a g e n d a - beh-mht.nhs.uk us/board papers/2019/28-01 … · 28-01-2019 · • director / owner...

Trust Board

Monday, 28 January 2019 at 1.00 pm

Lecture Theatre, St Ann’s Hospital, St Ann’s Road, London, N15 3TH

A G E N D A (Meeting of the Trust Board held in public)

Time Item Number

Agenda Item Page Number

Lead

1.00 Patient Focus:

The meeting will commence with a presentation from the Patient Experience Team

Amanda Pithouse/

Clare Scott

1.

General Business

1.25 1.1 Chairman’s welcome

Verbal Mark Lam

1.2

Apologies for Absence Verbal Mark Lam

1.3 Declarations of Interest and of any Conflicts of Interest

To review the attached Summary of Board Members’ declarations of interest and to declare at the meeting any conflicts.

Verbal Mark Lam

1.4 Minutes of the Meeting held on 26 November 2018 To confirm the minutes of the last meeting as a true record.

Mark Lam

1.5 Actions and Matters Arising from the Minutes To review progress set out in the attached written report and to discuss any other matters raised by Board Members.

Page 15

Mark Lam

1.30 1.6 Chairman’s Report To receive the Chairman’s verbal report

Verbal Mark Lam

1.40 1.7 Chief Executive’s Report To receive an update on Trust matters.

Page 19

Jinjer Kandola

Time Item Number


Lead

2.

For Discussion/Decision

1.50 2.1 Annual Workforce Report To receive the Workforce Annual Report

5

Jackie Stephen

3. For Assurance

2.05 3.1 Board Assurance Framework and Trust Risk Register

To consider the Board Assurance Framework

Page 37

Katia Louka

2.15 3.2 Trust Quality and Performance Report To review the Trust Quality and Performance Report.

Page 65

Stanley Riseborough

2.25 3.3 Financial Performance: Month 9 (December 2018) To receive an update on recent financial performance

Page 75

David Griffiths

2.35 3.4 Clinical, Quality and Safety Report To receive an update on the following: • Inpatient Quality Governance Assurance • CQC Action Plan

Pages 85 91

Amanda Pithouse

2.45 3.5 Safe Staffing Levels To note the Safe Staffing Levels report and the actions being taken.

Page

109

Amanda Pithouse

4. Other Items

2.55 4.1

Any Other Urgent Business The Chairman will be asked to consider any other urgent business which he has been previously notified of in advance of the meeting, but which has not been provided for on the agenda.

4.2

Date and Time of Next Meeting

Monday, 25 March 2019 at 1.00 pm

Lecture Theatre, St Ann’s Hospital Reports scheduled for consideration at the next meeting, include: • Chairman’s Report • Chief Executive’s Report • Board Assurance Framework • Trust Quality and Performance Report • Financial Performance

Time Item Number


Lead

• Clinical, Quality and Safety Report • Safe Staffing Report • Half yearly update on R&D • Information Governance Annual Report

5.

Exclusion of the Press and the Public

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

BOARD OF DIRECTORS’ REGISTER OF INTERESTS Board Member:

Interest Declared:

Mark Lam Trust Chairman

• Non-Executive Director, Airedale NHS Foundation Trust. • Non-Executive Director, Barking, Havering and Redbridge University

Hospitals NHS Trust • Trustee and Council Member, University of Essex • Former Chief Technology and Information Officer, Openreach, a BT

Group business • Non-Executive Director, Social Work England

Jonathan Bindman Medical Director

• Unpaid adviser to Raphael, a Jewish counselling service based in Barnet. • Wife’s interests are: o Works as a GP currently working at St Stephens Health Centre, Bow o Independent Clinical Adviser for Out of Hours Primary Care Service,

City and Hackney CCG o GP Clinical Lead for Medicines Optimisation at Tower Hamlets Clinical

Commissioning Group o Chair of the North East London Faculty Board of the Royal College of

General Practitioners

Neil Brimblecombe Non Executive Director

• Member of Thrive London, Suicide Prevention Reference Group. • Member of London Review of Mental Health Bed based Care Steering

Group • Professor of Mental Health, London South Bank University -

developing research programmes and collaborative links between LSBU and other organisations

• Clinical Lead Mental Health, London Urgent and Emergency Care Collaborative, Healthy London Partnership, supporting NHS services to deliver care in ways that reduces pressure on urgent and emergency capacity

Cedi Frederick Non Executive Director

• Non-Executive Director of ‘Independence and Wellbeing (Enfield), a local authority trading company established by LB Enfield to provide a range of community and possibly residential/nursing homes delivering care and support services that may be commissioned by the NHS.

• Owner of Article Consulting Ltd, a health and social care consultancy (not currently working with the NHS).

• Chief Executive Officer of La Nova Group, which delivers events, programmes and experiences which optimises health, wellbeing and personal performance.

• Board member of CommonAge, a Not for Profit organisation established to promote positive aging across the Commonwealth.

David Griffiths Chief Finance and Investment Officer

• Wife is Director of Finance at East Suffolk and North Essex NHS Foundation Trust.

Board Member:

Interest Declared:

Catherine Jervis Non-Executive Director

• Non Executive Director for First Community Health and Care, a not for profit company (social enterprise) which provides community health services (primarily to the NHS) in East Surrey. Registered in England No: 07711859.

• Non Executive Director for Achieving for Children, Community Interest Company Registered in England and Wales as a Private Limited Company, Registration Number 08878185.

• Non-Executive Director for the Independent Office for Police Conduct.

Jinjer Kandola, Chief Executive

• None

Amanda Pithouse • None

Stanley Riseborough • Owner and Director of SHR Health consulting – small consulting company • Wife works for Sussex Partnership Trust

Paul Ryb Non Executive Director

• Managing Director, The BIGlittle Co. Ltd. • Non-Executive Director of SpareRyb Global Alliance Ltd. • Co-Owner Anytime Fitness Mill Hill 24/hour Gym, North London • Trustee for The Macular Society • Finance Committee member for the Thomas Pocklington Trust

Ruchi Singh Non Executive Director

• Director, Kaleidoscope Transformations Ltd, a strategy consulting company.

• Ministry of Housing, Communities and Local Government - Delivery Strategy Advisor to the Post Grenfell Building Safety Programme.

• Department of Work and Pensions – Advisory support to mobilise and embed the strategy and planning function within the new estate organisation.

Jackie Stephen Executive Director of Workforce and OD

• None.

Charles Waddicor Non-Executive Director

• Director / Owner of SAMRO health and social care solutions • Chair / Trustee of The Primary Care Respiratory Society UK. • Mental Health Clinical Advisor to the Care Quality Commission. • Small shareholding in Ventura Group. • Chair of a Board, operated by Social Finance, overseeing projects running

in Haringey, Tower Hamlets, and Staffordshire, supporting people with mental health problems into employment.

• Chair of Herefordshire and Worcestershire Sustainability and Transformation Partnership.

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BEH-MHT – Trust Board – 28.01.19 1.4 – Minutes of the Board Meeting – 26.11.18

Minutes of the Board Meeting held on Monday, 26 November 2018 in the Lecture Theatre, St Ann’s Hospital, St Ann’s Road, London, N15 3TH

Present: Mark Lam Trust Chairman Jinjer Kandola Chief Executive Dr Jonathan Bindman Medical Director Neil Brimblecombe Non-Executive Director David Griffiths Chief Finance and Investment Officer Catherine Jervis Non-Executive Director Amanda Pithouse Executive Director of Nursing, Quality and Governance Stanley Riseborough Interim Chief Operating Officer Charles Waddicor Non-Executive Director In attendance: Tracey James Haringey Personality Disorder Stream Co-ordinator for item 1.6 David Harty Team Manager & Clinical Lead – Barnet Personality Disorder Service

for item 1.6 Dave Leonard Interim Deputy Director of Workforce Jackie Liveras Deputy Chief Operating Officer Katia Louka Trust Board Secretary (minutes) Patricia McHugh Clinical Lead – Barnet Personality Disorder Service for item 1.6 Karen O’Shaughnessy Personality Disorder Service – Enfield - for item 1.6 Sibylle Sparke Personality Disorder Service – Barnet - for item 1.6 Catherine Sunderland Personality Disorder Service - for item 1.6 Three service users attended for item 1.6 One member of the public attended Item No.

Minute Item Actions

1.

General Business

1.1 Chairman’s Welcome The Chairman welcomed Jackie Liveras, Deputy Chief Operating Officer and Stanley Riseborough, Interim Chief Operating Officer to their first Trust Board meeting.

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1.2 Apologies for Absence • Cedi Frederick, Non-Executive Director • Paul Ryb, Non-Executive Director • Ruchi Singh, Non-Executive Director • Jackie Stephen, Executive Director of Workforce and OD

The Chairman noted that there were a number of apologies received. He acknowledged the extenuating circumstances which required apologies to be provided in advance from several Board members for valid reasons on this occasion. However, he did not want to see a pattern of absence in future. It was noted that the meeting was quorate.

1.3 Declarations of Interest and Declarations of any Conflicts of Interest Neil Brimblecombe asked that three of his memberships to external organisations be removed as they had ceased or were coming to an end. Mark Lam said his view was to over report declarations of interest where in doubt. It was agreed that Neil Brimblecombe liaise with the Trust Secretary to establish which memberships could be removed from the Declarations of Interest. Stanley Riseborough declared that he was a Director of SHR Health Consulting Ltd. The Trust Board agreed to note:

• that there were no conflicts of interest declared in relation to items on the agenda.

• the Board of Directors' Interests would be updated for the next meeting.

1.4 Minutes of the Meeting held on 24 September 2018 The Trust Board confirmed the minutes of the last meeting as a true record subject to the following amendment: Item 4.1 Research and Development Annual Report. Jinjer Kandola referred to the minute and said that the minute did not reflect that Research and Development should be understood more widely within the Trust and could be taken as an opportunity to aid recruitment and retention.

1.5

Actions and Matters Arising from the Minutes The Trust Board noted the written update on the actions arising from the minutes.

1.6

Patient Focus – Personality Disorder Services in the Trust Dr Jonathan Bindman introduced staff and service users from the Trust’s Personality Disorder (PD) Service. The Trust Board had received a similar presentation at the meeting in January which had been well received and he thought it would be worth revisiting this subject to include the new members of the Board.

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Tracey James outlined the treatments available for personality disorder patients and described the Mentalisation Based treatment (MBT) which had been pioneered by the Trust. This form of treatment included highly structured group treatments delivered by a specialised team and Structured Clinical Management (SCM) which were individual treatments delivered by any health professionals with supervision by specialists. She said that the teams were very proud of the service they offered patients and whilst commissioning varied between boroughs, there was a solid core of expertise in place. The teams were hoping to build on innovation by developing the offer to adolescents and those in transition from CAMHS to adult mental health services; working to bring back out of area placements and continuing to provide training, education and SCM to other services. One service user described her experience with the service. She had been in mental health services for a long time and this form of treatment had provided choices she did not have before. The team had been trained and knew how to deal with her illness and this had given her faith that she would receive the appropriate help and treatment so that she remained out of hospital. One service user said that the experience she had received in group therapy had been very helpful. In particular the MBT course provided her with the ability to help with her thought processes and had changed her attitudes for the better. Jonathan Bindman explained that the diagnosis of PD had been stigmatised and patients were often labelled. He added that for some patients this was viewed as useful as it enabled them to receive the right treatment. As an example, one patient said that she had known her illness was more than depression and this was an opportunity to get better and change her life. One patient said she had spent a total of two years in hospital and that the PD service was very different to adult or CAMHS services. Once she was diagnosed and received the treatment, she had spent less time in hospital. Jonathan Bindman stated that there was expertise in the Trust to deal with PD and there was a high proportion of females accessing these services as opposed to males. Mark Lam said that the MBT technique had been developed by a Consultant in Haringey and he understood that it was now a major form of treatment in the USA. Charles Waddicor asked the service users what had made a difference in their lives. They responded that the knowledge and help that they had received had made a difference and could not praise the course highly enough as it had enabled them to make many changes in their lives which they were unable to do previously. One service user said she previously had low resilience levels and was easily overwhelmed by situations. The course had provided her with coping mechanisms and had meant that she could go back to education again. Amanda Pithouse asked if the service did any work with families. It was confirmed that there was a friends and families group which provided support to them regularly. Neil Brimblecombe asked whether there was a defined length of treatment. It

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was confirmed that 18 months was average although it was dependant on each individual case. Jinjer Kandola asked if there was anything that could be done to make the service even better. A service user said that an earlier diagnosis would have benefited her however all the clinicians she now came into contact with had the necessary training which had helped. Mark Lam thanked the staff and service users for taking the time to share their experiences with the Board. He said it took enormous courage to do this in this setting and the Board acknowledged and appreciated this. It was a powerful reminder that patients with PD faced significant challenges and it was important to continue to improve the services offered by the Trust. Following the presentation Charles Waddicor said that it was necessary to link this service with the Trust’s services in prisons and the secure unit. Jonathan Bindman said that there were differences in the commissioning arrangements within each Borough however these were continuing to be strengthened. Staff from the Haringey PD service had recently been out to prisons as this was seen to be the model way forward. Jinjer Kandola said that she had spent some time with the PD service recently and for the future needed to think about the right pathways and new models of care and how to embed these into business growth. The Trust Board agreed to note the Patient Focus on the Trust’s Personality Disorder Service and agreed to continue with the patient focus presentations at each meeting.

1.7

Chairman’s Report Mark Lam thanked his predecessor Michael Fox for his work which had led to a stabilised Board that was ready for change. This was his first meeting as Chairman and his second month with the Trust. His initial aim was to progress the work that had commenced in developing a compelling and socialised strategy both internally and externally with stakeholders and patients. He was pleased to have a well-functioning Board, most of whom had joined in the last year and that he wanted to develop the Board even further. The strategy would put the patients at the heart of everything. He said that there was a very strong pull from the local communities, colleagues and patients that was rich in potential. So far he had visited a large number of services across the boroughs, had met with many staff members, service users and their families. He was impressed with the wealth and range of services offered across the geographical area. He had attended the Staff Awards event which had been very successful and everyone had enjoyed the evening. He wished to express his thanks all those responsible for arranging it. There had been a lot of positive feedback from the Staff Awards. Three Mayors had attended from the local community and this was an opportunity that could be explored further as they all indicated they were willing to participate to present awards at future events. Amanda Pithouse commented that the awards had been very clinically centred and it was necessary to recognise other staff such as those within corporate

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functions. Neil Brimblecombe asked whether there was a way to further engage and energise staff for instance those that did not attend such as providing access to live links. He added that the event should be for all staff not just those that attended. Mark Lam said he had made a number of visits to service areas and continued to be impressed by the work being done. He recognised staff were loyal and committed to the local communities they served. There was some untapped potential that could be explored to support staff further. With regard to stakeholder events he and Jinjer Kandola had met with a number of MPs and further appointments were being arranged in order to maintain the close ties with the community. He had spent some time meeting NHSI, the Trust’s regulators and the next step was to arrange to meet leaders of the local authorities. He had already made some initial connections with social care and local authority bodies within the NCL sector. The Trust Board agreed to note the Chairman’s verbal report.

1.8 Chief Executive’s Report Jinjer Kandola referred to the Chief Executive’s Report and highlighted the following: She had attended a two day event organised by the North Central London Sustainability and Transformation Partnership with other NHS organisations and local authorities. The emphasis was on the development of more integrated health and care services which was expected to be an emphasis within the National NHS Long Term Plan. She said the event was very stimulating and thought provoking. She had attended a meeting of the Portland Group where newly appointed Chief Executives had the opportunity to meet with Matt Hancock, Secretary of State for Health where there was a clear steer regarding the development of integrated health systems. As part of Jinjer Kandola’s commitment to collective leadership, she had developed a new Senior Leadership Forum which included the top 90 leaders in the organisation. The first meeting was held on 15 November and included discussion on the development of the Trust’s strategy. Following on from the “Meet Jinjer” events which had provided her with an opportunity to meet staff across the Trust over the summer months, a number of staff roadshows had been organised. These provided further opportunities for staff to meet with members of the Executive Team and be involved and engaged in the development of the Trust’s Strategy. A CAMHS Visioning Event had been held which was an opportunity for clinicians across the Child and Adolescent Services to come together to discuss long term plans for this service. The event was well received. Jinjer Kandola referred to the Staff Awards event held on 22 November 2018. The event was attended by 500 staff which also recognised long term service.

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As previously discussed, the challenge would be to involve and engage over 3,000 staff not just those that were present. Jinjer Kandola was pleased to report that the preparatory work for the new inpatient building had commenced on the St Ann’s site. This was a recognition of the hard work by the Board over the last five years to reach this stage. The Trust Board agreed to note the Chief Executive’s report on recent Trust matters since the last Trust Board meeting.

2. Risk and Performance

2.1

Board Assurance Framework Katia Louka presented the report on the Board Assurance Framework (BAF), which identified the risks faced by the Trust in meeting the Trust’s objectives for 2018 / 2019, and a summary of the Corporate Risk Register. She stated that she had initial discussions with Amanda Pithouse to review both the BAF and the Risk Register. It was recognised that both documents needed to be developed in order to simplify the process. The new Risk Management system which was being introduced in the new year would help to develop the two documents. Mark Lam had initially made some comments to simplify the document and this was the first step in doing that. It was noted that the content was broadly the same as previous reports, however the format had changed. He added it was important to ensure the right format so that the Trust’s strategic risks were well managed at Board level. The BAF would evolve over the next few months. Charles Waddicor said that this work was necessary. He referred to risk 4 on skill mix which had previously been discussed and he noted that there was no action to mitigate this. However this was included in Risk 9 and he queried why it was included in one but not the other. He asked whether the Board was assured that there was adequate skill mix in the Trust. Jinjer Kandola acknowledged that there was still a reliance on bank and agency staff. The Trust had not yet carried out a full review of the skill mix and this would be a priority. Amanda Pithouse was carrying out a skill mix review across nursing and a report was expected to be presented at the March Board meeting. Stanley Riseborough added that it was important to take into consideration the roll out of the Mobility programme in the review of skill mix so that it was not seen in isolation as the Mobility programme will change this and it was important to connect the pathways. Neil Brimblecombe asked what the scope of the skill mix review would be. Amanda Pithouse responded that she would be looking across a wide breadth to include Allied Health Professionals (AHPs) as well as the associate mental health roles. She was currently looking at quality indicators. Jinjer Kandola said that the aim would be to discuss the workforce for the future, how it would look, including the use of mobile working. She added that it would be helpful to develop the BAF with first and second line assurance and to keep the Risk Register as a separate document. Non-Executive Directors pointed out that some risks remained on the BAF for

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several years and it was unclear how the mitigation was evaluated such as the recruitment from the Philippines under Risk 4. Jackie Liveras said that this initiative had not provided a good return on investment as the numbers anticipated from the recruitment programme had not materialised and this had been echoed within other neighbouring trusts. Dave Leonard was asked to provide lessons learnt from the overseas recruitment to the next Board meeting. Mark Lam acknowledged the work started by management to progress the BAF and welcomed further refinement. The next stage was that the Executive Management Team (EMT) would review the strategic risks to the organisation’s objectives and simplify them, ahead of a major refresh in March when the Trust’s new strategy and corporate objectives would be agreed. The Audit Committee will ratify the final format and processing of the BAF. Catherine Jervis agreed that it was important to treat the BAF and Corporate Risk Register as separate documents. The BAF was an opportunity to review the risks against the business plan. The Risk Register reviewed the tactical and operational risks to the organisation. Catherine Jervis acknowledged that there was work to do amongst the Committees to ensure the risks were monitored and there was a need to set out the governance arrangements in the Terms of Reference so that the Audit Committee had oversight of the BAF. The Trust Board agreed to note the latest Board Assurance Framework and that it will receive a further update at the next meeting.

DL EMT/KL

2.2

Trust Quality and Performance Report – October 2018 Jackie Liveras introduced the summary of performance against NHSI Single Oversight (SOF) Targets and the Trust Key Performance Indicators (KPIs) for the reporting month of October. There were a number of improvements in the following areas: • One hour response rate at the North Middlesex Liaison Service • Podiatry waiting times had improved but were still below target • Seven day follow up for patients discharged from wards continued to be

above target • Two week access standard for EIP continued to be above target at 76% • Enfield Let’s Talk IAPT service recovery rate further improved at 55.1% • Barnet Let’s Talk IAPT service had met all waiting times standards apart

from the six week standard. • Speech and language referrals to appointment continued to be above target

at 93% Mark Lam referred to the Trust Dashboard and noted that there were significant areas in red and the trend did not seem to be improving over time. He queried whether there was anything that could be done differently. Neil Brimblecombe said that he understood there were trends however the charts did not always clearly reflect this. Mark Lam asked Jinjer Kandola and the Executive Management Team to think about how this could be actioned and stated that the Board would welcome a revised report that provided a clearer narrative on the Trust’s performance. Jinjer Kandola said that work was planned to improve the Performance Dashboard and a meeting had been arranged to develop this in January.

SR/JL

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The Trust Board agreed to note • the Trust Quality and Performance Report for the year to date

performance for 2018 and • that more work was necessary to improve the information so that

the Board received assurance that performance against the metrics provided excellent services for patients.

2.3

Financial Performance: Month 7 (October) 2018 David Griffiths presented the update on the year to date financial performance report. He highlighted the following: • At Month 7 the Income and Expenditure deficit was £2.4m to date which was

£0.3m better than plan. • There was a variance of £0.2m against the control total set by NHS

Improvement (NHSI) and this reflected cost pressures inherited from the Agenda for Change pay award.

• All London Trusts had been requested by NHSI to review their financial assumptions and this would be done again at Month 9.

The Board discussed the key risks to achieving the control total. Out of Area Beds Due to the work recently completed to reduce Out of Areas (OOA) placements, DG said that these had been reduced from around 30 beds per night in total to 0 private sector beds plus 10 contracted NHS beds at East London Foundation Trust (ELFT) during the last 10 days. This would have a positive impact on the financial position and would be reflected in the next month’s figures. Charles Waddicor said that this had been discussed in detail at the recent Finance and Investment Committee meeting and he commended the tremendous effort from Jackie Liveras’s team to reduce out of area placements.

Mark Lam added that this was a phenomenal achievement and recognised how hard staff had been striving to sustain this level as it was important both for service users as well as for the financial position. Capital Programme David Griffiths referred to the discussion at the Finance and Investment Committee regarding potential network issues which might require significant investment. The financial costs would be known by January 2019 and this would have an impact on the Capital Programme for the next two years. Catherine Jervis said that the problem seemed to be that there were never enough capital funds to deal with all issues and she queried the impact on slow spending as was seen with the five year ligature programme. This had not delivered within the timescales and queried whether there were assurances that the Trust was on track with the programme. David Griffiths responded that £700k had been spent already on ligature works and this would reach £1.1m this year. From a cash perspective the Trust was forecasting that all Capital Funds would be fully spent in 2018/19. Cost Improvement Programme Neil Brimblecombe referred to delivery of the CIP programme and queried whether it was easier to have an overarching percentage level of the CIP details for each Board Committee to look at. David Griffiths said that he would look at the table and that it would equate to approximately 4% savings required for each

DG

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area. Mark Lam asked if the Trust had been made aware of the forthcoming NHS 10 year Long Term Plan and whether there were potentially any changes to tariffs and capital loans or any risks or opportunities presented. David Griffiths responded that there was only a limited amount of information that had been made available so far and no details had been provided to date. The planning guidance for 2019/20 was expected during December.

The Board agreed to note the Trust’s financial position as at the end of October 2018 and the priority areas to action to ensure that the Trust’s Control Total was delivered.

3. Quality and Safety

3.1

Clinical, Quality and Safety Report Amanda Pithouse presented the report outlining lessons learned from complaints and serious incidents during Quarters 1 and 2 of the year. It mirrored issues being discussed across the organisation such as care planning, transition of care, preparing for discharge and risk assessments. Mark Lam queried whether the report provided the necessary assurances to the Board around safety issues. Amanda Pithouse responded that this was one of a number of reports that were produced by the Patient Safety Team and further reports could be provided in this area as necessary. She added that overall there was more work to be done around risks such as those associated with ligatures. There were some pockets of excellence and other areas where fundamentals needed to be brought up to a good standard. She was planning to look at quality reviews and patient feedback for discussion at EMT within the next month. Charles Waddicor asked whether the report included Enfield Community Services and services in prisons. Amanda Pithouse said that it included all deaths involving patients under the care of the Trust. There were different reporting arrangements for deaths in custody and these were reported separately. With regard to prison health services, she said that this was a conversation that needed to take place outside of the Board around the Trust’s contractual obligations and be taken back to the Quality and Safety Committee. Catherine Jervis said that there did not appear to be a governance mechanism for measuring the quality of services outside of the normal route. There should be exception reporting to provide assurance or information where there could be concerns for services such as prison services. Jinjer Kandola said that the report reinforced everything reported in the CQC inspection and that more would be done to ensure that the Trust consistently performs and embeds the work that needs to take place. The Trust Board agreed to note the Clinical, Quality and Safety report.

AP

3.2 Safe Staffing Levels

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Amanda Pithouse presented the Safe Staffing Levels report. It provided an overview of nurse and health care assistant staffing for all inpatient wards from 1 September to 31 October 2018. She highlighted the following: The vacancy rate for inpatient areas increased by 4% from August 2018 to 12% in October 2018. Registered nurses accounted for 15.3% of the vacancy rate. The highest vacancy rates were in the Borough of Barnet with Avon Ward having the highest at 25%. It would be a useful measure to get some national benchmarking on this. Jonathan Bindman said that staffing concerns were one of the reasons for moving Avon Ward to the Chase Farm Hospital site and this had been picked up in the last CQC inspection. A steering group was in place to oversee the transfer to Chase Farm Hospital site. Jinjer Kandola said that it would be helpful for EMT to receive an action plan for improvement on Avon Ward. With regard to fill rates, although there was an improved picture in October 2018 7 of the 28 wards reported fill rates below 100% for both health care staff and registered nurses. The lowest was Silver Birches at 95%. Neil Brimblecombe asked whether there was any potential to show the data to indicate the highs and lows by each ward. Catherine Jervis queried the spike in vacancy rates being the highest in 12 months. Amanda Pithouse responded that this was mainly on those wards that were difficult to recruit to. Stanley Riseborough said that there should be more focus on time to hire and this would deliver the biggest benefits. Mark Lam said that the report was consistent with a range of workforce issues that needed to be discussed further by the Board as a matter of urgency, particularly the challenges faced in recruitment. He asked if there were any issues that needed to be raised. Amanda Pithouse said that staffing levels were safe and that she was aware at all times when wards were not staffed at 100%, however more assurance was needed in this area. Jackie Liveras added that Clinical Directors were monitoring staffing levels on a weekly basis. Jinjer Kandola said that the CQC had rated the Trust for the Safe and Effective domains as “Requires Improvement” and therefore the Trust needed to do more to improve services so that patients received the right care every time. The driver was cultural change across the organisation and she acknowledged that staff were working very hard to put patients first. It was agreed that a number of the Board reports needed to be developed further to provide clearer assurance to the Board. The Trust Board agreed:

• to note the safe staffing report • that managers be kept fully informed of newly recruited staff

especially in those areas with the highest vacancy rate. • that the Executive Management Team continues to monitor the

impact of the recruitment and retention strategies.

JB/AP

4. Governance and Assurance

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4.1

Medical Director’s Report Jonathan Bindman presented the report which covered two statutory issues to be reported to the Board. These were the report of the Guardian of Safe Working and data on deaths of patients under the care of the Trust from April – September 2018. He referred to the Guardian of Safe Working and said that this was a very important role in the Trust as it was a conduit to obtaining feedback from junior doctors in the Trust. The learning from deaths data provided comprehensive data on deaths of people under the care of the Trust for the year 2017/18 and had also been discussed by the Quality and Safety Committee in July 2018. The Trust Board agreed to note the report from the Medical Director.

4.2 Annual Review of Standing Orders, Standing Financial Instructions and Scheme of Delegation David Griffiths presented the annual review of the Standing Orders, Standing Financial Instructions and Scheme of Delegation. A number of amendments had been proposed and these had been discussed and agreed by the Audit Committee at its meeting on 12 November 2018. They had recommended that the Trust Board ratify the proposed changes. The Trust Board agreed: • the amendments of the Trust’s Standing Orders as attached at

appendix 2. • the amendments to the Trust’s Reservation of Powers to the Board and

Delegation of Powers as attached at appendix 3 • the amendments to the Trust’s Standing Financial Instructions as

attached at appendix 4.

4.3 Fit and Proper Persons Policy Katia Louka presented the updated Fit and Proper Persons Policy. It had been revised following updated guidance by the CQC and provided a more detailed explanation of their interpretation of serious mismanagement and serious misconduct and provided greater clarity about the obligations and responsibilities of those holding Director roles. In response to a query it was confirmed that all Directors would be asked to present a signed annual declaration that they were in compliance with the regulations in April of each year. The Trust Board agreed to ratify the updated Fit and Proper Persons Policy.

5. Annual Reports

5.1 Trust and Charitable Funds Annual Report and Accounts David Griffiths presented the Trust and Charitable Funds Annual Report and Accounts. These documents had been reviewed by the Trust and Charitable Funds Committee at its meeting on 19 November 2018 and recommended that

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the Board, as corporate trustee of the Charitable Fund, approve and sign the documents for submission to the Charity Commission by 31 January 2019. The Trust Board agreed to approve: • the Charitable Funds Annual Accounts for the year ending 31 March

2018 at appendix 1 • the Charitable Funds Annual Report for the year ending 31 March 2018

at appendix 2 • the Charitable Funds Letter of presentation for the year ending 31

March 2018 at appendix 3.

5.2 Annual Report of the Freedom to Speak Up Guardians Dave Leonard presented the annual Freedom to Speak Up (FTSU) Report. The report provided an overview of the Freedom to Speak Up Guardians’ work during 2018. He stated that it was proposed to provide additional resources in the form of establishing a team of FTSU Champions across the organisation so that they had more capacity and support to facilitate staff raising concerns about patient safety. Jinjer Kandola said that the FTSU Guardians were on a fixed term contract until December 2018 and provided an important role in the Trust. They provided a positive image and the personality to engage with staff. However there was some anxiety that these were temporary positions. Neil Brimblecombe said that it was an important role and there was a need to invest further. He commented that he would have liked to know more about the issues raised and to understand more about any action taken in response to the concerns. It would be useful to record the data in a way that was helpful to the Board. David Griffiths added that it was not evident where the concerns were reported to. Dave Leonard said that one of the aspects of their work was to identify issues before they escalated. Catherine Jervis said that this work had been ongoing for over a year and a half and she had previously been involved in bi monthly meetings as the Lead Non-Executive Director but there had not been any meetings with them since January. It would be useful to reinstate these so that there was an independent line of sight. She added that she had been disappointed that the report was not discussed with her prior to submission. Jinjer Kandola said that it seemed that the FTSU Guardians did not have access to the top team and it would be useful for the Executive Team to have regular access to them. The governance processes should also be strengthened. The Board fully supported these roles and welcomed hearing directly from the Guardians. The Board agreed to: • note the report from the FTSU Guardians • approve the proposal to develop a team of FTSU Champions to support

the Guardians subject to the financial element being agreed with the

DL/JS DL/JS DL/JS

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Chief Finance and Investment Officer and the governance arrangements were being strengthened.

6. Other Items

6.1 Any Other Urgent Business Public Attendance at Board meetings It was noted that very few members of the public and staff attended the public Board meetings. Mark Lam asked members of the Board to consider how to encourage public and staff attendance.

EMT

6.2 Date and Time of Next Meeting The next meeting will take place on Monday 28 January 2019 at 1.00pm in the Lecture Theatre, St Ann’s Hospital.

7.

Exclusion of the Press and the Public

The Trust Board resolved that representatives of the press and other Members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (Section 1(2) Public Bodies (Admission to Meetings) Act 1960).

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Page 14

BEH-MHT – Trust Board – 28.01.19 1.5 – Actions Arising

Actions Arising from the Minutes of the Trust Board Meeting held on 26 November 2018 Minute No.

Action Action by Current Status

2 Risk and Performance

2.1 Board Assurance Framework NEDs pointed out that some risks remained on the BAF for

several years and it was unclear how the mitigation was evaluated such as the recruitment from the Philippines under Risk 4. Jackie LIveras said that this initiative had not provided a good return on investment as the numbers anticipated from the recruitment programme had not materialised and this had been echoed within other neighbouring trusts. Dave Leonard was asked to provide lessons learnt from the overseas recruitment to the next Board meeting.

DL/JS

BAF risks are being reviewed and will be updated in April. International recruitment has resulted in lower than expected arrivals. Capital Nurse is planning a “once for London” approach to international recruitment. The agency appointed had limited experience and has now withdrawn from international recruitment. Lesson learned: work with experienced agencies. Delays in potential staff completing tests because of financial constraints. Lesson learned: manage expectations and have full understanding of the issues staff have in moving to the UK.

2.1 Mark Lam acknowledged the work started by management to progress the BAF and welcomed further refinement. The next stage was that EMT would review the strategic risks to the organisation’s objectives and simplify them, ahead of a major refresh in April when the Trust’s new strategy and corporate objectives were agreed.

EMT/KL

The Executive Leadership Group reviewed the risks at their meeting on 16 January – see agenda item 3.1

2.2 Trust Quality and Performance Report Jinjer Kandola said that work was planned to improve the

Performance Dashboard and a meeting had been arranged to develop this in January.

SR/JL The meeting has been scheduled for 28 January 2019.

2.3 Financial Performance: Month 7 (October) 2018 Neil Brimblecombe referred to delivery of the CIP programme DG This will be reported at future meetings

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and queried whether it was easier to have an overarching percentage level of the CIP details for each Board Committee to look at. David Griffiths said that he would look at the table and that it would equate to approximately 4% savings required for each area.

3. Quality and Safety

3.1 Clinical, Quality and Safety Report Charles Waddicor asked whether the report included Enfield

Community Services and services in prisons. Amanda Pithouse said that it included all deaths involving patients under the care of the Trust. There were different reporting arrangements for deaths in custody and these were reported separately. With regard to prison health services, she said that this was a conversation that needed to take place outside of the Board around the Trust’s contractual obligations and take back to Quality and Safety Committee.

AP

To be added to Quality and Safety Workplan for further discussion.

3.2 Safe Staffing levels Jonathan Bindman said that staffing concerns were one of the

reasons for moving Avon Ward to the Chase Farm Hospital site and this had been picked up in the last CQC inspection. A steering group was in place to oversee the transfer to Chase Farm Hospital site. Jinjer Kandola said that it would be helpful for EMT to receive an action plan for improvement on Avon Ward.

JB/AP

Added to the Executive Leadership Team agenda planner for 13 February 2019

5 Annual Reports

5.1 Annual Report of the Freedom to Speak Up Guardians Neil Brimblecombe said that it was an important role and there

was a need to invest further. He commented that he would have liked to know more about the issues raised and to understand more about any action taken in response to the

JS/DL

Feedback on the FTSU report is welcome. JS working with FTSU Guardians to start recording issues more robustly as well as actions. FTSU Guardians have also worked with counter-fraud colleagues.

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concerns. It would be useful to record the data in a way that was helpful to the Board.

5.1 Catherine Jervis said that this work had been ongoing for over a year and a half and she had previously been involved in bi monthly meetings as the Lead Non-Executive Director but there had not been any meetings with them since January. It would be useful to reinstate these so that there was an independent line of sight. She added that she had been disappointed that the report was not discussed with her prior to submission.

JS/DL

JS met regularly with FTSU Guardians in 2018 and has reinstated meetings with lead Non-executive Director.

5.1 Jinjer Kandola said that it seemed that the FTSU Guardians did not have access to the top team and it would be useful for the Executive Team to have regular access to them. The governance processes should also be strengthened.

JS/DL

FTSU Guardians have access to Executive Director of Workforce and OD and have not, as yet, requested access to other executive directors, but have been invited to contact.

6 Any Other Urgent Business

6.1 Public Attendance at Board Meetings It was noted that very few members of the public and staff

attended the public Board meetings. Mark Lam asked members of the Board to consider how to encourage public and staff attendance.

ELT

Added to Executive Leadership Team agenda planner for 20 February 2019

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BEH-MHT – Trust Board – 28.01.19 1.7 – Chief Executive’s Report

Title:

Chief Executive’s Report

Report to:

Trust Board

Date:

28 January 2019

Security Classification:

Public Board Meeting

Purpose of Report: This is a regular report to the Board, intended to provide an update on recent Trust matters, since the last meeting held on 26 November 2018.

Recommendations: The Trust Board is asked to note the update on recent Trust matters since the last Trust Board meeting. Sponsor:


Report Author:

Name: Katia Louka Title: Trust Secretary Tel Number: 020 8702 3035 E-mail: [email protected]

Report History:

Regular Report

Budgetary, Financial / Resource Implications:

No particular matters to highlight

Equality and Diversity Implications:

No particular matters to highlight

Links to the Trust’s Objectives, Board Assurance Framework and / or Corporate Risk Register

None

List of Appendices: • None

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Report

1. Introduction This report sets out key issues and developments since the last report to the Board on 26 November 2018. 2. External Update The national NHS Long Term Plan, setting out the priorities for the NHS for the next ten years, was published on 7 January 2019. It follows last June’s announcement of a £20.5bn annual real terms uplift for the NHS by 2023/24. The plan covers a 10 year window and sets out ways to ensure the NHS is fit for the future. The Plan will realise a £2.3billion investment ring-fenced for Mental Health services particularly for children and young people and will mean it will help us to deliver even better quality services to aid people with their recovery journey. There are significant opportunities for the Trust in integrating our services with other health and care services at local level. A consultation and engagement period will now begin on the plan, running until the summer. Following publication of the NHS Long Term Plan, the national NHS Planning Guidance for 2019/20 was published on 10 January. This sets out guidance for operational planning and contracting for all NHS organisations for 2019/20. The Trust has to submit its first draft Operational Plan for 2019/20 by 12 February, with the final Plan submission by 4 April. Once approved by NHS Improvement, the Trust’s Operational Plan for 2019/20 will be published on the Trust website. 3. Internal Events As part of my ongoing service visit programme across the Trust I have visited Trust services and met with staff working in: • Haringey Learning Disabilities Services • Enfield Drug & Alcohol Service, Claverings, Edmonton • St Ann’s Inpatient Wards • Cardamom Ward, North London Forensic Service 4. Board / Executive Leadership Team Membership Interim Chief Operating Officer I would like to welcome Stanley Riseborough, Interim Chief Operating Officer who took up the role on 26 November 2018, replacing Andy Graham who has left the Trust. The Trust is currently in the process of recruiting a substantive Chief Operating Officer. Chief Information and Performance Officer I can confirm the appointment of Sarah Wilkins as the Trust’s new Chief Information and Performance Officer (CIPO). Sarah will take up post on 18 March, reporting to the Chief Executive as a member of the Executive Leadership Team. She will lead on IT, information and performance reporting across the Trust. 5. Engagement with Stakeholders

Over the last two months, I met with John Hooton, Chief Executive and Richard Cornelius, Leader of London Borough of Barnet. I also met with Dawn Wakeling, Director of Adults, Communities and Health, LB Barnet.

The Chairman and I met with David Sloman on 17 December 2018, who has recently been appointed as the new joint NHS England / NHS Improvement Regional Director for London.

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As part of the Trust’s commitment to collaborative working with our local partners, I and other members of the Executive Leadership Team met with colleagues from the North Middlesex University Hospital Trust on 30 November 2018.

We are arranging a series of Executive to Executive meetings with our Clinical Commissioning Group colleagues over the next few months. The first of these was held on 10 January with Barnet Clinical Commissioning Group. I welcomed Catherine West, MP for Hornsey and Wood Green, to the Trust on 18 January 2019. Catherine visited two of our inpatient wards, Fairlands Ward and Haringey Ward and met staff and patients. 6. Inter-great Events with the Clinical Commissioning Groups ( CCGs)

Following on from the Inter-great Event across the North Central London sector during October, our local CCGs have organised separate Inter-great events, looking at the development of integrated care systems locally, as set out in the new NHS Long Term Plan. I attended the first two of these with Trust colleagues recently in Barnet on 15 January and in Enfield CCG on 17 January. The Haringey Inter-great event has been arranged for 6 February 2019, which Trust colleagues and I will also be attending. 7. Development of the Trust’s Strategy The Trust Board is in the process of refreshing the Trust’s Strategy and our corporate priorities. We have engaged PwC to support the Board in this and the aim is to publish the Trust Strategy during April 2019. The Trust is actively engaging with patients, carers, staff and our key partners to inform this work.

8. Trust Staff Roadshows A series of staff roadshows were held during November and December, to provide the opportunity for staff to meet with members of the Executive Leadership Team and get involved in developing the Trust’s Strategy. Over 200 staff attended the events. Staff unable to attend one of the roadshows have been encouraged to give their views via an internal staff questionnaire. We are planning further roadshows at the end of February to provide an update on the development of the Strategy. 9. Christmas Card Competition The Trust held its annual Christmas Card competition and invited children of staff to design artwork to be featured on the Trust’ official Christmas Card. The annual competition provided an opportunity for staff to engage with children about the valuable work that they do. There were three age categories; the winners and runners-up were: • 0-5 year old category – Jacob Agostini and Amelie-Rose Phillips • 6-9 year old category – Isabelle Price-Timmins and Maria Jovanovic • 10-12 year old category – Amber Sharma and Hetty Yona

The winning designs were featured as our official BEH Christmas card; each winner and runner-up received a gift voucher. Each child who entered received a chocolate gift. 10. Dragons’ Den One of the legacies of the ‘Listening Into Action’ programme the Trust used a few years ago was the Innovation Investment Fund, popularly known as the ‘Dragons’ Den’. This is a sum of money set aside to inspire staff to come forward with innovative ideas to improve service users’ or staff experience.

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This year 23 projects were submitted. The aim is to fund initiatives which not only make a difference, but can go on to be reproduced in other areas as a proven intervention to improve life for service users or staff at BEH. Joining me as Dragons for this year were, David Griffiths, Chief Finance and Investment Officer and Stanley Riseborough, Interim Chief Operating Officer.

We listened to ten outstanding presentations from projects looking for over £5,000 and considered a further 13 projects for under £5,000. Eleven projects were successful in securing funding. 11. New Service Update

Opening of Moselle House (formerly Seacole West) and Eden House (formerly Seacole East)

Moselle House and Eden House, two new wards within the North London Forensic Service, welcomed their first patients on 6 December 2018. Moselle House and Eden House each provide 12-bedded low secure ward for men with a mild learning disability. This new initiative has been commissioned by NHS England for patients who are from London but have been in hospitals a long way from home, and have returned to their local area. 12. Implementation of the dedicated Crisis Resolution Home Treatment (CRHT) Night

Service Team The Trust has recently implemented a new dedicated CRHT Night Service Team, operating as part of the centralised bed management team. The CRHT Night Service Team will ensure a safe service at night for Trust patients in crisis and will include a dedicated Place of Safety Team 24 hours a day. 13. Preparations in the event of a “No Deal – Brexit” The Trust is ensuring that it is well prepared in the event of a ‘no deal’ Brexit. The Department of Health and Social Care has recently published national guidance for the NHS and the Trust is working closely with NHS England to ensure that the appropriate preparations are in place should this occur. Stanley Riseborough, Interim Chief Operating Officer, is the Trust nominated Board –level Senior Responsible Officer for ensuring the Trust is appropriately prepared. 14. Well Led Review The Trust is making preparations for an internal review of our corporate governance against the NHS Improvement / Care Quality Commission Well-Led Framework. The Well-Led Framework has been adopted by both NHS Improvement and the Care Quality Commission to ensure robust leadership and governance of NHS provider organisations. All NHS provider organisations are encouraged by NHSI to undertake a developmental review of their leadership and governance against the Well-Led Framework every three to five years. The Trust has not undertaken such a review since the current NHSI guidance was introduced in June 2017. It is therefore making preparations to carry this out over the coming months. 15. Update on the redevelopment of St Ann’s Hospital in Haringey Following approval of the Trust’s Full Business Case by NHS Improvement in October 2018, the Trust signed a contract with Integrated Hospital Projects (IHP) for the new inpatient building at St Ann’s Hospital. Enabling works on the St Ann’s site commenced during the week of 19 November 2018. The site has been fully secured and cleared and the main construction works will commence in February 2019. Progress is running to timetable and completion of the new inpatient building is scheduled for August 2020. Soon afterwards, the current wards will be relocated into

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the new building which will then allow the planned refurbishment works and site infrastructure improvements to commence. 16. Use of Trust Seal Since the last report The Trust Seal has been affixed to the following documents:

Seal no.

Description of the document Date sealed

Names of those attesting Seal

280 Agreement for sale of Canning Crescent Health Centre, 276-292 High Road, London N22 to the London Borough of Haringey

3.01.19 Jinjer Kandola, Chief Executive David Griffiths, Chief Finance and Investment Officer

281 Tenancy Agreement =, room 30, Bowes road Clinic at 269 Bowes Road, Southgate, London

11.1.19 Jinjer Kandola, Chief Executive David Griffiths, Chief Finance and Investment Officer

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BEH-MHT - Trust Board – 28 January 2019 2.1 Annual Workforce Report

Title: Annual Workforce Report

Report to: Trust Board

Date: 28 January 2019

Security Classification: Public Board Meeting

Purpose of Report:

This report provides an overview of the last year’s activities led by the Workforce team, including progress on key workforce priorities as well as plans for addressing challenges in order to enable the Trust and its staff to deliver high quality care and be an employer of choice.

Recommendations:

The Trust Board is asked to note this report and comment on proposed areas of focus.

Report Author: Jackie Stephen, Executive Director of Workforce and OD

Report History: Annual update

Budgetary, Financial/Resource Implications:

There are both financial and resource implications in relation to strategy development and implementation.


Equality and diversity implications are addressed through the planning and implementation of initiatives to support improvement in our performance.

Links to the Trust’s Objectives, Board Assurance Framework and/or Corporate Risk Register

Links to the following objectives: • Happy staff • Excellent care • Value for money services

List of Appendices: Appendix A – Workforce profile

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1. Introduction

1.1 This paper aims to demonstrate progress against our priorities, whilst also highlighting ongoing challenges and what we are doing to address them. Appendix A provides a workforce profile which is informing our priorities.

1.2 The Workforce Directorate exists to provide services to a workforce of over 3,000 staff, to support the delivery of the Trust’s objectives, create a culture to deliver the Trust’s strategy, develop the organisation into an employer of choice and enable the organisation and its people to deliver high quality care.

1.3 The Workforce team delivers services in the following areas:

• Recruitment and resourcing • Learning and development • Medical staffing • HR business partnering • Temporary staffing and e-rostering • Workforce information • Equality, diversity and engagement • Management of outsourced services – Payroll, Occupational Health

1.4 The Workforce team aims to:

• Play a key role in delivering the Trust strategy and engaging staff in its development and implementation

• Address persistent staffing challenges e.g. nursing and medical vacancies, the proportion of staff over aged 50 and how to retain them so as not to lose experience and organisational memory and to support organisational change that is planned to prepare the organisation for future service developments. This necessarily involves collaboration with neighbouring Trusts and creating alliances with other Trusts in our STP

• Work towards fulfilling our ambition to be an organisation that is known for providing a positive working environment, opportunities for development and has a reputation for being a great place to work, delivering excellent care

• Address issues raised in the staff survey, in particular reducing the incidence of bullying and harassment, promoting fairness in career progression across the Trust and reducing discrimination

• Review and enhance workforce processes and policies to deliver an excellent service

2. Context

2.1 The Trust has experienced considerable change in the past year at executive and senior management level. The Workforce Directorate itself has experienced similar transition which has led to a refocus on priorities and provides opportunities for change and improvement. A review of the directorate structure is underway to ensure that the team is well equipped and resourced to support the organisation through organisational change (including the Fit for the Future borough leadership consultation) and implementation of the Trust strategy.

2.2 The recently published NHS Long Term Plan emphasizes the current and future workforce challenges that all Trusts face. Accordingly the Workforce team is focussed in addressing Trust-wide recruitment and retention issues, supporting operational teams to

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think differently and identify ways in which to shape their workforce to deliver excellent care.

2.3 The Trust has operated over the past year in an increasingly competitive environment in relation to workforce which means that we need to focus this year on our ambition to attract and retain the best, tackle persistent challenges and differentiate ourselves from other employers.

2.4 The following sections focus on the current position of the building blocks of our strategy and seek to demonstrate how we are putting processes, plans and resource in place to support implementation of the Trust strategy.

3. Core services

3.1 In line with the emerging Trust strategy to deliver excellent core services, the Workforce team are reviewing policies and processes and seeking technological solutions to improve our services to managers and staff.

3.2 The Learning and Development team have invested in developing expertise in the use of the electronic staff record system (ESR), improving ability to mine ESR data and provide greater access for staff. This has resulted in improved data quality, employee self-service and direct access to personal data.

3.3 The HR suite of policies is under review, seeking to ensure that they are guided by recognised good practice and continue to support staff and managers. For example, the sickness absence policy has a change of focus to improving attendance.

3.4 Outsourced services i.e. occupational health and payroll are also under review to ensure that appropriate service delivery standards are clearly defined and met.

3.5 Priorities going forward include improving quality reporting, responsiveness to staff and managers seeking advice and support as well as streamlining processes to improve efficiency and productivity.

4. Recruitment

4.1 Vacancy rates have varied throughout the year, peaking in August at 11.3%, reducing in the autumn but again starting to rise (currently 11.2%). Nursing vacancies peaked at 15.4% in July and fell month on month to 12.2% in November. We are likely to see a seasonal increase and continue to have areas which struggle to attract suitable candidates e.g. Haringey locality and prison-based teams (averaging 24% vacancy rate). The workforce team and lead nurses are working in partnership to address these recruitment difficulties and identify innovative ways to attract staff and consider alternative roles. The recruitment team have led a series of campaigns for staff across the year and supported borough-based recruitment initiatives such as the 18 January Haringey open day, at which 22 offers of employment were made.

4.2 International recruitment continued throughout 2018. Whilst our new international nurses have settled in well and most have now achieved the standards required to become nurses in the UK, it is acknowledged that the process has been lengthy and initial numbers arriving to join us have been significantly lower than hoped (eight in post vs. 100 offers of employment). It is anticipated that future international recruitment will be coordinated centrally in London, through a “once for London” approach. In the meantime, we are focussed on ensuring retention of the current cohort of international nurses.

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4.3 Senior nursing staff are developing closer relationships with local universities with a view to raising our profile with students. Retention of newly qualified nurses is very high in the first year (over 90% in 2017). Recruitment and nursing teams are seeking to address the high leaver rate beyond the first year.

4.4 The buddy scheme, offering informal support to new starters, has proved popular and is being refreshed this year. In addition, the team is developing a values-based recruitment model as part of our programme to embed the Trust values.

4.5 The draft Trust strategy commits to our making closer links with the communities we serve. From a recruitment perspective, local open days (the first this year in Haringey) and bespoke promotion of opportunities are planned. In addition, the Learning and Development lead is scoping a series of school visits to raise awareness of BEH as a local employer and the wide choice of careers available.

4.6 There is a national shortage of registered nurses currently and in the pipeline so we have to look elsewhere to fill the gaps. Our current nursing vacancy rate of 11% is sufficient to warrant attention and so skill mix reviews and workforce planning exercises have begun in order to identify where different roles might bridge gaps. The learning and development and nurse education teams have worked together to create a recruitment campaign for new trainee nurse associates. Interest has been very encouraging and 19 members of staff began their apprenticeship programme in December. We will start recruiting in April for the next cohort for a September start. We are working with nursing colleagues to incorporate Nurse Associate roles into current establishments to accommodate the trainees upon qualification in two years’ time.

4.7 Following the development of an Associate Practitioner template role, with clinical and operational input, we are now working with teams to support them in identifying skill mix opportunities, particularly in areas where it is difficult to fill vacancies.

Temporary staffing

4.8 Bank staff are essential for the effective delivery of our services, filling short-term gaps and vacancies. It is a concern that the current temporary staffing unit is in transition following participation in a North Central London STP collaborative bank proposal. Whilst fill rates are acceptable (average 82% for nursing), there are opportunities for improvement to increase use of bank and reduce the agency spend across the Trust. The executive leadership team has been invited to consider the merits of outsourcing or investing in the in-house service. Following that decision, there will be a move to implement the changes rapidly.

4.9 The medical staffing team support all medical staffing activity from recruitment to performance processes and reporting. The team also manages our “direct engagement” process for medical locums and has recently launched the service for allied health professionals. The direct engagement arrangements present a financial saving to the Trust whilst maintaining the quality of temporary staffing resource available to the Trust. Saving on medical locums in the past eighteen months has been over £450k.

4.10 Agency expenditure has been volatile over the past year and continues to be higher than desired, with five out of nine months in 2018/19 above our target of £675k. Close management is starting to pay dividends, combined with encouraging agency workers to convert to bank or permanent positions. We have introduced a monthly monitoring process whereby managers are asked to explain current levels of agency spend and identify actions to end long-term agency assignments. Given the continued high level of expenditure, we propose to increase the frequency of monitoring meetings.

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5. Retention and improving staff experience

5.1 The data below shows that the Trust has almost as many leavers as joiners. This is also evidenced in the workforce dashboard which indicates a steady turnover rate of c. 14%.

Starters and Leavers excluding Junior Doctors April 2017 - Mar 2018 Borough Starters Leavers Net gain/loss (-)

Barnet 84 65 19 Corporate 66 67 -1 Enfield 125 147 -22 Estates and Facilities 12 9 3

Haringey 44 48 -4 Specialist Services 105 82 23 Grand Total 436 417 19 Starters and Leavers including Junior Doctors April 2017 - Mar 2018 Borough Starters Leavers Barnet 94 78 16 Corporate 66 67 -1 Enfield 143 163 -20 Estates and Facilities 12 9 3

Haringey 55 59 -3 Specialist Services 117 93 24 Grand Total 487 467 20

5.2 We are committed to driving down turnover, retaining experienced staff and improving the working environment so that staff have the capacity and capability to deliver high quality services. With over a year of turnover being at c. 14%, it is clear that greater focus on staff experience is required if we are to have a step change in retention. We were pleased to accept an offer from NHS Improvement (NHSI) to participate in their national retention programme to help achieve this. The retention programme was launched in October, aiming to reduce turnover to 11% by October 2019. A representative staff group is focussing on three key areas of activity which are recognised as key drivers for retention – wellbeing, flexible working and learning and development. NHSI are monitoring our programme, as well as providing advice, and are pleased with the progress made – launch of non-pay benefits, review of flexible working and expansion of our apprenticeship programme.

5.3 Utilising the NHS Employers’ workforce wellbeing self-assessment tool to inform our focus, it is clear that we have the building blocks for improving staff wellbeing but they have not yet been embedded and so impact is small. For example, a rapid access to physiotherapy services is yielding good results but is under-utilised by our staff.

5.4 Staff have access to an employee assistance programme and clinical services provide staff with a range of support post-critical incident. It is recognised, however, that support to staff is variable across the Trust so medical and psychology leads met recently to

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assess current provision and seek to develop a Trust-wide offering, together with clarity around what staff can expect post-incident.

5.5 Over a quarter of our staff work part time. In addition, there is a large cohort of staff over the age of 50 in the organisation – Appendix A shows that 40% of our staff and 47% of our nurses are aged 50+, representing a considerable risk if staff choose to leave at retirement age. It is important, therefore, to promote and implement flexible working options to retain this group of experienced staff; anecdotal feedback suggests that staff are leaving when flexible working requests are turned down. The refreshed flexible working policy will be launched in February and complemented by a series of focus group/workshops to support staff and managers to recognise the benefits and practicalities of flexible working that can meet individual, team and organisational needs. The introduction of mobile working is helping to raise awareness and understanding of flexible working whilst still maintaining, or improving patient care. We also plan to introduce career clinics (building on successful career development days) and internal transfer clinics to retain staff who wish to move into a different role.

5.6 We compete for staff with local Trusts (some of which pay inner London pay rates) so we have recently introduced an integrated non-pay benefits portal, providing staff with access to a range of pay sacrifice schemes. Financial wellbeing education will be launched in the coming months.

5.7 The most recent Trust’s Workforce Race Equality Standard (WRES) results confirm that BAME staff continue to have a less positive experience of working at the Trust, particularly in respect to staff entering a formal disciplinary process (BAME staff over five times more likely to enter the process). A refreshed action plan is being developed which includes creation of a pre-disciplinary checklist to assess appropriateness of proposed action. To date, the Trust has focussed on a process for managers to reflect on the actions taken; this has not resulted in an improvement in this area so proactive, early intervention is required.

5.8 The ongoing Brexit situation has not resulted in a reduction of our EU staff but has had an impact on their morale and sense of belonging in the community, though they have stated that their experience within the Trust remains positive. To mitigate the risk of EU staff leaving, we have held regular forums, providing an opportunity for EU staff to share views and concerns and show that they are highly valued by the Trust. We have agreed to pay the application fee for settled status and are running information sessions in February and March for this group of staff, led by our employment lawyers.

5.9 The Trust’s values were refreshed in 2016, with extensive staff engagement throughout the process. A successful series of “Living our Values” workshops served to raise awareness of the values as well as deliver staff-led insights into the expected behaviours aligned to those values. Since then, a behavioural framework has been developed, training interventions designed around the values and values-based conversations encouraged at appraisal. There is much more to be done to fully embed the values and expected behaviours in the Trust. Our 2017 staff survey results showed that staff continued to experience inappropriate behaviours, often peer to peer; this remains one of our biggest challenges in terms of improving staff experience and retention. Our emerging Trust strategy is underpinned by our values so all our interventions, policies and activities will be informed by them.

6. Engagement

6.1 Having a structured approach to involving leaders in decision making and taking accountability for the delivery of high quality sustainable care is a key line of enquiry in the CQC well led framework. Engaging senior leaders first has been essential to gain their commitment and engender a sense of alignment to the Trust’s objectives.

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6.2 To this end, two new groups have been formed in order to build engagement, facilitate the implementation of the Trust strategy, engender a culture of collective leadership organisation and improve Trust governance. The Senior Leadership Team (top 30 leaders in the Trust) and the Senior Leadership Forum (top 100 leaders in the Trust) gives leaders an opportunity and vehicle for developing a consistent narrative, sharing ideas and contributing to Trust strategy.

6.3 The executive team is committed to increasing visibility and contact with staff across the Trust. The Chief Executive’s series of meetings during the summer and autumn have provided a rich seam of feedback and insight into staff views. These have been complemented by the executive roadshows which were held to socialise the building blocks of the Trust strategy and will continue on a regular basis.

6.4 Executive Directors and Non-executive Directors undertake visits to services regularly. It is accepted, however, that these visits have not always been planned in a coordinated way. From April there will a programme of visits to ensure wide coverage and coordinated follow-up to those visits. The nursing team are also scheduling an increased number of quality visits in 2019.

6.5 The Trust currently has several staff-led networks – Better Together, LGBT+ and Disability – with a Gender Equality network being set up. There is scope for these networks to have improved publicity and higher profile to enable more staff to be involved and their agendas to be driven more effectively. It is anticipated that the refreshed Equality and Diversity committee will help to achieve this.

6.6 The current method for measuring levels of staff engagement and opinion about their working environment is the annual NHS staff survey. This is not sufficient so a complementary solution is being sought to enable regular (at least quarterly) pulse surveys to be undertaken. The pulse surveys will be used to determine the impact of interventions or organisational change.

7. Learning and development

7.1 Learning and development opportunities are cited as being a key driver for retention so we have paid attention to providing a range of interventions. Apprenticeship programmes are proving to be an attractive development option for staff (40 underway) and we are keen to expand our portfolio as well as identify opportunities for more apprenticeship roles within the Trust. In addition to the recent launch of our Nurse Associate programme, apprenticeship programmes include senior management, customer service, business administration and project management.

7.2 Mandatory training compliance continues to be lower than required at 80% against a target of 90% (95% for information governance), despite persistent focus. Of particular concern, is the current compliance level of life support training (immediate life support is at 67%).

7.3 The Learning and Development team have sought to improve compliance through:

• Regular reporting on compliance (including predicted compliance), DNAs • Delivering onsite e-learning sessions • Outreach sessions to facilitate booking, improving data quality • Introducing employee self-service for bookings • Frequent reviews of capacity to ensure availability of courses

7.4 The Learning and Development team is refining the mandatory training needs analysis which will be submitted to the Quality and Safety Committee in March 2019, seeking to streamline requirements and so facilitate improved compliance.

Page 31


7.5 Leadership development

• The Learning and Development and Nursing teams are collaborating in the development of a leadership programme specifically for ward managers. This important group of staff have had access to a range of leadership development programmes over the past three years but take-up has been ad hoc and the programmes have not been tailored specifically to them.

• In 2017/18, we ran a successful post-graduate strategic leadership programme, co-produced with Middlesex University. 11 participants have graduated, stating that the blend of academic and Trust-specific input has improved their knowledge, skills and understanding of the environment in which they are working. We will track participants’ progress within the organisation as part of the programme evaluation. A number of senior managers and clinicians are embarking on NHS Leadership Academy programmes this year.

• Leadership and management development programmes are available for staff in their first management role, for more experienced managers and up to masters level (the latter via an apprenticeship programme). In addition, there is a programme of personal and professional development programmes ranging from motivational interviewing, resilience, to clinical skills, delivered in-house, through universities and collaboration with NHS Elect.

• A Trust-wide training needs analysis will be undertaken again in March/April to inform our learning and development programme for 2019/20.

8. Priority areas going forward

8.1 We are working with executive colleagues to:

• Prepare for the CQC by meeting requirements outlined in the well-led domain • Seek to reduce agency expenditure and manage the cost of staff pay • Support transformation and service development by providing workforce planning expertise

and supporting the design of new roles/identifying opportunities for skill mix changes • Deliver a culture change programme that embraces quality improvement, engenders

collective leadership, celebrates diversity and inclusion, empowers all our staff and is underpinned by everyone being treated fairly

• Focus on openness, living our values and leading real consultation in the development of our workforce

8.2 The workforce strategy is being developed alongside the Trust’s overall strategy. It will aim to enable services to provide the best patient care through a sustainable, highly skilled and motivated workforce as well as develop the organisation into an outstanding employer where people choose to work and stay, and are proud of the care they are able to provide. It is being informed by national and regional activity and will be tested with internal stakeholders, patients and staff to focus resources on what they think will make the biggest difference.

8.3 The workforce team is focussed on the following during the coming year:

• Delivering improvements in core services, responding to feedback from managers and staff

• Strengthening and aligning its resources to meet the needs of the Trust, including supporting organisational change

Page 32


• Supporting clinical and corporate teams to deliver their business plans and transformation through high quality, responsive HR provision, in partnership with trade unions

• Ensuring a focus on quality through audit, risk management, meeting regulatory requirements, quality improvement and providing accurate data

• Effective resourcing informed by robust workforce planning to ensure sustainable services that deliver outstanding care and are fit for the future

• Creating a culture that is consistent with our Trust values where staff are engaged as an enabler of the Trust strategy

• Improving staff health and wellbeing at work and facilitating effective and equitable management through high quality advice and policies

• Improving staff retention through developing a great place to work where staff feel valued, listened to, supported and treated fairly

• Developing the capability of the organisation through a targeted and aligned programme of education, learning and development

• Developing an employer brand and reward package that attracts and retains the best

• Delivering the workforce strategy and implementation plan

• Improving recruitment by tackling existing hotspots with bespoke campaigns

• Improving retention by delivering enhanced opportunities for development, benefits, flexible working

• Improving levels of engagement by implementing an engagement plan and improving sources of feedback to assess impact

9.4 It is intended that a workforce report will be submitted to every Board meeting so that progress against objectives can be monitored and the Board can be apprised of plans, achievements and challenges.

9. Summary

9.1 This report has highlighted both achievements and challenges for the Trust in developing and retaining a workforce that delivers consistently high quality patient care and a working environment that enables BEH to stand out as an employer of choice. Collaboration with senior leaders across the Trust, as well as colleagues within the North Central London STP footprint, gives us an opportunity to achieve this.

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Appendix A

Workforce Profile

Workforce FTE and Headcount

FTE Headcount

Staff Group Fixed Term Permanent Fixed

Term Permanent

Medical and Dental 84.81 119.90 92 132 Nursing and Midwifery Registered (including Students) 31.31 901.78 35 960 Allied Health Professionals 12.59 236.26 19 291 Scientific & Technical 33.21 220.77 44 281 Additional Clinical Services 53.25 649.98 67 707 Estates & Ancillary 62.44 70 Administrative and Clerical 38.00 459.72 44 513 TOTAL 253.18 2650.85 301 2954

Staff profile across bands *

* Figures as at November 2018. Band 8D includes three at Band 9. Band 1 posts were deleted in December 2018.

Full time vs. part time staff

Work Status by Headcount % Rate

Full time 72.6%

Part time 27.4%

AFC Band

Band 1

Band 2

Band 3

Band 4

Band 5

Band 6

Band 7

Band 8A

Band 8B

Band 8C

Band 8D

Staff in Post by Agenda for Change (AfC) Payband

Page 34


Staff Group Female Male

% Full time

% Part time

% Full time

% Part time

Medical and Dental 66% 34% 87% 13% Nursing and Midwifery Registered (including Students) 77% 23% 96% 4%

Allied Health Professionals 52% 48% 58% 42% Add Prof Scientific and Technic 45% 55% 65% 35% Additional Clinical Services 70% 30% 91% 9% Administrative and Clerical 66% 34% 90% 10% Estates and Ancillary 55% 45% 84% 16% TOTAL 66% 34% 88% 12%

A significant number of staff work part-time. Analysis of flexible working patterns is underway. The current risk is that line managers are reluctant to consider flexible working so education is required to help realise the benefits of considering flexible working options whilst continuing to meet service needs.

Ethnicity of our staff

Over 49% of staff are from a BAME background, with the majority in Bands 2-6 and under-represented at senior levels.

0%

10%

20%

30%

40%

50%Workforce Ethnicity Profile

BEH-MHT Nov 2018

Page 35


40% of staff (47% of nursing staff) are aged 50+, representing a significant retention risk. Promoting appropriate flexible working options is key to retaining this experienced group of staff.

0%

5%

10%

15%

20%

25%

30%

35%

40%

Up to 25 26 to 35 36 to 49 50 to 54 55 to 59 60+

% of workforce by age band

% of workforce by ageband

0%5%

10%15%20%25%30%35%40%45%

Up to25

26 to35

36 to49

50 to54

55 to59

60+

% of nursing workforce by age band

% of nursing workforceby band

Page 36

BEH-MHT – Trust Board – 28.01.2019 3.1 – Board Assurance Framework

Title:

Board Assurance Framework

Report to:

Trust Board

Date:

28 January 2019



Purpose of Report: At the last meeting it was noted that the Trust had commenced a process of reviewing the format of the BAF. This will continue over the next few months building on the original format which Board Members will be familiar with. Since the last Board meeting the content has been discussed by the Executive Leadership Team (ELT) at its meeting on 16 January 2019. It has been updated to make it simpler and provide more clarity. It is proposed that the ELT have a more direct role in overseeing the detail of the BAF before it is presented to the Trust Board each meeting. The current Trust BAF will be updated in April and presented to the Board at the May meeting, following publication of the refreshed Trust Strategy and the Trust’s revised corporate objectives for 2019/20. The proposed Well-Led Review of corporate governance processes will also inform the further development of the BAF and ensure that there are appropriate links to the Corporate Risk Register. From March onwards, the Corporate Risk Register will be known as the Trust Risk Register and a new format will be developed in line with the Trust’s new risk management system, Ulysses. The existing Corporate Risk Register was reviewed by the Quality and Safety Committee on 15 January to ensure Board-level assurance and the revised Trust Risk Register will be introduced at Board meetings from the March meeting. Recommendations: The Trust Board is asked to note the latest Board Assurance Framework. Sponsor:


Comments / Views of the Report Sponsor:

The BAF sets out details of the identified risks to meeting the Trust’s organisational objectives and the progress being taken to mitigate these.

Report Author:

Name: Katia Louka Title: Trust Board Secretary Tel Number: 020 8702 3035 E-mail: [email protected]

Report History:

Regular Report

Page 37

BEH-MHT – Trust Board – 28.01.19 3.1 – Board Assurance Framework Budgetary, Financial / Resource Implications:

The BAF contains risks which have a combination of resource and budgetary implications. All risks are mitigated and subject to regular review.


None.


This report presents the BAF outlining the key risks to achieving the Trust’s organisational objectives.

List of Appendices: Board Assurance Framework

Page 38

BEH-MHT – Trust Board – 28.01.19 3.1 – Board Assurance Framework 1. Introduction 1.1 The purpose of the BAF is to ensure that the Trust is monitoring and addressing the

principal risks that would prevent the Trust achieving its organisational objectives, sets out the controls (or ways the risks are being mitigated) and the assurance the Board is receiving that these risks are being managed. This report presents the Board Assurance Framework for 2018 / 2019, which identifies the highest risks faced by the Trust in meeting its principal objectives.

2. Board Assurance Framework (BAF) 2018 / 2019 2.1 The Trust agreed the following Objectives on 30 April 2018:

1. Excellent care (coloured yellow) 1.1 Providing excellent care for our patients, evidenced in improving service user

and carer feedback and meeting service and CQC requirements.

2. Happy staff (coloured purple) 2.1 Developing our staff to be the best they can be, to deliver excellent patient care.

2.2 Increasing staff engagement evidenced in improved Staff Survey results.

3. Value for money services (coloured blue)

3.1 Providing the best outcomes for patients and meeting NHS requirements, within

the resources available. 2.2 Set out below is a summary of the risks contained in the BAF for 2018 / 2019. The table

highlights the ‘Initial Risk’ score, the ‘Current Risk’ score as a result of mitigating actions, and the ‘Tolerable Risk’ score which indicates the level of risk that the Trust is willing to accept or retain.

Risk

Initi

al

Ris

k

24 M

ay 2

018

16 J

uly

2018

24 S

epte

mbe

r 201

8

28 N

ovem

ber 2

018

Cur

rent

Sco

re

Tole

rabl

e R

isk

2. Regulatory Standards

12 12 12 12 12 12 9

3. Managing Services within Resources

12 12 12 12 9

4. Recruit and Retain Staff

16 16 16 16 16 16 12

5. Development of the Trust’s Culture

20 12 12 12 12 12 9

6. Staff Engagement

20 12 12 12 12 12 9

7. Financial Management

16 16 16 16 16 9 9

8. Medium / Long Term Financial Sustainability

12 12 12 12 12 12 12

Page 39

BEH-MHT – Trust Board – 28.01.19 3.1 – Board Assurance Framework

Risk

Initi

al

Ris

k

24 M

ay 2

018

16 J

uly

2018

24 S

epte

mbe

r 201

8

28 N

ovem

ber 2

018

Cur

rent

Sco

re

Tole

rabl

e R

isk

9. Local Health Economy

9 9 9 9 9 9 9

10. Estates Management

16 12 12 12 12 9 9

12. Performance Information

20 9 9 9 9 9 12

3. BAF Risk Rating Matrix 3.1 Set out below is the risk rating matrix used to calculate each risk.

4. Achievement of Tolerable Risk Scores 4.1 The following risks have achieved or bettered their tolerable risk scores:

• Risk 7 - Financial Management • Risk 9 - Local Health Economy • Risk 10 - Estates management • Risk 12 - Performance Information

5. High Rated Risks 5.1 The Trust has currently one risk rated as high:

• Risk 4 – Recruit and Retain Staff (Risk Score 16)

R I S K R A T I N G M A T R I X Impact

Likelihood

Insignificant (1)

Minor (2)

Moderate (3)

Major (4)

Catastrophic (5)

Almost certain (5)

Likely (4)

Possible (3)

Unlikely (2)

Rare (1)

Impact Score x Likelihood Score = Risk Rating:

Page 40

BEH-MHT – Trust Board – 28.01.19 3.1 – Board Assurance Framework Implications 6. Budgetary / Financial Implications 6.1 The BAF and the Corporate Risk Register contain risks which have a combination of

resource and budgetary implications. All risks are being mitigated and subject to regular review via the controls and assurances identified for each risk.

7. Risk Management 7.1 The BAF sets out details of the key risks faced by the Trust in meeting its organisational

objectives which have been identified as part of a regular review process. A failure to operate a risk management system would expose the organisation to the risk of inadequate governance arrangements and inadequate management and mitigation of the key risks that may hinder the Trust from achieving the organisational objectives.

8. Equality and Diversity Implications 8.1 None.

Page 41


Page 42

Board Assurance Framework – Provide Excellent Services for Patients Objective:

1.1 - Providing excellent care for our patients, evidenced in improving service user and carer feedback and meeting service and CQC requirements.

Board Lead: Amanda Pithouse Date of review: January 2019

Lead Committee Quality and Safety Date of next review: March 2019

Risk ID:

2 Risk: Regulatory Standards - If services consistently do not meet regulatory core standards in respect of essential standards for quality and safety, this will impact on the quality of care given to patients and may result in regulatory action.

Relevant CQC Domain(s):

Caring / Effective / Responsive / Safe / Well-led

Relevant H&SC Act 2008 Regulations:

4, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18

Relevant CQC Regulations 2009:

16, 17, 18,

Risk Rating: (Likelihood x impact):

Relevant Key Performance Indicators:

Initial Risk Score: 3 x 4 = 12

Current Risk Score: 3 x 4 = 12

Tolerable Risk: 3 x 3 = 9

Direction of travel:

Rationale for current score: Following the outcome of the CQC inspection in the autumn of 2017 which identified concerns where several services did not fully meet the regulator standards, the Trust produced a Quality Improvement Plan (QIP) which is subject to regular review with CQC colleagues and Commissioners. The Trust’s ability to deliver the QIP is, in part, dependent on additional resources to address environmental and other service related issues. Issues that are on the CQC’s “Must Do” list and which are clearly linked to patient safety will be prioritised. Controls: (What are we currently doing about the risk?)

Assurances: (How do we know if the things we are doing are having an impact?) (Key: I = Internal / E = External)

1. The Trust’s Quality Strategy 2016 – 2019 aims to address quality issues for patients

• Quality metrics reported to every meeting of the Quality and Safety Committee and Trust Board via the Trust Quality and Performance Report and the Clinical, Quality and Safety Report (I).

• Patient feedback via complaints & claims, as reported in the KPIs reported to every Trust Board meeting (I). • Safety Thermometer data submitted and reviewed quarterly (I). • Safe Staffing Report to every meeting of the Trust Board (I). • Appraisal / revalidation in place across all Trust teams (I).

2. Quality Account, which details the quality priorities for the Trust:

• Six monthly update reports to the Quality and Safety Committee (I) and Clinical Quality Review Group (E) meetings.

• Quality metrics reported to every meeting of the Quality and Safety Committee and Trust Board via the Trust Quality and Performance Report (I).

• Annual External Audit review of the Quality Account 3. Statutory Committees in respect of Safeguarding, Health and Safety

and Infection Control.

• Annual reports are produced for Safeguarding, Infection Control and Health and Safety which are reviewed by the Quality and Safety Committee and ratified by the Trust Board each financial year. (I)

0

5

10

15

20

25

RiskScore

TolerableRisk

Page 43

4. Skill Mix Review.

• Trust receives Safe Staffing report at each Trust Board meeting (I). • SafeCare module implemented which will allow for real time acuity / dependency data.

5. CQUIN and Contract monitoring process. • CQUIN delivery monitored through meetings of the Integrated Performance Meeting 6. Quality impact review process of all CIP plans.

• All CIPs have a Quality Impact Assessment in place and key milestones tracked through to delivery and monitored via the Integrated Performance Meeting (I).

• There is a QIA monitoring group in place to review and monitor the process with reports to the Quality and Safety Committee.(I)

7. Serious Incident Groups at Team / Borough Level

• All Serious Incidents scrutinised and action plans in place to address learning (I).Trust Serious Incident Review Group (I)

• There is also independent scrutiny which is overseen by Commissioners €

8. Borough Level Clinical Governance meetings.

• All key clinical governance indicators reviewed and actions agreed to address any variations (I).

9. Raising Concerns Policy and Procedure (Whistleblowing).

• The Trust has two Independent Freedom to Speak Up Guardians in place with regular reporting to the Trust Board.

10. Patient Experience Committee.

• The Patient Experience Committee (PEC) reports regularly to the Quality and Safety Committee. (I). • There is an Engagement and Involvement Strategy 2016-2019 in place with Borough level action plans in place to

deliver strategy (I). • Friends and Family Test and ‘You said, we did’ identifies actions taken (I). • Patient Experience & Complaints Annual Report is ratified annually by the Trust Board.

11. Delivery of the Trust Quality Improvement Plan (QIP). • QIP reported to every meeting of the Quality and Safety Committee and regularly to Trust Board Robust Borough level plans are in place to deliver the plans. (I)

12. Internal Peer Assessment Programme which mirrors CQC inspections.

• Quality assurance monitoring in place via key performance discussions and Deep Dive meetings (I).

Gaps in controls and assurances: (What additional controls and assurances should we seek?)

Mitigating actions: (What more should we do?)

1. Skill Mix Review to be undertaken. 2. CQC Action Plan now being superseded by the Top Ten Priorities

as agreed by Quality and Safety Committee

Skill Mix Review is currently in progress by the Executive Director of Nursing, Quality and Governance Engagement and Involvement Strategy 2016-2019 to be reviewed.

Additional Comments:

Page 44

Board Assurance Framework – Provide Excellent Services for Patients Objective:

1.1 - Providing excellent care for our patients, evidenced in improving service user and carer feedback and meeting service and CQC requirements.

Board Lead: Stanley Riseborough Date of review: January 2019

Lead Committee Finance and Investment

Date of next review: March 2019

Risk ID:

3 Risk: Managing Services within Resources – If the Trust does not have sufficient resources to manage the demands on its service then there is a risk that patients will not get an appropriate service and/or the Trust will not achieve its financial control total

CQC Domain: Caring / Effective / Responsive / Safe / Well-led


-


-

Risk Rating: (Likelihood x impact):


Initial Risk Score: 3 x 4 = 12 Financial Performance is measured against the Trust’s Control Total set by NHS Improvement




Rationale for current score: The main risks relate to adult mental health bed occupancy and long waits for psychological therapies where demand is increasing. Controls: (What are we currently doing about the risk?)


1. Perfect week completed in July 2018 • Performance management systems in place

2. Additional investment in improved admissions, discharge and bed management. • Establishment of CEO led Improvement and Delivery Board to manage these (I). • Progress reviewed at Finance and Investment Committee (I).

3. Repatriation of 10 beds from East London Foundation Trust to Barnet in July 2019 • Capital Plan in place. Project Group established to manage repatriation. Progress reviewed at Finance and Investment Committee (I).

4. Review of psychological therapies underway aiming to address long waits within current resource limit. A final report will be ready in February for consideration by Clinical Directors and the Executive Leadership Team.



1. Clinical activity to be improved so that it is linked to the overall Trust Performance.

This is currently in development and due to be completed by April 2019


0

5

10

15

20

25

May 18 Sep 18 Nov 18 Jan 19

RiskScore

TolerableRisk

Page 45


Page 46

Board Assurance Framework – Develop our Staff Objective:

2.1 - Developing our staff to be the best they can be, to deliver excellent patient care

Board Lead:

Jackie Stephen Date of review: January 2019

Lead Committee

People and Culture Committee (under establishment)


Risk ID:

4 Risk: Recruit and Retain Staff - If the Trust is unable to recruit and retain sufficient levels of staff or staff with appropriate skills and capability to meet the needs of changing services, this will result in a continued dependency on the need for temporary staffing which impacts on the quality of care delivered and financial sustainability of the Trust.

CQC Domain: Effective / Safe / Well-led


18


13

Risk Rating:

(Likelihood x impact):


Initial Risk Score: 4 x 4 = 16 Turnover Vacancy rates Current Risk Score: 4 x 4 = 16



Rationale for current score: Whilst we continue with a wide range of activities to support recruitment, we continue to carry vacancies across the Trust, with some hotspots that are difficult to recruit to. For such areas, we are developing bespoke recruitment campaigns and have seen increased ownership and collaboration with recruiting managers. Controls: (What are we currently doing about the risk?)


Recruitment

1. Continuing to monitor relevant data e.g. vacancy rates, time to hire, turnover. 2. Training for first-line managers to improve their knowledge of workforce policies (including recruitment, disciplinary

etc) has been launched and is expected to improve their skill in dealing with employee matters. 3. Continuing to hold a weekly Vacancy Control Panel, led by Executive Directors, to review all recruitment and non-

urgent temporary staffing requests and ensuring that managers are considering all feasible options for filling vacancies.

4. There has been an increased level of engagement with universities to recruit newly qualified nurses and mental health workers and the launch of rotation programmes for newly qualified nurses. Staff Retention

5. Electronic exit interview monitoring and feedback is shared with boroughs for change and remedial action. 6. Standardised pay rates for bank work so that bank work is more competitive. 7. Progressing the NHSI-supported retention programme, focussing on flexible working, learning and development and

wellbeing which are recognised as important levers for improving retention. 8. Monthly agency monitoring meetings, requiring manager to share plans for ending assignments whilst maintaining

safe staffing.

Workforce KPIs: vacancy rate, time to hire, agency spend, mandatory training compliance, turnover rate

0

5

10

15

20

25

RiskScore

TolerableRisk

Page 47



Visibility of team-level workforce metrics. Setting up fortnightly forum to review team-level metrics, identifying hotspots and targeting those areas to support recruitment and/or retention.


We continue to maintain pace in respect of recruiting to vacancies. We now offer courses to support staff in planning for retirement which also have a focus on encouraging staff to work for longer. Work is underway to review the retirement and flexible working

policies and practice to maximise retention of experienced staff.

Staff Survey Action Plan will be presented to the Trust Board in March 2019.

Page 48

Board Assurance Framework – Increasing Staff Engagement Objective:

2.2 - Increasing staff engagement, evidenced in improved Staff Survey results

Board Lead: Jackie Stephen Date of review: January 2018

Lead Committee: People and Culture Committee (under establishment)


Risk ID:

5

Risk: Development of the Trust’s Culture - If the Trust fails to develop an open, people-focused and values-based organisational culture this will result in concerns not being effectively reported, failure to adopt best practice, inability to attract / retain staff and deliver change programmes including Quality Improvement and Enablement.

CQC Domain: Well-led Relevant H&SC Act 2008 Regulations:

18


-

Risk Rating:



Initial Risk Score: 4 x 5 = 20 Staff survey results Current Risk Score: 3 x 4 = 12



Rationale for current score: The risk remains that levels of staff engagement will not improve, impacting on recruitment and retention. Controls: (What are we currently doing about the risk?)


0

5

10

15

20

25

May18

Jul 18 Sep18

Nov18

Jan 19

RiskScore

TolerableRisk

Page 49

1. Identifying actions to contribute to improving staff engagement and staff survey results.

2. Undertaking a series of roadshows to share early thinking around Trust strategy and seeking staff feedback.

3. Undertaking informal and planned visits to services to discuss working environment with staff.

4. Ongoing training sessions in bullying and harassment 5. Raising Concerns Policy and Procedure (Whistleblowing) and Freedom to

Speak Up Champions provide point of contact to raise concerns. 6. Refreshing our wellbeing and equalities forums to increase staff engagement. 7. Developing staff networks which give opportunities for shared learning, input to

policy and practice 8. New Equality and Diversity Group chaired by CEO

Staff Survey results (E). Feedback from the Freedom to Speak Up Guardians appointed Promotion of Dignity and Wellbeing

Advisors and other sources of support via the intranet and posters (I). Friends and Family Test (I).



Insufficient sources of staff feedback to help assess whether interventions have had a positive impact.

Sourcing portal which will provide options to survey staff regularly.


None

Page 50

Board Assurance Framework – Increasing Staff Engagement Objective:

2.2 - Increasing staff engagement, evidenced in improved Staff Survey results

Board Lead: Jackie Stephen Date of review: January 2019

Lead Committee People and Culture Committee (under establishment)


Risk ID:

6 Risk: Staff Engagement - If the Trust fails to engage effectively with staff through robust communication, appraisals and the development of personal development plans, this will affect their ability to deliver excellent care and maintain professional standards.

CQC Domain: Well-led CQC Outcomes: 14 - Supporting workers

Risk Rating:


Relevant Key Performance Indicators: (taken from the Performance and Quality Dashboard Report)





Rationale for current score: The Risk Score remains the same as compliance with mandatory training and completion of appraisals remain below the Trust’s target. Mandatory training continues to be discussed at a range of meetings – Deep Dives, IPMs, meetings with subject matter experts and safety huddles. The Learning and Development team continue to provide outreach and e-learning clinics, as well as producing a training bulletin to remind staff of ways to achieve and maintain compliance. Work continues with colleagues in NCL STP to streamline mandatory training and improve portability. Awaiting national guidance to implement changes to appraisal in line with last year’s pay deal arrangements. Controls: (What are we currently doing about the risk?)


1. Workforce Development and Study Leave Policy, including arrangements for appraisals

2. Training Panel processes for the agreement of training. 3. Recording appraisals on Electronic Staff Record 4. Booking and recording course attendance on Electronic Staff Record 5. Regular updates on training opportunities through Trust communication

channels. 6. Providing support and training to managers to improve appraisal quality

Workforce KPIs, including compliance with mandatory training, appraisals (I). Workforce Information Reporting Engine Database (WIRED) IT system which shows levels of compliance from

Trust-wide to individual level – the data illustrated on WIRED is driven by our ESR records .(I) Annual training needs analysis and delivery against it.



None

0

5

10

15

20

25

May18

Jul 18 Sep18

Nov18

Jan 19

RiskScore

TolerableRisk

Page 51


None

Page 52

Board Assurance Framework – Meeting NHS requirements within the resources available Objective:

3.1 - Providing the best outcomes for patients and meeting NHS requirements, within the resources available

Board Lead: David Griffiths Date of review: January 2019

Lead Committee: Finance and Investment


Risk ID:

7 Risk: Financial Management – If the Trust fails to have appropriate mechanisms in place to ensure delivery of Cost Improvement Programmes, the management of budgets and improvements in productivity then the Trust will not deliver its financial plan, and may face further regulatory action.


-


13

Risk Rating:


Relevant Key Performance Indicators: (taken from the Financial Performance Report)

Initial Risk Score: 4 x 4 = 16 Service Line

YTD Plan

YTD Act

YTD Variance

Full Year

Forecast

Full Year

Variance

Barnet 829 839 11 951 17 Corporate 899 895 (5) 1,178 (8) Enfield 1,041 873 (168) 1,375 (410) Estates 331 335 4 671 12 Haringey 479 478 (1) 626 (2) Specialist 934 763 (171) 1,253 (109) Trust wide 1,643 1,301 (342) 1,766 (454) Grand Total 6,156 5,483 (673) 7,820 (953)

(Full year variance is against planned schemes of £8.8m, which is in excess of the Trust’s CIP target of £8.2m. Variance to target is £0.4m)




Rationale for current score: The risk rating has been reduced to reflect the fact that the overall variance against the minimum CIP requirement of £8.2m in 2018/19 has reduced to c£400k, and which is being covered by other underspends across the Trust. Controls: (What are we currently doing about the risk?)


1. Programme Management Office oversight of the Cost Improvement Programme with dedicated Project Managers ensuring that CIPs are planned and delivered in accordance with set milestones.

2. Fortnightly Improvement and Delivery Board chaired by the Chief Executive receives reports on each Service Line’s CIP position and actions are agreed to progress CIP delivery.

3. Workshops continue to be held with Service Lines that still have a gap to their CIP target.

Financial Performance Report considered at all meetings of the Trust Board and Finance and Investment Committee (I).

Current financial position and actions taken to deliver cost control and CIP savings discussed fortnightly and Improvement and Delivery Board (I)

CIPs are a standing item at each Service Line Senior Management Team meeting (I). Amber/Green Assurance report from Internal Audit on CIP Governance arrangements

(2017/18) (E). 4. Monthly Integrated Performance Meetings to review Service Line performance, risks and

opportunities, including CIP delivery.

0

5

10

15

20

25

May18

Jul18

Sep18

Nov18

Jan19

Mar19

RiskScore

TolerableRisk

Page 53

5. Monthly review of financial performance of each Service Line. 6. Service Line Recovery Plans to identify CIPs where a gap remains to target. Gaps in controls and assurances: (What additional controls and assurances should we seek?)


No significant gaps in controls and assurances identified, as evidenced by extant Internal Audit reports and the Statement of Internal Control. The Trust’s Medium Term Financial Plan has been updated to reflect the 2017/18 financial performance and the latest plans for 2018/19, including planning for CIPs beyond the current financial year taking into account transformation programmes such as mobility, workforce and estates. This was presented to Finance and Investment Committee in July 2018 and will be subject to review after publication of the planning guidance. A further review of the Trust’s CIP control environment is being undertaken by Internal Audit in Q1 2019 and will be reported to the Audit Committee in due course.

Action Update since last reviewed by Trust Board Lead Deadline

Continue to identify other CIP opportunities that can be implemented in-year or for 19/20 CIP plan to mitigate risk of slippage or non-delivery.

CIP programme now fully identified at a Trust level however there remains a gap to the Enfield service line target. The Clinical Director is continuing to lead sessions with his team to identify further schemes.

ELT Ongoing

The Trust is part of the pilot cohort for Lord Carter’s review of productivity and efficiency and is optimistic that there will be early learning that will lead to savings.

Lord Carter’s report into unwarranted variations in mental health and community services was published on 24 May 2018. This identified a number of areas for the Trust to review itself against. Opportunities for procurement savings are monitored via the Trust’s Procurement team with regular updates being given to the F&I Committee.

DG Ongoing

A number of strategic work streams have been developed to deliver more transformational service changes and efficiency improvements; including Mobility and Workforce Strategy

Mobility Transformation project board established – Pilot underway in District Nursing and Haringey CRHT. Scoping Work for new Workforce Strategy underway

SR JS

On-going On-going

Update the Trust’s Medium Term Financial Plan for 2017/18 outturn and 2018/19 plans to demonstrate actions necessary to return to financial balance in the medium term.

Full Medium Term Financial Plan presented to Finance and Investment Committee on 16 July. To be reviewed when national planning guidance is issued which is anticipated to be in early part of 2019.

DG / ELT

TBA


The Cost Improvement Programme was fully achieved in 2017/18, albeit with c£1m of non-recurrent savings. The CIP for 2018/19 is fully identified, however again with £1.7m of non-recurrent savings. At end the of Q3 there were no red-risk CIPs schemes included in the forecast CIP delivery for Q4. All schemes continue to be closely monitored by the Improvement and Delivery Board. The Trust’s Medium Term Financial Plan presented to Finance and Investment Committee in July 2018 indicated a forecast CIP requirement of 4% in 2019/20 (c£8m) and 2% a year thereafter. This is being reviewed in light of the recently issued Planning Guidance, and will be updated once contracts have been agreed for 2019/20. CCG allocations were published in early January.

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Board Lead: David Griffiths Date of review: January 2019

Lead Committee: Finance and Investment


Risk ID:

8 Risk: Medium / Long Term Financial Sustainability - If the Trust is unable to achieve and maintain financial sustainability, this will lead to widespread loss of public and stakeholder confidence with potential for regulatory action such as financial special measures.


-


13

Risk Rating:


Relevant Key Performance Indicators: (taken from the Financial Performance Report)

Initial Risk Score: 3 x 4 = 12 Indicator

17/18 outturn

Oct 18 Nov18 Dec 18 YTD 18/19 Forecast £000’s

Budget – surplus / (deficit)

(4,616) (61) (75) (85) (2,873) (3,346)

Actual performance – surplus / (deficit)

32,710 (188) (168) (16) (2,619) (3,346)

Variance to budget – Favourable / (adverse)

37,326 (127) (93) 69 254 0




Rationale for current score: There is a possibility of the risk occurring which could have a major impact. The Risk Score reflects the fact that the Trust is planning for a deficit in 2018/19. The Medium Term Financial Plan presented to F&I in July 2018 showed a breakeven position for 2019/20 onwards, however this is dependent on the delivery of a number of assumptions regarding additional funding from the CCGs, NHSE and local authorities, along with the achievement of some challenging CIP targets. Whilst the Trust is forecasting (at M9) delivery of its 2018/19 Financial Plan/Control Total, the risk inherent within this forecast is substantial due to the ongoing bed pressures and gap to the CIP target. Controls: (What are we currently doing about the risk?)


1. Standing Financial Instructions (SFI) providing framework of financial controls. 2. Reservation of Powers to the Board and Delegation of Powers. 3. Full suite of financial policies and procedures, in line with best NHS practice. 4. Controls for approving bank and agency staff usage to reduce costs associated with the use of

temporary staffing. 5. Agency Review Group targeting highest spending areas with action plans to reduce.

SFI and Reservation of Powers considered annually by the Audit Committee and approved by the Trust Board . Last review in November 2018.(I)

6. Efficiency plan in place to achieve c. £8.2m of savings, overseen by a Programme Management Office.

7. Monthly Integrated Performance Meetings to review Service Line performance, risks and opportunities.

8. Monthly review of financial performance of each Service Line.

Financial Performance Report considered at all meetings of the Trust Board and Finance and Investment Committee (I).

Current financial position and actions taken to deliver cost control and CIP savings discussed fortnightly and Improvement and Delivery Board

Unqualified Value for Money opinion issued in respect of 2017/18 accounts issued by

0

5

10

15

20

25

May18

Jul18

Sep18

Nov18

Jan19

Mar19

RiskScore

TolerableRisk

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9. Fortnightly meetings of the Improvement and Delivery Board which includes CIP delivery 10. Service Line Recovery Plans to address top 3 over spending areas 11. Mobility and Workforce redesign projects underway to identify medium-term transformational

savings

External Auditors (E)



No significant gaps in controls and assurances identified, as evidenced by extant Internal Audit reports and the Statement of Internal Control. The Trust’s Medium Term Financial Plan has been updated to reflect the 2017/18 financial performance and the latest plans for 2018/19 onwards. This was presented to Finance and Investment Committee on 16 July 2018 and will be reviewed again on publication of the national planning guidance.

Action Update since last reviewed by Trust Board Lead Deadline

A number of strategic work streams have been developed to deliver more transformational service changes and efficiency improvements; including Mobility and Workforce Strategy

Mobility pilot continues in District Nursing and Haringey CRHT. Scoping Work for new Workforce Strategy underway

SR JS

On-going On-going

Agree with commissioners disinvestment / decommissioning proposals to ensure that services are affordable within the commissioners’ financial envelopes.

Deep dives proposed by CCGs into areas for potential savings. Planned to be completed during Q1 2018/19 but not yet received from CCG. The outcome of the Deep Dives conducted by Enfield CCG on Older Adults inpatient services has concluded that there was no further scope for savings. Contract Notice issued to NHSE to take forward Pricing Review conclusions in respect of Specialist Services for 19/20. Contract round meetings commenced 16 January. Contract notice issued to associate CCGs to review block contract values for 2019/20. Revised values to be issued 21 January.

DG / SR DG DG

Mar 19 Mar 19

Update the Trust’s Medium Term Financial Plan for 2017/18 outturn and 2018/19 plans to demonstrate actions necessary to return to financial balance in the medium term.

Full Medium Term Financial Plan presented to Finance and Investment Committee on 16 July. To be reviewed when national planning guidance issued and contract offers received from CCGs/NHSE.

DG / ELT

Mar 19


There was a substantial gap between income and expenditure for 2018/19. The Trust has agreed its control total for 2018/19 however this is dependent on achievement of the CIP target and continued management of bed pressures. The MTFM presented to F&I in July showed a breakeven position in 2019/20 and the return to a small surplus in future years, however this is dependent on the achievement of CIPs and the agreement of additional funding from the CCGs/NHSE. The Trust is working with Commissioners to implement the recommendations from the Bailey & Moore Pricing Review. Funding has been agreed with the CCGs, and the Pricing Review is a key issue for discussion during the Contracting Round with NHSE. Negotiations continue with local authorities to ensure appropriate overheads are included in contracts. The Trust is actively participating in the sector wide 5 year Sustainability and Transformation Plan and continues to forecast achievement of the 2018/19 control total although there are substantial risks within the position that will need to be managed. Funding of £2.1m has been agreed to fund the Agenda for Change pay deal for 2018/19 and the part year effect of the medical pay deal (from October 2018). The national inflationary uplift in the tariff has been increased to 3.8% (from 1.1%) for 2019/20 to take account of the revised pay deal, and efficiency has been reduced to 1.1% (from 2%).

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The NHS Long Term Plan reinforced the requirement for CCGs to meet the Mental Health Investment Standard, and CCG allocations were announced on 10 January 2019. Contract offers for 2019/20 have yet to be received from commissioners. The Trust will be developing a new Medium Term Financial Plan, taking into account the outcome of the NHS Long-Term Plan and revised financial framework for providers during 2019/20. This will also take into account the output of the new Trust Strategy currently in development.

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Board Lead: Stanley Riseborough Date of review: January 2019

Lead Committee: Trust Board Date of next review: March 2019

Risk ID:

9 Risk: Local Health Economy – If the Trust fails to engage in the local health economy in the North Central London sector and beyond, this will lead to failure to deliver health improvements or capitalise on opportunities, undermining transformation and sustainability.


17


-

Risk Rating:



Initial Risk Score: 3 x 3 = 9 No relevant Key Performance Indicators identified. Current Risk Score: 3 x 3 = 9



Rationale for current score: The Trust is represented at CEO / Director level at the key North Central London forums and on the Mental Health, Workforce and Estates workstreams of the North London Partners STP. Directors are also engaged in the relevant national, London and NCL professional networks. Relevant information is fed back to the Trust Board at Board meetings, Board Workshops and Board Committees. Controls: (What are we currently doing about the risk?)


1. Ensuring appropriate Trust representation at key forums and workstreams in NCL and beyond.

Regular reviews of effectiveness via the Executive Leadership Team (I).

2. Effectively Influencing wider health economy and ensuring that Trust priories are taken into account.

Ability to deliver Trust priorities and capitalise on opportunities (I).

3. Trust Board is made aware of wider issues in the local health economy. 4. Regular 1:1s between COO and Enfield Director of Commissioning. 5. Borough based forums attended by Clinical Directors 6. CEO engaged with NCL level meetings 7. BEH regular contributor to STP development 8. Exec-to-exec team meeting with all CCGs in January/February 2019

Board understanding of wider issues (I).

0

5

10

15

20

25

May18

Jul18

Sep18

Nov18

Jan19

Mar19

RiskScore

TolerableRisk

Page 59



None identified.


The Trust is effectively engaged in the wider local health economy and able to influence partners, formally and informally. However, this needs to be kept under review, with effective feedback to Board members on issues and opportunities.

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Board Lead: David Griffiths / Stanley Riseborough (John Mills / Andrew Wright)

Date of review: January 2019

Lead Committee: Finance and Investment Committee


Risk ID:

10 Risk: Estates Management - Failure to modernise the Trust’s estate may result in a failure to realise the potential estate cost reductions and detrimentally impact on the quality and safety of services, poor patient outcomes and affect the patient experience.

CQC Domain: Safe / Well-led Relevant H&SC Act 2008 Regulations:

15


-

Risk Rating:


Relevant Key Performance Indicators: (taken from the Performance and Quality Dashboard Report)

Initial Risk Score: 4 x 4 = 16 Annual PLACE Inspection (undertaken between February and June):

National Average

2017

BEH 2017

National Average

2018

BEH 2018

Cleanliness 98.10% 99.57% 98.50% 99.56% Food 89.50% 90.09% 90.20% 95.65% Privacy, Dignity and Wellbeing 82.30% 86.86% 84.20% 89.67% Condition, Appearance and Maintenance 93.80% 96.30% 94.30% 96.32% Dementia 76.90% 82.00% 78.90% 87.42% Disability (new measure for 2017) 79.70% 84.12% 84.20% 87.02%

PLACE scores improved slightly.




Rationale for current score: The Trust’s Full Business Case (FBC) for the redevelopment of St Ann’s Hospital was approved by NHS Improvement and construction has commenced on the new inpatient unit , therefore

the Risk Score has been reduced Work continues to take place to improve the environment for service users of wards at St Ann’s in the interim, and the implementation of the Trust Wide prioritised ligature mitigation plan. Planned maintenance work continues to take place in line with the Estates Strategy and maintenance programmes. Controls: (What are we currently doing about the risk?)


1. Estates Strategy, which sets out how the Trust will achieve the desired facilities that best accommodate the services provided in the most cost effective way.

HealthWatch Enfield’s Patient Led Assessments of the Care Environment (PLACE) - Summary report of 2018 inspection. Annual PLACE Survey reported to the Trust Board on 24.09.18 as part of the Clinical, Quality and Safety Report (E).

Asbestos Register and Management Action plan reported to the Health and Safety Committee (I). Compliance with the Legionella Water Management Policy, reported to the Health and Safety Committee (I). Estates and Facilities KPIs (I). Services provided at Baytree House relocated to Somerset Villa. Future use of Baytree House under review.

2. Adherence to the Estates and Facilities work programme. 3. Delivery of agreed NCL Estates Strategy.

Estates and Facilities KPIs (I).

0

5

10

15

20

25

May18

Jul18

Sep18

Nov18

Jan19

Mar19

RiskScore

TolerableRisk

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4. Implementation of the re-development of the St Ann’s Hospital site to provide new mental health inpatient facilities.

.Approval for the FBC was given by NHSI in September 2018. Construction of the new mental health facilities commenced in January 2019, with completion by late summer 2020.

5. Ligature Mitigation Work Plan. A five year programme (2015 – 2020) for mitigating ligature risks is in the process of being implemented. Approximately £700k was programmed in year one and two, with a further expenditure of £1.2M over the following three years.

Summary of Highest, Medium and Low Risk areas following Review of In-Patient Ligature Risk Assessments considered by the Quality and Safety Committee regularly(I).

Update report last presented to the Quality and Safety Committee on 15.01.18 (I). Regular reports to the Trust Board.(I)



None identified


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Board Lead: Stanley Riseborough

Date of review: January 2019

Lead Committee: Date of next review: March 2019

Risk ID:

12 Risk: Performance Information - If the Trust fails to ensure reliable, accurate, timely or complete clinical or management information this may impair decision-making, the optimal use of resources to deliver safe patient care efficiently, and the Trust’s ability to evidence this to commissioners in line with contractual requirements.


17


-

Risk Rating:

(Likelihood x severity):

Top Relevant Key Performance Indicators: (taken from the Performance and Quality Dashboard Report)


Year to Date Activity Recording - Percentage variance from contracted activity plan (CCG Contracted Activity.




Rationale for current score: The Risk Score has been downgraded The likelihood of information being incomplete has reduced through the new controls which continue to prove effective via the assurances described. Recording of activity has improved in 2018/19 with the activity plan being set aligned to the services included in the Adult Pathway. While CCG plans have been reset according to previous years, the Adult MH Pathway Reviews and associated changes are likely to present some variation this year. Most of the work will remain the same, despite being delivered by a restructured service, and should not impact activity levels. There will however be some areas in which the nature of the work itself has changed, and the number of contacts will change as a result. Controls: (What are we currently doing about the risk?)


1. The Integrated Performance and Quality & Safety Dashboard Report and the Corporate Risk Register is considered by the Quality and Safety Committee and Trust Board at each meeting.

2. Integrated Performance and Quality Dashboard Report which presents performance information across a number of KPIs.

3. Validity and completeness of information is being monitored as part of Borough level performance reporting.

4. Further controls include scrutiny at the new Performance Improvement Committee and the Integrated Performance Meetings.

5. Productivity information is being produced weekly. Some evidence that IT is impacting negatively on

Activity recording is now more in line with expectations, based on the team-level delivery plans and analyses. Indicative Activity Plan 19/20 is in place with the proposed activity levels agreed with the services and CCGs.

Trust Quality and Performance Report presented to every meeting of the Quality and Safety Committee and Trust Board (I).

Bi-Monthly Data Quality Improvement Meetings (I). Data Quality (validity) is part of 18/19 contracts. Data is scrutinised by the CCGs

via the NELCSU (E). Integrated Performance Meeting with each Borough and Specialist Team (I).

0

5

10

15

20

25

RiskScore

TolerableRisk

Page 63

recording is being addressed through Open Rio functionality and a 12-month project to improve information reporting.

6. Any apparent under recording is now cross referenced with ESR staffing data and discrepancies are queried within the month, prior to reporting. The unoutcomed appointments and activity levels are sent weekly to the teams by patient and staff level in order to ensure updates are reflected on RiO within timescale provided.

Activity is being monitored in staff supervision and weekly basis by Team Managers to ensure accurate recording of activity in timely manner.



1. The replicability of performance information (i.e. the ability to reproduce the same, validated information from a source that integrates all of our key systems) is impacted by the absence of a static reporting data warehouse.

Action Update since last reviewed by Trust

Board Lead Deadline

Activity recording will be queried at team level and teams where under-recording is an issue are supported to improve. Weekly activity reports are sent out to teams to flag any areas of concern.

Indicative Activity Plans for 19/20 is in discussion with the services and CCGs, activity for Adult Pathway in Enfield & Haringey will be aligned to the service reconfiguration in 18/19.

Jayshree Pindoriya

Ongoing

Ongoing work in comparing the actual values each month against the plan is monitored by team and borough level and escalating underperformance greater than 3% across the three boroughs

Activity continues to be monitored by the services on a weekly basis – reports are available on Trust Reporting Services for teams to access.

Jayshree Pindoriya

Ongoing


The information presented to the Trust Board is increasingly complete and reliable, and the likelihood of misleading information being reported is low. With routine, operational validation and multiple points of scrutiny, the impact of minor data inaccuracies would be minimal. The Board and Committee level performance report for 2018/19 calculates key indicators directly from RiO data extracts. This applies to the borough-level reports as well as the Trust Board view, so performance is unavoidably reflective of the information recorded in our clinical systems. The ‘live’ nature of the reporting database is less of a problem for board-level decision making than it is for retrospective analyses and CCG assurance. The reports on SSRS – reporting services provide read-only access by CCG and team level activity.

Page 64

Title:

Trust Quality and Performance Report – December 2018

Report to:

Trust Board

Date:

28 January 2019


Public Meeting

Report Author:

Jayshree Pindoriya Assistant Director of Information & Performance

Report Sponsor:

Stanley Riseborough Interim Executive Chief Operating Officer

Comments / views of the Report Sponsor:

The Board is recommended to note the content of this report.

Overview of the report: This report provides a summary of performance against both NHSI Single Oversight (SOF) Targets and the Trust Key Performance Indicators (KPIs) for 2018/19 reporting month - December. This report provides an overview of September performance, assessed against the indicators under the CQC domains, Safe, Effective, Caring and Responsive. Key issues to bring to bring to the attention of members: The Board is asked to note: The key challenges on service performance is mainly on NHSI and National targets:

• Accident and Emergency – 1 hour response at North Middlesex Liaison Service performance has improved further in December reporting at 92.6%, this is the highest performance this financial year with a target of 95%. Performance is steadily improving due to a cash injection of 150k Winter Resilience funding from Enfield CCG. Additional resources required to support the team are now being put in place. A&E referrals fell by 9% in the month. Referral for the 65+ age group also fell by 22% and appears to have stabilised since the proactive work of the dementia team. The service is aware of the changes in the patterns of referrals. This will be closely monitored in the coming winter months to enable underlying factors affecting performance to be highlighted.

• Accident and Emergency – 1 hour response at Barnet Hospital performance is reporting a marginal improvement reporting at 86.9% but still remains under target. The improvement in performance can be partly contributed to a 22% reduction in the number of referrals/patients seen in A&E. Since last month there has been no change in the number of patients seen on the wards, this has remained in the region of 40% & 60% respectively. The main reason for the number of breaches each month is constantly recognised as multiple referrals received at a time delaying the nursing staff to see all referrals within the 1 hour target.

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• CAMHS Improved Access rate to CAMHS service – to increase the number of new referrals to treatment within 6 weeks. The national target of 32% by the end of the reporting year is for all CCGs (this includes Voluntary and Local Authority sectors). This KPI is monitored locally in each borough.

• Podiatry waiting times has met the target for the first time this financial year and is reporting at 94% against target of 95%. The improvement is due to the service now reporting full establishment of staffing. Further improvement of this indicator is expected in February reporting.

• The Mental Health year to date activity for the Trust resulted in a -3% from plan. The services performance varied with Barnet meeting the plan by 2%, Enfield under by -3% and Haringey under plan by - 9%. This variance is due to long-term sickness and vacancies in team and the Adult Pathway review. The activity plan for 19/20 will review this in line with the service reconfiguration.

Enfield Community services year to date activity resulted in -6% against plan. The CYP service is on track against the plan. The AOP year to date shows -6% a slight drop compared to previous month. The AOP service is negotiating activity plan for 19/20 in line with service changes. Management will continue to focus and monitor performance to ensure activity levels are achieved.

Areas of above target or improved performance in NHSI and National Targets:

• 7 day follow up for patients discharged from Inpatient wards seen within 7 days continues to be above target month on month, weekly monitoring is place to ensure compliance - reporting month at 100% (99/99) against target of 95%.

• The 2-week access standard for Early Intervention in Psychosis continues to be above

target – reporting month 64% against the national target of 53%.

• Enfield’s ‘Let’s Talk’ IAPT service recovery rate has continued to maintain good performance reporting at 55.7% against the national target of 50%. The service has sustained all waiting times standards.

• Barnet’s ‘Let’s Talk’ IAPT service has met all waiting times standards apart from 6 weeks target, this is due to high volume of referrals entering treatment against the 348 target. The CCG have released additional funds to reduce these but more funds are required to make an immediate significant difference to performance. Supporting measures particularly the number of people who enter first treatment appointment continues to improve reporting at 52.6% against national target of 50%.

• Speech and Language Therapy (school age) waiting times (referral to appointment)

continues to be above target at 95% performance against a 75% target.

Report History:

This is a regular report to the Board

Implications of the decision / actions:

Performance improvement activity will be guided by comments and feedback from this committee.

Links to the Trust’s Objectives, Board Assurance Framework

Performance against these metrics informs the Board and the Quality and Safety Committee of the extent to which that we are providing excellent services for patients.

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and / or Corporate Risk Register List of Appendices: • Trust Dashboard

Page 67


Page 68

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Trend Target

99% 98% 96% 98% 96% 97% 96% 98% 96% 98% 97% 96% 95%

82.4% 88.2% 77.8% 85.7% 85.7% 72.7% 81% 95% 89.0% 75.0% 75.0% 64.0%

53%

99.6% 100.0% 100.0% 100.0% 100.0% 99.5% 100.0% 100% 100.0% 100.0% 100.0% 98.7% 95%

92.1% 92.9% 90.0% 90.7% 935.0% 88.4% 89.9% 89% 90.0% 94.1% 93.4% 87.9% 75%

506 458 523 529 429 454 436 479 433 483 557 368

441

46.7% 50.0% 57.2% 51.5% 52.3% 48.4% 49.8% 47.6% 52.9% 55.1% 50.0% 55.7% 50%

100.0% 99.2% 99.4% 100.0% 100.0% 100.0% 99.8% 99.4% 100.0% 100.0% 99.0% 100.0% 95%

96.0% 90.2% 88.9% 81.0% 82.0% 72.0% 66.8% 62.1% 50.4% 49.3% 50.0% 50.0% 75%

434 345 436 496 552 504 396 423 416 416 509 443 300

34.8% 52.5% 46.8% 51.5% 54.6% 55.0% 55.4% 50.7% 56.3% 53.8% 50.8% 52.6% 50%


99% 99% 100% 100% 99% 97% 100% 100% 99% 98% 100% 100% 95%

91.4% 90.0% 93.4% 93.5% 95.4% 92.5% 90.4% 93.6% 96.7% 96.5% 96.5% 96.1% 95%

87.2% 85.0% 84.0% 85.1% 84.6% 83.8% 84.2% 85.2% 87.3% 87.2% 87.1% 86.4% 85%

1.4% 1.7% 0.8% 4.2% 2.2% 3.1% 6.5% 4.9% 3.6% 6.0% 4.4% 4.2% 5%

7.3% 7.1% 7.7% 6.1% 5.9% 6.4% 5.9% 7.4% 5.3% 5.0% 5.3% 4.6% 2.5%

7.3% 5.1% 5.1% 4.7% 5.2% 5.8% 3.9% 6.6% 5.1% 4.1% 5.4% 4.6% 2.5%

7.3% 12.9% 19.2% 12.6% 9.2% 9.5% 16.4% 10.8% 6.1% 8.2% 7.0% 5.1% 2.5%

27 29 26 19 33 41 18 17 19 20 29 11

Trust Dashboard 2018-19 - Reporting Month: December 2018

2017/18 2018/19Q4 Q1 Q2 Q3

OPERATIONAL Trust Performance against NHSI Standard Operating Framework (SOP) Comments

Saf

e, E

ffect

ive,

Car

ing

& R

espo

nsiv

e

% Patients gate kept by the Crisis Resolution and Home Treatment Team

First Episode of Psychosis % of people treated within 2 weeks

During the month 9 out of 14 referrals met the FEP target. The 5 breaches were allocated as 2 in Barnet, 1 in Enfield and 2 in Haringey. Exceptions reported were patients DNAs, difficult to contact, transfer from another hospital and 1 data quality error.

Let's Talk (Enfield IAPT) % of people treated within 18 weeks of referral

Let's Talk (Barnet IAPT) % of people treated within 18 weeks of referral

Let's Talk (Barnet IAPT) % of people treated within 6 weeks of referral

The fall in performance is due to the large waits at the front door, the CCG have released additional funds to reduce these but more funds are required to make a significant difference to performance, particularly as referrals numbers are currently higher than average.

Let's Talk (Barnet IAPT) number entering treatment each month

Let's Talk (Enfield IAPT) % of people treated within 6 weeks of referral

Let's Talk (Enfield IAPT) number entering treatment each month

December is traditionally a challenging month for access due to the bank holidays and staff annual leave. However due to the higher than average access figure in November, the year to date access rate remains on target.

Let's Talk (Enfield IAPT) Recovery Rate

Let's Talk (Barnet IAPT) Recovery Rate

Q4 Q1 Q2 Q3

OPERATIONAL - National & Local Targets Comments

CPA Acute & PICU % of patients followed-up 7 Days after discharge

Care Programme Approach: % of patients reviewed in the last 12 months

% PbR Cluster Reviews completed on time

% Admissions that are emergency readmissions within 28 days of previous discharge

DToC - Number of Patients delayed in the month

DToC - % All Occupied Bed Days (OBDs) due to delayed transfers

Overall there has been improvement in performance for the combined number of Adults and Older Adults DToCs. A total of 11 DToCs was reported compared to 29 in November. The total number of OBDs pertaining to DToCs was also lower in the month but, the average was higher as patients spent a longer time on the wards. Most improvement seen in Barnet and Haringey. Effective management is aiming to reduce numbers and the time spent on the wards. At the end of the month responsibilities for DToCs were assigned as NHS 8, LA 1 and Joint 2.

DToC - % Adult OBDs due to delayed transfer of care

Slight improvement in performance this month . A total of 7 adult DToCs were reported in the month compared to 17 last month. The average number of bed days lost as a result of DToCs also increased in the month, due to patients sending a longer time on the wards. Most improve performance was in Barnet at 3%. Enfield achieved 4% and Haringey 6%.

DToC - % Older People's OBDs due to delayed transfer of care

There was improvement in the Older Adults. The number of DToCs fell to 4 compared to 12 reported last month. The average number of bed days occupied by DToCs increased as patients spend a longer time on the wards. Performance was much improved in Enfield and Haringey both achieving 0% & 1% respectively. Barnet having 3 out of the 4 DToCs reported performance at 13%

Page 69

35 35 37 40 38 36 36 37 37 42 40 39 35

25 27 19 25 27 21 22 22.5 28 27 22 25 28

11.7% 12.6% 12.4% 11.2% 12.8% 12.9% 10.8% 11.4% 13.8% 12.7% 14.8% 14.7% 25%

45 116 23 91 102 33 80 40 62 42 36 87 40

23 53 23 48 99 29 97 38 56 26 44 70 40

None 84.2% 95.5 71.4% 90%

73.9% 80.5% 66.7% 67.1% 72.0% 83.4% 86.4% 76.5% 79.0% 80%

89.0% 92.0% 86.1% 80.8% 71.9% 70.2% 67.6% 72.4% 78.4% 86.6% 90.3% 92.6% 95%

95.0% 95.0% 94.2% 95.1% 88.3% 89.4% 93.3% 89.2% 92.7% 86.5% 84.7% 86.9% 95%

79% 79% 79% 81% 81% 81% 81.0% 80% 80% 81% 81% 80% 70%

26% 25% 26% 26% 26% 25% 25.0% 26% 25% 25% 25% 22% 20%

7.6% 7.2% 7.3% 7.8% 7.2% 7.3% 7.7% 7.3% 7.1% 6.6% 6.9% 7.3% 10%

8.5% 8.2% 8.3% 8.6% 8.1% 7.9% 8.2% 8.1% 8.2% 7.6% 8.1% 1.6% 10%

3.0% 2.4% 2.8% 2.8% 2.7% 2.8% 2.6% 2.4% 1.9% 2.6% 2.7% 2.6% 4%

8.9% 8.3% 7.9% 9.9% 9.6% 9.8% 8.2% 10.4% 8.4% 7.6% 8.1% 8.5% 10%

37% 52% 53% 57% 61% 67% 66.7% 54.7% 58% 29% 34% 37% 95%


Safe

, Effe

ctiv

e, C

arin

g &

Res

pons

ive

Adults - Mean length of acute inpatient stay on discharge (Untrimmed) December saw a slight improvement in the mean. A total of 91 patients were discharged (113 last month), of which 9 had length of stay of 100 days and over including one Barnet patient at 196 days and one Haringey patient at 294 days.

Adults - Median length of acute inpatient stay on discharge (Untrimmed)

Patients triaged by the CRHT as clinically requiring a response within 4 hours. These referrals are assessed as Emergency

Performance fell to 71.4% as a result of 2 breaches in the month. In total there were 7 emergencies of which 5 were seen within the 4hr target. The breaches all allocated to Haringey were due to one patient difficult to contact and engage with the service . The other patient was transferred from another trust and refused to cooperative with the team..

Patients triaged by the CRHT as clinically requiring a response within 24 hours. These referrals are assessed as Urgent.

Performance for the this KPI was just under target. Barnet and Enfield achieved target at 87% & 84% respectively. Haringey achieved 66% . A total of 528 referrals were received of which 417 were seen within the 24hr target. A number of explanations have been ascertained for the breaches as patients not available, cancelled, rescheduled or did not want to be seen. The teams are still experiencing a few data quality issues in term of defining the indicator but, these are rectified before the reports are final for reporting.

Liaison Service - North Mid 1-hour response time for A&E Referrals

Performance is steadily improving due to a cash injection of 150k Winter Resilience funding from Enfield CCG. Additional resources required to support the team are now in place. A&E referrals fell by 9% in the month and referrals to the wards also fell by 9%. Referral for the 65+ age group was down by 22% and appears to have stabilized since the proactive work of the dementia team. The service is aware of the changes in the pattern of referrals. This will be closely monitored in the coming winter months to enable underlying factors affecting performance to be highlighted .

Adults - percentage people on the acute inpatient caseloads that have had stays of over 100 days

Older People - Mean length of acute inpatient stay (Untrimmed)

The mean length of stay increased in the month as a result of 5 patients discharged across all three CCGs including 1 Enfield patient with a LoS of 207 days.

Older People - Median length of acute inpatient stay (Untrimmed)The median increased in the month as a result of 1 out of 5 discharges having an exceptionally long length of stay at 207 days.

Mental Health DNA Rates (Excluding CRHTs)

- Mental Health DNA Rates - Adults

- Mental Health DNA Rates - Older Adults

Liaison Service - Barnet 1-hour response time for A&E Referrals

Performance in December slightly improved, but still remained under target. The improvement in performance can be partly contributory to a 22% fall in the number referrals/patients seen in A&E. Since last month there has been no change in the number of patients seen on the wards. The split between patients seen in A&E and on the wards have remained approximately 60% & 40% respectively. The main reason for the number of breaches each month is constantly recognised as multiple referrals received at a time delaying the nursing staff to see all referrals within the 1 hour target.

Percentage of people in receipt of Community Mental Health services who are in settled accommodation

Percentage of people in receipt of Community Mental Health services who are engaged in structured occupations, including actively seeking work, parenting and running a home

- Mental Health DNA Rates - CAMHS

Memory Clinic: Percentage of patients waiting less than 6 weeks from Referral to Diagnosis

This indicator is based on patients seen and diagnosed within 6 weeks of referral. All services are currently finding it extremely challenging to achieve target. Barnet achieved 52%. Since September Barnet has been experiencing medical staffing gaps regarding sickness & paternity leave. Recovery is expected January 2019. Enfield and Haringey achieved 14% & 73% respectively. Both services have extreme funding gaps within the service particularly pertaining to medical staffing resources and commissioned groups.

Q4 Q1 Q2 Q3

WORKFORCE Comments

Page 70

84.8% 84.7% 86.1% 85.2% 85.0% 85.4% 82.5% 83.4% 81.8% 80.1% 81.0% 81.3% 90%

4.5% 4.2% 3.7% 3.9% 3.6% 3.5% 3.5% 4.1% 4.2% 4.4% 4.3% 3.9% 3.5%

5.0% 4.3% 5.6% 5.2% 5.1% 6.1% 5.0% 5.9% 5.9% 4.2% 5.4% 5.6% 8%

9.3% 9.2% 9.0% 10.4% 9.8% 9.4% 8.9% 8.3% 9.0% 9.6% 9.1% 9.6% 10%

10.2% 10.4% 10.0% 10.1% 9.9% 9.8% 10.8% 11.3% 10.9% 11.0% 11.0% 11.2% 10%

13.5% 12.5% 13.5% 12.1% 12.0% 12.7% 15.1% 15.0% 13.4% 13.0% 12.2% 13.3% 10%

8.0% 10.1% 8.6% 7.3% 7.4% 7.5% 9.7% 6.3% 2.9% 5.3% 6.8% 6.7% 10%

88 97 86 86 86 98 90 77 87 86 81 74 77

14.4% 14.4% 14.6% 14.4% 15.0% 14.7% 14.7% 14.2% 14.5% 14.1% 14.3% 14.1% 15%

14.4% 14.4% 14.6% 11.6% 12.0% 12.0% 11.8% 11.5% 11.1% 11.4% 11.3% 11.4% 11%

2.9% 2.9% 2.8% 2.8% 3.0% 2.7% 2.9% 2.7% 2.8% 2.7% 3.0% 2.7% 5%

63.0% 63.0% 63.0% 63.2% 62.4% 62.6% 61.9% 61.9% 62.3% 61.3% 61.2% 61.6% -

50%

55%

The figure is largely stable in that slightly less than 2/3rds of staff who leave the Trust would recommend it as a "great place to work". Exit interviews are monitored and where trends/themes can be identified, these are fed into the retention working group for consideration. The Workforce team is considering options to increase the level of exit interview completion.

Wel

l Led

Proportion of staff compliant with individual mandatory training requirementsSlight improvement in compliance this month. The L&D team's recovery plan has been approved by the executive leadership team for approval. Outreach and e-learning clinics continue.

Sickness/absence rate %

Sickness absence fell again in December. Long term sickness has fallen to 1.7%, this is a 0.3% decrease from last month (November 2.0%). It is hoped that the new attendance policy, with its focus on facilitating return to work, will continue to have a positive impact on the level of sickness absence.

Agency as a % of Employee Spend (Financial - agency spend as a percentage of staffing spend)

Medical vacancy rateWhilst the vacancy rate remains within the Trust target, there are challenges in particular areas which are being addressed by the boroughs and medical HR.

Time to hire (mean number of days from advert start to provisional start date)The time to hire figure is within target. The recruitment team remain focussed on streamlining the process to ensure effective recruitment, selection and on boarding processes.

Staff Turnover (Total)

Total staff turnover remains within target. We have set an ambitious target to reduce the turnover rate to 11% by September 2019. The retention programme is well supported with good engagement from boroughs. NHSI undertook a review on 12 December, reported good progress and were particularly pleased with our focus on engaging staff in the process and delivery of projects. The launch of Vivup (a portal providing a range of non-pay benefits) has been well received.- Staff turnover (Unplanned)

- Staff turnover (Planned)

There has been a slight rise in the Agency and Bank expenditure in December. It remains a challenge and so the business partnering team continue to work with managers to convert agency to bank or permanent and to manage vacancies proactively. Workforce team is working with borough managers to address hotspots.

Bank as a % of Employee Spend (Financial - bank spend as a percentage of staffing spend)

Total vacancy rate (% established posts without staff members in place)

Vacancies remain slightly above our target. Haringey are hosting an open day in January to encourage members of the local community to consider BEH as a potential employer. Bespoke activities are underway in vacancy hotspots, with consideration of skill mix reviews to fill gaps that remain hard to fill.

Nursing Vacancy RateFollowing a steady decline in vacancies within nursing, there has been an increase within the reporting month. There are still some hotspots and both Nursing and Workforce are supporting those areas to facilitate filling those vacancies.

Percentage of exit interviews where the trust was described as a good place to work

61% 57.0%

Staff FFT - Overall score: % would recommend as a place to work 55.1% 53.8% 61% 58.0%

2017/18 2018/19Q4 Q1 Q2 Q3

The Qtr 3 score as measured in the national staff survey shows a small decline in both scores. We do not yet have the final weighted figures which might indicate if this is statistically significant change. There is no obvious reason for the movement in the scores.

Staff FFT - Overall score: % would recommend as a place for care

60.9% 56.9%

Page 71


-5.0% -6.0% -6.0% -2.0% 3.0% -3.0% 0.0% -2.0% -2.0% 0.0% -3.0% -3.0% ±3%

-4.0% -5.0% -6.0% -17.0% -9.0% -11.0% -9.0% -10.0% -9.0% -6.0% -5.0% -6.0% 3%


0 0 0 1 0 0 0 0 0 0 0 0 0

2 2 1 7 6 2 1 0 2 7 2 1 0

13 9 10 6 6 10 7 6 8 4 8 tbc -

62% 44% tbc 100% 83% 40% 50% 67% 0% 0% tbc tbc 90%

93% 93% 92% 91% 91% 92% 93% 91% 93% 93% 91% 91% 80%

89% 87% 86% 87% 85% 85% 88% 85% 89% 89% 87% 87% 80%

96% 95% 95% 94% 94% 94% 94% 94% 95% 96% 94% 93% 80%

92% 91% 90% 90% 89% 89% 91% 89% 92% 92% 90% 90% 80%

90% 91% 91% 90% 92% 89% 93% 90% 93% 90% 90% 86% 80%

89% 88% 87% 86% 88% 87% 90% 88% 92% 89% 92% 87% 80%

96% 96% 98% 97% 97% 97% 97% 98% 98% 99% 99% 99% 90%

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

1 0 2 0 4 6 3 1 2 9 6 13 0


90

100% 100% 100% 100% 100% 100% 100% 100% 100% None 100% None 90%

100% 100% None 94% 100% 100% 100% 100% 100% 100% 100% 100% 90%

None None 100% 100% None None 100% 100% 100% 100% None 100% 90%

90% 80% 100% 100% 80% 73% 75% 83% 71% 100% 90% 92% 90%

91% 83% 92% 82% 85% 74% 87% 74% 57% 55% 62% 85% 90%

FINANCE - Activity Comments

Activity Recording - Percentage variance from CCG contracted activity plan (MH Community Activity)

The year to date activity for the Trust resulted in a -3% from plan. Across all services performance was slightly down compared to the previous month. Barnet remained within plan by 2%, Enfield under by -3% and Haringey below plan by - 9%. Management will continue to focus and monitor performance in all services to ensure high activity recording levels are maintained.

Activity Recording - Percentage variance from CCG activity plan (ECS Contracted Activity)

The year to date performance for community services resulted in a -6% from plan, a slight fall from the previous month. CYP year to date activity figures resulted in a -03% from plan and AOP -7% below plan. Much improvement has been made in contrast to activity recording in the earlier part of the year especially in CYP. Management will continue to focus and monitor performance to ensure activity level are achieved.

Safe

& C

arin

g

Falls resulting in severe injury or death

Grade 3 or 4 pressure ulcers

One reported incident in the District Nursing Highland team.

Formal Complaints received

Q4 Q1 Q2

Datix is a live system so figures are expected to change as complaints are reviewed and re-categorised. Minor changes to the figures are to be expected.

Complaints: Response in time

25 day compliance figures are one month in arrears as the 25 working day period is not yet complete for the current month, so the report analysis relates to the most recent reporting month. Previously, complaint suspensions (when the formal complaint process is stopped for a specific reason but the complaint is not withdrawn) did not have a new agreed timeframe and had the potential to drift. The Trust's new approach is to ensure those complaints suspended have a new agreed timeframe which if not met is reported as a breach. Recovery plans for individual Boroughs have been put in place with the full detail of these in the Patient Safety and Quality Report.

Patient Survey - Information provided

Patient Survey - involved in decisions

Q3

QUALITY Comments

Patient FFT - Mental Health Overall Score

Patient FFT - ECS Overall Score

Inappropriate use of inpatient beds

Patient Survey - treated with dignity

Overall Patient Satisfaction

Overall Carer Satisfaction

Q3

ENFIELD COMMUNITY HEALTH Comments

DISTRICT NURSING

% of urgent referrals responded to within 4 hours

Number of Never Events

136 Suite – inappropriate useThirteen patients were kept in the S136 suite after the time had expired due to unavailability of an inpatient bed.

Q4 Q1 Q2

% of routine referral seen within 8 weeks

The service is making good progress towards achieving the target. Previously staff sickness had impacted on performance. The service is still dealing with the backlog of referrals which has improved in the domiciliary part of the service but remains high in adult neurology due to the existing maternity leave cover being below established capacity.

% of referrals responded to within 48 hours

% of urgent referrals to OOH nursing responded to within 4 hours

COMMUNITY PHYSIO

% of urgent referrals seen within 5 working days

Page 72

NONE 100% NONE NONE NONE NONE NONE NONE NONE NONE NONE NONE 90%

98% 97% 98% 98% 96% 98% 98% 97% 97% 98% 98% 99% 90%

56% 57% 66% 66% 69% 59% 79% 74% 70% 88% 87% 94% 95%

None 100% None None None None None None None None 100% None 90%

96% 96% 97% 96% 95% 95% 96% 95% 96% 86% 95% 94% 80%

91% 91% 90% 92% 86% 86% 86% 87% 86% 84% 85% 90% 80%

100% 89% 100% 95% 100% 100% 100% 84% 85% 100% 82% 89% 90%

100%

96% 83% 95% 95% 95% 100% 95% 95% 94% 95% 92% 91% 95%

99% 97% 95% 98% 99% 97% 98% 97% 99% 99% 99% 97% 95%

99% 89% 91% 100% 91% 100% 89% 79% 82% 93% 94% 95% 75%

100% 97% 100% 99% 100% 100% 98% 100% 100% 100% 100% 98% 85%

98% 97% 100% 100% 100% 100% 98% 100% 100% 98% 98% 100% 95%

PHYSIO MSK

% of urgent referral seen within 5 days

% of patients whose first appointment is within 13 weeks

% up to date with required Level 1 & 2 safeguarding Training

% up to date with required Level 3 Safeguarding training

% of Health Visitor child protection supervision sessions completed within 3 months timescale Eight out of nine sessions were completed within the timescale. The only breach was due to sickness, the session has been rescheduled but could not be offered within the target timescale.

PODIATRY

% of non-urgent referrals assessed within 13 weeksGood improvement now made in the service as recruitment process near completion.

% of urgent referrals responded to within 48 hours

SAFEGUARDING CHILDREN & YOUNG PEOPLE

CHILDREN LOOKED AFTER

% health assessments carried out by the specialist nurses within timescale

There were 22 assessments of which 20 were carried out within the target timescale. The two breaches were due to one patient refusing to be seen and another kept changing appointments.

% of School Nurse child protection supervision sessions completed within the previous term 100% 100%

CHILDREN'S PHYSIO (MSK)

% Routine referrals for initial Physio assessment seen by 13 weeks

CHILDREN'S OCCUPATIONAL THERAPY

% Complex referrals for initial OT assessment seen by 13 weeks

NEW BIRTH HEALTH VISITING

% of new birth assessments carried out between 10-14 days

SALT - EARLY YEARS DROP-IN

% Referrals (following drop-in assessments) for specialist interventions, that are seen within 13 weeks

Page 73


Page 74

BEH-MHT – Trust Board - 28.01.2019 3.3 Finance Report as at Month 9 2018/19 Title:

Finance Report as at Month 9 2018/19

Report to:

Trust Board

Date:

28 January 2019



Purpose of Report: To update the Trust Board on the Trust’s financial position. Recommendations: The Trust Board is asked to note:

• I&E deficit £2.6m year to date, which is £0.3m better than plan (£0.7m better than NHSI Plan profile);

• I&E forecast outturn is a deficit of £3.3m in line with the control total set by NHSI, with the key risks being the continued use of private beds, the delivery of savings plans and the requirement for further savings with the cost pressure inherited from the AfC pay award;

• Cost Improvement Plan (CIP) delivery is £0.7m behind plan year to date, with a forecast outturn of £7.8m;

• Cash balance is £56.2m which is £2.5m favourable to plan. Capital expenditure is £6.03m against a plan of £14.4m year to date;

• NHSI Single Oversight rating is currently 3 and is forecast to stay as a 3 for the rest of the year.

• Priority areas for action to ensure that the Trust’s Control Total is delivered are: o continued focus to improve the acute care pathway and reduce the demand for

external placements; o minimising, as far as possible, the need for agency staffing; o ensuring that the Trust’s CIP delivery is maintained, particularly for those schemes

not due to start until Q4.

Report Sponsor:

David Griffiths, Chief Finance and Investment Officer


Report Author:

Nina van Markwijk Deputy Director of Finance 0208 7023712 [email protected]

Report History:

Monthly report to the Trust Board to update on the current financial position of the Trust


These are covered in the report.


None


This report supports the Trust’s objective to “meet our financial and other targets”.

Page 75

mailto:[email protected]

BEH-MHT – Trust Board - 28.01.2019 3.3 Finance Report as at Month 9 2018/19 List of Appendices: None

Page 76

BEH-MHT – Trust Board – 28.01.2019 3.3 Finance Report as at Month 9 2018/19

Financial Performance Executive Summary

Measure Description Status Position Trend Variation

Performance against NHSI Control Total

Net income and expenditure

Amber

Net surplus/(deficit) in month: Plan (£0.1)m, actual (£0.0)m, variance £0.1m favourable Net surplus/(deficit) YTD: Plan (£2.9)m, actual (£2.6)m, variance £0.3m favourable

Income: On plan YTD. Pay: Favourable to plan £2.7m - vacancies. Non Pay: Adverse to plan by £2.5m –bed placements and CIP slippage, partially offset by release of provision and depreciation charges behind plan.

Cost Improvement Programme (CIP)

Savings against the CIP plan Red

CIP in month: Plan £0.8m, actual £0.7m, variance (£0.1)m. CIP YTD: Plan £6.2m, actual £5.5m, variance (£0.7)m adverse.

Actual delivery is adverse to plan due to several schemes waiting to be finalised, and the IT savings lower than anticipated.

Capital expenditure

Year to date cumulative expenditure in non-current assets

Green

CAPEX in month: Plan £0.7m, actual £0.8m, variance £0.1m adverse CAPEX YTD: Plan £14.4m, actual £6m, variance £8.3m adverse

Capital expenditure is so far happening at a slower pace than planned. However, there has been large increase in Capital Expenditure since November as the new building works at St Ann’s begins.

Cash Cash held with the Government Banking Service

Green

Cash flow in month: Plan £1.4m inflow, actual £3.9m inflow, variance £2.5m favourable. Cash balance: Plan £53.7m, actual £56.2m, variance £2.5m favourable.

Cash balance is £2.5m higher than planned due to a delay in capital expenditure, partially offset by earlier payment of creditors etc.

Page 77

BEH-MHT – Trust Board – 28.01.2019 3.3 Finance Report as at Month 9 2018/19

NHSI Single Oversight Framework

NHSI Use of Resources rating

Amber

The Trust’s YTD and current risk rating is a 3. The Trust has generally had a risk rating of 3 except at the end of 2017/18 when the Trust had a risk rating of 1 thanks to the proceeds of the partial sale of the St Ann’s site.

Page 78

BEH-MHT – Trust Board – 28.01.2019 Finance Report Month 9 2018/19

Report

1. Introduction and Background 1.1 This report presents the financial position of the Trust as at the end of December 2018

(month 9 of the 2018/19 financial year). 2. Financial Performance Overview 2.1 Performance against the NHSI Control Total 2.1.1 Financial performance at the end of month 9 is a deficit of £2,619k against a planned deficit

of £2,873k. Performance is reported against the Trust’s re-profiled budget with adjustments which is now different to the plan submitted to NHSI in April 2018. Financial performance at the end of month 9 against the NHSI plan of £3,326k means that the deficit is £707k favourable to NHSI plan.

2.1.2 The table below shows the values for planned and actual performance against the

budgeted deficit of £3.3m submitted to NHS Improvement in April, with £1.6m of Provider Sustainability Funding PSF) included in the forecast.

2.1.3 The current Trust forecast is to meet its control total - £3.3m deficit. It is expected that the

Trust will meet the shortfall in funding for the AfC pay award through additional income received for other services, and underspend in other areas. The advice from NHSI (London) was to reflect the pressure in our forecast outturn if we were not certain we could completely mitigate the pressure. The settling of prior year OSV invoices has helped improve the Trust’s position this year.

2.1.4 The actual deficit in month is better than plan by £0.1m. A high level of vacancies

continues, and Overseas Visitor activity billed has improved. Without these, the position would have been worse than plan in month and year to date, mainly due to the use of private beds and slippage on several CIP schemes.

Annual ForecastBudget Budget Actual Variance Budget Actual Variance Outturn£000's £000's £000's £000's £000's £000's £000's £000's

208,700 Patient Care Income 17,599 18,339 740 155,898 156,035 137 209,7917,768 Non Patient Care Income 650 580 (70) 5,937 5,842 (95) 7,895

(166,054) Pay (13,990) (13,559) 430 (124,164) (121,461) 2,704 (163,063)(41,298) Non Pay (3,307) (4,474) (1,167) (31,207) (34,640) (3,433) (46,430)

9,117 EBITDA 952 886 (66) 6,463 5,776 (688) 8,193-4% EBITDA % -5% -5% 4% 4% 4%

- Profit / (loss) on disposal of assets - - - - (2) (2) (2)- Fixed Asset Impairments - - - - (361) (361) (361)

(6,757) Depreciation and Amortisation (563) (503) 60 (5,068) (4,661) 407 (6,213)(5,441) PDC Dividend (453) (400) 53 (4,081) (3,652) 429 (5,217)

(351) Interest payable (29) (28) 1 (263) (287) (23) (382)100 Interest Receivable 8 29 21 75 206 131 275

(3,332) Surplus / Deficit (85) (16) 69 (2,873) (2,980) (107) (3,708)- Fixed Asset Impairments removed - - - - 361 361 361

(3,332) Surplus / Deficit excluding impairments (85) (16) 69 (2,873) (2,619) 254 (3,347)

Month 9 YTD Month 9

Page 79


2.1.5 Income is ahead of plan in month (£0.7m) due to billing for Barnet CAMHS Transformation

income for costs already incurred, the billing for New Model of Care income as the Trust’s role of commissioner, and further improvement in ADHD activity. Overseas Visitor income is also improving its strong position (£300k billed for November). Year to date income is on plan. Additional income mentioned above is offset by OSV credit notes issued to Enfield CCG in September to resolve the final OSV invoices for 2016/17 and 2017/18 (£790k). In addition the underachievement of CQUIN – billing at 50%, is driving the overall position.

2.1.6 Total pay expenditure of £13.6m in month is £0.4m better than plan. Vacancies across the

Trust are offsetting the overspend on HCA’s, driven by 1:1 usage. Agency expenditure of £0.8m in December is a deterioration of £0.1m from November. Nursing and Scientific have both deteriorated since last month, however HCA spend is zero in month. Overall, agency usage remains high. An agency review group is in place chaired by the Executive Director of Workforce allocating actions to reduce expenditure.

2.1.7 Non pay expenditure is overspent by £1.2m in month. Secondary commissioning (mainly

private beds expenditure) was over spent by £366k in month, which is partially offset by a ring-fenced reserve of £158k for the ELFT beds. Bad debt provision increased by £400k in month to reflect further income billed for OSVs, NCAs, Extraordinary Packages of Care (EPoC) for Paprika Ward, the RFH Liaison Assessment service and Barnet CAMHS transformation. Other expenditure is overspent by £330k in month due to initial invoices received for the Mobility project. Drug spend is also overspent due to high FP10/dispensing costs incurred in the Enfield Substance Misuse service (under review).

2.1.8 An average of 21 private beds per night were used during December, compared to 14 in

November. The volatility of the Trust’s bed position is presented below. The year to date private bed cost of £3.4m is partly offset by £1.4m of reserves. The continued use of private beds is the most significant expenditure risk to the trust.

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2.2 Cost Improvement Programme

2.2.1 CIP performance is behind plan in month (£0.1m), and (£0.7m) behind plan year to date. 2.2.2 The trust’s savings target is £8.2m, and the Trust now has £8.8m of identified schemes. Of

the identified schemes, £6.7m are classified as green, £1.8m as amber, and £0.3m as red. 2.2.3 The current forecast is for £7.8m of CIPs to be achieved. £2.0m of identified CIP is non-

recurrent, £1.4m of which was planned. 2.3 Key Areas of Risk 2.3.1 The underlying degree of risk in achieving the forecast outturn has improved from last

month by £0.6m. At month 9 the degree of risk (the difference between the extrapolation of the current run rate, adjusted for planned CIP delivery in later months and the Control Total) is c£2.2m, with potential mitigations identified of £2.2m.

2.3.2 The forecast out-turn for the services has improved by £0.6m this month due to a reduction

in anticipated depreciation charges (£0.2m) following some slippage on the capital programme, the billing for Overseas visitor activity continues at a high level (£0.2m improvement), and the forecast activity for ADHD is further improved (£100k). Other additional ad hoc income in month 9 improved the forecast further.

2.3.3 In conjunction with the existing risks at month 8, the key risks are considered below:

• The new AfC pay rates have added cost pressure to the Trust. Outsourced services with staff on AfC rates were not covered by the DH funding, £0.2m uplift in the Medirest contract is expected.

• Private bed usage has averaged 23 beds per night this year. There was an

improvement in November, with an average of 14 beds per night. The mid case forecast assumes an average of 23 beds for the remainder of the year.

• Unachieved CIPs continues to be a risk for the Trust. 25% of identified CIPs remain

Red or Amber rated. Failure of these CIPs to deliver will have a significant impact on the ability of the Trust to meet its control total.

• Acuity of patients driving unbudgeted use of 1:1’s across all wards remains high and will

need to be controlled for the remainder of the financial year.

• The impact of the 2017/18 Incentive STF funding on PDC calculations. We are waiting for the Department of Health to confirm the correct accounting treatment but have assumed worst case in our forecast position.

Service Line 18-19 Target

In-Month Plan

In-Month Act

In-Month Var

YTD Plan YTD Act YTD Var FY Plan FY

Forecast FY Var

Barnet 934 86 88 2 829 839 11 934 951 17Corporate 1,172 96 96 (0) 899 895 (5) 1,185 1,178 (8)Enfield 1,785 181 141 (40) 1,041 873 (168) 1,785 1,375 (410)Estates 659 41 41 0 331 335 4 659 671 12Haringey 668 41 40 (1) 479 478 (1) 628 626 (2)Specialist 1,361 142 153 11 934 763 (171) 1,361 1,253 (109)Trustwide 1,600 193 155 (38) 1,643 1,301 (342) 2,220 1,766 (454)Grand Total 8,179 780 714 (66) 6,156 5,483 (673) 8,773 7,820 (953)

Page 81


2.4 Actions to achieve the Forecast Outturn 2.4.1 The actions agreed in the improvement plan led by the Deputy Chief Operating Officer

continue. The actions include additional resources at night to gate-keep referrals, and to carry out full assessments when there is a bed request; and a review of all patients in private placements. Further details of the action plan is in Appendix A. A reduction to an average of 20 beds per night (currently 23) from January would mitigate against the gap to reach the Control Total by £150k. A reduction to 15 beds per night for the remainder of the year would reduce spend further by £250k.

2.4.2 Continued focus on CIP delivery where savings are forecast to start delivering later in the

year. Enfield are holding weekly meetings to review their CIPs, and additional workshops to close the gap. Enfield are currently forecast to be £410k behind their CIP target.

2.4.3 Continued focus on run rate. Both Enfield and Haringey are putting together a recovery plan

to reduce their run rate. The Haringey recovery plan focuses primarily on reducing out of area placements (see above), and agency spend. Private placements in Haringey reduced significantly in December. Enfield presented an initial recovery plan at IPM in October closing their gap by £300k. On review this has reduced to £100k. An update is to be presented at the next IPM (January).

2.4.4 Confirmation has been received that the CCG has settled the residual £0.7m OSV invoices

from 2016/17 and 2017/18. There is a further £0.7m bad debt provision that can therefore be released into the position. An OSV manager was recruited and joined the Contracts team in July. Following this, the activity invoiced in 2018/19 has increased each month, as the profile and focus on OSVs has been raised.

2.4.5 Focus on agency expenditure via the Agency Review Group, focussing particularly on

medical agency and the conversion of agency posts to permanent or fixed term (if non-recurrent funding) posts wherever possible. Barnet is currently initiating plans to increase uptake of bank shifts, and therefore reduce agency spend.

2.4.6 Resolving successfully the Edgware hospital premises costs for 2016/17 and 2017/18 and

the accounting treatment for PDC calculations, but these would only be non-recurrent benefits, which will impact on the savings required in 2019/20.

2.4.7 Improvement in the Trust’s CQUIN position. An improvement to 60% CQUIN achievement

would improve the Trust’s position by £0.2m. A project manager has been recruited into the PMO dedicated to CQUIN delivery and project plans are in place for each target.

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2.5 Balance Sheet

2.6 Non-Current Assets and Capital 2.6.1 So far in year £6.0m has been spent on capital projects, which is £8.4m behind plan. The

mothballing of 2 surplus properties has impaired non-current assets by £1.1m. 2.6.2 The main item of capital expenditure so far this year has been preparatory work costing

£2.2m for the new building at St Ann’s. 2.6.3 It is forecast that £15.5m will be spent on capital projects in total in year. The main projects

are £6.9m for the St Ann's redevelopment, £1.5m on Mobility IT projects and £2.0m on a new transformer for the Chase Farm site. Whilst this is £2.7m less than planned, £2.4m of this reflects NHSI guidance that capital expenditure being funded by asset sales should only be included/ incurred at the point an asset is sold. The Trust still expects to dispose of Canning Crescent in the current financial year and anticipates that forecast capital expenditure at year-end will therefore be marginally underspent against the original plan.

2.7 Cash 2.7.1 The cash balance at the end of December 2018 was £56.2m, £2.5m above plan, largely due

to a delay in capital projects and thus capital expenditure not being incurred 2.7.2 Construction of the new building at St Ann’s and the redevelopment programme has now

begun, incorporating both new build and refurbishments will take 3 years to complete. The cash balance will gradually reduce over this period as payments are made in instalments to the companies involved in the project.

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2.8 Single Oversight Rating

2.8.1 The Trust scores 3 against the NHS Improvement Single Oversight Risk Assessment

Framework for the year to date, and sustaining it going forward is dependent upon achieving the full year financial plan.

3. Conclusion 3.1 The year to date position at month 9 has benefitted from the release of part of the bad debt

provision for overseas visitors. Without this, the deficit year to date would be approximately £0.4m worse than reported here. Achievement of the control total of a deficit of £3.3m is dependent on managing a number of material risks including external placements expenditure and delivery of further CIP schemes.

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BEH-MHT – Trust Board – 28.01.19 3.4 Inpatient Quality Governance and Assurance

Title:

Inpatient Quality Governance and Assurance

Report to:

Trust Board

Date:

28 January 2019



Report Author:

Name: Margaret Southcote-Want Title: Deputy Director of Quality

Report Sponsor:

Amanda Pithouse, Executive Director of Nursing, Quality and Governance


The Trust has developed governance and assurance processes and this paper describes actions that will be implemented to further strengthen these across inpatient services.

Overview of the report: The report summarises the Quality Governance and Assurance processes in place within Trust in regards to inpatient wards and describes improvements being made to further enhance these. Decisions / actions required: The Trust Board is asked to note the contents and agree the developments planned Report History:

Approved by the Quality and Safety Committee January 2019

Implications of the decision / actions:

Failure to comply and/or evidence compliance with the CQC’s Regulatory Framework and outcomes could result in poor delivery of care, fines, conditions placed upon registration or termination of registration as a provider of services. Equality and diversity is one of the fundamental principles of the CQC outcomes.


• Excellent Care

List of Appendices: None

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1. Introduction and Background 1.1 The Trust’s Quality Strategy 2016-2019 aims to ensure that the Trust’s approach and

commitment to quality and quality governance is clearly defined so that all Trust staff are clear in their role and drive to continually improve the quality of care and ensure quality governance and risk management continue to be integrated into the Trust’s culture and everyday practice.

1.2 BEH is an organisation that embraces continuous improvement and learning. Our

quality governance systems support the arrangements in place to provide the Board of Directors with assurances on the quality of BEH’s services and to safeguard patient safety. The trust currently has a quality assurance programme which includes team level quality heat maps, quality dashboards, clinical audit and quality assurance programme and responsive quality compliance reviews.

1.3 Following unannounced Care Quality Commission (CQC) inspections to Silver

Birches and Magnolia wards in March 2018 a number of areas were highlighted for improvement and actions were taken to address these. Following these inspections the Trust identified concerns with regards to the number of disciplinary hearings involving staff from the Oaks ward. An internal quality review of the Oaks was requested to determine if there were similar issues at the Oaks as those identified by the CQC in relation to Silver Birches and Magnolia ward. The quality review was conducted and the outcome was reported to the Trust Quality and Safety Committee in November 2018.

1.4 The review found that there were care and patient safety issues, issues with staffing,

leadership, ward organisation, blanket restrictions on drinks for patients and competencies of staff on the ward. Immediate actions were taken by Enfield management team with on-going oversight and action and a formal action plan was put in place.

1.5 One of the root causes of the issues found was that there had not been a recognition

or triangulation of workforce data against quality data in a robust manner. It was also recognised that quality reviews are reactive rather than proactive and therefore may not identify quality issues in a timely way. Consistent leadership visibility and engagement at team and senior level could be improved to support teams to raise concerns and identify and act on issues. Committee members requested that the Trust strengthen the oversight of quality issues in inpatient wards and ensure that there is a more consistent approach to this across all wards to reduce variation and improve governance.

1.6 Current practice is that the trust processes are mainly reactive in nature and there is

considerable variation across the organisation and as such do not fully embed ward to board assurance. This paper aims to outline how this will be addressed so that quality issues can be addressed in a robust and timely manner. This will focus on ensuring there are the right staff in the right place at the right time, our ward environments are safe and ligature anchor points are managed safely and effectively, increasing oversight of safety and quality issues before any negative impact on staff and/or service users occur and raising the visibility of leadership at trust and local level; ward to board.

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2. Future developments to strengthen governance

A programme of developments within the next 6 months is required and proposed to build on the foundations and roots of our current quality assurance processes to ensure that quality assurance is truly ward to board with consistency and minimal variation across the organisation.

2.1 Leadership visibility and engagement - Trust Board quality and safety visits. Currently there is not a systematic and focussed programme of visits for the Trust

Board of Directors and Non-Executive Directors to trust teams and services. The visits currently being carried out are not routinely planned and do not have a consistent template or purpose to the visits.

It is proposed that a planned routine monthly programme is put in place with a quality

template that can be used for feedback and are triangulated with other trust data. These visits will focus on quality and safety and are aimed to engage and support frontline staff/ service users. It is envisaged that this could be expanded to incorporate senior leadership within the trust not only visiting their own areas but carrying out peer visits to other boroughs and services. A regular report would be provided to the Quality and Safety Committee on key findings, themes and actions.

2.2 Early warning tool - Quality Effectiveness Safety Trigger Tool (QuESTT) The trust has acknowledged that there is a need to improve current systems to

support the routine systematic triangulation of quality data to detect areas of potential risk of deterioration in quality. A simple quality improvement tool, based on peer review, has been developed in the South West of England, which gives a voice to the intuitive feel that many nurses and managers have when thinking about standards of care. It had been observed that the best hospitals monitored information about outcomes on a ‘ward-by-ward’ basis enabling them to respond to emerging conditions quickly but that something tangible to measure this was needed.

The Quality, Effectiveness Safety Trigger Tool, (QuESTT), was developed and is an

early warning tool based on the principles of other early warning scoring systems to address gaps identified in quality assurance processes. This tool has been adapted specifically for use in mental health settings and has also been tested widely in a variety of mental health inpatient services in South London.

The QuESTT informs ward leaders about how they are doing and provides robust and

reliable information from ward to board, offering the trust board assurance of quality of care at individual clinical team level. Crucially, it is underpinned and validated by peer review. It is therefore not a performance management tool but one that aids understanding and enables action to be taken to remedy any precursors to underperformance at grassroots level. It is planned to be introduced for use across all inpatient services to complement and strengthen our current processes and scores will be reported, reviewed and monitored at ward, borough level and up to the Quality and Safety Committee routinely.

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2.3 Systematic proactive annual quality reviews It is recognised that our current quality reviews add value and provide a

comprehensive overview of clinical practice in our inpatient wards. In order to further strengthen these it is important to ensure these reviews are systematic and proactive rather than simply being reactive to quality concerns. The future reviews will be consistent in the areas of focus and review, take into account of innovations as well as areas for improvement, planned annually in advance and will be carried out by a diverse group (incl service users and carers).

A planned programme of quality review visits has been scheduled for January to

March 2019 for all inpatient wards. Moving forward to 2019/2020 a full trust wide quality review programme will be

planned to include all teams both inpatient, community and prisons teams. It is envisaged that this programme will complement the newly introduced QuESTT tool.

2.4 Environmental safety - Ligature Management Committee The trust has a ligature reduction policy, annual audit process and 5 year ligature

reduction plan in place but at the current time there is limited oversight and escalation of the annual audit programme, detailed short/long term monitoring of works to reduce ligatures and monitoring of practice against policy implementation.

A committee is being set up chaired by the Director of Nursing with attendance from

Health and Safety, Operations and Estates and Facilities to ensure that oversight of this key safety priority for the trust is monitored and escalated to the Quality and Safety Committee routinely.

2.5 Safety Huddles Building a culture of safety is a priority for the Trust. Ensuring that staff are aware of

safety issues and are open, transparent and feel supported to raise safety concerns is a key factor in improving safety for all.

Safety Huddles, a research based, short, multidisciplinary meeting offers an opportunity for the multidisciplinary team to coordinate care, delegate tasks and trouble shoot issues that have arisen for the purpose of collaborating, exchanging information and bringing awareness to patient safety concerns.

Safety huddles have been found to improve patient safety, staff morale and

engagement. The trust introduced a corporate safety huddle 8 months ago. This has now developed further and focusses on core safety data providing statistical process control charts to monitor improvement and variation and aid discussion. It is now planned to roll this out to all teams across the organisation. Going forward an escalation report will be provided to the Quality and Safety Committee routinely.

2.6 Right skills, right staff, right place - Inpatient staffing skill mix review Trusts must ensure that National Quality Board (NQB) guidance (2013, 2016) is fully

embedded with an annual strategic staffing review, from the nurse director, medical director and finance director. The annual staffing review should identify safe sustainable staffing levels for each team with evidence these were developed using a

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triangulated approach. The approach should make use of evidence-based tools, professional judgement and comparison with peers.

The Director of Nursing, Quality & Governance is leading a nursing skill mix review of

all inpatient areas, this will include a clinical discussion with each team and a collection of data on the acuity and dependency for each ward using the evidence based Mental Health Optimum Staffing Tool (MHOST).

The findings and recommendations will be reviewed with finance with a paper to the

Trust Board in March 2019. From April 2019 NHSI will require annual reporting to include the annual workforce

plan and an annual workforce safeguards compliance statement. The overall aim is to assess and ultimately gain consistency of application (of safeguards) across the system

3. Conclusion To ensure there is robust quality assurance processes and systems from Ward to

Board there needs to be effective identification and reporting of quality issues. Implementing the developments described in this paper will strengthen the Trusts current processes and practice to minimise variation and increase Board oversight. A detailed implementation plan with timeframes will be developed and presented to the March Quality and Safety Committee.

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Page 90

BEH-MHT – Trust Board 28.01.19 3.4 CQC Action Plan

Title:

CQC Action Plan

Report to:

Trust Board

Date:

28 January 2019



Purpose of Report: To outline progress with the CQC action plan and propose ten core themes for future focussed improvement. Recommendations: The Trust Board is asked to note the progress made against the CQC action plan following inspection in 2017 and agree the proposal to focus on core themes identified for improvement to ensure the Trust embeds and sustains these improvements. Report Sponsor:



This report has been presented to the Trust Quality and Safety Committee who support the proposal.

Report Author:

Name: Margaret Southcote-Want Title: Deputy Director of Quality Tel Number: 020 8702 3835 E-mail: [email protected]

Report History:

Regular report to Trust Board.


None


None

Appendices: • CQC Quality Improvement Plan – Working document • CQC MHA visits 2017/18

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1. Introduction and Background

1.1 The report details the current position of the Trust’s CQC Quality improvement action plan, makes a recommendation to close the action plan and move to working on key themes as business objectives and identifies key Trust priority areas for further development.

1.2 The CQC Hospital Inspection Report published January 2018 was received by the Trust and the Trust was given an overall rating of ‘Requires Improvement’. Within the report the CQC issued 18 compliance actions, ‘must dos’ and 76 ‘should dos’, a significant reduction on the inspection report of 2015.

1.3 Regular Mental Health Assessment visits are conducted by the CQC Inspectors throughout the year and this report outlines the key issues highlighted for improvement from these visits.

1.4 Ten key priority areas of patient safety and governance have been identified from the CQC Hospital Inspection plan, CQC Mental Health Assessment visits, the Trust’s quality assurance programme and serious incident investigations which will form the basis of the work stream for the forthcoming year 2019/2020.

2. Quality Improvement Plan

2.1 The CQC Quality Improvement Plan continues to be reviewed fortnightly at a monitoring group meeting led by the Director of Nursing, Quality & Governance, at identified trust and borough governance meetings, and overseen by the Quality & Safety committee on behalf of the Board and to date the majority of individual actions have been completed.

2.2. The Trust received 18 ‘must so’ actions and 76 ‘should do’ actions. One ‘must do’ action is still in progress; a trust wide diabetes policy to be ratified; borough protocols are in place and 11 ‘should do’ actions, recruitment, mandatory training figures, reducing violence and aggression involvement of carers; all have work in progress.

3. Progress as of 31 December 2018 3.1 Must Do Actions: Compliance as of 31 December 2018

17 of the 18 actions due for completion are now green, completed with evidence to support the actions.

Must Do Actions, Red:

None.

Must Do Actions, Amber:

There is one ‘must do’ action currently in progress; diabetes protocols are in place across the trust but work is still in progress to ratify a trust wide diabetes policy. .

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M7 – Wards for older people – April 2018 - The trust must ensure staff have sufficient training and knowledge to support patients with diabetes and that care plans are detailed and reflect requirements outlined in the trust policy. – Staff on older person’s wards have received training, diabetic protocols now agreed but waiting for approval of Trust wide policy on diabetes management which is in progress. The Trust Consultant Nurse in Diabetic Care who was leading on this has left the trust and the action is being completed by the Deputy Director of Quality.

3.2 Should Do Actions: Compliance as of 3t December 2018

Red

None

Should Do Actions – Amber

Amber – 11/76 in process but not completed

S3 – Corporate – March 2019 - The trust should further embed the trust values for example as part of recruitment processes. – Values placed recruitment remains work in progress

S10 – All inpatient wards – July 2018 - The trust should ensure that restraints are always carried out using the correct techniques and are recorded correctly. – Positive and safe group in progress and audit completed, action plans in place. Trust wide quality improvement projects in inpatient wards.

S14 - All inpatient wards – July 2018 - The trust should ensure that physical health equipment is calibrated in line with trust guidelines. – Policy in place

S18 - Workforce and CDs – March 2018 - The trust should ensure that staff complete all mandatory training that is below the target on each ward. – Trust remain below target

S26 – All inpatient wards – Sept 2018 - The trust should ensure that wherever possible staff involvement with patients is caring and supports patient recovery. – work in progress, waiting for evidence of meetings minutes

S28 – Inpatient wards at Chase and Barnet – July 2018 - The trust should ensure that they review the quality and quantity of food and drink provided to patients at Edgware Community and Chase Farm hospitals. – awaiting evidence of meetings and audits.

S49 – Community based services of working age - The trust should continue to improve waiting times for patients to access individual psychological therapies and review service provision where needed – March 2019 – Work in progress across the Trust – Psychology review in progress

S53 – Community Teams – March 2019 - The trust should ensure that team managers have a way of monitoring non-mandatory training and are aware of the additional training that members of their teams have so they can judge what further training may be needed. – Trust remains below target

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S65 CRHTT – March 2019 - The trust should ensure that all staff completes mandatory training. – Trust remains below target

S67 – CAMHS – Sept 2018 - The trust should ensure that physical health monitoring equipment is well-maintained and calibrated in line with trust policies. The trust should also ensure that the content of first aid kits and pads for defibrillators, if these are going to be used, are in date and fit for purpose. – Physical healthcare leads leading, work in progress

S76 – Corporate – April 2018 - The trust should ensure that staff are consulted about the proposed changes linked to the trusts estates strategy for working remotely. – Work in progress

4. CQC Mental Health Assessment (MHA) monitoring visits and actions

4.1 Eighteen MHA monitoring visits have taken place in quarters 1 to 3 2017/18.

4.2 The thematic concerns of the visits are care planning, 11/18 visits found issues, primarily with the service user involvement or carer views not documented in their care plans and risk assessments not updated or easily identified; 7/18 regarded environmental issues included not having separate bathroom facilities in seclusion room in Barnet, general environmental issues in St Ann’s and ligature points in Enfield requiring staff supervision in patient bathrooms; 6/18 with regards explanation of rights to detained patients – staff were found not to have repeated explanations of patient rights; 6/18 assessment of capacity and consent to treatment under MHA, no documented records of capacity and consent assessments and 3/18 with consent to treatment certificates not being attached to patient medication charts. Action plans are in place to address the issues identified.

4.3 Three wards, Blue Nile, Juniper and Devon had very positive monitoring visits with no outstanding actions required.

5. Quality and Patient Safety Themes

5.1 The trust quality improvement plan has reached the stage where remaining actions are included in business and performance monitoring. Workforce Directorate has plans in place to address mandatory training and recruitment issues still outstanding and remain a priority area of business. Trust wide work and individual team quality improvement plans are in place to improve further the standards of restraint, seclusion and reducing violence and aggression led by the Deputy Director of Nursing, and the Physical Healthcare leads in the Boroughs are now on substantive contracts with the trust and working to work plans within their areas

5.2 It is proposed to formally close the trust CQC Quality Improvement Plan consisting of actions and move to a themed base work programme, embedding the areas into everyday activity. Triangulating the themes from serious incident investigations, quality reviews, CQC inspections and patient feedback - Ten priority areas are:

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Timely access to beds Policies Safe environments – Ligature Floor to Board data incl workforce/ quality Risk Assessments and Care planning Reducing restrictive practices Staffing and skill mix 132 rights/capacity to consent Mandatory training Physical Health Monitoring

A paper will be presented to the Executive Leadership Team by the Director of Nursing to consider how these themes will be taken forward for ongoing action and improvement. The Quality and Safety Committee will receive a routine report on progress against these workstreams.

6. Conclusion

Significant movement of the Trust CQC Quality Improvement Plan has taken place since the last report.

The CQC standards and key lines of enquiry need to be embedded as business as usual and by identifying themes for future work this will enable this to occur.

Implications

7. Budgetary / Financial Implications

The Trust has a number of financial implications related to the key priority areas but will need to be addressed at the trust Capital Review Group and directorate and team budgets..

8. Risk Management

The Trust has a risk of non-compliance with both financial and regulatory risk of non-compliance of the Trust CQC quality standards in all areas of the trust.

9. Equality and Diversity Implications

None.

10. Consultation

Our lead Commissioner has been advised of our Trust Quality CQC Improvement Plan and plans to move forward with thematic business priorities.

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Recommendations - All Recommendations by Borough Trust Rag Rating for Should Do Trust Rag Rating for Must Do

Date: 28 November 2018 Must dos = 18 Barnet Must dos = 15 / Should dos = 43 Should Do - G 65 Must Do - G 17

Should dos = 76 Enfield Must dos = 17 / Should dos = 49 Should Do - A 11 Must Do - A 1

Haringey Must dos = 15 / Should dos = 39 Should Do - R 0 Must Do - R 0

Specialist Servs Must dos = 0 / Should dos = 7

Category Ref. Core Service Borough Team Recommendation

Action Required

Deadline for completion

Evidence Required Executive and / or Director Lead

Borough / Service Lead

Monitoring Group / Committee

Date of current review

Progress NotesEvidence provided and date of validation (PST)RAG Rating

Must Do

M7 &M4 & M10 & S74

Wards for older people with mental health problems

BarnetEnfield

Ken Porter

Cornwall VillaSilver BirchesSomerset VillaThe Oaks

The trust must ensure staff have sufficient training and knowledge to support patients with diabetes and that care plans are detailed and reflect requirements outlined in the trust policy.

The Trust will ensure a EIS protocols are up to date and circulated as required. All registered nurses to undertake Diabetes competency assessment. All HCA to complete diabetes quiz Physical Health care leads to work and develop MH inpatient health protocol with help form Nurse Consulatant Circulate agreed portocols. Trust to review and consider effective diabetes awareness training to all relevant staff

Sep-18 Comptency assessment records Trust Diabetes Policies

Medical Director

Physical Healthcare leads

Borough Operation Management GroupsQuality & Safety Committee

06.03.18 26.11.18 Trust Policy still outstanding as local protocols not amalgmated into one doucment14.11.18:JB advised will got to PH Committee 15.11.18.19.09.18 Draft policy being reviewed for compliance with Trust standards and ensure that it has been to PH committee12.07.18 Trust wide Diabetes policy to be written and implemned as advised by Policy review group - Nurse Consulatnt Diabetes to lead13.06.18 Enfield: • Diabetes working group has completed with summary presented to Enfield Adult MH Clinical Governance on Tuesday, 13TH March 2018 (attached) with the following outcomes: o Roles established for junior doctors o Borough Physical Health Lead and Inpatient Team Lead overseeing compliance with: key standards of care; External Quality Audits of medical devices (Blood sugar machines) o Training now available for mental health nurses within BEHMHT being attended by ward staff o Ward nurses completing a competency assessmento New editable diabetes care plans uploaded to RiO addressing hyper and hypoglycaemiao Posters displayed on wards with key clinical information13.06.18 Protocols not ratified as Policy committee advise to be put into one overarching policy – awaiting confirmation of date17.04.18 Work in progress for review and updating of protocols04.04.18 Physical healthcare leads meeting 16.04.18 to devise trust wide plan and agree protocol for diabetesBlood Glucose Monitoring for Community Nursing, Due for

A

Should Do S3

Trust-wide Corporate OD&L / Workforce The trust should further embed the trust values for example as part of recruitment processes.

The trust is further embedding the trust values by commencing a values-based recruitment processTrust values have been introduced during the Trust induction but will be reviewed to further enhance the values of the trustAdd trust values into all leadership development programmes

Mar-19Interview question banksRecruitment skills training programmeTrust Induction programme recruitment training records

Director of Workforce

Deputy Director of Workforce

Performance & Improvement Committee

29.11.18 Advised by JR Director still work in progress26.11.18 E mail to Dep Director of HR for info24.07.18 e mail to DD of HR for updateWork in progress in interview question banks, training in place for recruitment

A

Should Do S10

Acute wards for adults of working age and psychiatric intensive care units (PICU)

All All inpatient wards The trust should ensure that restraints are always carried out using the correct techniques and are recorded correctly.

The trust will review PVMA training Staff will be able to access training for PVMA as trust policy - Incident forms will be audited for reports of restraint

July 2018 Training RecordsAudits of RIO entries - Audit of Clinical Incident forms

Chief Operating Officer

Deputy Chief Operating Officer


26.11.18 Email sent to C Scott for confirmation of training19.09.18 the restraint and seclusion audits were from the audit team but we did review in P&S; Seeking info from audit team on what action plans arising from the audits in place12.07.18 Trust Safe & Positive group reviewing PVMA trainingQA audtit of restraint in progress result August 2018 A

Should Do S14 & S43 & S67


All All inpatient wards The trust should ensure that physical health equipment is calibrated in line with trust guidelines.

Ward managers to complete checks as required per Trust policy and document in allocated folder

The Trust Facilities team will continue to ensure that the medical devices maintenance programme is up to date and manage the EMBE contract for medical devices and review callibration and maintenance schedule

Jul 18 Ward Audits and Physical Health Lead to provide monthly audit online reports

Estates to report on maintenance and contract to Health & Safety Committee and advise any gaps

Clinical Directors/Director of Facilities

Ads Boroughs/Deputy Director of Estates

Health & Safety Committe

07/08/2018 - Physical Health Equipment evidence received from Finsbury ward.27/07/2018 - Evidence submitted from HAW. Saved in evidence 25.07.18 Chasing e mail for evidence to ward managersMedical Devices Policy, V4 in place Actions as detailed by Policy by Ward Mangers in progress

A

BEHMHT CQC Quality

Improvement

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Action Required







Should Do S18


All All inpatient wards The trust should ensure that staff complete all mandatory training that is below the target on each ward.

Standing item for monitoring every month in supervision. Borough moniting in OMG

Mar-18 Regular OMG reports locallytrust reports

Director of Workforce/Chief Operating Officer

Deputy Director of Workforce/Clinical Directors

Performance and Improvement Committee

26.11.18 Mandatory figures remain below trust target - work ongoingWork in progress as still below standards. Quality bulletin piece to be circulated in November 2018.

A

Should Do S22


All All inpatient wards The trust should keep to a minimum patients returning from leave that need to be cared for on another ward.

The trust will work with our commissioners to continue work on the acute be pathway to alleviate this issue

Sep-18 Review with Commissioners evidenced


Deputy Chief Operating Officer


01.12.18 Work in progress re bed management which has seen a significant reduction in beds being used when patient on leave and incidents of not being returned to their beds26.11.18 Chasing evidence from JLReview completed, awaiting evidence of review

G

Should Do S26


All All inpatient wards The trust should ensure that wherever possible staff involvement with patients is caring and supports patient recovery.

Feedback to be sought from service users via audit / Community meetings

Sept 2018 Audit resultsFeedback from Community meetings

Executive Director of Nursing, Quality & Govenrance

Inpatient Service Manager

Significant work in this area and Patient Expereince Committee meeting regularly and regular feedback provided to teamswork in progress; community meet minutes confirm this is in place

A

Should Do S28


BarnetEnfield

All inpatient wards The trust should ensure that they review the quality and quantity of food and drink provided to patients at Edgware Community and Chase Farm hospitals.

The Trust will ensure via the Estates Team that feedback from patients and service users will be reviewed and actioned as applicable

Jul-18 Review evidence to establish if problem is specific to one area or moreEvidence of patient/service user feedback inclusive of PLACE assessmentsPatient feedback reflects improvements

Director of Facilities

Inpatient Service Manager

Facilities 01.13.18 Issues discussed at regular Estates led meetings - servic e users still highlight issues with food12.07.18 Food and drink monitored, awaiting evidence

A

Should Do S49

Community based services for adults of working age

All All MH Community Services

The trust should continue to improve waiting times for patients to access individual psychological therapies and review service provision where needed.

Ongoing monitoring and review of waiting times. Action plan in plan to introduce local initiatives which includes reduction in the number of assessments and increase in available treatment time + alternatives treatment options to individual therapy offerred. Review of Trust wide service provision underwayHaringey will conduct demand and capacity modelling to identify resource shortfall and review options and action on decisions made

Psychology HUB is part of the wave 2 haelo project and will develop a phase one treatment for service users experiencing psychosis in group format to address waiting times.

Ongoing and March 2019

Reduction in Waiting times/referrals. Evidence of discussion with Commissioners


Psychology Leads for BoroughHelen Brindley - HaringeyRichard Rushe (Consultant Clinical Psychologist) in Barnet Adult MH


Work in progress across the Trust – Psychology review in progressthe Trust has commissioned a Psychology Review that is being undertaken by Chris Lambourne and review should be able to provide some ideas about how we can improve waiting times.

We have not been able to resolve the problem and continue to have waiting times that are far longer than we would like. As far as I am aware we do not have an agreement with the CCGs about what they would consider to be acceptable waiting times. At present we are aiming to provide assessments within 13 weeks and are putting waiting lists on the Risk Register if they are longer than six months (from assessment).

ST: 08/03/18: Psychology HUB is part of the wave 2 haelo project and will develop a phase one treatment for service users experiencing psychosis in group format to address waiting times. Update requested on 03/05/18 from RR. Minutes from Haringey Psychosis Psychological Treatment Stream Workshop received. Capacity Modelling planner received & email evidence x2.

A

Should Do S53

Community based services for adults of working age

AllCorporate

All MH Community Services

OD&L

The trust should ensure that team managers have a way of monitoring non-mandatory training and are aware of the additional training that members of their teams have so they can judge what further training may be needed.

The trust will ensure that team managersmonitor non-mandatory training and are aware of the additional training that members of their teams have so they can judge what further training may be needed.

Mar-19

Monitored through appraisal & PDP's

Director of Workforce

Deputy Director of Workforce

Workforce Committee/Deep Dives

ST: Barnet - 03/05/18: Manual recording template being devised to incorporate Non-Mandatory and MCA training. Workforce have sent the list of thsose who are recorded as being out-of-date and require training

A

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Action Required







Should Do S65

Mental health crisis services and health-based places of safety

BarnetEnfieldHaringeyCorporate

CRHTTOD&L

The trust should ensure that all staff complete mandatory training.

Standing item for monitoring every month in supervision.

Borough monitoring in OMG

Monitoring of training and meeting with LD quarterly.

Mar-19 Mandatory training compliance records


Assitant Directors /Deputy Director of Workforce


31.12.18 Training figures remian below compliance trust wide24.07.18 e mail to DD of HR for update

A

Should Do S67 &S14 &S7 &S68

Specialist community mental health services for children and young people

BarnetEnfieldHaringey

All CAMHs The trust should ensure that physical health monitoring equipment is well-maintained and calibrated in line with trust policies. The trust should also ensure that the content of first aid kits and pads for defibrillators, if these are going to be used, are in date and fit for purpose.

Re: Physical health monitoring equipment: local register to be put in place to check expiry date + remind EBME for annual checks. Re: First Aid kits: list of items of content of First Aid kit to be clarified + local register to be put in place for weekly checks on First Aid Kit. Re: defib: team to maintain register for daily defib checks

BEHMHT equipment: governance and assurances process to be reviewed to ensure fully implemented.

Enfield: The service has raised this with the LA department responsible and maintains physical health equipment and first aid equipment. Clarify being sought.

Sep-18 Review of maintenance and EMBE contract completed by Estates identifying any gaps and making recommendationsand submitted to Capital Review Group

Evidence collated that wards have carried out checks and claibration as per trust policy

Director of Estates/Medical Director

Physical Healthcare leads/Deputy Director of Estates

Physical Healthcare Committee/Health & Safety Committee

01.12.18 Work in progress re review of contract and service moving forward. First aid kits ordered and distributed12.07.18 Work in progress by Pyhsical Health aare leads and H&S advisor - awaiting results of audits

A

Should Do S76

Community health services for children, young people and families

Corporate Mobile working team The trust should ensure that staff are consulted about the proposed changes linked to the trusts estates strategy for working remotely.

The Trust will ensure there is engagement with senior Managers of each boroughOrganisae team workshops andLink in with the Trusts IT Strategy so that staff are consulted about proposed changes

April 2018

Minutes of senior meetings and team workshops

Director of IT

Head of PMOIM&T Committee

12.07.18 Staff were included in work for mobile working and IT

A

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CQC MHA visits 2017/18

Visit Date Ward Division

Thematic areas of concern

Summary of critical feedback

Summary of response to critical feedback

Ward environment

/ facilities

Care planning

Explanation of rights to

detained patients

Assessment of capacity

and consent to treatment under MHA

Consent to treatment

certificates

10/05/17 Sussex Enfield X

The seclusion room bathroom had ligature points which require staff to closely supervise the occupant.

Described the mitigation measures in place to ensure the safe and dignified use of the bathroom, and described the service’s plans to review the feasibility of capital works.

22/05/17 Oaks Enfield X X

The reviewer questioned whether ward staff were repeating explanations of rights to detained patients with sufficient regularity, and noted a lack of evidence of service user and carer views in care plans.

Detailed the relevant aspects of the Trust’s MHA rights policy, and the monitoring systems in place. Ward manager will now be auditing care plans every week to ensure there is sufficient evidence of patient / carer views.

13/06/17 Finsbury Haringey X X X* X

For two patients no record could be found of a capacity and consent to treatment assessment prior to treatment commencing. Insufficient evidence of patient participation in care planning. Some features of the ward environment compromise the privacy and dignity of patients. Alleged delays in explaining rights to two detained patients.

Described new monitoring arrangements implemented by ward regarding care planning and capacity assessment recording. Described the environmental mitigation measures in place pending the rebuild of the St. Ann’s site. *Clarification that reviewer had looked in wrong place on RiO for rights evidence, and the criticism regarding rights was factually incorrect.

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Ward environment

/ facilities

Care planning


detained patients




certificates

15/06/17 Beacon Specialist X X

Negative service user feedback noted in relation to the ward’s interior decoration, the availability of activities and the communication style of some members of staff. Service users didn’t feel sufficiently involved in the care planning process.

Confirmed that funds have been made available to redecorate the ward, and that appropriate action was taken with the individual members of staff who were the subject of concerns. Described a series of measures to improve SU participation in care planning and increase the range of activities on offer.

26/09/17 Fairlands Haringey X X

Insufficient information being provided to patients (e.g. in relation to informal patients’ rights, lists of contraband items, leave authorisations, advocacy information). No evidence that patients were being encouraged to create advance statements of wishes and feelings. Capacity assessments not being regularly undertaken and recorded. A number of concerns were raised in respect of the ward environment and the understanding of staff (e.g. MHA training is not mandatory, supervision sessions are sometimes delayed, no hard copy Code of Practice on ward).

Confirmed the Trust would review the information provided to informal patients and in relation to searches, and clarified the information to be provided in respect of advocacy and interpreting services. Described the monitoring arrangements in place in respect of staff supervision, capacity assessments and s.17 leave documentation, and described the changes to discharge CPA procedure to ensure that patients are encouraged to develop advance statements of wishes and feelings when they are well. Confirmed a new hard copy of the Code of Practice had been ordered.

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Ward environment

/ facilities

Care planning


detained patients




certificates

26/09/17 Suffolk Enfield X X X X

Rights explanations for detained patients not being provided promptly enough. Care plans not containing sufficient evidence of patients’ views, and some patients reporting not having received a copy. Capacity assessment not recorded for one patient since their admission. Concerns about placement of the ward’s seclusion room and that adjoining beds were not separated by a curtain.

Described updated ward procedures to ensure that explanations of rights are provided more promptly, and additional monitoring measures implemented in respect care plans. Described the monitoring arrangements for capacity assessments, timescale for the installation of a curtain between the adjoining beds, and the trust’s overall estates strategy with respect to improving seclusion facilities.

29/09/17 Sage Specialist

The ward did not appear to have arrangements in place to allow for unsupervised visits.

Confirmed protocol for visits has been amended to allow for the possibility of unsupervised visits on the basis of individual risk assessment.

29/09/17 Avon Barnet X X

Some care plans did not contain sufficient evidence of patients’ views, and others contained out of date items. The ward’s seclusion room does not have bathing facilities.

Detailed arrangements put in place to monitor the content of care plans, and described the plans to move ward into a purpose-built PICU environment on the Chase Farm site.

09/01/18 Blue Nile Specialist None N/A

09/01/18 Juniper Specialist None N/A

20/02/18 Devon Specialist None N/A

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CQC MHA visits 2018/19 Q1 & Q2

Visit Date

Ward Division




Ward environment

/ facilities

Care planning


detained patients




certificates

02/05/18 Mint Specialist X X

Risk assessments for two patients were out of date. An apparently superseded treatment certificate was still attached to one patient’s medication chart.

Clarified that the apparently superseded treatment certificate was in fact still being used to provide treatment in conjunction with the more recently issued certificate, action for the consultant to ensure clinical records are clearer in future. Confirmed training will be provided to staff on correctly linking and validating RiO risk assessment updates.

22/05/18 Haringey Haringey X

Some care plans were not up to date, others contained insufficient evidence of patient participation, and others contained a lack of information about after-care services to be provided upon discharge

Detailed refresher training to be provided to staff and a range of new audit and monitoring arrangements implemented to provide assurance of sustained improvement.

05/07/18 Cardamom Specialist X

Reviewer queried whether new statutory treatment certificates should be obtained for two patients whose capacity and consent status appeared to the commissioner to have changed since the existing certificates were issued.

Clarified that both patients had been reviewed by the responsible clinician and a new treatment certificate had been obtained for one of the patients, but that the existing certificate was still deemed to be appropriate for the other.

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Ward environment

/ facilities

Care planning


detained patients




certificates

17/07/18 Dorset Enfield X X X

Some care plans were not up to date and others contained insufficient evidence of patient participation. One patient’s capacity and consent to treatment had not been assessed upon admission. Two detained patients, who had been explained and understood their rights, had not received a repeat explanation.

Detailed some new auditing arrangements in respect of care planning, and explained the measures in place to audit and monitor capacity to consent to treatment assessments for detained patients. Confirmed that procedure for repeating rights explanations will be redrafted in current review of the Trust’s MHA Information Policy.

17/07/18 Sussex Barnet X X X

One care plan was very poor, containing out of date information. Two patients who had not understood their rights when they were first explained had received no repeat explanation. The ward’s seclusion room does not have its own toilet or bathroom and that occupants would therefore have to use the adjoining disabled bathroom and toilet whilst closely supervised by staff, potentially compromising privacy and dignity.

Detailed some new auditing arrangements in respect of care planning. Described the audit and monitoring framework around explanations of rights and some new ward-specific measures introduced to support compliance following the visit. Confirmed that a proposal for redesigning the ward’s seclusion facilities will be submitted to the capital review group in the hope of securing funding for capital works.

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Ward environment

/ facilities

Care planning


detained patients




certificates

06/08/18 Trent Barnet X X X

Some plans were not up to date and that others contained insufficient evidence of patient participation and view. Inconsistencies were noted in the recording of inconsistencies in the recording of Section 17 leave authorisations, capacity assessments, and rights discussions. Some patients had not received an explanation of their rights on admission. A consultant had failed to review a course of emergency treatment on by the review date that he had specified on the treatment record form. For one detained patient, for whom the applying AMHP had been unable to identify a nearest relative, there was no evidence that ward staff had attempted to identify a nearest relative following the patient’s admission to the ward.

Detailed the existing policy requirements in respect of the recording of Section 17 leave, capacity assessments and rights discussions, and stated that the ward staff have been reminded of these. Clarified that the course of emergency treatment under s.62 has been reviewed and discontinued, and that some additional monitoring arrangements have been implemented to ensure that reviews take place as scheduled. Highlighted the Trust’s view that the requirement held by the commissioner, that hospital managers have a general duty to identify nearest relatives, is not supported by the Act or Code and would be neither safe nor practicable to implement; but that the Trust’s MHA Information Policy will be amended to specify that the MHA office maintain records of each patient’s nearest relative.

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Ward environment

/ facilities

Care planning


detained patients




certificates

04/09/18 Thames Barnet X X X

Patients reported not have received copies of their care plans and initial 72-hour care plans contain little evidence of patient participation and views. In two of the four records reviewed there was no evidence of a capacity to consent to treatment assessment having taken place on admission. For one patient a copy of the current statutory treatment certificate was not attached to the medication chart.

Detailed some new auditing arrangements implemented by the ward to provide assurance of improved evidence of service user participation in care planning, and to ensure that statutory treatment certificates are attached to current medication charts. Described the rolling audit and monitoring arrangements in place with respect to assessments of capacity to consent to treatment upon admission.

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Page 108

BEH-MHT – Trust Board – 28.01.2019 3.5 - Safe Staffing Levels

Title:

Safe Staffing Levels

Report to:

Trust Board

Date:

28 January 2019



Purpose of Report: The January 2019 Safe Staffing report provides an overview of nurse and health care assistant staffing for all inpatient wards for 1st November 2018 to 31st December 2018. This is an exception report that demonstrates both the planned level of staff and the actual level achieved. The Board can be assured there is local monitoring and oversight of staffing. Recommendations: The Trust Board is asked to agree: 1. To note the Safe Staffing report. 2. That managers to be kept fully informed of newly recruited staff and when they are coming into

post and to what areas, to be targeted at areas of highest vacancy rate. 3. That the Executive Management Team continues to monitor the impact of the recruitment and

retention strategies. 4. That the Executive Management Team continues to support an improved use of

e-Rostering in order that the available resource can be used more efficiently and effectively. Report Sponsor:



Vacancy levels remain variable across all wards, the overall Trust wide vacancy rate for inpatient wards remains the same as in the previous reporting period, at 12.8% in December 2018 and remains the highest vacancy rate in the last 12 months. Recruitment and retention of skilled staff is essential and remains a high priority with continued recruitment and retention initiatives both locally, across London with Capital Nurse and partnership universities, targeting the final year nurse students. Overall, the wards have met their planned number of hours worked for registered and care support staff. The Care Hours Per Patient Day (CHPPD) is presented in this report.

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Report Authors:

Name: Amanda Pithouse Title: Executive Director of Nursing, Quality and

Governance Tel Number: 020 8702 3032 E-mail: [email protected] Name: Clare Scott Title: Deputy Director of Nursing Tel Number: 020 8702 6051 E-mail: [email protected]

Report History:

Regular Report.


Numerous financial implications associated with safe staffing including:

- costs associated with use of temporary staffing or savings from reduced usage


Planning of staff is taken into account across all Trust services and is compliant within our Equality and Diversity duty.


Links to Trust objectives: Happy Staff, Excellent Care and Value for Money and is in accordance with regulatory standards

List of Appendices: • Appendix 1 – Barnet, Enfield, Haringey, Specialist Indicator Data Sets November and

December 2018 • Appendix 2 – Care Hours Per Patient Day, November and December 2018

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1. Introduction 1.1. The purpose of this exception report is to advise the Board of fill rate across the Trust’s 29

in-patient areas where nurse and health care assistant staffing levels fell below planned requirements and actions taken to address this where required.

1.2. 28 of 29 in-patient areas within the Trust have reported the details of their staffing levels on a shift by shift basis for November and December 2018. Moselle House, the new complex rehabilitation service opened in December and is partially occupied, they will start reporting in February 2019 once the ward is occupied and minimum staffing numbers are established.

1.3. This report is provided in accordance with the expectations set out in the National Quality

Board Guidance (2013, 2016) that Trust Boards take full responsibility for nursing and care staffing capacity and capability.

1.4. Managers are required to report their planned numbers of registered nurses and health

care assistants on duty, against the numbers actually present on shift. 1.5. This work has included the daily monitoring and robust management of planned and actual

staffing of both registered and unregistered staff across all 29 in-patient areas. The analysis allows for any emerging challenges to be addressed in a timely manner to ensure the delivery of planned staffing levels, to support the provision of safe and high quality care to service users and improved patient experience.

1.6. This exception report provides details of all shifts where the fill rate fell below 100%,

therefore not meeting their planned numbers. Borough teams continue to flex their approach and increase staffing to support acuity/dependency and enhanced observations where appropriate, this approach has ensured that staffing levels have remained safe throughout the reporting period.

2. Fill Rate

2.1 Table 1 gives an indication of overall fill rate for November and December 2018 across all

inpatient wards, which shows little variance between both Registered and Care staff during this period; the fill rate fell just below 100% for Registered nurses both day and night shifts in September, this was supported by additional health care staff. Average fill were rates were at or above100% for both registered nurses and health care staff in October 2018. For detailed rates per ward in both September and October 2018 see Appendix 1

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Table 1

Registered Nurses Average Fill Rates - DAY (%)

Registered Nurses Average Fill Rates - NIGHT (%)

Care Staff Average Fill Rates - DAY (%)

Care Staff Average Fill Rates - NIGHT (%)

2017

November 100 99 101 104 December 99 99 101 99

2018

January 101 100 102 99 February 100 101 103 101 March 100 99 102 103 April 102 100 104 104 May 101 99 102 102 June 100 99 101 100 July 101 99 100 102 August 98 99 101 104 September 98 99 103 104 October 100 100 105 105 November 100 95 102 97 December 104 100 102 98

2.2 Of the 28 inpatient wards reported on, 7 wards fell below the planned numbers for both registered nurses and care staff in November, they were not able to fill all of the shifts with either registered nurses or care staff. Of these 1 ward (Fennel) fell below 95% for the day shift across the month for registered nurses but had an average fill rate of 99% for health care assistants. Six of the wards had an average fill rate that fell below 95% across the months; this has been explored with the teams and it is due to unplanned sickness absence and inability to get bank staff to cover at short notice. Where this occurred the ward was supported by the ward manager.

2.3 There was an improved picture in December 2018, with 6 of the 28 wards reported fill rates below 100% for both health care staff and registered nurses. Five of the wards had a fill rate under 95%, Magnolia were unable to fill all shifts for health care assistants at night; Suffolk, Tamarind and Finsbury were unable to fill all day shifts for registered nurses during December 2018 and Juniper were unable to fill all of the shifts for both day and night, Juniper currently have a high number of staff required for enhanced observations. The ward managers confirmed that they support the ward but that this is not reflected in the safe staffing returns.

3. Vacancy Factor 3.1 The overall vacancy rate for our inpatient areas stabilised at 12.8% in December 2018 with

little variance from September to December 2018. 3.2 Vacancy rates continue to be variable across the Trust, with wards in the borough of Barnet

continuing to be among the highest rates. The Trust is working with the University of Hertfordshire and has 8 student nurses a year placed in Barnet and Edgware in addition to the student nurses from Middlesex university. The four wards with the highest vacancy rate in December 2018 were; Avon Ward at 27.5% and Thames at 22%, although Thames have recently recruited into post and have reported that their vacancy rate has reduced to 13%. Devon ward remains high at 23% and Beacon has a 26% vacancy rate. Seacole East is showing a vacancy rate of 62% due to staff movements for the opening of Moselle

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House. All posts have been advertised with more than 50 staff shortlisted for interview. There are a number of wards that are over established; Cornwall Villa, The Oaks, Finsbury, Suffolk and Derwent.

3.3 The Trust will start the recruitment campaign in February 2019 for student nurses due to qualify in September 2019.

3.4 Three Trainee Nursing Associates completed the pilot programme and will be registered with the NMC in January 2019; all have been recruited into Band 4 posts; two in Enfield Health and one in Haringey Home Treatment Team. A further 18 members of staff commenced the Trainee Nursing Associate apprenticeship programme in December 2018.

4. Sickness Rate 4.1 The overall sickness rate across the Trust in-patient wards remains stable at an average of

5% in December 2018. Sickness rates vary across in-patient wards; with some long term sickness impacting on specific areas.

4.2 The three wards with the highest sickness rate in December were Magnolia and Fairlands,

both at 14% due to long term sickness; and Derwent ward at 11%. Avon Ward sickness rate has reduced to 11% from 26%. The monitoring and discussion of both vacancy and sickness rates in monthly meetings with workforce.

5. Care Hours Per Patient Day (CHPPD) 5.1 The care hours per patient day (CHPPD) metric was developed to provide a consistent way

of recording and reporting deployment of nursing staff providing care in inpatient ward settings. The metric was designed initially for acute hospitals but has since been tested and adapted for use in mental health and community inpatient wards. The Trust has been reporting the CHPPD information to NHSI since April 2018 when it became a mandatory requirement.

5.2 NHSI have noted that it is not uncommon for some inpatient mental health and community trust inpatient wards to include professionals other than nurses in their ward establishment. The CHPPD measure must include these roles to provide an accurate record of the care hours available. Therefore, from November 2018, for mental health and community trusts NHSI have extended the national CHPPD data collection to include all registered and non-registered AHPs. The Trust is required to submit this date from November 2018 and it will be published on ‘My NHS’ and ‘NHS Choices’ in January 2019. See Appendix 2 for current submission of nursing and health care assistants only for September and October 2018.

6. Conclusion 6.1 Vacancy rates continue to be a challenge for the Trust on in-patient areas with an overall

vacancy rate of 12.8% . 6.2 The Trust is working hard to recruit registered nurses and health care assistants and there

is on-going recruitment for a number of areas. The nursing directorate will work with workforce to develop a rolling programme of recruitment for registered nurses in mental health, learning disability and general specialisms, for both substantive rolls and bank.

6.3 The nursing directorate are contributing towards a Trust wide retention programme led by

workforce and staff from across the Trust in addition to a local quality improvement initiative for workforce in Haringey.

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6.4 Safe staffing reports are published on the Trust website monthly; promoting transparency and providing assurance in relation to the Trust monitoring of safe staffing. Our fill rates are reported via monthly UNIFY submission; a requirement of all NHS providers.

7. Recommendations 7.1 In order to deliver on NHSI publication ‘Developing Workforce Safeguards’ the Director of

Nursing has commenced a formal nursing establishment and skill mix assessment across all inpatient wards; this will include the consideration and development of new roles to include the Nursing Associates. A full report with recommendations to be brought to Trust Board in March 2019

8. Budgetary / Financial Implications 8.1 Financial costs associated with the procurement of electronic IT solutions to record and

track staff usage. 8.2 A reduction in the reliance on temporary staff, and associated savings. 9. Risk Management 9.1 Consistency in high calibre, well trained and competent staff will contribute to risk reduction

and improved quality of care and patient experience. Investment in staff development will also assist in retaining high quality staff and assist in the recruitment of staff in the future.

10. Equality and Diversity Implications None

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Appendix 1 – Barnet, Enfield, Haringey, Specialist Indicator Data Sets November 2018

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Barnet, Enfield, Haringey, Specialist Indicator Data Sets December 2018

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Appendix 2 -Care Hours Per Patient Day November 2018

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Care Hours Per Patient Day – December 2018

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