5.1
The Committee is responsible for making recommendations to the Council of Governors relating to: Regularly Identifying Governor training needs Setting the agendas for the Governor Training and Development Days Regularly reviewing the Governor Code of Conduct Maintaining and developing the Governors Induction Manual in conjunction with the Governance Support Office
Duties
The duties of Training & Development Committee are categorised as follows:
Contribute to Governor elections campaigns and related publicity Assist with Governor Induction meetings. Contribute to and maintain the content of the Governor Induction Manual. Annually review and recommend any necessary revisions to the Code of Conduct Organise the agendas of Governor Training and Development Days. Oversee and organise other Governor training initiatives as necessary Identify Governors training needs via regular issues of the survey, particularly after an influx of new Governors following elections Contribute to and maintain the training needs survey To evaluate its own membership and performance on a regular basis. To ensure that the Committee membership is refreshed and that undue reliance is not placed on particular individuals when undertaking the responsibilities of the Committee To review and update annually these Terms of Reference, recommending any changes to the Council of Governors.
Authority
The Committee is authorised by the Council of Governors to carry out any activity within its Terms of Reference.
Members Quorum
Not less than three Governors (Any constituency) The Chair (or agreed Chair in their absence) plus a minimum of two governors. Membership will be by self-nomination and Governors will serve a 1 year term with the option of self- nomination for one additional term.
All appointments to the Committee will be approved by the Council of Governors and will be reviewed annually.
The Committee will elect one of its members as Chair
The Committee may ask any member of staff to be in attendance for all or part of a meeting to advise the Committee
The Corporate Governance Office will provide administrative support for the Committee, including producing the agenda and papers and taking notes at the meetings.
The Head of Corporate Governance or their nominee will be in attendance to provide an essential link to the Governance support office
Frequency Calling Meetings
Meetings will take place as frequently as it may Meetings will be called at the request of the Chair. determine to be necessary to undertake its duties but as a minimum at least twice a year. Notice of each meeting, including an agenda and supporting papers will be sent to the members of the All meetings are in accessible venues, taking into Committee 5 clear days before the date of the meeting. account the needs of all attendees.
Reporting Communication
The Committee will agree key messages for The Committee reports to the Council of Governors and communication to the Council of Governors at the end will present an update to the next meeting of the of each meeting Council of Governors.
All papers, minutes and documents are available in A statement regarding the Committee’s activities will be alternative formats, if requested included in the Annual Report.
All members of the Committee are required to observe The notes of the meeting will be agreed by the Chair the strictest confidence regarding the information within 5 working days of the meeting. Action points will presented to the Committee and must not disclose any be circulated to members within 10 working days of the confidential information either during or after their term meeting. of membership. Failure to comply with these
requirements could result in the termination of membership of the Committee and/or could be deemed a breach of the Governor Code of Conduct
Review
These terms of reference will be reviewed annually.
Report to Council of Governors Agenda item CG 33.2/17 Attachment L EHRIA N/A code Date of meeting 16 October 2017 Format of Paper Title of paper Council of Governors Written Declaration of Interests Register Author Natalie Hennings, Corporate Oral ☐ Governance Manager Presenter Adam Churcher, Head of Presentation ☐ Corporate Governance Committees/meetings where this item has been considered Purpose of report (tick all that apply) To provide assurance For decision ☐ Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information To highlight patient, carer or staff experience ☐ Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care ☐ 2. Local, joined up care ☐ 3. Put research, innovation and learning into practice ☐ 4. Be the provider, employer and partner of choice ☐ 5. Living within our means ☐ Summary of Report The Constitution of Sussex Partnership requires members of the Council of Governors to declare any potential conflict of interest as soon as these arise. It is good practice to review the Council of Governors declaration of interest register annually and this is available in the public domain through Sussex Partnership’s publication scheme and detailed in the Annual Report.
Recommendation The Council is asked to receive the register for information and inform the Corporate Governance Manager of any changes to the register as soon as these arise.
1. INTRODUCTION In accordance with the Constitution, governors are required to declare any potential conflict of interest as soon as these arise, and this report is being presented to ask governors to receive the Council of Governors register for information. This register is published online as part of the Trust’s publication scheme. 2. REPORT This report has attached the governor declaration of interest register (appendix A). Timely declarations are essential as there may be times when Governors have a particular interest in an item being considered by the Council. This might be a financial interest, for example, relating to the company for whom they work. There are other occasions where the interest may be non-financial but could relate to a friend or something like the membership of an association. The Governance Office actively asks all governors to complete a declaration of interest form upon appointment and the register is also circulated annually for review and acceptance. Some forms and responses are awaited from Governors. These should be completed and returned as soon as possible. 3. RECOMMENDATION & NEXT STEPS The Council is asked to receive the register for information and inform the Corporate Governance Manager of any changes to the register as soon as these arise.
Sussex Partnership NHS Foundation Trust ‐ Council of Governors ‐ Declaration of Interests Register 2017‐18 End of Term/ First Name Surname Appointed Elected Category Interests Declared Stepped Down Health and Care Professions Council, College of Paramedics. Employeed by South East Coast Ambulance Service NHS Foundation Giles Adams X Appointed Trust. Partner is Miss Charlotte Peacock who for East Sussex Health Care NHS Trust. Gary Beecheno X Public Current employee, ends on 28 October 2017; Steward for Unison; Member of RCN Jose Belda X Staff 31/07/2017 Owner Hair on Wheels. Bi‐polar UK Lewes Group Facilitator. Senior State Registered Hairdresser. Member of Bipolar UK, Action for Karen Braysher X Service User Hearing and the Hair Council. Sister, Lorraine Mercer MBE Voluntary Chaplin work PRH. Director of Children and Young People, employed position with YMCA DLG. Currently the lead for YMCA DLG being part of Brighton Rachel Brett X Appointed and Hove Community Wellbeing Service Partnership Bid with SPFT. Director on YMCA DLGs trading company. Gillian Brown X Public Jayne Bruce X Staff Paul Burris X Service User Occupational Therapy Course Representative for Brighton University Diana Byrne X Service User Recovery College trainer and Peer recovery trainer on bank employment. 31/07/2017 Sophie Campbell X Carer 31/07/2017 Angie Culham X Service User Michael Decker X Service User Director of Arabian Garden Ltd. Appointed to the Scrutiny Panel of Moat Housing, a Housing Trust in the South East.
Trustee of (a).Friends of Sussex Hospices (b) Citizens Advice East Sussex. Deputy Lieutenant for East Sussex. Associate Hospital Managers Panel for SPT and The Priory. Member of The Law Society. Gifts or hospitality offered (a)farewell dinner and gift from Phyllida De Salis X Public Burrswoodon retirement as Trustee (b) refreshments on various occasions when deputising for Lord Lieutenant a Deputy Lieutenant. Amy Dickinson X Service User James Domanic X Service User None Terry Dorsett X Service User Brian Doughty X Appointed David Fowler X Appointed 31/07/2017 Gabrielle Gardner X Service User Director of Shine for Life, Equine Assisted Psychotherapy Alex Garner X Staff Sarah Gates X Appointed None Katie Glover X Appointed CEO and Company Secretary of Coastal West Sussex MIND Bryan Goodenough X Carer Wife is on NHS Pension. Shannon Guglietti X Staff Elizabeth Hall X Service User HWO RAFA;Treasurer Adur Stroke Club, Vice Chair PPG and member of the Patient Experience Panel WSC CCG Walmer Parish Council ‐ Councillor. NHS England South East ‐ Eating Disorders Network; NHS England South East ‐ CHYPS IAPT Amy Mary Rose Herring X Service User Trasformation Programme; NHS England South East ‐ Perinatal Care (Mental Health) John Holmstrom X Chief Executive Worthing Churches Homeless Project, Trustee YMCA Downslink Group Group Coordinator ‐ Worthing Rethink Mental Health Carers Grop. Committee member ‐ South Eastern Kidney Patient Association. Retired member ‐ Unison. Chair of Patient Transport Forum, run by High Weald Lewes Havens (HWLH) CCG, Coperforma and patient Mark Hughes X Carer groups, with me representing South Eastern Kidney Patient Association (SEKPA).
Scott Hunt X Public A member of the Royal College of Nursing as a retired Nurse. Husband works as a Support Worker for Sussex Partnership.
Debbie Kennard X Appointed Councillor West Sussex County Council and member Health and Adult Select Committee . Deputy Cabinet Member for Children 31/07/2017 Fiona McLay X Service User Louise Patmore X Staff None
Trustee (Treasurer) The Circus Project, Finance Manager/Deputy Chief Executive of University of Brighton Students Union. Member of Clare Quigley X Public the Association of Chartered Certified Accountants (ACCA). Sister and Brother in law are Clinical Psychologists within the NHS 31/07/2017 Sarah Reynolds X Staff 31/07/2017 Natasha Sigala X Appointed None David Simmons X Appointed Mel Smith X Service User Simon Street X Staff None Peter Thompson X Public Andrew Voyce X Service User Trustee of Seap ‐ advocacy service. 31/07/2017 Glen Woolgar X Staff Chartered member of Institute of Occupational Safety and Health
Report to Council of Governors Agenda item CG 33.3/17 Attachment M EHRIA N/A code Date of meeting 16 October 2017 Format of Paper Title of paper To agree the Frequency & Written Council of Governors Meeting dates for 2018 Author Adam Churcher, Head of Oral ☐ Corporate Governance Presenter Adam Churcher, Head of Presentation ☐ Corporate Governance Committees/meetings where this item has been considered Purpose of report (tick all that apply) To provide assurance For decision Regulatory requirement ☐ To highlight an emerging risk or issue ☐ To canvas opinion ☐ For information ☐ To highlight patient, carer or staff experience ☐ Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care ☐ 3. Put research, innovation and learning into practice ☐ 4. Be the provider, employer and partner of choice 5. Living within our means ☐ Summary of Report
It is good practice to review the cycle for meetings of the council of governors at least annually. This paper set out the recommendations for 2018.
Recommendation The Council of Governors is asked to confirm whether the schedule at (Appendix 2) effectively allows them to discharge their duties and to approve - The cycle of business for the council in 2018 - The use of an external Brighton location for COG meetings - The timings of COG meetings
1. INTRODUCTION
It is good practice to review the cycle for meetings of the council of governors at least annually.
The Constitution of Sussex Partnership requires the Council of Governors to meet at least three times a year (SO4.3.2), including the Annual General Meeting (AGM).
Since 2016 the Council has held a separate Annual Members Meeting in October around World Mental Health Day.
2. REPORT
Annually the Council is asked to commit to;
- A minimum of three Council of Governor Meetings - Two Joint Council and Board Workshops - Three Council Development Days
The chair may call an extraordinary meeting at any time to transact business, for example the appointment of a Non-Executive Director.
In addition, council members are asked for expressions of interest in observing a maximum of two board sub committees and a committee of the council. This can require attendance at up to an additional 4-8 meeting to those expected of all council members.
Venues The cost of using an external venue has been considered in the past, most recently in October 2015 when the council agreed to return to Trust premises under the wider review of all corporate expenditure. At this time it was noted that there was limited availability of rooms suitable to hold council meetings but with a number of vacancies this has been achieved to date.
However with the recent appointment of 13 new council members a number of the original venues are no longer suitable based on the potential attendance captured in Appendix 1. It is therefore recommended that the council consider the use of an external Brighton location to achieve our aspiration of holding council meetings across the counties we provide services.
Training Centre, Swandean – Suitable with the purchase of additional tables Lecture Theatre, Mill View – Not Suitable Conference Room, Langley Green – Not Suitable Roebuck Suite, Hellingly – Suitable with the purchase of additional tables
Timings Historically, the council meetings have been held on a Monday, it is recommended that this continues but that the council are open to a range of timings, including one council meeting outside of 9-5 business hours per annum.
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Cycle of Business A meeting planner and cycle of business for the Council of Governors has been developed which captures the statutory responsibilities of the council and ensures these are set out accordingly throughout the year (Appendix 2)
3. RECOMMENDATION & NEXT STEPS
The Council of Governors is asked to confirm whether the schedule at (Appendix 2) effectively allows them to discharge their duties and to approve - The cycle of business for the council in 2018 - The use of an external Brighton location for COG meetings - The timings of COG meetings
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Appendix 1
Service User Staff Appointed Public Carer Karen Braysher Simon Street Brian Doughty Phyllida De Salis Bryan Goodenough Michael Decker Jayne Bruce Cllr David Simmons Scott Hunt Mark Hughes Gabrielle Gardner Alex Garner Dr Natasha Sigala Gillian Brown Vacant Amy Mary Rose Herring Shannon Guglietti Giles Adams Peter Thompson Amy Dickinson Glen Woolgar Sarah Gates Gary Beecheno Fiona McLay Rachel Brett Angie Culham John Holmstrom James Domanic Katie Glover Terry Dorsett Mel Smith
Non Executives Executives Corporate Governance Richard Bayley Sam Allen Adam Churcher Anne Beales Dominic Ford Natalie Hennings Lewis Doyle Exec Rep Minute Taker Martin Richards Exec Rep Diana Marsland Gordon Ferns Vacant
Appendix 2
Jan Feb July May April June March August October November December September
19 18 17
Council of Governors Meeting Swandean Brighton Hellingly
Training and Development Committee TBC
Membership Committee TBC
Nomination and Remuneration 27 28 Committee
Joint Board and Council (1/2 Day) TBC TBC COUNCIL
TBC TBC TBC Governor Development Days
Annual Members Meeting 15
17
Annual General Meeting Hellingly
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PUBLIC MEETING – CYCLE OF BUSINESS
Sept
June Item Owner February INTRODUCTION Introductions and apologies for absence To receive any declarations of interest √ Questions from members of the public Minutes of the XXXXXXX held on *** and matters arising (not covered on the agenda) CURRENT PRIORITIES (Driven from agenda setting meeting)
UPDATES Chief Executive’s Report Sam Allen √ √ √ Lead Governors Report Lead Gov √ √ √ Sustainability and Transformation Partnership Update Sam Allen √ ASSURANCE CQC Compliance and Strategic Assurance Diane Hull √ √ Annual Mortality and Serious Incidents Report Diane Hull √ Annual Report on Patient Experience (including complaints) Diane Hull √ FTSU Annual Update Lynn Richardson √ HOLDING TO ACCOUNT Audit Committee Summary & Feedback from Governor Observers Sally Flint √ √ √ Finance and Investment Committee Summary & Feedback from Governor Observers Sally Flint √ √ √ Mental Health Act Committee Summary & Feedback from Governor Observers Martin Richards Quality Committee Summary & Feedback from Governor Observers Gordon Ferns Charitable Funds Committee & Feedback from Governor Observers Anne Beales Issues from the Council of Governors All Govs √ √ √ WORKFORCE & STAFFFING
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Staff Survey Report (including results) Sue Esser √ Feedback from Staff Governors Staff Govs √ √ √ GOVERNANCE Annual Business Objectives Sally Flint √ Progress against the 2020 Vision Sally Flint √ Annual Operating Plan Sally Flint √ Election Update Adam Churcher √ To receive the Register of Declarations of Interest Adam Churcher √ To review the Council Committee’s Terms of Reference Adam Churcher √ To receive an update from the Governors Development Day Amy Herring √ √ √ To receive an update from the Membership Committee Mark Hughes To receive an update from the Nomination and Remuneration Committee Chair To receive an update from the Training and Development Committee TBC AGM ITEMS To receive the annual report and account accounts Sally Flint √ To receive a report from the External Auditor on the annual accounts External Auditor √ Proceedings of Council meetings/Changes to Governors report Adam Churcher √ An update on the progress against the Membership Strategy Lou Morgan √
PRIVATE MEETING – CYCLE OF BUSINESS
Sept June Item Owner February INTRODUCTION Chair’s Welcome and Introduction Apologies for Absence & Declarations of Interest √ Minutes of the XXXXXXX held on *** and matters arising (not covered on the agenda) HOLDING TO ACCOUNT
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GOVERNANCE To feedback on the performance of the chair and non‐executive directors for the purpose of their Adam Churcher √ annual appraisal To receive Chair and Non‐Executive Director’s Appraisals Adam Churcher √ To receive the Chair and Non‐Executive Directors objectives for ADD YEAR √ Governors Attendance Adam Churcher √ √ √ To appoint Governor members to Committees and Governor observers to Board Committees Chair √ To agree the Appointment of the Lead Governor and Deputy Lead Governor Chair √ STATUTORY COUNCIL REQUREMENTS – ADHOC To appoint/remove the Chair and other non‐executive directors Adam Churcher To appoint one of the non‐executive directors as Deputy Chair Chair To consider and recommend the appointment of one of the non‐executive directors as Senior Chair Independent Director To decide the remuneration an allowances, and the other terms and conditions of office, of the Chair/Adam Churcher non‐executive directors To approve the appointment of the Chief Executive Chair To appoint or remove the External Auditor Sally Flint To consider disputes as to membership Adam Churcher To consider resolutions to remove a governor Adam Churcher To approve amendments to the Constitution Adam Churcher To approve any increase of non‐NHS income by 5% or more of the proportion of total income Sally Flint To suspend a Standing Order of the Council of Governors (must be reviewed by the Audit Chair Committee and Board of Directors) To approve a variation and amendment to the Standing Orders (must also be approved by the Chair Board of Directors)
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