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BoD Public – 21st November 2019 – Agenda

Version 0.1 Author: Jean Clark Department: Corporate

of 2 Date produced: 13th September 2019 Retention period: 20 years

Board of Directors – Public Session

Meeting to be held on Thursday 21st November 2019 at 12:30 – 4:00pm in IP-City Centre, 1 Bath Street, Ipswich IP2 8SD

AGENDA

11:30 19.126 Staff Improvement Story Presentation

BREAK FOR LUNCH

Timing Item No

Item Presenter Paper/ Verbal

12:30 19.127 Chair’s welcome, apologies for absence and notification of any urgent business:

Marie Gabriel

12:35 19.128 Declarations of Interest Marie Gabriel Paper A

12:40 19.129 Voice of the Service User Diane Hull Verbal

12:55 19.130 To approve the minutes of the previous public meeting, held on 19th September 2019

Marie Gabriel Paper B

13:00 19.131 To address any Matters Arising from the minutes of the previous meeting and Action Log

Marie Gabriel Paper C

13:05 19.132 Chair’s report Marie Gabriel Paper D

13:15 19.133 Chief Executive’s report Jonathan Warren Paper E

Quality

13:25 19.134 Patient Safety and Quality Report Diane Hull Paper F

13:35 19.135 Access and Waiting Times Stuart Richardson Paper G

Strategy

13.45 19.136 Strategic Activity Update

Mason Fitzgerald Daryl Chapman

Paper H

BREAK

Performance

14.10 19.137 Integrated Performance Report Stuart Richardson Daryl Chapman

Paper I

14.20 19.138 Freedom to Speak Up Report Jonathan Warren Paper J

14.30 19.139 People and Workforce Report Mark Gammage Paper K

14.40 19.140 Equality and Diversity Strategy Mark Gammage Paper L

Governance

14.50 19.141 EPRR Update Stuart Richardson Paper M

15.00 19.142 Statement of Compliance revalidation Bohdan Solomka Paper N

1Tab 1 Agenda

1 of 181Board of Directors, Public - 21st November 2019-21/11/19

BoD Public – 21st November 2019 – Agenda

Version 0.1 Author: Jean Clark Department: Corporate

of 2 Date produced: 13th September 2019 Retention period: 20 years

15.10 19.143 Board Terms of Reference Jean Clark Paper O

15.15 19.144 Governance Structure Jean Clark Paper P

15.20 19.145 Charitable Funds Annual Report and Accounts approval Tim Stevens Paper Q

15.25 19.146 Items for Information:

i. Quality Assurance Committee Chair’s Report Tim Newcomb Paper R

ii. Audit & Risk Committee Chair’s Report Adrian Matthews Paper S

iii. Finance, Business and Investment Committee Chair’s Report

Adrian Matthews Paper T

To follow

iv. People Participation Committee Chair’s Report

Pip Coker Paper U

v. Appointments and Remuneration Committee Chair’s Report

Tim Stevens Paper V

15.35 19.147 Questions from the public in relation to the Board papers

presented at today’s meeting Marie Gabriel

15.50 19.148 Any other business previously notified to the Chair

Marie Gabriel

16.00 19.149 Date, time and location of next meeting

The next meeting of the Board of Directors in public will be held on Thursday 23rd January 2020 in the Active Business Centre, 33 St Andrew Street South, Bury St Edmunds, IP33 3PH

Motion to exclude public and press from the confidential part

of the meeting to be held on 23rd January 2020

CLOSE

1Tab 1 Agenda

2 of 181 Board of Directors, Public - 21st November 2019-21/11/19

NORFOLK & SUFFOLK FOUNDATION TRUST - DECLARATION OF INTERESTS – Board of Directors November 2019

TITLE FIRST NAME

LAST NAME

POSITION / BASE

DETAILS OF INTEREST DATE FROM

DATE TO Date of Declaration

Mr Jonathan Warren CEO Faculty Member - Institute Healthcare Innovation Chairman - Ardingly Rowing Club

2018 2017

Present

09.05.19

Mr Tim Newcomb NED NIL 17.07.17 Present 11.10.19

Mr Tim Stevens NED Trustee - The Woolf Institute, Cambridge Trustee - St John International

Present 19.05.19

Dr Bohdan Solomka Medical Director NIL 17.07.17 Present 10.10.19

Mr

Adrian

Matthews

NED

Owner - XE Associates Consulting Jan.2015 Present 21.09.19

Specialist Advisor - CQC Jan.2017 Present

National Job Evaluation Trainer - NHS Employers Nov.2016 Present

Trustee/NED - Diversa Multi Academy Trust Nov.2016 Present

Director - Diversa Trading Ltd. Oct.2016 Present

Trustee/NED - Evolution Academy Trust Present

Audit Committee Member - Norfolk Police & Crime Commission & Norfolk Constabulary

Oct.2016 Present

Mr

Ken

Applegate

NED

Project Manager for Create Norwich at UTCN Sept. 2018

Present 08.03.19

Enterprise Advisor at UTCN

Date: 21st November 2019 A

Item: 19.128

4

Tab 4 Item

19.128: Declarations of Interest

3 of 181B

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Ms Pip Coker NED Continued relationship with Julian Support Trustees and Management Team. I will not take part in any matters relating to their business relationship with the Trust. 2008 to present. Former CEO of Julian Support

07.11.18 Present 28.05.19

Mr. Daryl Chapman Interim Finance Director

Volunteer Treasurer for Spooner Row Primary School Pre-School

07.03.19 Present 15.05.19

Ms Diane Hull Chief Nurse NIL 21.11.18 Present 12.09.19

Mr. Stuart Richardson Chief Operating Office

NIL 01.08.18 Present 07.03.19

Ms

Marie

Gabriel

Chair

Chair: East London Foundation Trust 01.10.12 Present 22.03.19

Self-Employment: MSG Consultancy 1996 Present (inactive as from 01/02/19)

Trustee east London Business Alliance Present

Foundation for Future London Present

West Ham United Foundation Present

Member of the Labour Party Present

Dr Jan Falkowski Medical Director/Workforce

Private and Medical Legal Work - Self Employed Trustee Royal College of Psychiatrists

15.05.19 Present 15.05.19

Ms Jean Clark Company Secretary

Currently employed by Norwich CCG on secondment to NSFT

12.03.19 Present 12.03.19

Mr Daniel Dalton Chief Medical Officer/Hellesdon

National Specialist Adviser (Specialised commissioning) Mental Health, remunerated, NHSE Honorary member of the Secretary of State for transport's clinical advisory panel on mental disorders and driving, DfT Spouse is a clinical psychologist employed by Cambridgeshire Community Services NHS Trust who also undertakes private clinical practice in Norfolk

01.10.19 Present 01.10.2019

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Tab 4 Item


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Mr Mason Fitzgerald Deputy CEO and Director of Strategic Partnerships

NIL 01.10.19 Present 01.10.19

Mr Mark Gammage HR Advisor to the Board

Managing Director of Dearden HR an HR management consultancy company and Managing Director of Dearden interim, an interim management company

Present 16.07.19

Ms Katy Steward NED Self-Employment: Isle of Wight NHS Trust, Belfast NHS Trust, London Leadership Academy

Present 14.11.19

Charities: Trustee of Oxfam GB April 2020

Ms Tricia Fuller NED Co-Opted Governor West Earlham Junior School 08.11.19 present 08.11.19

4

Tab 4 Item


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Board of Directors – meeting in public Draft minutes – 19 Sept 2019 Page 1 of 13

Unconfirmed

Minutes of the Board of Directors – held in public

held on Thursday 19 September 2019 at 12:30

in the Pedlars Meeting Room, The George Hotel, Swaffham, PE37 7LJ

Present:

Board of Directors

Marie Gabriel (MG) Trust Chair

Pip Coker (PC) Vice Chair – Norfolk

Adrian Matthews (AM) Non-Executive Director

Tim Newcomb (TN) Vice Chair – Suffolk

Prof Jonathan Warren (JW) Chief Executive Officer

Daryl Chapman (DC) Interim Director of Finance

Diane Hull (DH) Chief Nurse

Stuart Richardson (SR) Chief Operating Officer

Dr Bohdan Solomka (BS) Medical Director

Attendees: Jean Clark (JCl) Trust Secretary

Jane Crolley (JCr) Care Quality Commission

Dr Jan Falkowski (JF) Workforce Medical Director

Mark Gammage (MGe) HR Advisor to the Board

Mason Fitzgerald (MF) ELFT, Director of Planning & Performance

Michael Lozano (ML) Head of Quality Improvement (Item 19.111)

Liz Keay (LK) Freedom to Speak Up Guardian (Item 19.116)

Andrea Goldsmith (AG)

Amy Abbott (AB)

Governance Support (minutes)

Charge Nurse (item staff improvement)

There were 14 members of the public present

The Staff presentation commenced at 11:33

Item No Agenda title Action

Lunch and Staff improvement Presentation

i. Amy presented the QI work on Waveney and Lark Wards to reduce the

use of rapid tranquilisations and restrictive interventions. Waveney Ward

had reduced their restrictive interventions by approximately 70%, and

Lark Ward by approximately 60%. This had been recognised by the

Royal Society of Psychiatrists, who are leading the national programme.

Other areas of the Trust had since contacted them to share the learning.

ii. Additional staff had been recruited to the wards to arrange more

activities, and service users were being encouraged to take more

ownership of their care plans by writing them themselves and re-

Date: 21st

November 2019 B

Item: 19.130

6

Tab 6 Item 19.130: To approve the minutes of the previous public meeting, held on 19th September 2019




designing the prompts. The review meetings were less formal; although

there was more work underway to improve staff engagement and

involvement.

iii. These changes had led to more positive interactions with service users,

who feel they are being listened to and can see the changes being made.

The atmosphere in the ward was much more positive, with staff sickness

below the national average.

iv. When new staff joined the ward, there had been a short-term increase in

interventions which had reduced once the staff had got used to the ways

of working.

v. MG thanked Amy and her colleagues for their work and having such a

positive impact on the experience of service users and staff, and the

Board agreed that a note be sent to the wards: ACTION. JCr echoed

the congratulations of the Board. JW added that he had been asked to

present the work on a conference call to NHS medical and nurse

directors and asked Amy to join him.

MG, SG

vi. The Board welcomed that other areas had contacted her to ask for her

advice, with Amy adding that she had been invited to away days across

the Trust to share their work. ML noted that learning was being shared in

national networks, with people outside NSFT asking for information too.

MG asked how service users could be part of this. BS added that he

would raise with the clinical directors.

vii. The meeting discussed how this work could be included in training for

nurses and welcomed that new staff had taken to this way of working so

quickly. The staff and service users would be moving back to their

refurbished ward soon, where further changes would be made.

Board meeting in public

19.101 Chair’s welcome, notification of any urgent business and apologies

for absence

i. MG welcomed those present and advised that apologies had been

received from Ken Applegate and Tim Stevens.

19.102 Declarations of Interest

i. There were no additional declarations of interest.

19.103 The voice of the Service User

i. Sasha spoke to the Board about her experience of moving from CAMHS

to Adult services on her 18th birthday, and the problems she had

encountered. Although she had requested that her transition be planned

some months in advance, she was told that this was not possible. On

her 18th birthday she was told that she would be transferred to an adult

unit, but there had been a number of delays and changes of destination.

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During this period, her notes had been lost with all her care and

medication history. This had been very stressful and frightening, and had

impacted her recovery.

ii. Sasha went on to praise the staff who had helped her, encouraged her

and saved her life, reading a poem that she had written to them. With

their support, she was applying to university. She thanked the staff for

always being willing to help, even if they had already done a long shift.

iii. MG apologised to Sasha for the transition she had experienced,

acknowledging that the Trust has let her down, and thanked her for

sharing her story and helping to make improvements. JW added that he

would contact Sasha to talk about her experiences and asked her to

share her story with the new care group leaders at their inductions.

iv. JW advised that both STPs were looking at Youth services for 0 to 25,

and while some services were already working with young people there

was more to be done. JW stated that following Sasha’s story he would

revisit the timescales to see whether they could be brought forward and

in creating youth wards: ACTION. JW and SR agreed to look at the

transition planning, starting this 6months+ before the person’s 18th

birthday and to share Shasa’s story with the Care Groups: ACTION.

JW

JW, SR

19.104 To approve the minutes of the last meeting – held on 18 July 2019

i. The minutes were approved, subject to the correction of a spelling

mistake on page 10.

19.105 Matters arising from the minutes and action log

i. The Board noted the closed actions, and those to be discussed here.

ii. Min 19.61: JW reported that discussions were ongoing with Norfolk

County Council and STP regarding the Children and Young People’s

services and what would be included within the service scope. A report

would be brought back to future meetings: ACTION.

JW

iii. Min 19.62: DC confirmed that the strategy had been expanded to a

Digital Strategy, to look at how to support services and models of care

with technology. MG noted that there was currently no NED leading on

ICT, and would discuss this with the two new NEDs, subject to their

appointment by the Council of Governors

iv. Min 19.97: DH confirmed that Governors would be invited to the launch

of the Physical Health Strategy: ACTION.

DH

19.106 Chair’s report

i. MG advised that the Council of Governors would be meeting the

following day to consider the Trust strategy and the appointment of two

new NEDs. Rebecca Toye had been elected as Deputy Lead Governor

and would help with the relationship between the Board and the Council.

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The Board congratulated Rebecca Toye on her appointment.

ii. MG reported on meetings she had had with local voluntary partners and

suggested that a dedicated meeting be held to discuss how we can work

better together. It was agreed that PC would work with her on this.

iii. MG reminded those present that she had identified three key areas of

focus for the six months from her March 2019 Chair's report:

A. Improve key indicators for service users and carers – progress had

been made but there was still a lot of work to be done, this will

therefore remain a key focus.

B. Development of the Board and Council governance – JC, MF, AG,

Cathy Lilley and communications were thanked for their help in the

work done so far. The Council would be considering their own

improvement plan the following day.

C. Development of a Trust strategy – This would be discussed under

Item 19.118 and at the Council meeting. Chairs Action would be

taken to approve the Strategy. The Chair thanked staff, service

users, carers, directors and governors for their contribution.

19.107 Chief Executive’s report

i. JW presented his report, outlining the improvements in performance

whilst noting that there was still much to be done. The number of people

in out-of-area placements had fallen from 92 to 16, with only four actually

out of Norfolk: the rest were close to their family and support network but

in non-NHS beds, and visited regularly by their Care Co-ordinators and

other Trust staff.

ii. As heard during the lunch-time staff presentation, there had been

significant reductions in the number of restrictive interventions. In

addition, the number of people waiting over 18weeks had also reduced.

160 additional clinical staff had been recruited, and it had been

announced that the Trust will receive approx. £40m to extend provision

on the Hellesdon site.

iii. JW added that he was currently meeting a couple of teams every week to

hear from them and about the new structure. MG asked that key themes

from these meetings be included in the workforce report: ACTION.

JW, MGe

iv. MG noted that BBC Look East had covered the out-of-area placements

the previous night and queried their different reporting of Out of Area

Placements. SR clarified that these could be measured by number of

bed days and by number of individuals, and also advised that people who

had been furthest away had been brought back first. The number of bed

days were compared to the same time the previous year, whereas the

number of people provided real time information on those currently

affected. JW noted that for some service users it was appropriate for

them to complete their treatment out-of-area, and these were kept under

review.

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v. JW noted that with additional provision at Yare Ward, Crisis House and in

the community, it was hoped that the Trust could achieve 85%

occupancy, which will enable NSFT to be flexible with care and meet

unexpected demand. It was also explained that the actions underpinning

this improvement would make it sustainable, although there will always

be some variance due to differing demand.

vi. SR advised that the patient flow group looking at this would continue to

meet for the foreseeable future, as it was a good opportunity to discuss

and solve problems with local partners such as delayed transfers of care.

This had led to a shared understanding and ownership across the

system.

vii. JW thanked the directors and staff for their work in achieving the outlined

improvements, which was echoed by the NEDs.

Quality

19.108 Quality & Safety report

i. DH advised that the work detailed within the report had been reviewed by

the Quality Assurance Committee and sub-groups.

ii. The Quality and Safety Reviews had been well received across the Trust

as opportunities to share success, best practice and challenges.

iii. There was further work underway to improve seclusion and rapid

tranquilisation compliance in some areas, particularly where rapid

tranquilisations was not often and as such staff were not as familiar with

the process as other areas of the Trust.

iv. There had been 28 serious incidents in the two-month reporting period,

with 12 deaths. Of those 12 deaths, seven are likely to be attributed to

“took own life”. Four patient safety alerts had been issued from early

learning review findings.

v. There had been an MHA inspection to the mother and baby unit, which

had been generally positive, with improvements to be made regarding

rights and additional advocacy support. Quality & Safety Review return

visits to the CHRTs had seen improvements since the initial visits, but

there was more to be done. The August 2019 visits were to older

people’s inpatient and community services and secure services.

Feedback from service users and carers was positive about their care.

DH agreed to invite NEDs to future Quality and Safety Summits:

ACTION.

DH

vi. JW explained that the variations seen in restraints, seclusion and rapid

tranquilisation were within standard variation and were not therefore a

cause for concern. The Trust had tried to obtain benchmark information,

but this had proved difficult; however, they were working with ELFT on

this.

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vii. Falls prevention had been emphasised in care plans, and any clusters

were reviewed and mitigations put in place.

19.109 Changes to Serious Incident Process

i. DH presented the revised process, which had the involvement of families,

and the support available to all those affected. In the event of an SI, the

next of kin is advised, and a condolence letter is sent from the CEO

outlining the support available and next stages with contact numbers of

key individuals. The Family Liaison Officer (FLO) started in June 2019

and works with the Suicide Prevention Lead to support families.

ii. An early learning review was undertaken, with any immediate learning

shared across the whole Trust. The formal SI process would involve the

families, if they wished to, and the new People Participation Leads, who

would bring their knowledge and expertise. The new SI Committee

would be meeting the following day, and would be attended by the new

care group leadership. The PPL were new in post, and so had not been

involved as yet. The new care groups will allow for more local scrutiny,

ownership and challenge of the SIs in their area.

iii. MGe added that the HR team were also looking at support available for

staff, acknowledging that people react in different ways and need

different types of support. DH advised that the FLO was supported by

the clinical colleagues, their manager and the Suicide Prevention Lead.

iv. MG noted that support would be different to service users on a ward

compared to those in the community who were affected by a SI, and DH

agreed to review how support in the community could be provided.

19.110 Mortality Review – update

i. BS presented the report, advising that there would be a new format to

future reports. The theme around dual diagnosis had been raised with

the STP. The themes were shared with the care groups to look at and

own within their group. They would have protected time for QI/learning

models. BS agreed to include more information on the themes and

related actions in the next report: ACTION.

BS

ii. In response to an issue raised by MG from the Council of Governors, BS

advised that the way deaths were reported had changed in line with the

National Learning from Deaths guidance in April 2017, and so it was not

possible to do a year-on-year comparison.

iii. The recommendations from the Structured Judgement Reviews were

being followed-up: to ensure that all service users had allocated support

and looking at the physical health of service users with partners. BS

advised that there were frailer people on wards and their needs were

being taken into account by staff.

iv. Four cases had been reported under the Learning from Deaths in

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Learning Disability services (LeDER) and reviews commissioned. There

were also regular system discussions, every two months. It was agreed

that more detail would be provided for LeDER learning.

19.111 Quality improvement

i. ML presented the report, highlighting the significant work discussed

under Item 19.100. Approx. 180 staff, service users, governors and other

stakeholder had had QI training and there were approx. 40 projects

underway. Co-production and engagement with partners are important

parts of the QI process. Discussions were underway with ELFT

regarding increasing the number of QI-trained staff and coaches.

ii. ML confirmed that clinical and corporate areas had QI projects, with HR

looking at reducing the time to recruit. MG advised that the Governors’

QI project related to communication and engagement with members.

iii. The Board welcomed the enthusiasm of staff for this work and the

improvement in quality and staff morale that were being seen. MG

suggested that the Board should discuss how they could be support this

work and that this would be a topic for a Board Development Session:

ACTION.

MG, MF

19.112 Access and waiting times

i. SR presented the report, highlighting the reduction in people waiting over

18weeks, although it was recognised there was more to be done There

was a focus on ensuring people were safe while they waited, and on

addressing capacity and reducing Did Not Attend (DNA) rates. It was

confirmed that the Clinical Harm Reviews’ outcomes were being

embedded.

ii. The leadership and ownership now sits with the Care Groups with the

focus on keeping people safe. DH advised that plans and figures would

be kept under review centrally for some time yet, and it was agreed that

this would remain as a Board item.

19.113 Out-of-Area placements

i. As discussed under Item 19.107ii-v, the number of placements had

reduced and were reviewed weekly by the Executive and clinical

colleagues at weekly safety huddles.

ii. SR advised that the Crisis House would provide a short-term safe space

for people. It would be provided through joint working with the voluntary

sector, and funding had been agreed with the CCG. There was still more

to do with delayed transfers of care.

Strategy

19.114 Strategic Activity – update

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i. MF presented the report, highlighting the closer working arrangements

between NSFT and NCH&C, and would keep the Board up-to-date on

developments in future reports.

ii. MG advised that the Council of Governors had written to the STPs

regarding governor engagement. The Lead Governor, Howard Tidman,

had also contacted the other local Lead Governors to work together on

the STPs and other areas of joint interest.

iii. The potential 2% increase in council tax for social care funding was

noted, and the Board also noted the impact this could have on service

users both as recipients and residents.

iv. The Trust’s strategy had been considered by staff, service user,

Governors and directors, and would be taken to the Council again the

following day. The Board requested a small number of additions

regarding equality and diversity, infrastructure and resources, rewording

and reformatting, and agreed the final version would be approved by

Chair’s Action after the Council meeting: ACTION.

JW, MG

v. JW confirmed that once the strategy had been agreed they would start to

look at timescales, key indicators and a dashboard to monitor progress.

The strategy would also be published and communicated extensively,

with more accessible formats available.

Break: 14:33-14:48

Performance

19.115 Integrated Performance Report

i. DC presented the report, noting that the draft submission for the Five-

Year Plan would be made at the end of September 2019, with the final

version in November 2019. The plans were to show how STPs would

work towards the achievement of the Long-Term Plan over the next five

years. The Trust would ensure alignment with as a partner within the

STPs.

ii. The financial position was on target at the end of August 2019. The

forecast to the end of the year had been reviewed by the Executive and

budget holders and was agreed to still be achievable. Conversations had

begun with the new care groups for the next financial year. The financial

position was being kept under review by the Finance, Business and

Investment Committee.

iii. There was currently no risk of breaching the NHS England/Improvement

Agency Cap. The Board noted that it was important to ensure that

agency and locum staff worked to the standards required and within the

values expected. JF advised that he and BS met all locums after one

month to review the placement.

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iv. DC confirmed that all cost improvement plans were impact assessed for

quality, explaining the process. It was agreed to consider how this

process could involve NEDs: ACTION.

MG, DC

v. The FBIC had considered the Newton Consultancy report and demand

management actions and there are to be pilots in two areas of the Trust

to review the response.

vi. Performance for completeness of CPAs was kept under review. The new

CPA form had been issued in July 2019, and the impact should be seen

in the next report. They had been delays in the implementation of

Dialogue+ due to IT hardware, which was being worked through.

Dialogue+ will support the Trust in ensuring both the medical and social

needs of service users are met.

vii. There had been difficulties with completing the cardio-metabolic

assessment audit due to the historic model of early intervention provision,

which had now been changed. However, these were being addressed

and SR advised that they were confident that after review, the

assessment would be increased to Level 2, and agreed to report back to

the Board: ACTION.

SR

viii. JCl advised that the BAF was the first report with the new risks and new

format.

19.116 Freedom to Speak Up report

i. LK advised that the next report would reported by care groups, not

localities. There had been 18 cases in the reporting period, with nine still

in progress, or passed to HR for advice or further action.

ii. It was currently FTSU month, and LK reported that staff were aware of

the role on her site visits, which was welcomed by the Board.

iii. The case study highlighted of the need to ensure there was adequate

support provided to staff in new roles, and the importance of having the

right people in mentoring and coaching roles. MGe added that this had

been discussed with LK, and this would be considered within the

development of the new leadership programmes.

19.117 People and Workforce – update

i. MGe presented the report, noting that the HR section of the Integrated

Performance Report would be moved into this report in future.

ii. HR were reviewing the time to hire and recruitment material with the

Recruitment and Retention Group; some recruitment processes had a

long lead time and this may be skewing the measure, such as student

nurses or senior staff with long notice periods. There were also links with

the cultural change work, and staff having a workplace they want to join

and remain in.

6





iii. MG advised that the Governors are keen to support recruitment and

retention of staff, and had discussed this at a previous Council meeting.

JW agreed to respond to the Council on this point: ACTION.

JW –

closed

iv. Planning was underway for the next staff survey, with JW highlighting the

actions taken following staff feedback. External support had been

engaged to assist with the national Workforce Race and Disability

Equality Standards which must be published by the end of the month.

Both will be brought back to the next Board meeting: ACTION.

MGe

v. The care group induction had been well received, with the HR team

moving on to the next phase of the leadership programme. The majority

of posts had been recruited to, with bespoke inductions planned for

specific roles. JW noted that there was now £1k per nurse available for

training, although it was unclear on any details or restrictions at present.

19.118 Culture Change – update

i. MGe presented the report and the need to define the current position and

process to be in the top quartile for staff engagement by 2023, such as

being a just, kind and learning organisation. There was work to be done

on understanding why issues were raised with HR. MG stated that the

need to change our culture had also been raised by the Council and that

there needed to be more discussion to define the new culture and inform

the steps we should take to achieve this. It was agreed that this should

be discussed by the Board at a Board development session, informed by

the Culture Champions or is it ambassadors and feedback to the Council:

ACTION.

MG, MF,

JCl

19.119 Medical Education report

i. BS presented the follow-up report to the visit by the Deanery and GMC in

February 2019. There were a number of actions that had been closed,

which had been recognised during a follow-up visit in July 2019. JF

added that the recent Junior Doctors’ Forum had been positive, as had a

recent meeting between the senior and junior doctors. The Trust had

also agreed to cover junior doctors’ exam fees. The Board thanked Drs

Falkowski and Solomka for achieving this progress.

ii. Dr Somayya Kajee had been appointed as the new Director of Medical

Education, and the Board thanked the outgoing Dr Trevor Broughton for

his work.

19.120 e-prescribing report

i. BS presented the report and the Board noted that ePMA, the system to

allow electronic prescribing, would be implemented across the Trust

following a successful pilot.

Governance

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19.121 Emergency Preparedness Resilience and Response (EPRR) self-

assessment and EU exit

i. SR advised that it was a requirement to bring EPPR and EU exit report to

the Board, and that the Trust had 12months to fully comply with the

criteria. This involves looking at business continuity plans, flu plans and

on-call policies, with a live simulation later in the year. Following a

comment from MG on the inconsistency of scoring against the matrix, SR

agreed to look at the ratings again: ACTION. JW added that the Trust

was being told to plan for food and fuel shortages only, and that

medications were being dealt with centrally. Update reports would be

brought to future meetings: ACTION.

SR

SR

19.122 Items for information

i. The Board noted the reports and the request to standardise the

formatting: ACTION.

JCl

a. Quality Assurance Committee – Chair’s report

b. Audit & Risk Committee – Chair’s report

ii. AM advised that the review of the Consultant Job planning process was

still awaited. JF added that they were looking to align the plans with the

strategy and streamline the process to reduce the number of sign-offs

required. AM suggested that Internal Audit could be asked to do spot

checks on the job plans.

c. Finance, Business and Investment Committee – Chair’s report

iii. AM reported on the CIP and budget discussions, and the Newton

Consultancy feedback and how this would be driven by the care groups.

d. People Participation Committee – Chair’s report

e. Mental Health Act Committee – Chair’s report

iv. MG advised that this Committee had replaced the Mental Health Law

Forum to provide direct reports to the Board on our performance in

relation to the mental health act. The Committee would have both NED

and Senior Executive representation and its first meeting discussed the

use Section 136 and 136 suites and contributions were requested from

partners for our review of the Trust’s 136 suites. The Committee also

noted the shared learning work underway with ELFT.

19.123 Questions from the public in relation to the Board papers presented

at today’s meeting

i. Christine Hawkes, Carer Governor, questioned the out-of-area placement

figures presented in comparison to the previous year and asked why the

increase in demand had occurred. JW reiterated that the number of

people out-of-area had dropped and the Trust was committed to having

6





85% bed occupancy to cope with demand, with the support of the STP as

previously outlined.

ii. Christine Hawkes, Carer Governor, queried whether routine

appointments were suspended in Central Norfolk. SR confirmed that

they were not currently. JW replied that in addition to actions already

taken to support the team, the new Assertive Outreach Team which was

being developed would have a positive impact. SR confirmed that the

current situation was very challenging and being kept under review.

iii. Councillor Michael Chenery noted that the waiting times in West Norfolk

had improved, but questioned IAPT waiting times: SR agreed to check

and send Councillor Chenery details: ACTION.

SR

iv. Howard Tidman, Lead Governor, noted that while the number of out-of-

area placements were reducing, there were still vulnerable people away

from friends and family, which the Board had already discussed. There

were concerns about frailer, older patients being on adult wards. JW

stated that this was being looked at with the STP and primary care

partners. Finally, HT said that anecdotally, there had been patients who

had not come onto the ward voluntarily because of the smoking ban and

so had to be sectioned. BS agreed to look into: ACTION.

BS

v. Kevin James, Service User Governor, raised concerns about

communications, involvement of people with lived experience and

physical health, the substance misuse provider and inappropriate

referrals from primary care. JW agreed that the Trust should join the

Equally Well Network, The Trust was part of the discussions on the

substance misuse provider, and SG was looking at communications

within and outside the Trust. BS advised that the Trust was working with

primary care colleagues and networks on referrals.

vi. A member of staff asked how the Trust monitored service quality in other

providers and what actions were taken when this fell short, following a

recent problem. DH advised that due diligence was undertaken before

placements were made, and then providers are kept regularly under

review and that any concerns were investigated. If the concerns were

serious enough, the service user was moved, and the family and Care

Quality Commission informed. If someone had concerns, they could be

raised with the Trust and with the CQC. JCr offered to talk through the

issues outside the meeting. The timescales to rectify any concerns

would depend on the complexity of the issues raised.

vii. MG passed on a question regarding whether NSFT records clinical

conversations. SR advised that this had been investigated and that there

was the ability to do so with our system. The policy associated with this

appropriately was currently being reviewed to identify how best to

address this request.

19.124 Any other business, previously notified to the Chair

6





i. There were no other items of any other business.

19.125 Date, time and location of next meetings

i. The Annual General Meeting will be held on 10th October 2019 from

13:00 in The Forum, Norwich

ii. The next meeting of the Board of Directors in public will be held on

Thursday 21st November 2019 in Ip-City Centre, Ipswich, IP2 8SD

iii. Motion to exclude public and press from the confidential part of the Board

of Directors’ meeting to be held on 21st November 2019 was carried.

There being no other business, the Chair thanked those present for their contribution and closed the meeting at 16:15.

Chair: ……………………………………………

Date: …………………………………………….

6



Date: 21st November 2019 C

Item: 19.131

Board of Directors – Action Log

Agenda item no

Date Item Action Action by Due Date Status / Comments Date Closed

19.75 30/05/2019 AOB Next Safer Staffing Report to include community care

Diane Hull January 2020

In progress, community numbers will be added in the January report

19.89 18/07/2019 Strategic Activity Update

To update the Board on the patient safety strategy once discussed by the Quality Assurance Committee (QAC)

Diane Hull January 2020

Developing Quality Strategy with all quality & safety ambitions; will be discussed by QAC

19.123 19/09/2019 Questions from the public

Report back to the Board on the progress of the cardio-metabolic assessment audit

Stuart Richardson

To be discussed as part of Performance Report

Check IAPT waiting times and contact Councillor Michael Chenery

Stuart Richardson

In progress

7

Tab 7 Item

19.131: To address any M

atters Arising from

the minutes of the previous m

eeting and Action Log

19 of 181B


ublic - 21st Novem

ber 2019-21/11/19

<Name of meeting> - <Date of mtg>

<Name of document>

Version <0.1>

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Page 1 of 3 Date produced: <date> Retention period: 20 years

Date: 21st November 2019

D Item: 19.132

Report to: Board of Directors

Meeting date: 21st November 2019

Title of report: Chair’s report

Action sought: For assurance

Estimated time: 10 minutes

Author: Marie Gabriel, Chair

Director: Marie Gabriel, Chair

Executive Summary:

The report informs the Board of the

- key points arising from the Council of Governors discussions to ensure their views are taken into account in Board decision making

- Chair’s most significant activities that will particularly inform the strategic direction of the Trust

The report specifically outlines the Council of Governors focus on the appointment of Non-Executive Directors and in improving their own governance so that they can better hold the NEDs to account for the performance of the Board and effectively represent the views of Members and the Public in the Board’s strategic decision making.

The report also highlights the next steps in ensuring the Board effectively addresses bullying and harassment and key recommendations from a Non-Executive Director visit to older people services.

The report will impact on service users and carers by ensuring that their voice informs the Trust’s strategy and service development.

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Tab 8 Item 19.132: Chair's report



<Name of document>

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1.0 Background/Introduction

1.1 This report informs the Board of the Council of Governors key conclusions so that the Council views inform Board decisions. It also provides information on the Chair’s main activities and strategic outcomes of those activities.

2.0 Council of Governors

2.1 The Governors have been focused on recruiting two new Non-Executive Directors, (NEDs), who will, due to their specific skills, build the capacity and knowledge of the Board. As a consequence of their work, I am very pleased to welcome Tricia Fuller and Katy Steward to their first Public Board meeting. Tricia, has been appointed as the NED lead for Workforce and Organisational Development and Katy has been appointed as NED lead for Quality and Quality improvement. The governors have also elected Rebecca Toye, as the Deputy Lead Governor, who will with Howard and myself in ensure that the Council is effectively supported to discharge it responsibilities. In addition, Governors also assisted in the appointment of the 2 new Executive Directors, Mason Fitzgerald as Deputy Chief Executive and Director for Strategy and Partnerships who will formally take up his role next month and Dr Dan Dalton, who has been appointed as our new Chief Medical Officer. I take this opportunity to welcome Dan to his first Board meeting and to say thank to you to Dr Bodhan Solomka for his years of service as our outgoing Chief Medical Officer.

2.2 The September Council meeting received the final draft NSFT strategy, noting the

amendments made and also requesting that the strategy includes a commitment to

sustainability, emphasises the development of staff and was underpinned by the principles of

co-production in it delivery. These amendments were accepted and it was agreed that the final

strategy should be communicated widely and in accessible formats.

2.3 The meeting also noted the developing County Governor Forums and noted how these would be improved with the attendance of appropriate Care Group leadership to share local developments and to hear feedback on Members and the public views. In addition, they agreed a revised Code of Conduct and a process for the appraisal of Non Executive Directors. Importantly, Governors have agreed to establish a Communications and Engagement Task Force to ensure that communication between Governors, between Governors and the Board/Trust and between the Council and Members is as effective as possible.

2.4 In the run up to the last Council meeting and subsequently Governors have been concerned to know more about the detail of the national developments that the Trust may participate in, including most recently New Care Models. It would therefore be useful if we could ensure a Governor briefing in between Council meetings to keep Governors informed and to consider whether we could do more to appropriately involve Governors in such developments.

2.5 Finally, the Board and Council held a second joint meeting in September which considered the Trust’s quality journey and discussed current quality improvement priorities. This productive debate will inform the next iteration of the Trust’s quality improvement strategy.

8




<Name of document>

Version <0.1>

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3.0 Chair Activities

3.1 I continue to meet with service users and carers and with a range of partners from the voluntary sector. There has been a common thread throughout these meetings which has been about a willingness and indeed a request to work with the Trust to improve services. One key theme has been the need for us to be clear on the pathway a service user and carer may follow once they are referred to our services to support people accessing our services, their carers and the people advising and supporting them from our partner organisations. I know that this quite a complex task and that such information will be part of our revised website but it would be helpful to consider, with service users and carers, how to strengthen understanding further.

3.2 The Non-Executive Directors most recent visits across our geography was to our Child and Adolescent Services. The last of these visits has yet to take place so a verbal report will be made at the Board of the cross-cutting themes.

4.0 Action Being Requested

4.1 The Board is asked to RECEIVE and NOTE the report.

1.0 Quality implications

1.1 The focus on delivering quality will enable a focus on sustained improvement

2.0 Equality implications / summary of consultation

2.1 Ensuring that our strategic decisions are informed by the diverse views of our Membership and public through our Governors will assist the Trust in ensuring that our services are inclusive

3.0 Risks / mitigation in relation to the Trust objectives

3.1 Effectively engaging with our Governors, Staff and partners will help in identifying risks and the solutions for their mitigation.

4.0 Recommendations

4.1 To receive and note the report

5.0 Background papers / information

5.1 20th September Council of Governor meeting draft minutes and 30th September Joint Board and Council meeting notes.

8



Board of Directors 21st November 2019

CEO Report

Version 1.0

Author: Jonathan Warren

Department: CEO

Page 1 of 2 Date produced: 06/11/19 Retention period: 20 years


E Item: 19.133


Meeting date: 21 November 2019

Title of report: Chief Executive Officer Report

Action sought: For Information


Author: Jonathan Warren, Chief Executive Officer

Director: Jonathan Warren, Chief Executive Officer

Executive Summary:

The purpose of this report is to provide the Trust Board with the Chief Executive Officer’s update on significant developments and key issues over the past two months. The Board is asked to receive and note this report.

1.0 Purpose

1.1 The purpose of this report is to provide the Trust Board with the Chief Executive Officer’s update on significant developments and key issues over the past two months.

2.0 Trust Changes

2.1 The main event since my last report has clearly been the CQC’s inspection which took place in October. I want to thank staff for the way they welcomed inspectors and rose to the challenge of showing how we’ve improved since their last visit.

2.2 The initial feedback highlighted several areas of improvement, as well as many challenges and issues that we still need to address. Around the time of the inspection and the Annual General Meeting and Annual Members Meeting, I carried out various TV and radio interviews highlighting how we are improving in key areas, including reducing out of area placements, appointing 170 extra clinical staff in a year and in reducing waiting times.

2.3 ITV Anglia also interviewed me in an item broadcast on World Mental Health Day (10 Oct) after NSFT invited ITV Anglia to find out about our ongoing work to reduce restrictive interventions. On the same day, I attended and spoke at the launch of Healthwatch Norfolk’s City of Wellbeing initiative in Norwich.

9

Tab 9 Item 19.133: Chief Executive's report


Board of Directors 21st November 2019

CEO Report

Version 1.0

Author: Jonathan Warren

Department: CEO


2.4 We also need to be open and honest when we don’t deliver the services that our communities deserve. I appeared on BBC Look East to apologise and explain lessons learned after NSFT paid compensation to the family of Henry Curtis-Williams, a 21-year-old student who took his own life in 2016. I would like to reiterate my sympathy and apologies to Henry’s family.

2.5 It’s our staff that make this Trust what it is. It is therefore vital that we engage with them and find out what they think about working in NSFT. That is why I am actively encouraging staff to complete the Annual NHS Staff Survey which is open until November 29th. The more people that respond, the more accurate picture we will get.

2.6 I am also encouraging staff to get the flu jab. By protecting themselves, they will protect service users who often are more vulnerable to the flu virus and its complications.

2.7 As chair of the Trust’s BAME network, I opened a conference, ‘Who Am I’, to mark the start of Black History Month together with our chair Marie Gabriel in Rickinghall, Suffolk. We heard from inspirational speakers who explored and celebrated what it means to be black before enjoying Afro-Caribbean food and dancing.

2.8 Meanwhile, we have been able to show some of our services to important and influential visitors. I accompanied Sean Duggan, Chief Executive of NHS Confederation’s Mental Health Network, to Waveney Ward, Hellesdon, and NHS Providers Deputy Chief Executive Saffron Cordery to see our central wellbeing services.

2.9 An important task I’ve been undertaking has been chairing the Quality and Performance meetings for our newly created Care Groups where we’ve been learning about what is going well and what could be going better. These will be taking place bi-monthly as we continue our quest to be in the top quarter of mental health trusts for quality by 2023.

2.10 By the time I report to the next Board meeting we should have had our formal feedback from the CQC. In the meantime, our work goes on to improve services. It’s been a remarkable first eight months in my role. I believe if we continue to improve as we are, we will deliver the quality of services that our communities need and deserve.

3.0 Recommendation

3.1 The Board is asked to RECEIVE and NOTE the report.

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Tab 9 Item 19.133: Chief Executive's report


Trust Board – 21st November 2019

Version 05

Author: Saranna Burgess Department: Patient safety and Quality

Page 1 of 16 Date produced: Retention period: 30 years

Report To: Trust Board of Directors – Public

Meeting Date: 21st November 2019

Title of Report: Quality and Patient Safety – September and October 2019

Action Sought: For information and discussion

Estimated time: 10 mins

Author: Saranna Burgess, Deputy Director for Patient Safety and Quality

Director: Diane Hull, Chief Nurse.

Executive Summary:

The Trust has sustained a 25% reduction in prone restraints which is a positive sustained

change, validating the quality improvement interventions in place and driving expansion

across the organisation reaching into all areas of restrictive practice. Further sustained

improvements are evident in the weekly monitoring data which has demonstrated consistent

compliance >90% for observations post rapid tranquillisation and completion of seclusion

monitoring.

Rapid tranquillisation compliance: in October 2019 the Trust achieved 91% compliance (94% in September 86% in August and 95% in July). Shortfalls in observation levels were noted in the Norfolk PICU and acute wards (this relates to 13 incidents of RT use).

Seclusion compliance: in October 2019 the Trust achieved 94% compliance, being

96% in September 95% in August and 92% in July 2019. The areas achieving less

than 100% were West Suffolk and Norfolk PICU, both due primarily to record keeping

in respect of seclusion ending, plus nursing and medical reviews not being undertaken

within the prescribed time (this reflects 8 incidents of the use of seclusion).

To promote sustainable improvement competency documents, provide clear standards that

identify the skills and knowledge needed to perform a task. These are embedded into our

teams for a variety of topics, including medication administration and conducting enhanced

observations. Competency frameworks have been developed to support staff in the

development of their knowledge in relation to rapid tranquillisation and seclusion. Work is

also being completed to share this framework with colleagues who work for NHS

Professionals, to ensure a consistent standard of knowledge is established. It is anticipated

that the provision of clear and consistent expectations for all frontline staff will have a positive

impact on the reduction of restrictive interventions and the standard of care provided.

Date: 21st November 2019 F

Item: 19.134

10.1

Tab 10.1 Item 19.134: Patient Safety and Quality Report



Version 05



The Safeguarding Committee held in October 2019 was attended by external partners from

the Designated Safeguarding teams alongside Governor, service user and clinical

representatives. The committee noted that training compliance is >90% in level 1 child and

adult training, which includes basic awareness in domestic abuse, and Prevent WRAP.

Likewise, for L3 WRAP Prevent training the Trust is above 90% compliant. Adult

safeguarding at L3 and Domestic Abuse training is at 87% across the organisation for all

practitioners.

The Trust has benefited from National Suicide Prevention Funding Wave 1, as outlined within

the body of this report, and will be utilising Wave 2 funding supported by commissioning

colleagues across the alliances. Both Norfolk and Waveney STP and Suffolk and North Essex

STP have received funding. It has been agreed that NSFT will commence a piece of work

focusing on Safety Planning in inpatient areas. The aim of the project is that every service

user who is discharged from one of the inpatient units in the project area will leave with an

individualised Safety Plan. The funding is being used as follows:

Each ward will receive a 3-hour Safety Planning Course from the Recovery College.

A Peer Support Worker is employed for 1 - 2 hours a week on each ward to help staff

formulate safety plans with service users, carers and families.

10.1




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1.0 Report contents

2.0 Reducing Restrictive Interventions

2.1 Restraint

2.2 Seclusion and the use of rapid tranquillisation

2.3 Innovation

2.4 Use of rapid audit cycles as an intervention for improvement

2.5 Consistent standards

2.6 Oversight

2.7 Blanket restrictions

2.8 Spread of good practice

2.9 Intelligent use of data

2.10 Training accreditation

2.11 Therapeutic observations

3.0 Serious Incidents and incident reporting

3.1 Serious incidents within the Trust

3.2 Prevention of future deaths (PFD - Regulation 28)

3.3 Incident reporting

4.0 Safeguarding

4.1 Overview

4.2 Serious case reviews

4.3 Safeguarding adult reviews

4.4 Domestic homicide reviews

5.0 Suicide Prevention updates

5.1.1 National suicide prevention funding wave 1

5.1.2 National suicide prevention funding wave 2

5.1.3 48-hour discharge QI project

5.1.4 Experienced Based Co-Design Project – Introducing Zero Suicide

Ambition to Inpatient Units

5.1.5 A study of inpatients who were absent without leave (AWOL)

5.2 Family liaison officer

6.0 Flu vaccinations

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2.0 Reducing Restrictive Interventions

2.1 Restraint

Following the commencement of the Trust’s refreshed programme on reducing restrictive

interventions in April 2018 there is evidence of shifts in the data. Of the four indicators we

measure (restraint, prone restraint, seclusion and rapid tranquillisation) we have seen:

Reductions of 25% in the average rate of prone restraint and seclusion per 1,000 occupied

bed days contributed to significantly by wards from the adult service line. Key contributions

observed from the three wards (Lark, Waveney and Great Yarmouth Acute Service) that

are part of a national collaborative.

Restraint data is showing a reduction in the average rate per 1,000 occupied bed days since

November 2018 by 17%. This reduction returns the organisation to the baseline level,

requiring further data points before confirmation that a reduction has been sustained.

Rapid tranquillisation data is showing a reduction in the average rate per 1,000 occupied

bed days since November 2018 by 37.5%. This reduction returns the organisation to the

baseline level, requiring further data points before confirmation that a reduction has been

sustained.

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2.2 Seclusion and the use of rapid tranquillisation

Seclusion compliance – in October 2019 the Trust achieved 94% compliance, being 96% in

September 95% in August and 92% in July 2019. The areas achieving less than 100% were

West Suffolk and Norfolk PICU, both due primarily to record keeping in respect of seclusion

ending, plus nursing and medical reviews not being undertaken within the prescribed time (this

reflects 8 incidents of the use of seclusion).

Rapid tranquillisation compliance: in October 2019 the Trust achieved 91% compliance (94% in September 86% in August and 95% in July). Shortfalls in observation levels were noted in the Norfolk PICU and acute wards (this relates to 13 incidents of RT use).

50%55%60%65%70%75%80%85%90%95%

100%

Seclusion - Trust wide Compliance (all wards reporting incidents)

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2.3 Innovation

Three wards (Waveney, Lark and GYAS) have been involved in the national collaborative

programme facilitated by the National Collaborating Centre for Mental Health (NCCMH) since

November 2018. Significant reductions in the use of restrictive interventions have been

publicised by the NCCMH as 71% for Waveney Ward and 59% for Lark Ward. Examples of

their change ideas include increased access to activity and environmental changes which have

enhanced opportunities to co-produce care plans with service users.

Key learning in this first year is the microsystem complexity within each individual ward and its

impact on efforts of reduction. The experience of the three wards who have been part of the

national collaborative shows the benefit of such an approach. This will be a focus for the

forthcoming year with an in-house Trust collaborative commencing from January 2020 (six

wards have been selected). The collaborative will be using quality improvement methodology

with teaching and coaching from the quality improvement team. Critically, service user and

carer involvement will form a key component of the programme.

0102030405060708090

100

Weekly Compliance Trends - Physiological Obs following Rapid Tranquillisation (recorded Practice) Audit

% Comp First 4 hours % Comp for First hr10.1




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2.4 Use of rapid audit cycles as an intervention for improvement

All incidents of seclusion and rapid tranquillisation are audited to ensure quality standards are

maintained to provide safe care for our service users. The lead for restrictive interventions

views all incidents and provides clinical input into the audit process. Weekly monitoring data

has demonstrated consistent compliance >90% for observations post rapid tranquillisation and

completion of seclusion monitoring.

2.5 Consistent standards

Competency documents provide clear standards that identify the skills and knowledge needed

to perform a task. These are embedded into our teams for a variety of topics, including

medication administration and conducting enhanced observations. Competency frameworks

have been developed to support staff in the development of their knowledge in relation to rapid

tranquillisation and seclusion. Work is also being completed to share this framework with

colleagues who work for NHS Professionals, to ensure a consistent standard of knowledge is

established. It is anticipated that the provision of clear and consistent expectations for all

frontline staff will have a positive impact on the reduction of restrictive interventions and the

standard of care provided.

2.6 Oversight

The Restrictive Interventions Committee (RIC) commenced in its current form from July 2019.

Attended by lead nurses (or their representative) its role is to provide strategic and practical

direction in the programme to reduce restrictive interventions. The committee is co-chaired by

a peer tutor.

2.7 Blanket restrictions

The RI committee has completed work on design and approval of the Blanket Restrictions

Policy, offering a structured and governed approach. Monitoring of blanket restriction use will

be completed by the committee.

2.8 Spread of good practice

A focus will be on the diffusion of innovations that contribute to reduced restrictive

interventions. Key elements of this approach will be enabling an opportunity for adopters to

learn from others (i.e. those who have been a part of the national collaborative) and

communication of positive results and ideas.

2.9 Intelligent use of data

The mental health minimum data set (MHMDS) is a national data set which collects data from

providers on restrictive interventions. These requirements have recently been amended and

now require a greater amount of detail for restrictive interventions. The Trust’s incident

reporting system is being adapted to meet the revised requirements and is currently being

piloted on four wards across the organisation. Organisation-wide rollout is anticipated from

1st December 2019. The output benefit for the Trust is more detailed data from which to gain

insight and knowledge.

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2.10 Training accreditation

The Restraint Reduction Network (RRN) launched the first training standards to protect human

rights and minimise restrictive practices in April 2019. The Trust will be assessed for

accreditation via our affiliation with the West London NHS Trust and their ‘Positive and Safe’

syllabus.

The Trust’s prevention and management of violence and aggression training syllabus will be

reviewed to ensure there is a further strengthening of the service user voice and experience.

There will be increased emphasis on preventative skills, such as de-escalation.

2.11 Therapeutic observations

The current Observation and Engagement Policy (C36) is in the process of being reviewed.

Staff workshops have been facilitated to define its content including observations forms,

competency processes, and resources for service users/carers/staff.

3.0 Serious Incidents and patient safety updates

3.1 Serious incidents within the Trust

In this reporting period there have been 25 serious incidents reported, sixteen of these were

unexpected deaths, two related to drug and alcohol misuse, all are to be investigated.

There has been one patient safety alert issued because of early learning findings and action

was needed immediately; this related to an incident whereby an inpatient used a plastic bag

to asphyxiate. As a result, the Trust has issued a blanket ban on plastic bags within working

age adult inpatient areas.

There have been two abconsions resulting in no harm within specialist services.

There have been two incidents of serious assault; one on a member of agency staff by a

patient, police are aware, and the staff member is receiving support; and one where a patient

seriously assaulted his partner.

There has also been one ‘near miss’; an attempted assault where a patient whilst on leave

visited a fellow patient’s home and threatened her, support was offered to her at the time; on

his return to the ward he was subsequently violent towards staff, his behaviour such that it

could not be managed safely on an open acute ward and he was transferred to one of the

Trust’s intensive care units with the support of police colleagues.

There has also been one fall in Older Persons’ Services resulting in injury, the circumstances

around the fall will be investigated for learning however it his was not reported as a RIDDOR.

A RIDDOR report requires evidence of a lapse in health and safety planning, for example

environmental risks, and/or a failure to appropriately assess and manage the patient’s physical

risk of falling, in this case there is no evidence of any omissions.

3.2 Prevention of future deaths (PFD - Regulation 28)

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The Trust has received one PFD in this period. This relates to a young person who died

following a Paracetamol overdose. The Coroner recorded a verdict of “natural causes”.

The Coroners concerns related to three areas;

There was evidence that there was a 11-week delay in seeing the young person by the

Eating Disorder Team. In order to prevent delays accessing care when a service user

presents with complex co-morbid mental health conditions the following process has been

developed;

Care coordinators will request other teams to joint work and/or provide consultation

to ensure all relevant expertise is promptly accessed

Input from another team will be prioritised according to risk, the person will not be

held on a waiting list if there is an urgent need

Any concerns regarding capacity and access to care will be escalated to the locality

operational manager.

The teams will work closely together to ensure that relevant interventions and

treatments are offered in line with the service user’s care plan

Reviews and meetings will include professionals from all the care teams involved.

The service user and family/carer will be kept informed throughout.

There was no written up-to-date care and crisis plans in place; the Trust recognises the

importance of Care Plans for all service users and that these need to be done in collaboration

with the service user and their families / carers if possible. However, in some circumstances

this can take time in which case an interim care plan will be put in place whilst a more

comprehensive and collaborative is being developed. The Children’s and Family Mental Health

team plan to offer updated training in care planning and crisis or safety planning with all staff

over the coming months.

The Trust was also criticised for not proactively following up on a joint learning event to be

organised by the Acute General Hospital. A small task and finish group attended by the Trust

to address this action went ahead in early November 2019; as a result, a multi-agency learning

event is planned for the New Year.

The Trust has responded to the Coroner’s concerns in full within the appropriate timescale.

3.3 Incident reporting

There is nil of note in relation to the data in incident reporting currently, all SPC are displaying

common cause variations (incidents, complaints, compliments, safeguarding, leave and self-

harm). Medication incidents shows a ‘spike’; however, this is one data point only, an

astronomical point, and will require monitoring. The increase is predominantly across our

Suffolk inpatient services, one hypothesis being this is due to a medicine’s management focus

undertaken following the CQC inspection. Medicines Management forms one of the Trust

workstream priorities and this hypothesis will be tested through that workstream.

4.0 Safeguarding

4.1 Overview

As of September 2019, each clinical care group has an allocated safeguarding practitioner link

who is available to deliver bespoke training, supervision, case discussion and support in the

10.1




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completion of safeguarding investigations. The Safeguarding Team also commenced

delivering safeguarding supervision to all senior staff responsible for case management and

supervision in line with the updated addendum within the C89 Safeguarding Children Policy.

The Named Doctor for Safeguarding Children, Dr Maxwell, and the Named Nurse, Rebecca

Clegg, delivered the first session of bespoke level 3 safeguarding children training to medical

staff alongside an open case discussion and supervision session in September 2019. The

feedback from medical staff was positive and this mode of delivery will continue every six

months.

Despite an improvement in level 3 safeguarding children training with an overall Trust

compliance of 72% there remain areas of concern predominantly in Suffolk. All clinical care

groups have been tasked with providing an action plan to address this deficit; this will be

monitored and escalated where necessary by the Trust Safeguarding Committee by January

2020.

4.2 Serious Case Reviews

Currently there is one ongoing SCR (AE) with Trust involvement in Norfolk; this is yet to be

signed off by the Safeguarding Partnership. There has been one multi-agency learning event

in Suffolk, the actions from which have not yet been finalised.

4.3 Safeguarding Adult Reviews

Norfolk has finalised one SAR with Trust involvement which is due for publication in January

2020.

4.4 Domestic Homicide Reviews

In Suffolk there are two reviews in progress, one of which is due for publication soon; both

have Trust involvement. There are also two reviews ongoing in Norfolk with Trust involvement

- timescales to completion and publication are pending.

5.0 Suicide prevention

5.1.1 National Suicide Prevention Funding Wave 1:

Norfolk and Waveney STP benefited from this funding; it was agreed that the Trust

would use their allocated share to complete a Quality Improvement (QI) project into

improving family involvement in their loved ones’ care when they are suicidal focusing

on the Great Yarmouth and Waveney Care Group. A Consultant Psychologist,

Deirdre Williams, was funded to complete this for one day a week. Funding ends in

February 2020. Following a series of listening events “change ideas” resulted in the

following:

1) Delivery of the Stepping Back Safely course for carers (full day)

2) Delivery of 3 - 4 staff workshops (half day)

3) A safety planning clinic for three individual service users and their carers for four

consecutive weeks in December and pilot the approach.

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Version 05



Deidre Williams has been invited to present this project by Maria Gabriel in January’s

Board Meeting.

5.1.2 National Suicide Prevention Funding Wave 2:

Both Norfolk and Waveney STP and Suffolk and North Essex STP have received

funding for Wave 2. It has been agreed that NSFT will commence a piece of work

focusing on Safety Planning in inpatient areas. The aim of the project is that every

service user who is discharged from one of the inpatient units in the project area will

leave with an individualised Safety Plan. The funding is being used as follows:

Each ward will receive a 3-hour Safety Planning Course from the Recovery

College.

A Peer Support Worker is employed for 1 - 2 hours a week on each ward to

help staff formulate safety plans with service users, carers and families.

The six wards agreed that will benefit from this funding are:

Great Yarmouth and Waveney

Samphire

Thurne

Northgate

Poppy

Avocet

Currently we are in the process of booking in the Safety Planning teaching with

individual wards. An expression of interest for the Peer Support Worker has been

worded and sent to the Recovery College for approval and circulation.

5.1.3 48-hour discharge QI project

As part of the Trust’s “Zero Suicide Ambition for Inpatient Units”, a QI Project is

proposed to ensure that a meaningful 48hr contact takes place with the patient

following discharge from an inpatient unit. National evidence indicates that people

are at increased risk of suicide in the first three days following discharge from an

inpatient unit.

Inpatient wards invited to be part of this project are those identified through an audit

to be completing less than 60% of follow-ups within 48 hrs and who have a number

of patients discharged of over 50 within the month; these are:

Thurne Ward

Waveney Ward

Glaven Ward

Northgate Ward

Avocet Ward

Southgate Ward

Poppy Ward

Failures Project charts are to be sent to lead nurses and modern matrons to progress.

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Version 05



5.1.4 Experienced Based Co-Design Project – Introducing Zero Suicide Ambition to

Inpatient Units

As part of the Trust’s “Zero Suicide Ambition to eliminate suicides in Inpatient Units”

an Experienced Based Co-Design Project (EBCD) is to take place on Samphire Unit

in West Norfolk. This is to take ideas from staff, service users and carers about how

we make the inpatient environment more therapeutic which will increase the inpatient

ability to engage in inpatient treatment and lessen the risk that they will take their life.

The EBCD project will include people with experience of feeling suicidal engaging with

current inpatient and carers to formulate ideas of change. A core group has been

established, the project with begin late December / early January 2020.

5.1.5 A study of inpatients who were absent without leave (AWOL)

The Suicide Prevention Lead is to commence a study of all inpatients who were

AWOL (near misses) with support from Dr Kapil Bakshi. The purpose is to see if there

were any common factors, and indicators for change which could influence a future

QI project.

5.2 Family Liaison Officer

Jenni Carvey commenced her role in July 2019; following a one-month induction she began to

see families who have lost loved ones through an unexpected death under Trust Services.

Contact with the FLO is offered at initial contact between our Chief or Deputy Chief Nurse and

families; this offer is offered again at one month and three months post the loss as not all

families or carers are ready to accept the offer at the immediate time of their loved one’s death.

So far, a number of families have been offered Jenni’s support, of which ten are active. A

further cohort of families has been offered support and their cases will remain open.

We are discussing ways in which we can start gaining feedback about the FLO role in order to

ensure that the service is meeting demand. The FLO has met with a number of peers from

other mental health Trusts. The model is interpreted in different ways across the health

landscape; it will be of interest to begin to formulate a framework to measure the success of

the role utilising feedback from individuals who have used it in the future.

6.0 Flu vaccination Campaign

The Board of Directors recognise the importance and value of healthcare workers being protected

from seasonal influenza through vaccination to protect staff, their families and our service users.

The Trust aims to improve uptake of vaccination of healthcare workers in NSFT, with an ambition

of 100% of healthcare workers being vaccinated against influenza.

The Trust has a multi-disciplinary flu group that has produced a multi-component annual flu plan to

help reach this ambition, which is based upon the National Institutes for Health and Care

Excellence guidelines (NG103) and Public Health England’s Campaign for healthcare staff

vaccination.

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Version 05



To ensure best practice has been followed, the NSFT Board of Directors wishes to publish a self-

assessment of this year’s staff flu vaccination campaign attached below.

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Trust Board –2019

Version 01



Patient Safety SPC charts

Appendix 1

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Tab 10.1 Item

19.134: Patient S

afety and Quality R

eport

38 of 181B


ublic - 21st Novem

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Version 01



Staffing SPC charts

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Tab 10.1 Item

19.134: Patient S

afety and Quality R

eport

39 of 181B


ublic - 21st Novem

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Version 01



Service user experience SPC charts

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Tab 10.1 Item

19.134: Patient S

afety and Quality R

eport

40 of 181B


ublic - 21st Novem

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G Item: 19.135


Meeting date: 18th November 2019

Title of report: Access and Waiting Times Report



Author: Gill Morshead, Access Improvement Director

Director: Stuart Richardson, Chief Operating Officer

Executive Summary:

NSFT has identified the improvement of access to services and the reduction in waits to community and in-patient services as one of its highest strategic priorities. We recognise that timely intervention and treatment is key to better outcomes for service users and their families and carers and is a basic tenet of the NHS Constitution 2010. Remedial Action Plans for all teams with waits, with measurable actions required to meet access standards, have been instigated and will are owned by the Care Group Service Directors with progress monitored by at the monthly Quality and Performance Meetings. A trust wide to team level to service user level Waiting Times Report has been introduced to teams to ensure responsive and consistent information to drive remedial action and ongoing referral management.

The following high-level plan has been established:

To introduce a defined community Referral to Treatment (RTT) pathway for community services. The scope is for adults, older people, children families and young people and learning disabilities.

To have consistent practice in the management of referrals from assessment to allocation to treatment.

Service users’ safety & experience is always maintained with visibility of those awaiting treatment & system for clinical review.

To regularly report waiting times at Team, Care Group / Service Line & Board.

To ensure there are monitoring systems in place to assess demand and capacity.

To take improvement actions where waits are outside of the defined access standards.

Progress against the plan is monitored by the Access improvement Taskforce which reports to the Quality Committee and is referenced in the performance report to the Board. There will be a slide deck available to the Board at the meeting which gives a performance overview as of the end of September for waits to assessment and treatment. Following the introduction of the Care

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Tab 10.2 Item 19.135: Access and Waiting Times


Groups in September 2019, reporting has been aligned to the new configuration and will be reported against these in the next period.

The Board of Directors is asked to note and approve the oversight of access improvement and action in progress.

1.0 Recommendations

1.1 To note the content of the report.


2.1 Slide set – Access Improvement

10.2

Tab 10.2 Item 19.135: Access and Waiting Times


BoD: 21 November 2019

Strategic Activity Update

Version 1.0 Author: Mason Fitzgerald

Department: Corporate

Page 1 of 9 Date produced: Retention period:



Title of report: Strategic Activity Update



Author: Oli Matthews, Head of Strategy & Business Development

Mason Fitzgerald, Deputy CEO / Director of Strategic Partnerships

Director: Mason Fitzgerald, Deputy CEO / Director of Strategic Partnerships

Executive Summary:

The aim of this report is to provide the Trust Board with an update on key areas of the Trust’s strategic decision-making, planning and management. It is structured to provide information on:

∑ The national context.∑ Our partnership working in local integrated care systems.∑ Progress in developing the new Trust strategy.

The report contains a number of national news items that will be of interest to the Trust, as well as updates from our local systems. The report provides an update on the project to develop new wards at the Hellesdon Hospital site. A project structure is in place and a Project Board will commence in January 2020.

The report also provides an update on the implementation of the new Trust strategy. A set of priorities for the remainder of the 2019/20 financial year have been developed and are included in the report for Board review. The key next steps are to develop of care group plans aligned with the strategy, integrating the strategy into induction and development programmes, and commencing the development of Trust-wide annual priorities for 2020/21, following consultation with governors, staff and other stakeholders.

The report links to the risk 2.2 on the BAF.

Recommendation:

The Board is asked to discuss and discuss the contents of this report.


HItem: 19.136

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Tab 11.1 Item 19.136: Strategic Activity Update








1.0 National Context: Emerging Themes, Policies and Initiatives

1.1 Online primary care: response from the CQC

1.1.1 Online provision of health and care services challenges the existing regulatory landscape by transforming how care is delivered, where and by whom. The majority of medicines are prescribed and dispensed safely and appropriately online. However, in some cases people are able to access medicines that are not appropriate for them, or in quantities that their regular GP or other NHS services would not prescribe for them. The impact on people and their families can be catastrophic.

1.1.2 The CQC have become concerned that some providers of online primary care are configuring services in ways that take them out of scope of some or all UK regulators. This means they are not legally subject to the same inspections and safety checks.

1.1.3 The professional and system regulators are working together with partner organisations to develop shared principles on remote consultations and prescribing to provide support to regulated healthcare providers and professionals.

1.1.4 The General Pharmaceutical Council (GPhC) has published updated guidance for pharmacy owners providing pharmacy services at a distance, including on the internet. This includes further safeguards to help make sure that people can only obtain medicines from online pharmacies that are safe and clinically appropriate for them. GPhC inspectors are looking for evidence that the guidance is being followed during pharmacy inspections.

1.1.5 The General Medical Council (GMC) has guidance for doctors on remote consultations and prescribing, as well as specific advice on good practice in this area. Later this year GMC plans to launch a call for evidence on whether its prescribing guidance needs to be updated in light of the fast pace of change in remote healthcare services.

1.1.6 The CQC has inspected all registered online providers in England and published the findings fromthe first programme of inspections. All registered online providers will now receive a quality rating following inspection. CQC has requested changes to the law to bring online providers into regulation that have so far been out of scope due to their configuration, which means they must be registered with CQC by law.

1.2 NHS bids to cut up to 100 million plastic straws, cups and cutlery from hospitals

1.2.1 The NHS will reduce the use of plastic in hospital canteens as part of its drive to lower waste and make hospitals healthier for patients and staff. Major high street names operating in hospitals and suppliers have cut the amount of single-use plastics in hospitals, starting with straws and stirrers from April with cutlery, plates and cups phased out over the following 12 months. This is part of a

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https://www.pharmacyregulation.org/sites/default/files/document/guidance_for_registered_pharmacies_providing_pharmacy_services_at_a_distance_including_on_the_internet_april_2019.pdf

https://www.pharmacyregulation.org/sites/default/files/document/guidance_for_registered_pharmacies_providing_pharmacy_services_at_a_distance_including_on_the_internet_april_2019.pdf

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices/remote-prescribing-via-telephone-video-link-or-online

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices/remote-prescribing-via-telephone-video-link-or-online

https://www.gmc-uk.org/ethical-guidance/ethical-hub/remote-consultations






package of measures in the NHS Long Term Plan to reduce the environmental impact of the health service.

1.2.2 NHSE chief executive Simon Stevens has urged hospital trusts who have in-house catering to step up and match stores’ commitment by signing a pledge to support the moves to reduce the amount of plastic waste in the NHS.

1.2.3 The NHS Long Term Plan outlines a number of steps the NHS will be taking to reduce impact on the environment in other areas as well, including a shift to lower carbon inhalers and anaesthetic gases, as well as ensuring hospitals make progress in reducing waste, water and carbon to cut air pollution and save lives. The NHS is also drawing up designs for new more environmentally friendly ambulances that could be used across the country and is working with developers, local councils and other partners to ensure new housing developments have health and wellbeing built in from the start.

1.2.4 Statistics

1.2.5 The NHS bought at least 163 million plastic cups, 16 million pieces of plastic cutlery, 15 million straws and 2 million plastic stirrers last year. If the NHS cut its use of catering plastic in half it could mean over 100 million fewer items each year end up polluting the oceans or in landfill. The NHS has also been at the forefront of reducing waste and its impact on air pollution, with the carbon footprint of the health and social care sector cut by 19% since 2007 despite a 27% increase in activity. Between 2010 and 2017 health and care also reduced water consumption by 21%, equivalent to around 243,000 Olympic swimming pools.

1.2.6 Sign up to the Pledge

1.2.7 NHSE has written to providers urging them to back the campaign, sign the pledge and curb plastic waste. Many parts of the NHS are already tackling the unnecessary use of these items:

1.2.8 Yorkshire Ambulance Services NHS Trust is saving around four tonnes of plastic waste a year after a campaign to remove plastic waste from the staff canteen. The trust replaced plastic milk bottles

11.1



https://www.engage.england.nhs.uk/survey/dee161d9/

https://www.longtermplan.nhs.uk/






with glass, plastic cutlery with wood and plastic drinks bottles with cans and introduced a water refill point.

1.2.9 Sheffield Teaching Hospitals NHS Foundation Trust has removed more than half a million single-use plastic items from its canteens, including 227,000 pieces of cutlery and 231,180 cups.

1.2.10 The Newcastle upon Tyne Hospitals NHS Foundation Trust is saving £80,000 and has removed every year almost 2 million single-use plastic items, including cutlery and bowls.

1.2.11 The full list of suppliers who have signed up to the pledge is: WHSmith, Marks & Spencer, Boots, Greggs, OCS Group UKIME, Serco, Sodexo, NHS Supply Chain, Hospital Caterers Association, Hubbub and WRAP.

1.3 NHS taskforce to drive improvements in young people’s hospital mental health, learning disability and autism care

1.3.1 NHSE Chief Executive Simon Stevens announced that a new taskforce will be set up to improve current specialist children and young people’s inpatient mental health, autism and learning disability services in England. The NHS Long Term Plan sets out an ambitious programme to transform mental health services, autism and learning disability; with a particular focus on boosting community services and reducing the over reliance on inpatient care, with these more intensive services significantly improved and more effectively joined up with schools and councils.

1.3.2 Anne Longfield OBE, Children’s Commissioner for England, will chair an independent oversight board to scrutinise and support the work of the taskforce. The Children’s Commissioner and her board will be given wide-ranging scope to track progress and propose rapid improvements in existing services, examine the best approach to complex issues such as inappropriate care, out of area placements, length of stays and oversee the development of genuine alternatives to care, closer to home. The establishment of the inpatient taskforce and independent oversight board, comes as part of a package of measures in the NHS Long Term Plan to ensure that all NHS services operate at safe and effective levels, as well as immediately injecting a boost in care quality.

1.3.3 The taskforce will seek to:

ß Make a rapid set of improvements in care – over 18 months – but starting immediately.ß Agree a set of recommendations for next steps.

1.3.4 Specialist taskforce delivery teams will be made up of doctors, nurses, psychologists, psychiatrists and other medical professionals. The group will be asked to consider the best way to deliver compassionate care for acute need – including reviewing independent sector and NHS provision –

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https://www.longtermplan.nhs.uk/






including giving nurses and other staff the right clinical expertise and managing issues like seclusion and segregation in inpatient settings.

1.3.5 The NHS Long Term Plan is already committed to expanding access to ‘CYPMHs’, creating more crisis alternatives, developing new models of care for young adults and ending the so-called ‘cliff edge’ that can exist when 18-year olds transition to adult mental services. Alongside treating acute conditions, the Plan commits to delivering a £2.3 billion funding injection for community mental health services, as well as record-high investment in children’s care, to provide care for 345,000 extra young people and more than 370,000 adults with severe mental illness.

1.4 Self-harm: Girls 'more likely to end up in hospital

1.4.1 Swansea University academics looked at 15,739 cases where young people, aged from 10 to 24, accessed health services for self-harm between 2003 and 2015. Girls are more likely to end up in hospital after self-harming than boys, according to a study. It found cases of self-harm were highest among 15 to 19-year-olds. The study found a big gender disparity among 10 to 15-year-olds, with 76% of girls admitted to hospital and 49% of boys.

1.4.2 The findings have been used by the Welsh Government to provide guidance to schools in Wales about self-harm in that it was a "cause for concern" that fewer boys were admitted although they can choose not to remain in hospital.

ß From 2011 the largest increases in self harm were seen among 10 to 14-year-olds, particularly girls.

ß Self-harm rates more than doubled in deprived areas compared with affluent communities.ß More than half (58%) of those seeking emergency care for self-harm were boys and young men.

1.4.3 The study looked at data from the places young people sought help; such as GPs, A&E units, outpatient clinics, and hospital admissions in Wales. It did not look at the reasons behind why people self-harm but was noted the findings highlighted opportunities for early intervention important to recognise that any contact with healthcare services is an opportunity to provide support and intervention. GPs have said they would welcome further training or help to know how to support young people who present to them.

1.4.4 The fact that boys and young men are preferentially seeking help in emergency departments means that this is an important setting for this often hard to reach group for healthcare. The findings have been published in the Archives of Disease in Childhood. The Welsh Government launched a consultation aimed at tackling mental health issues with new data showing 11,000 young people sought counselling in 2017-18.

1.4.5 Papyrus the suicide prevention charity noted the report findings were consistent with its experiences from handling inquiries to its national helpline, mostly from young women in the 15 to 19 age group.

11.1



https://gov.wales/suicide-and-self-harm-guidance-launched-support-schools

https://gov.wales/suicide-and-self-harm-guidance-launched-support-schools

https://adc.bmj.com/content/early/2019/09/16/archdischild-2019-317248.full

https://www.bbc.co.uk/news/uk-wales-50151883






Analysis of data around calls from 'concerned others' - including parents, teachers, youth workers, and anyone concerned with the wellbeing of a young person - has shown an increase in the number of calls concerning young people aged 12 to 16 years who are self-harming.

2.0 Regional Update: New Care Models Collaborative

2.1 New Care Models Collaborative

2.1.1 The New Care Models Collaborative launch event was held on 4 October 2019, attended by service leaders, commissioners and governors from Norfolk and Suffolk. Papers will be considered by the Finance, Business & Investment Committee in November.

2.1.2 Clinicians and managers from the effected services are currently engaged in service modelling. We still await full financial and usage data from NHSE, which should arrive imminently.

2.1.3 The final business cases will be submitted to NHS England in April, following approval by the six Collaborative Trusts.

2.2 Local Integrated Care Systems

2.2.1 Both systems have submitted their draft responses to the Long-Term Plan to NHS England, which will be published in December. NSFT has been well engaged in the development of the plans. Summaries will be presented to the Council of Governors in the new year.

2.3 Norfolk & Waveney STP

2.3.1 An initial ‘test offer’ of a three-strong mental health team in one GP practice per PCN footprint has been agreed, comprising a Band 7 and Band 6 clinician and a Peer Support Worker.

2.3.2 Suggestions have been invited for ideas as to how “111 press 2” can be implemented locally.

2.4 Suffolk and North East Essex ICS

2.4.1 The Suffolk Mental Health Alliance transformation work has entered the next phase, with the focus now on the development of more detailed service pathways within the four priority workstreams:

∑ Priority One: Children, Young People and Families

∑ Priority Two: Community (including IAPT/Wellbeing)

∑ Priority Three: Crisis

∑ Priority Four: Learning Disabilities and Autism

2.4.2 This work is scheduled to be completed by the end of February 2020.

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2.5 Hellesdon Hospital New Wards Development

2.5.1 On 2nd August 2019 NSFT received a letter from the Department of Health and Social Care (DHSC) confirming that the Trust had been allocated £38m capital funding following the original application submitted via Norfolk and Waveney STP in July 2018.

2.5.2 The original application was based on the build of 4 new twenty bedded adult acute wards on the lower plateau of the Hellesdon Hospital site.

2.5.3 A Project Group has been established and the first meeting was held on 5th September 2019. The Deputy CEO/Director of Strategic Partnerships is the SRO for the project.

2.5.4 Initial discussions at the Project Group has suggested that the Trust consider building 5 x sixteen bedded wards and not the original 4 x twenty bedded wards. A clinical workstream has been established and is meeting to assess the current and predicted future need for adult and transitional age acute services across Norfolk and Waveney, and the clinical model. The proposed solution will replace Glaven, Waveney and Thurne wards, as well as Yare ward which opened in September 2019.

2.5.5 A 48 month programme has been drafted, which is longer than the initial programme (36 months). The longer term programme allows for more engagement time at design stage and reduces the risk by planning and design happening consecutively and not parallel to each other.

2.5.6 The project group has also established workstreams around Estates and Communications/Engagement. Co-production is a key theme through out the project and Terms of Reference have been drafted to guide the project group and each workstream to ensure appropriate levels of involvement from staff, service users, carers, families and local communities.

2.5.7 STP oversight of the project is currently being led by the STP Chief Operating Officer, and the project reports in to relevant STP and NHSI/E leads and groups.

2.5.8 A Project Board will be established from January 2020 and will include non-executive and governor representatives, as well commissioner, STP and other key stakeholders.

3.0 Trust strategy

3.1 A framework for implementation of the Trust strategy is attached as Appendix A. It has been discussed at the executive meeting and the Service Delivery Board. The overall objective of the framework is to provide a structure that enables successful implementation of the strategy, ensuring that systems and plans are aligned to and support delivery of the strategy, and that we work effectively with our staff, service users, carers, governors and stakeholders in the development and delivery of plans.

3.2 Main areas of progress to date are as follows:

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∑ Revision of the Board Assurance Framework to assess and monitor strategic risks associated with the strategy

∑ Development of a suite of measures, and commencement of a review of current performance information to ensure alignment

∑ Development of supporting plans that support delivery of the strategy, including people, communications and digital. The communications plan is attached.

∑ Development of publicity material

∑ Development of priorities for the remainder of the 19/20 financial year. The priorities are as follows:– Continuing to develop the culture of the organization through our staff engagement, equality

and inclusion and culture and leadership programmes– Improving People Participation by supporting our PP Leads and developing our strategy– Further development of clinical leadership within our care groups– Financial sustainability – delivery of the 19/20 plan and planning for 2020/21– Providing effective care closer to home, through further reductions in out of area placements

and focus on delayed transfer of care– Improvements in access, physical environments and medication management

3.3 Key next steps are:

∑ Development of care group plans aligned with the strategy

∑ Integrating the strategy into induction and development programmes

∑ Commencing the development of Trust-wide annual priorities for 2020/21, following consultation with governors, staff and other stakeholders

3.4 The high level Communications plan is shown below:

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HIGH-LEVEL COMMUNICATIONS AND ENGAGEMENT PLAN DRIVERS COMMUNICATIONS & ENGAGEMENT ACTION

Engage & Inspire Our Staff

Improved staff intranet and staff communication channelsStaff engagement planCelebrate successEmpower staff through two-way communicationsPublicity to support visible leadership and awareness around new Trust structureRoll out of Trust strategy to staffStaff engagement around future optionsPromotion of staff networks

Co-production, Partnerships & Recovery

People Participation promotion and micrositeJoint communications & engagement with partners to promote Norfolk & Suffolk mental health strategiesImproved media coverageInform and engage NHSI/NHSE on NSFT’s improvement journey

Align Our Governance and Systems

Promote excellence within Care Groups by highlighting best practice

Build Improvement Skills

QI promotion, microsite and event supportExternal promotion of QI successes

Projects Website dashboard on key performance areasStakeholder engagement & messaging around Trust improvementMarketing campaign to support recruitment

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1

Appendix A

NSFT Strategy Framework

1.0 Background

Norfolk and Suffolk NHS Foundation Trust (NSFT) has reviewed its strategic ambition following the recent appointment of a new Trust Chair and Chief Executive. The Trust had previously developed a strategy for 2016-2021, and also completes the NHSI/NHSE operating plan and contributes to local system plans.

Norfolk and Suffolk NHS Foundation Trust provides services for adults and children with mental health needs across Norfolk and Suffolk. Services for people with a learning disability are provided in Suffolk. They also provide secure mental health services across the East of England and works with the criminal justice system. Several specialist services are also delivered including a community based eating disorder service and a new perinatal mental health unit.

Norfolk and Suffolk NHS Foundation Trust was formed when Norfolk and Waveney Mental Health NHS Foundation Trust and Suffolk Mental Health Partnership NHS merged on 1 January 2012. Norfolk and Waveney Mental Health NHS Foundation Trust had gained foundation trust status in 2008.

The Trust has 392 beds and runs over 100 community services from more than 50 sites and GP practices across an area of 3,500 square miles. The Trust serves a population of approximately 1.6 million and employs over 3,600 staff including nursing, medical, psychology, occupational therapy, social care, administrative and management staff. It has a revenue income of £227 million for the 2019/20 financial year.

NSFT was subject to a CQC inspection in July 2017 and has been rated as “inadequate”, and placed in quality special measures. The Trust was previously in special measures and had exited in October 2016. The Trust has been progressing its Quality Improvement Plan and had a further inspection in September 2019.

The Trust is an active partner in local systems and is part of two Sustainability & Transformation Partnerships, Norfolk and Waveney STP and Suffolk and North Essex ICS.

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2

2.0 The proposed strategic planning framework and cycle

In light of the new Trust strategy, the Board wishes to review its approach to strategy development and implementation, in order to ensure the successful delivery of the strategy.

The proposed framework draws heavily on experience of engagement and improvement methodologies, with the following key principles:

• Effective working with staff, service users, carers, governors and stakeholders in the development and delivery of plans

• Regularly coming together to review progress, share learning and plan ahead

• Ensuring strategic alignment throughout the organisation, with all services and functions contributing towards the overall aim

• Being open and transparent in measuring and assessing our progress• Being ambitious and bold, whilst being clear about the risks involved and

how we are managing them

All strategy documents will be visual, “plans on a page”, in order to ensure focus on a small set of priorities, and promote engagement.

Figure 1 below provides an outline illustration of the trust’s framework for developing and implementing strategy

Analysis

Vision, mission, values

Strategic priorities, outcomes and risks

Annual Plan priorities, plans and measures

Supporting strategies

Care Group annual plans

Service/team priorities

Individual objectives

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3

3.0 Refresh of the mission and strategic objectives

The new Chief Executive, Professor Jonathan Warren, has led a review of the Trust’s vision, mission and strategic objectives.

The initial draft of the strategy was informed by staff engagement sessions, people participation days, feedback from governors and stakeholders, and a review of the external environment in which the Trust works.

The draft has gone out to consultation to all Trust staff, as well as being discussed at the following forums:

∑ Service Delivery Board June 2019∑ Oversight and Assurance Group June 2019∑ Council of Governors July 2019

The final draft was submitted to the September 2019 Council of Governors meeting, and to the Trust Board.

4.0 Measurement framework

As set out above, it is important for the strategy to have a clear measurement framework so that progress can be monitored. The Trust has not previously had any robust measurement system for strategic objectives, with measurement focusing largely on operational performance.

The principles of a new measurement system are as follows:

∑ To integrate strategic and operational measures so that all staff are engaged in both the delivery of high quality services and the development of services in line with the Trust’s vision and mission

∑ To choose measures that are most relevant to the vision and mission, impact across all strategic outcomes, and link to our portfolios of work.

∑ To select a small number of measures that are regularly monitored at Board, committee and Trust operational meetings, with other measures being monitored and reported by exception

∑ To utilise the way we view data in line with quality improvement methodology ∑ We will have the right balance between task, process and outcome measures∑ Recognise that not all measures we need will currently exist, and that these

will need to be developed over time ∑ To use measures as indicators of progress, rather than absolute targets, and

use other sources of quantitative and qualitative of information to assess overall progress

∑ To balance the requirements of regulatory and contractual targets

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4

5.0 Supporting and care group plans

It is vital that all parts of the organisation are pulling in the same direction, and therefore current strategies and plans need to be aligned to the new Trust strategy.

The following supporting plans will be reviewed and aligned to the strategy:

Supporting plan: Lead:People Director of HROrganisation Development Director of HREqualities Director of HRCommunications Director of CommunicationQuality Chief Nursing OfficerEstates Chief Operating Officer Digital Director of Finance

The following care groups will also complete annual plans aligned to the strategy.

∑ Norwich City and North Norfolk∑ West and South Norfolk∑ Great Yarmouth and Waveney∑ East Suffolk∑ West Suffolk∑ Secure∑ CYFP Norfolk

∑ CYFP Suffolk

6.0 Alignment of governance systems

Executive directors will be sponsors of the strategic objectives, and be accountable for the organisation of work in that area and reporting against objectives.

Strategic objective: Executive sponsors:Engaging and inspiring our staff Director of HRCo-production and partnerships Chief Nurse

Medical Director Align our governance and systems Director of Strategy

Director of FinanceBuilding improvement skills Chief NurseImmediate priorities Chief Operating Officer

Director of Finance

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5

The following governance systems will be reviewed in order to support delivery and monitoring of the new strategy.

Governance system: Lead:Risk Management Trust SecretaryPerformance Framework Director of FinanceInternal audit programme Director of FinanceHR framework Director of HR

7.0 Communication and engagement

A communications and engagement plan is being developed to promote awareness of the strategy and ensure staff, service users, carers, governors and stakeholders are actively involved in delivery of the strategy.

Key components of the plan are as follows:

∑ Inclusion of the strategy in all outward facing communications channels and material (i.e. recruitment pack, website etc.)

∑ A slot at Trust induction in order to translate the strategy to the role of individual staff

∑ Inclusion in staff development programmes and OD programmes ∑ Care Group away days to be held 3 times per year, focusing on learning and

sharing across the care groups ∑ Engagement with service users, carers, governors and stakeholders through

relevant forums, i.e. People Participation Committee, Council of Governors, Oversight and Assurance Group, and local system meetings.

8.0 Annual business cycle

It is important for progress to be monitored, and plans reviewed in light of changes in the internal and external environment. The Trust strategy will also inform planning submissions the Trust makes to national bodies and local systems, including the NHSI/E operating plan, and responses to the NHS Long Term Plan.

The following annual business cycle sets out key activities which need to be aligned. This will be updated as and when further requirements are known.

Month: Activity:September 2019 ∑ Draft STP LTP mental health

implementation submissions due∑ Commissioning intentions for

2020/21 received∑ Annual General Meeting/Annual

Members Meeting

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6

November 2019 ∑ Planning commences for 2020/21December 2019 ∑ National planning guidance and

commissioning allocations published

∑ STP LTPs publishedFebruary 2020 ∑ Annual Plan consultation

exercise commencesMarch 2020 ∑ Council of Governors feedback to

Trust Board ∑ Trust Board approval of 2020/21

plans∑ Commissioner contracts finalised

April 2020 ∑ Revision of supporting plansMay 2020 ∑ Revision of care group plans

9.0 Monitoring progress

Progress against the strategy will be monitored as follows:

∑ Monthly reports to the Service Delivery Board (strategy update; integrated performance report)

∑ Board sub-committees reviewing progress in relevant areas through deep dives and other agenda items

∑ Bi-monthly reports to the Trust Board (strategy update; integrated performance report and other items when due, i.e. approval of supporting plans)

∑ Regular reports to the Council of Governors/Performance Committee∑ Progress will also be reported as required to external meetings (i.e.

Performance Review Meeting; Oversight and Assurance Group)

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BoD in Public –21st November 2019 Integrated Performance Report

Version v1 Author: Daryl Chapman Department: Executive

Page 1 of 21 Date produced: 11th November 2019 Retention period: 20 years

Report To: Board of Directors


Title of Report: Integrated Performance Report

Action Sought: For Assurance

Estimated time: 10 Minutes

Author: Daryl Chapman, Director of Finance

Directors: Daryl Chapman, Director of Finance

Stuart Richardson, Chief Operating Officer

Executive Summary:

The purpose of this report is to provide information on Trust wide performance against a range of key performance indicators for the period to 30th September 2019.

Financial performance is reported for the period ending 31st October 2019.

The Board Assurance Framework is included in Appendix 3, showing the risks to delivery of the Trust’s strategic objectives and in relation to performance and mitigations to address those risks. It shows the movement in risk rating this month and target dates for meeting the target risk rating governed by the Board’s risk appetite in each area.

The information contained within this report is to inform practices and policies, identify areas for improvement, and to ensure NSFT delivers effective and efficient care for its service users.

Operational Performance

Waiting Times - The Trust continues to face challenges in meeting waiting time targets for commencement of both assessment and treatment. Performance against the 4 hour assessment waiting target for Emergency referrals for over 18 year olds has dropped by more than 21% since September 2018. Over the same period, performance against the 28 day waiting target for Routine referrals has dropped for under 18 year olds by nearly 17%, and 4% for over 18 year olds.

The Trust has been issued with three Contract Performance Notices for failure to meet waiting time standards, although assurances have been received from Commissioners that financial sanctions will not be taken.

This is a priority area of focus for operational teams and the new Service Directors have started work to understand the demand and capacity position for each of their services. Each Care Group has also been tasked to provide a Remedial Action Plan to address their waiting time performance, and these will be tracked through the ongoing Quality and Performance Meetings.


I Item: 19.137

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Tab 12.1 Item 19.137: Integrated Performance Report





Care Planning – After previous periods of improvement both CPA and Non CPA completeness performance since the start of the financial year has fallen by 4.9% and 1.4% respectively and remains behind target. However, feedback from Quality and Safety Reviews, People Participation Lead sample tests, and external inspections have suggested that the quality of care planning has improved over this period.

Work is underway to review whether the current Completeness metric is the most appropriate to use, as it requires all five elements of Care Planning Approach to be complete to obtain overall achievement, whereas individual elements are all more than 85% and have been for the last 12 months. Consideration is also being given to how the quality of care plans can be reflected in performance.

Delayed Transfers of Care (DToC) - Have exceeded target for five consecutive months. Performance was 1.9% above target (7.5%) for September 2019. However, the low DToC rate in Suffolk hides the Norfolk and Waveney DToC position, which reports at 16.8% for September 2019, largely driven by increased DToC’s within older people services

Inappropriate OAP bed days – OAP for adult mental health services is at its lowest point over the last year, down to 574 bed days. However, OAPs are still 75 bed days above target for September 2019 and therefore remain an area of focus. OAPs in Norfolk and Waveney account for c96% of the bed days reported in September 2019, with the majority relating to Older Persons placements, which reflects the impact of the high DToC rate identified above.

Work is ongoing with Norfolk and Waveney commissioners and the Local and District Councils to identify actions that will reduce the DToC rates and subsequently allow for Service Users to be repatriated to local beds.

Local commissioner specific metrics

The Norfolk and Waveney Wellbeing service was 1.89% under the cumulative

IAPT access target for September 2019

In Suffolk the % of young people under 19 with an eating disorder receiving

NICE-approved treatment within 1 week for urgent cases and 4 weeks for routine

cases was 37.0% and 9.0% below the locally agreed targets respectively. The

Norfolk and Waveney performance for 4 weeks for routine cases is 30.7% below

the 95% target

Across Suffolk and Central Norfolk Psychiatric Liaison, emergency referrals seen

within 1 hour reported 6.8% and 6.2% under target respectively

In Suffolk the Emotional Wellbeing Hub service has 220 cases open to the Hub

who have been open more than 10 working days at the end of September, down

from 334 reported in July. A recovery plan is now being implemented which is

working towards a trajectory of meeting the target in November 2019

In Suffolk the % of inpatients admitted with a mental illness who received a

physical health check was reported at 70.4% against a target of 95%

In Suffolk none of the service users out of seven aged 0-18 received an

assessment within 13 weeks of referral in September

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Finance Performance

The position for the month was a deficit of £0.1m which was in line with annual plan

Out of Trust (OOT) placements expenditure was £0.3m in October

Secondary commissioned placements expenditure was £0.5m in October

The spending on agency staffing was above the NHS Improvement agency cap for the month and is £0.7m overspent YTD

Cash held by the Trust at 31st October 2019 was £15.4m

The 2019/20 CIP target of £10.9m is forecast to be delivered in full

The full performance and finance reports were discussed at the Finance and Business Investment Committee on 15th November 2019.

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Section A (i): Operational Performance Indicators not achieved in the period

This section summarises the indicators which were not achieved in the period to the end of September 2019.

Area Indicator Indicator

Reference Target Actual Change

SOF Data Quality Maturity Index (DQMI) – MHSDS score OP05 95% 94.69% 0.15%

SOF Inappropriate out of area placements for adult MH services OP09 499 574 638

WAITS Emergency referrals assessed within 4 Hours OP11 95% 73.89% 1.68%

WAITS Routine referrals assessed within 28 days OP12 95% 71.92% 5.49%

WAITS Referrals awaiting treatment >18 weeks OP14 0 169 19

CPA Service users allocated to either a CPA or Non CPA level OP17 95% 92.84% 0.06%

CPA CPA Service Users Completeness OP18 95% 63.99% 0.34%

CPA Non CPA Service Users Completeness OP19 95% 47.85% 1.30%

INPAT Inpatients whose transfer of care was delayed OP20 7.5% 9.36% 0.01%

INPAT Women’s Secure Service Bed Occupancy Rate (Inc. leave) OP24 95% 68.54% 0.21%

INPAT No. of Adult Acute inpatients with Length of Stay > 117 days OP25 0 14 1

INPAT Care programme approach (CPA) - proportion of discharges from hospital followed up within 7 days

OP27 95% 94.94% 0.63%

LOCAL Suffolk Under 19's with an eating disorder receiving NICE-approved treatment within 1 week for urgent cases

OP15a 67.0% 30.00% 24.55%

LOCAL Suffolk Under 19's with an eating disorder receiving NICE-approved treatment within 4 weeks for routine cases

OP16a 69.0% 60.00% 1.67%

LOCAL Suffolk Psychiatric Liaison - Emergency referrals seen within 1 hour

OP28a 95.0% 88.16% 5.87%

LOCAL Suffolk DIST Service users have individual care plan once DIST take over active case management

OP31a 95.0% 91.84% 3.51%

LOCAL Suffolk DIST Service users have individual care plan once DIST take over active case management

OP33a 95.0% 91.86% 0.85%

LOCAL All patients admitted with a mental illness should receive a physical health check

OP41a 95.0% 70.37% 11.94%

LOCAL Suffolk Learning Disability Service users have an up to date appropriate care plan

OP42a 95.0% 90.78% 1.25%

LOCAL Suffolk CMAS Service - Time from referral to first assessment within 6 weeks

OP44a 95.0% 71.43% 8.18%

LOCAL Suffolk CMAS Service - The diagnosis is given within 12 weeks of referral, unless any further specialist assessments or investigations are required

OP45a 95.0% 27.78% 3.17%

LOCAL Suffolk EWH Patients will have a total time in the Hub from point of referral to discharge (encompassing Screening, triage and discharge) of 10 working days

OP51a 95.0% 49.68% 17.65%

LOCAL Suffolk Youth Autism services (ages 0-18): 13 Weeks from Referral to Assessment in accordance with NICE guidance

OP52a 95.0% 0.0% 0.0%

LOCAL Norfolk and Waveney IAPT: Proportion of people that enter treatment

OP10b 9.5% 7.61% 0.17%

LOCAL N&W Under 19's with an eating disorder receiving NICE-approved treatment within 4 weeks for routine cases

OP16b 95.0% 64.29% 19.05%

LOCAL Norfolk and Waveney Psychiatric Liaison - Emergency referrals seen within 1 hour (NNUH Psy Liaison only)

OP28 90.0% 83.84% 5.48%

LOCAL Norfolk and Waveney DIST Emergency referrals assessed within 4 Hours

OP32b 95.0% 25.0% 25.00%

LOCAL Norfolk and Waveney DIST urgent referrals assessed within standard (120 hours Central & West CCG's Only)

OP31b(i) 95.0% 83.56% 10.96%

LOCAL Norfolk and Waveney DIST urgent referrals assessed within standard (72 hour GY&W Only)

OP31b(ii) 95.0% 91.67% 8.33%

LOCAL Norfolk and Waveney CAMHS LD - Percentage of assessments to be initiated within 8 weeks of acceptance of the referral.

OP46b 90.0% 80.00% 20.00%

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Community Performance

Data Quality Maturity Index (DQMI)

Performance

As of January 2019 the DQMI now includes 17 data items of which two, ethnicity and primary reason for referral, are the main reason for not achieving the 95% target (actual – 94.69%). Primary reason for referral is reporting at 56% which has increased by 1% month on month for the past 6 months, whilst ethnicity was reported at 92%. The Trust are working on expanding the DQMI measure to introduce a further 19 data items to bring it into line with the full 36 as selected by the NHS England Mental Health Policy Team. There are no plans to introduce any further additional metrics for the remainder of the 2019-20 contract financial year.

Actions

Staff have been advised at Trust’s Data Quality meeting that this primary reason must be captured on both external and internal referrals as per the standard operating procedure. A report to care groups to identify the specific breaches on a regular basis is being developed. Ethnicity data is available to care groups on a daily basis via the business intelligence tools. Ethnicity is not a spine held value so the electronic referral system (ERS) cannot help in terms of an automated update. All access teams are aware that they should update the core demographic data if it is on the referral documentation from the GP. Recording ethnicity is within the NSFT Standard Operating Procedures and is recommended practice. The November Service Delivery Board received a paper on the DQMI and MHSDS requirements and committed to support the developments needed to achieve this metric.

Wait to Assessment Metric 4 hours and 28 days

Performance

The clinical change for 100% of emergency (4 hour) referrals to be seen face to face by a clinician as from the 1st December 2018 negatively impacted the reported performance as demonstrated by the drop in performance shown in Chart 1.

Chart 1

Emergency referrals assessed within 4 hours are reported under target at 73.9%. This is a 1.7% improvement on the reported performance for August. Table 1 demonstrates that trust wide performance is significantly impacted by the underperformance attributable to Norfolk and Waveney for service users aged 18 and over. This is particularly in the West Norfolk, and North Norfolk and Norwich Care Groups.

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Table 1

Region Age Group Performance

Norfolk & Waveney

Under 18 93.33%

18 and Over 56.93%

Suffolk Under 18 94.12%

18 and Over 93.19%

Further analysis on the length of time that a Service User waits for an emergency assessment is shown in Table 2. While the majority are seen within 5 hours, there is a noticeable spike in Servicer Users waiting over 12 hours, which relates to the West Norfolk, and North Norfolk and Norwich Care Groups. The Care Groups are investigating these breaches and will provide assurance that these Service Users are not at an increased risk of harm as a result of these extended waits.

Table 2

Routine (non-emergency) referrals assessed within 28 days reported under target at 71.9%, a 5.5% reduction on August’s reported performance. As chart 2 demonstrates the system will be expected to consistently fail this target unless significant actions are taken to address performance.

Chart 2

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Actions

Breaches now reviewed under the clinical harm review policy to provide assurance. Teams are looking to free capacity by releasing staff from training, offering additional working hours, finding alternative venues, reducing DNA’s and recruitment of additional staff. A minimum 24/7 staffing requirement across the crisis pathway is in place. In Suffolk a review of the access and assessment team and service delivery is underway.

Further assurance is required in respect of emergency referrals, to evidence that people not being seen within four hours are safe and the delay is not increasing their risk of harm. The Norfolk and Waveney's Health and Care Partnership (STP) has won national funding to improve services and support the priorities established in Norfolk and Waveney's Adult Mental Health Strategy, launched earlier in 2019. £1.1m of funding over two years will be used to increase staffing levels across the Trust's Crisis Resolution and Home Treatment Teams, focusing on developing 7-day, 24-hour provision across Norfolk and Waveney.

Wait to Treatment Metric

Performance

The number of incomplete pathways waiting for treatment greater than 18 weeks is reporting 169 incomplete waits, which equates to c4% of all incompletes. This is a decrease of 19 when compared to August 2019. Of the 18 week waits:

62 (36.7%) relate to ADHD services in Suffolk, a fall of 19 from August 2019

57 (33.7%) relate to CFYP services in Norfolk and Waveney, a fall of 5 from August 2019

Chart 3 demonstrates the system will be expected to consistently fail this target unless significant actions are taken to address performance.

Chart 3

Actions

Across the Trust targeted work is underway with teams to ensure the waits are monitored and specific areas of concern are escalated when service design is identified as limiting performance. In Suffolk CFYP there is an agreed action plan for the Children’s ADHD service and the service is reducing the number waiting over 18 weeks in line with the recovery plan trajectory. Provisional performance for October shows the number waiting over 18 weeks for Suffolk ADHD services has fallen to 46. In CFYP services in Norfolk and Waveney resource was ‘front loaded’ in an effort to meet the 28 day assessment standard. This reallocation of resource has had an unintended consequence of service users having to wait longer for treatment. In an effort to address this the service will be piloting an assessment clinic to free up capacity to treat service users within the expected timeframes. Waits across the Trust continue to be monitored through the weekly SUTL meetings.

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CPA and Non CPA completeness

Performance

The percentage of Service users allocated to either a CPA or Non CPA level was 92.8%, a 4.3% improvement on the reported performance 12 months previous. However performance has stagnated since January 2019 and remains under the 95% target. CPA (Care Programme Approach) completeness (all items required are completed within the service user electronic record) was reported at 64.0%, a 0.3% reduction on August’s performance. Non CPA completeness was reported at 47.9%, a 1.3% improvement on August’s performance. Charts 4 and 5 demonstrate that after periods of improvement both measures have fallen since the start of the financial year and the system will be consistently expected to fail this target unless significant actions are taken to address performance.

Chart 4

Chart 5

Actions

CPA policy has been reviewed and process simplified for service users receiving non-CPA care. A new combined assessment has been developed and implemented in consultation with services lines in Norfolk and Suffolk. Starting in early 2020, the phased introduction of a new Care Planning Approach (CPA) system will take place across NSFT. Teams will use DIALOG+, a simple evidence-based intervention, to assess satisfaction with quality of life, treatment and address concerns, while helping to pave the way to good communication between service users and their clinicians. A Trust wide CPA Lead and deputy continue to lead on delivery of the new approach.

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It is intended that the current metric is reviewed to ensure that the target is appropriate and that the quality element of the CPA process is also monitored. At the most recent Oversight and Assurance Group, there were offers of support from stakeholders representing our Service Users and Carers. Updates on progress of this work will be given at future meetings.

Inpatient Performance

Inappropriate Out of Area Placements (OAP) bed days for adult mental health services

Performance

Chart 6 demonstrates inappropriate OAP bed days for adult mental health services is at its lowest point over the 12 month period September 2018 to September 2019, down to 574 bed days. However OAPs are still 75 bed days above target for September 2019 and remains an area of focus. OAPs in Norfolk and Waveney account for c96% of the bed days reported in September 2019.

Chart 6

Actions

NSFT, Norfolk & Waveney CCGs and NHS England have collaborated through a Patient Flow Mobilisation group to review and approve, monitor and challenge a number of change projects designed specifically to positively impact on the inappropriate OAP position. There are three key areas of focus:

Community mental health services capacity and transformation – with plans to deliver as much

mental health care as possible at a Primary Care Network level.

Crisis responses – additional funding is being used to strengthen crisis team services in NSFT and

increase mental health support within the QEHKL and JPUH acute hospitals

Reducing delayed transfer of care (DToC) – actions are outlined in the section below

Executive level governance and assurance on OAP occurs every week on plans for the upcoming week

Inpatients whose transfer of care was delayed

Performance

Chart 7 demonstrates that delayed transfers of care (DToC) across NSFT remain a cause for concern. Performance has been above target for 5 consecutive months. The low DToC performance for Suffolk reduces the impact of the Norfolk and Waveney DToC position which reports at 16.8% for September 2019 largely driven by increased DToC’s within older people services.

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Chart 7

Actions

Alongside the Inappropriate Out of Area Placement position, the Patient Flow Mobilisation group is also monitoring the DToC position for the Trust. In September 2019 NSFT and Norfolk County Council have agreed to use new national DToC guidance (November 2018) to reduce the minimum period of time required before DToCs are declared (from 10 to 3 days). Following a DToC workshop with system partners in July 2019, a new Standard Operating Procedure will be developed to support this change. NSFT are working with housing, social care, district councils and wider services to support people to leave hospital at the right time. Local Commissioner Specific Metrics

IAPT Access metric

Performance

The Norfolk and Waveney Wellbeing service was 1.89% under the cumulative IAPT access target for September 2019. The cumulative target is based on achieving the currently commissioned 19% annual target in Norfolk and Waveney by the end of the 2019/2020 financial year.

Actions

An Access Strategy Group continues to meet monthly to review actions to improve access and updating the strategy when necessary. Actions include initiatives to; work with Primary Care Networks to source increased clinical space in GP Practices to increase service visibility, improve waiting times and reduce dropout rates to improve the image of the service, the implementation of an online choose and book system to reduce demand on the telephony system and increase capacity, a targeted social media campaign and utilising underspend accrued from staff vacancies to purchase additional digital treatment options.

Eating Disorders Wait to Treatment Metric

Performance

In Suffolk the % of young people under 19 with an eating disorder receiving NICE-approved treatment within 1 week for urgent cases and 4 weeks for routine cases was 37.0% and 9.0% below the locally agreed targets respectively. The expectation nationally is that CYP Eating Disorder services will achieve the 95% target by Q4 2019/2020 and in Suffolk a trajectory has been agreed with commissioners to achieve this.

The Norfolk and Waveney performance for 4 weeks for routine cases is 30.7% below the 95% target. This equates to 5 breaches out of 14 which were primarily attributable to service users not wishing to engage with the service.

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Actions

In Suffolk work is underway to reduce the delays occurring in the Emotional Wellbeing Hub service who receive the original referral before referring onto the Eating Disorders service. In Norfolk and Waveney the service are working collaboratively with commissioners to address service user non-engagement.

Psychiatric Liaison Emergency Wait to Assessment

Performance

Across Suffolk and Central Norfolk Psychiatric Liaison emergency referrals seen within 1 hour reported 6.8% and 6.2% under target respectively.

Actions

In Suffolk a business case for the Psychiatric Liaison service has been approved by the Suffolk Alliance for additional investment and performance is expected to improve once the new posts are filled. Additionally the referral process is to be reviewed to ensure that patients referred to the team are medically fit to be assessed.

Emotional Wellbeing Hub

Performance

In Suffolk the Emotional Wellbeing Hub service has 220 cases open to the Hub who have been open more than 10 working days at the end of September, down from 334 reported in July. A recovery plan is now being implemented, working towards a trajectory of meeting the target in November 2019. This recovery plan is already beginning to have an effect as the average length of wait of those waiting at month end has reduced from 73 days in April to 12 days in September for under 18’s and has reduced from 33 days in April to 11 days in September for under 18 to 25’s.

Actions

Additional Leadership posts have been recruited to provide clear clinical and operational management.

Learning Disability (LD)

Performance

In Suffolk the % of LD Service users who have an up to date appropriate care plan was reported at 90.8%, a 1.3% improvement on August’s performance. This equates to 25 service users behind the 95% target.

In Norfolk and Waveney the percentage of CAMHS LD assessments initiated within 8 weeks of acceptance of the referral reported at 80% for September 2019, which equated to one breach out of 5 assessments.

Actions

Deputy Service Managers and Clinical Team Leads across Suffolk have worked closely with teams to support clinicians in completing care plans to increase compliance.

Physical Health Checks at admission

Performance

In Suffolk the % of inpatients admitted with a mental illness who received a physical health check was reported at 70.4%, an 11.9% improvement on August’s performance. The majority of breaches relate to either; data entry issues which are being addressed (41%) or service users who have declined physical health checks (27%)

Actions

Training is currently being set up for clinical support workers to work with junior doctors to set up physical health clinics. The Deputy Service Manager has been working with ward managers and modern matrons to improve the recording of reasons why physical health checks are not done at point of admission. There is ongoing work to identify frequent data entry issues and resolve these prior to reporting.

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Community Memory Assessment Service (CMAS)

A number of new local commissioner KPI’s for the CMAS service in Suffolk have been incorporated into reporting for the 2019/20 financial year for the first time. Business Support Managers continue to investigate recording practices to ensure these KPI’s reflect true performance. Youth Autism Service

Performance

In Suffolk none of the service users out of 7 aged 0-18 received an assessment within 13 weeks of referral in September.

Actions

The service is working collaboratively with commissioners to review the Autism pathway in line with national guidance. This will explore what actions can be taken to ensure a safe wait and how to address capacity issues longer term

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Section B: Financial performance in the period – October 2019 Our financial position is as follows:

OUT OF TRUST & SECONDARY COMMISSIONED PLACEMENTS

Total OOT bed days decreased from 522 in September to 435 in October. Total expenditure for the month

was £0.3m.

Secondary commissioned placements spend was £0.5m.

Per the Norfolk and Waveney contract risk share agreement, NSFT fund the first £3.1m from within block

funding, CCG’s fund the next £2.9m, with a 50:50 risk share on any further spend.

The current forecast trajectory of OOT spend coupled with the current level of specialist placements

suggests NSFT has a forecast cost pressure of c.£2.8m.

TEMPORARY STAFFING

The NHS Improvement (NHSI) Trust agency spending cap has been set to the same limit as 2018/19 at

£10.3m.

The following table provides a summary on overall temporary staffing spend.

The key booking reason for agency for qualified nursing and medical staff is unfilled vacancies.

STATEMENT OF COMPREHENSIVE INCOME (SOCI) - YTD

Plan Actual Variance

£'000 £'000 £'000

Operating Income (144,946) (146,861) 1,915

Pay Costs (Substantive, Bank & Overtime) 102,624 101,190 1,434

Agency & Locum Costs 5,776 6,779 (1,003)

Drugs Costs 1,340 1,534 (194)

Other Costs 28,627 30,606 (1,979)

EBITDA 6,579 6,752 173

Depreciation 4,724 5,023 (299)

Non Operating Income (25) (78) 53

Non Operating Expenses 2,380 2,310 70

Net surplus / (deficit) (501) (503) (2)

EBITDA margin 4.5% 4.6%

ACTUAL SPEND £'000s ACTUAL SPEND £'000s

Agency Bank Total Agency Bank Total

Medical 577 577 Medical 3,928 - 3,928

Qualified nursing 306 201 507 Qualified nursing 1,962 1,400 3,362

Unqualified nursing 33 521 554 Unqualified nursing 102 3,739 3,841

Clinical A&C 7 34 41 Clinical A&C 179 187 366

Scientific & Therapeutic 21 1 22 Scientific & Therapeutic 208 11 219

Corporate 150 150 Corporate 400 - 400

1,094 757 1,851 6,779 5,337 12,116

NSFT Annual Plan 802 NSFT Annual Plan 5,776

NHSI Cap 870 NHSI Cap 6,123

OCTOBER YEAR TO DATE12.1






CIP

The agreed CIP target for 2019/20 submitted in the revised Annual Plan is £10.9m, and this is forecast to

be achieved in full, although there remains £1.5m of unidentified savings as at the end of October.

CASH FLOW

As at the end of October, the Trust held cash and cash equivalents of £15.4m, which was £5.7m ahead of annual plan. CAPITAL SPEND

The total capital spend YTD is £2.8m against the planned capital spend of £5.9m.

Quality implications

Adherence to our financial plan and compliance with Standing Financial Instructions enables the Trust to

improve its service quality within the financial resources available.

Equality implications / summary of consultation

There are no equality implications arising from the plan.

Risks / mitigation in relation to the Trust objective

Based upon current performance and in order to achieve the revised control total, the following areas need

to be closely monitored and controlled.

(i) Agency and locum spend

(ii) External placement trajectory and forecast costs for the year

(iii) Financial impact of CQC recommendations and requirements

(iv) Directorates not manging their financial performance

(v) Identification and delivery of CIP programme

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Appendix 1: Operational Performance Dashboard September 2019 Notes: 1) OP01 - Only reporting on referrals to existing (a) 14-35 year old early intervention services in Suffolk, and (b) 14-65 year old early intervention services in Norfolk & Waveney. No NSFT early intervention services currently

commissioned to triage, assess and treat people with an at-risk mental state

NHS Oversight Framework KPI's

People with a first episode of psychosis begin treatment within 2 weeks of referral OP01 Rolling 3 months 56% 66.67% 0.00%

a) in inpatient wards OP02 Annual 90% 20.83%

b) early intervention in psychosis services OP03 Annual 90% 43.59%

c) community mental health services (people on Care Programme Approach) OP04 Annual 65% 45.45%

Data Quality Maturity Index (DQMI) – MHSDS dataset score OP05 Quarterly 95% 94.69% 0.15%

IAPT: Proportion of people completing treatment who move to recovery OP06 Quarterly 50% 54.79% 0.45%

IAPT: waiting time to begin treatment (from IAPT minimum data set) within 6 weeks OP07 Rolling 3 months 75% 94.10% 0.45%

IAPT: waiting time to begin treatment (from IAPT minimum data set) within 18 weeks OP08 Rolling 3 months 95% 100.00% 0.00%

Inappropriate out of area placements (bed days) for adult mental health services OP09 Monthly 499 574 -638

Waiting Times KPI's

Emergency referrals assessed within 4 Hours OP11 Rolling 3 months 95.0% 73.89% 1.68%

Routine (Non-emergency) referrals assessed within 28 days OP12 Monthly 95.0% 71.92% -5.49%

Referrals treated within standard OP13 Monthly 95.0% 95.15% -1.61%

Referrals awaiting treatment >18 weeks OP14 Monthly 0 169 -19

Care Programme Approach KPI's

Service users allocated to either a CPA or Non CPA level OP17 Monthly 95.0% 92.84% -0.06%

Care Programme Approach (CPA): CPA Service Users Completeness OP18 Monthly 95.0% 63.99% -0.34%

Care Programme Approach (CPA): Non CPA Service Users Completeness OP19 Monthly 95.0% 47.85% 1.30%

Inpatient KPI's

Inpatients whose transfer of care was delayed OP20 Monthly 7.5% 9.36% 0.01%

Long-term inpatients that have received an annual Physical health check OP21 Monthly 100.0% 100.00% 2.27%

Medium Secure Bed Occupancy Rate (including leave) OP22 Monthly 90.0% 91.11% 0.01%

Low Secure Bed Occupancy Rate (including leave) OP23 Monthly 90.0% 100.66% 4.10%

Women’s Secure Service Bed Occupancy Rate (including leave) OP24 Monthly 95.0% 68.54% -0.21%

Number of Adult Acute inpatients with Length of Stay > 117 days OP25 Monthly 0 14 1

Patients requiring acute care who received a gatekeeping assessment OP26 Rolling 3 months 95.0% 97.25% 0.82%

Care programme approach (CPA) - proportion of discharges from hospital followed up within 7 days OP27 Rolling 3 months 95.0% 94.94% 0.63%

Outcomes KPI's

IAPT Service users shall demonstrate reliable improvement OP36 Monthly 60.0% 70.56% 2.88%

Performance

TrackerTrend

Performance

TrackerTrend

Performance

TrackerTrend

Performance

TrackerTrend

Performance

TrackerTrend

Ensure that cardio-metabolic assessment and treatment for people with psychosis is delivered routinely:

TargetIndicator Reference

Reporting Period

ChangeCurrent Performance


Reporting Period



Reporting Period



Reporting Period



Reporting Period


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Appendix 1: Operational Performance Dashboard September 2019 (cont.)

Local - Suffolk CCG Specific KPI's

IAPT: Proportion of people that enter treatment OP10a Cumulative YTD 9.5% 10.77% -0.01%

Under 19's with an eating disorder receiving NICE-approved treatment within 1 week for urgent cases OP15a Rolling 3 months 67.0% 30.00% -24.55%

Under 19's with an eating disorder receiving NICE-approved treatment within 4 weeks for routine cases OP16a Rolling 3 months 69.0% 60.00% 1.67%

Psychiatric Liaison - Emergency referrals seen within 1 hour OP28a Monthly 95.0% 88.16% 5.87%

Psychiatric Liaison - Routine referrals seen within 24 hours OP29a Monthly 95.0% 97.16% -0.82%

Connect Service - Time from referral to treatment OP30a Monthly 90.0% 100.00% 10.00%

DIST referrals (excluding referrals from A&E) - assessment within 1 Operational Day of receipt of the referral OP31a Monthly 95.0% 91.84% -3.51%

DIST referrals from A&E - Assessment within 4 hours of receipt of referral during DIST operational hours OP32a Monthly 95.0% N/A N/A

DIST Service users have individual care plan once DIST take over active case management OP33a Monthly 95.0% 91.86% 0.85%

Discharges that have a Valid Pair of HoNOS scores where applicable OP39a Monthly 25.0% 31.72% -0.83%

Active Referrals with no activity recorded within 9 months OP40a Monthly 4.0% 3.20% -0.36%

All patients admitted with a mental illness should receive a physical health check OP41a Monthly 95.0% 70.37% 11.94%

Learning Disability Service users have an up to date appropriate care plan OP42a Monthly 95.0% 90.78% 1.25%

CMAS - Initial contact is made with all people who are newly referred within two weeks of referral OP43a Monthly 95.0% 98.95% -1.05%

CMAS - Time from referral to first assessment within 6 weeks OP44a Monthly 95.0% 71.43% 8.18%

CMAS - The diagnosis is given within 12 weeks of referral, unless any further specialist assessments or investigations OP45a Monthly 95.0% 27.78% -3.17%

Patients will have a total time in the Hub from point of referral to discharge (encompassing Screening, triage and OP51a Monthly 95.0% 49.68% -17.65%

Youth Autism services (ages 0-18): 13 Weeks from Referral to Assessment in accordance with NICE guidance OP52a Monthly 95.0% 0.00% 0.00%

Youth ADHD services (ages 0-18): 13 Weeks from Referral to Diagnosis (point at which ICD10 code is applied) OP53a Monthly TBC 0.00% -10.34%

Local - Norfolk and Waveney CCG Specific KPI's

IAPT: Proportion of people that enter treatment OP10b Cumulative YTD 9.5% 7.61% -0.17%

Under 19's with an eating disorder receiving NICE-approved treatment within 1 week for urgent cases OP15b Rolling 3 months 95.0% 66.67% -33.33%

Under 19's with an eating disorder receiving NICE-approved treatment within 4 weeks for routine cases OP16b Rolling 3 months 95.0% 64.29% -19.05%

Psychiatric Liaison - Emergency referrals seen within 1 hour (NNUH Psy Liaison only) OP28 Monthly 90.0% 83.84% -5.48%

Psychiatric Liaison - Emergency referrals seen within 4 hours (JPUH & QEHKL only) OP28b Monthly 95.0% 99.30% 0.88%

Psychiatric Liaison - Routine referrals seen within 24 hours (NNUH Psy Liaison only) OP29b Monthly 95.0% 96.09% -1.49%

DIST urgent referrals assessed within standard (120 hours Central & West CCG's Only) OP31b(i) Monthly 95.0% 83.56% -10.96%

DIST urgent referrals assessed within standard (72 hour GY&W Only) OP31b(ii) Monthly 95.0% 91.67% -8.33%

DIST Emergency referrals assessed within 4 Hours OP32b Monthly 95.0% 25.00% -25.00%

Adult Acute Service (CRHT) - Referral to Treatment met the 12 hour standard (Central Norfolk CCG areas Only) OP34b Monthly 50.0% 77.00% 5.73%

CAMHS LD - Percentage of assessments to be initiated within 8 weeks of acceptance of the referral. OP46b Monthly 90.0% 80.00% -20.00%

Under 18 urgent referrals assessed within standard (120 hours Central & West CCG areas Only) OP47a(i) Monthly 95.0% 64.71% 18.04%

Under 18 urgent referrals assessed within standard (72 hour GY&W CCG areas Only) OP47a(ii) Monthly 80.0% 100.00% 0.00%

18 and Over urgent referrals assessed within standard (120 hours Central & West CCG areas Only) OP47b(i) Monthly 95.0% 70.31% -2.79%

18 and Over urgent referrals assessed within standard (72 hour GY&W CCG areas Only) OP47b(ii) Monthly 80.0% 90.00% -0.44%

Percentage of dedicated 136 staff available in s136 suite within a maximum standard (1 hour) of police arrival in the OP48b Monthly 95.0% 100.00% 7.14%

Increase the number of people being diagnosed with dementia, and starting treatment, within six weeks from referral OP49b Monthly TBC 57.83% -5.63%

CAMHS Service (under 18 years of age) Percentage of accepted and assessed as requiring crisis support having a OP50b Monthly TBC 0.00% 0.00%

National

Completion of a valid NHS Number field in mental health and acute commissining data sets submitted via SUS. NQR02 Monthly 99.0% 100.00% 0.31%

Completion of Mental Health Services Data Set ethnicity coding for all Service Users. NQR03 Monthly 90.0% 93.82% 0.94%

Performance

TrackerTrend

Performance

TrackerTrend

Performance

TrackerTrend


Reporting Period



Reporting Period



Reporting Period


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Appendix 2: Statistical Process Control (SPC) Charts An SPC chart is a plot of data over time. It allows you to distinguish between common and special cause variation. It includes a mean and two process limits which are used in the statistical interpretation of data. SPC charts are used to measure changes in data over time. SPC charts help to overcome the limitations of RAG ratings, through using statistics to identify patterns and anomalies, distinguishing changes worth investigating (Extreme values) from normal variations. The charts consist of;

A line graph showing the data across a time series. The data can be in months, weeks, or days- but it is always best to ensure there are at least 15 data points in order to ensure the accurate identification of patterns, trends, anomalies (causes for concern) and random variations.

A horizontal line showing the Mean. This is the sum of the outcomes, divided by the amount of values. This is used in determining if there is a statistically significant trend or pattern.

Two horizontal lines either side of the Mean- called the upper and lower control limits. Any data points on the line graph outside these limits, are ‘extreme values’ and is not within the expected ‘normal variation’.

A horizontal line showing the Target. In order for this target to be achievable, it should sit within the control limits. Any target set that is not within the control limits will not be reached without dramatic changes to the process involved in reaching the outcomes.

Normal variations in performance across time can occur randomly- without a direct cause, and should not be treated as a concern, or a sign of improvement, and is unlikely to require investigation unless one of the patterns defined below applies. Identifying patterns

Normal variation- (common cause) fluctuations in data points that sit between the upper and lower control limits that do not reach the criteria for a Trend.

Extreme values- (special cause) any value on the line graph that falls outside the control limits.

These are very unlikely to occur- and where they do, there is likely a reason or handful of reasons outside the control of the process behind the extreme value.

A Trend- a trend may be identified where there are 7 consecutive points in either a pattern that could be; a downward trend, and upward trend, or string of data points that are all above, or all below the mean. A trend would indicate that there has been a change in process resulting in a change in outcome.

E.g. on an SPC chart showing patient waiting times; there may be a run of 7 points below the mean. This indicates that there has been a change in the process- such as there are more appointment slots available than what there was previously (this would reduce the waiting times). This could be down to something like there has been a new member of staff recruited (increasing the potential appointments available), or appointment times have been shortened (meaning that more appointments can be booked in the same period). Icons are used throughout this report either complementing or as a substitute for SPC charts. The guidance below describes the meaning behind each icon.

12.1






Appendix 3 – Board Assurance Framework

Strategic

Objectives

Risk

Ref

Risk Description Inherent

Risk

Rating

(LxC)

Existing Controls

(measures in place to reduce

likelihood)

Assurances on controls Nov 2019

Risk

Rating

LxC

Gaps in controls and/or

assurance

Target

Risk

Rating

Progress with actions to address gaps Date for

Review

Lead

Assurance

Committee Lead

1.1 Lack of focus on staff

engagement and development

will adversely impact on

leadership and staff morale,

resulting in poor outcomes for

patients and carers.

R

4 x 4 = 16

Culture change programme, led

by HR team and overseen by

NED-led Cultural Change Group.

Medical Education Improvement

Plan working closely with Health

Education England. Nursing

education programme. Quality

Improvement projects on

employee relations. increased

focus on clinical supervision.

Staff Governors. Equality &

Diversity work

Trust Parntership Forum.

Annual Staff Survey

Monthly Pulse Surveys

Workforce reports to Board.

Regular HR reports to executive

Service Delivery Board and

Quality Committee.

Quality Assurance Committee

and Appts & Remuneration

Committee take assurance of

effective staff engagement.

Council of Governors - have set

this as focus area. Medical

Education Survey

WRES data. FTSUG reports to

BoD

A

3 x 4 = 12

Annual Staff Survey and

WRES data highlights

improvements needed.

Internal audit report on

consultant job planning -

No assurance opinion

staff vacancies

A

2 x 4 = 8

Mar 2020

1. Culture Change programme underway,

monitored by Culture Change Group 'People

Before Process'. Report to each Board.

Diagnostic phase to be completed by end Jan

20

2. Trust's People Strategy implementation

3. Equality Diversity & Inclusion Strategy for

approval by Nov BoD

4. Medical Director for workforce reviewing

support for medical workforce and training

places for junior doctors and addressing

actions for consultant job planning. Working

closely with HEE. and Associate Nurse

Director and AHP lead focusing on nursing and

AHP development and Preceptorship

programme.

5. Care Groups implementing priority actions

from Staff Survey results.

Jan-20 Service Delivery

Board

Appointments &

Remuneration

Committee

MG

1.2 Lack of development and

support for the new Care

Group management

structures, and their

relationship with the executive

and Board, impacts on the

effectiveness of those

leadership teams and results

in poor clinical outcomes.

R

4 x 4 = 16

Programme of NED and exec

visits to teams. Care Group

Leadership induction

programme. Regular comms

bulletins. Breakfast meetings with

teams. Care Group senior

leadership now in place and

comprehensive induction

programme throughout

September and on going.

FTSUG. comprehensive

induction for new care group

leader complete

Quality Performance Meetings.

Monthly Pulse Surveys.

Executive walkabouts and

breakfast meetings. Clinical

outcome KPIs and performance

reporting dashboards reviewed

by BoD, Executive, FBIC

A

2 x 4 = 8

Phase 2 of care group

management re-structure

underway

Y

1 x 4 = 4

March

2020

1. Leadership programme continues for Care

Group - Trust Five-year leadership

development strategy for all levels of staff.

2. Care Group Senior leadership review

complete and phase 2 under development

3. People before Process culture change

programme.

4. New governance framework of reporting and

accountability co-produced with care group

leadership

5. Reviewing leadership development strategy

for all levels of staff

6. Quarterly leadership forums implemented

plus Service Delivery Boards

Dec-19 Service Delivery

Board

Quality

Assurance

Committee

MG

Norfolk & Suffolk Foundation Trust Board Assurance Framework (BAF) - 11 November 2019

NSFT Strategic aim - Supporting people to live their hopes, dreams and aspirations

The Board Assurance Framework forms the key document for the Trust in ensuring all principal risks to the Trust's objectives are controlled, that there is sufficient assurance as to the effectiveness of these controls, which underpins the Trust's system of internal control.

The Trust Risk Management Framework details how the Assurance Framework is populated and maintained.

1. E

ngage a

nd in

spire o

ur

sta

ff

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2.1 Poor engagement with service

users and carers and other

stakeholders will mean that

their views are not heard and

responded to, and result in

services that do not meet the

needs of local communities.

A

3 x 4 = 12

Appointment of People

Participation Leads in each Care

Group. newly established Patient

Participation Committee reporting

to BoD - overseeing PP Strategy.

Triangle of Care. Working

Together Hub. Carers Network.

Service User Engagement

Forum. Service Users, Carers

and Governors trained in QI

methodology as part of last

cohort. and taking forward QI

projects.

Reports to BoD and People

Participation Committee.

Progress with Quality

Improvement projects involving

SUs reviewed by Quality

Committee. CQC inspection

Reports. Progress reported In

Quality Improvement Plan at

Board. Council of Governors.

Healthwatch. HOSC

A

3 x 4 = 12

Further develop people

participation and carer

involvement and true co-

production

Y

1 x 4 = 4

Jul 2020

1. Making Families Count conferences 14th

November

3. People Participation leads appointed for

each of the care groups, developing clear

objectives and workstreams, with infrastructure

to support them.

Jan-20 People

Participation

Committee

DH

2.2 Not working in a collaborative

way with STP colleagues and

other system partners will

prevent the transformation of

services and result in risks to

services and Trust

sustainability.

A

3 x 4 = 12

Key member of STP/ICS groups

Norfolk & Waveney and Suffolk &

North East Essex. NSFT CEO is

SRO for N&W STP MH Group.

Working with partners to deliver

the two adult MH and CYP

strategies (Norfolk and Suffolk).

New Models of Care Work in

collaboration with regional MH

Trusts.

Feedback from STP/ICS

partners, including

commissioners, primary care,

Healthwatch, HOSC. OAG

meetings open to all

stakeholders. BoD and CoG

receive regular updates on

implementation of the strategies

and implications for NSFT

A

3 x 4 = 12

Implementation of Mental

Health strategies in

partnership with Norfolk &

Waveney and Suffolk &

North East Essex STP/ICS

- Alliance working

A

2 x 4 = 8

Mar 2020

1.Active partner in development of MH offer to

Primary Care Networks (PCNs)

2. Suffolk Alliance - work underway to

implement Suffolk MH & Emotional Wellbeing

strategy; high level models agreed for

workstreams

3. NSFT and NCH&C signed MoU to work

together to deliver better integrated services

4. Working with both STP/ICS to develop local

5 Year plans

5. Working closely with all partners and

agencies on EU Exit plans 6. Mapping and

prioritisation of transformation work to be

completed

Dec-19 Service Delivery

Board

MF

3.1 Lack of support for the Trust’s

Quality Improvement

programme will jeopardise the

successful establishment of

the programme and result in

poor staff morale and patient

outcomes.

R

4 x 4 = 16

Quality Improvement Team

provide support and training to

staff, service users, governors,

stakeholders on QI methodology.

Building capacity and capability.

Individual coaching sessions for

each project. Working with Care

Group Leadership

Quality Improvement Report to

BoD. Quality Assurance

Committee scrutinises

performance. Quality

Performance Meetings with

Care Groups

A

2 x 4 = 8

Address CQC

recommendations on

quality and safety and to be

a learning organisation

Y

1 x 4 = 4

Mar 2020

1. Continuing to embed Quality Improvement

(QI) methodology throughout the Trust - key

tenet of Trust Strategy; advertising for more

infrastructure support.

2. more staff and service users trained in QI

methodology. Providing pocket introductory QI

session in December. Board training on QI

methodology in October.

3. Participating in National QI projects:

Reducing Restrictive Intervention, Sexual

safety

6. Quality& Safety reviews underway, learning

from these and from incidents

Dec-19 Quality

Assurance

Committee

DH

3.2 Not implementing learning

from complaints, incidents,

Coroner’s recommendations

and other information means

that issues continue to occur

and may result in harm to

patients.

R

4 x 4 = 16

Serious Incident (SI) policy and

process - RCAs, liaising closely

with families for each incident.

Duty of Candour. SI Scrutiny

panel. newly appointed Family

Liaison Officer. Suicide

Prevention Lead. Patient Safety

Manager. Patient Safety Alert

process. Organised variety of

learning events. Complaints and

PALs process. Quality and safety

reviews. E9

Quality Performance Meetings

CQC inspections

Quality Improvement Plan

monitored by Quality

Committee and Quality

Assurance Committee. SI

reports to BoD

CCGs review performance at

contract meetings. OAG and

OSM with NHSI. Commissioner

contract meetings

R

4 x 4 = 16

Address CQC

recommendations on

quality and safety, to be a

learning organisation

Y

1 x 4 = 4

Mar 2020

1. Changes to Serious Incident process;

involving families and carers in every review.

New SI and Mortality Review Group.

2. Pop Up Learning events, Patient Safety Alert

process, co-produced learning events

3. Care Group Lead Nurse and Clinical Director

now responsible for leading complaints

process to enusre learning and embedding of

changes to practice

4. employing a Peer Support Worker to

improve learning

5.Learning from Quality & Safety reviews

6. Continuing to roll out QI methodology with

Care Groups to be learning organisation

Jan-20 Quality

Assurance

Committee

DH

2. C

o-p

roductio

n a

nd p

art

ners

hip

s3. B

uild

ing q

ualit

y im

pro

vem

ent skill

s

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4.1 Not achieving compliance with

CQC essential standards

results in risks to patient and

carers, as well as the Trust’s

sustainability and reputation.

R

4 x 4 = 16

"Buddy" arrangement with ELFT

for Trust support. Quality

Improvement Plan - QI

methodology, Quality & safety

reviews, learning organisation.

Culture change programme

New Governance architecture to

improve assurance reporting and

flow of information ward to board

to ward. New clinically led Care

groups established. MH Act

compliance work. Recruitment of

new NEDs and Executive

Directors

Oversight & Assurance Group

meetings and PRM with NHSI


reported to each Board and

scrutiny by Quality Assurance

Committee; CQC Inspections;

Contract meetings with

commissioners

R

4 x 4 = 16

CQC report - Inadequate

November 2018; awaiting

report from October 2019

inspection

Y

1 x 4 = 4

January

2020

1. Quality Improvement Plan implementation to

address quality and safety, restrictive

interventions; monitored closely by NHSIE

2. New clinical leadership in Care Groups, with

revised governance and Quality Performance

Meetings to monitor performance and provide

support.

3. improvements in ward to board flow of

information and assurance, more work

underway to develop clinical governance and

sub-group meetings and workplans.

4. CQC inspection mid October 2019 and

further table top review November; initial

feedback, awaiting final report for publication in

January 2020.

Jan-20 Board of

Directors

JW

4.2 Not making progress in

reducing waiting times creates

a risk to service users, as well

as breaches of contractual

and regulatory standards.

R

4 x 4 = 16

Clinical harm review process

reviewed. Service User tracker in

place. Quality & Safety Reviews.

New Director appointed to

address waiting times. Access

Improvement Team in place

reporting to COO. Service users’

safety & experience is always

maintained with visibility of those

awaiting treatment & system for

clinical review.

High level Performance

Dashboard reports reviewed by

Board include deep dives on

waiting times and processes for

keeping people safe; Quality

Assurance Committee provides

scrutiny. Access Improvement

Task Force receives

escalations from SUTL. CQC

Inspections

OAG and OSM monthly

meetings with NHSI. Contract

meetings with commissioners

R

4 x 4 = 16

Increasing demand leading

to high waiting times

Ensuring service user

safety is maintained and

visibility of those awaiting

treatment

A

2 x 4 = 8

Nov 2020

1. Access Improvement Director to ensure SU

Tracker List becomes BAU within Care

Groups, with oversight by Trust Wide Access

Improvement Group

2. Service Directors to provide RAPs to Access

Improvement Team (AIT) for non compliant

areas

3. Care Groups to implement Trust wide

Access Policy from Jan 20

4. Access Improvement Director (AID) and

Clinical Leads to conduct deep dives into

ADHD, Autism and ED pathways by 29.02.20

and shared with key stakeholders by 31.03.20

5.Quality Summits to be held before March to

include feedback from the Quality Safety

Reviews and Clinical harm Audits.

6. AID and Deputy Director Contracts,

Performance and Information to undertake a

demand and capacity analysis for 2 PCNs in

partnership with local Care Groups by march

to determine the effect on access rates and

compliance following proposed

transformational changes and access to

services via PCN’s.

Dec 19

Dec 19

Jan 20

Feb 20

Mar 20

Mar 20

Mar 20

Service Delivery

Board

Quality

Assurance

Committee

SR

4.3 Non-delivery of savings and

income plans, including plans

to reduce out of area

placements, and investment

required to deliver change

programme, adversely

impacts on the Trust’s

financial position and results in

a risk of regulatory action and

risks to long-term financial

viability.

R

4 x 5 = 20

Agreed mitigation plan in Sept to

achieve Control Total,

Standing Financial Instructions,

finance controls, monthly review

with budget managers,

Monthly scrutiny and challenge by

Executive Group

Finance & Business Investment

Committee scrutiny,

Finance reports to Board,

Internal and external audit

reports,

Annual Accounts approval

OAG and PRM

R

4 x 5 = 20

Gap on delivery of

mitigation plan of £1.4m,

High reliance on non-

recurrent schemes,

Unknown cost pressures in

response to Quality

Improvement Plan,

Poor budget management

within operational teams,

Delay in implementing and

ongoing slippage OOT/SP

reduction plans

Y

1 x 4 = 4

March

2020

1. Executive have committed to delivering

mitigation plan, and confirmed appropriate and

achievable

2. Ongoing executive discussions on cost

pressures with individual Executive Director

ownership and accountability

3. External placement recovery plan being

reviewed and prioritised by COO

4. New Service Directors in place and

undertaking leadership training to include

financial management

Dec 19 Finance and

Business

Investment

Committee

DC

4.4 An imbalance between the

pace of change required to

address quality and safety

issues, versus the need for

long-term cultural change,

undermines change efforts

and results in disengaged

staff, patients and

stakeholders.

A

3 x 4 = 12

Cultural change programme

overseen by Cultural Change

Group led by NED. Regular

reports to BoD. BoD reviews

balance of financial sustainability

and quality and safety

requirements. FBIC provides

deep dive scrutiny

BoD and committee oversight.

Monthly Pulse reports

Staff Survey

Internal audit reports

OAG and PRM

Council of Governors

CQC inspection

NHSIE - exec to exec meetings,

OAG/OSM

A

3 x 4 = 12

Balancing pace of change

vs cultural programme with

some parts of the

organisation. Time and

resource to adequately

address quality and safety

issues

Y

1 x 4 = 4

Oct 2020

1. Cultural Change programme cultural change

work

2. Quality Impact Assessments for CIP and

change projects, reviewed by Quality

Committee

3. Phase 2 of Care Group management

structure underway to provide capacity to

address any outstanding issues

4. Quality Improvement approach to change

projects

Dec-19 Quality

Assurance

Committee

JW

4. A

lign o

ur

govern

ance a

nd s

yste

ms

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STP Memorandum of Understanding MoU

HOSC Integrated Care System ICS

Jonathan Warren JW CCG Primary Care Networks PCN

Diane Hull DH NHSE Workforce Race Equality Scheme WRESStuart Richardson SR NHSI Workforce Disability Equality Scheme WDES

Mark Gammage MG CIP Freedom to speak up Guardian FTSUGBohdan Solomka BS BCP

Daryl Chapman DC ELFT

NED

CQC

LXC

PCN

OAG

PRM

CYP

Service Users SU

Remedial Action Plan RAP

Access Improvement Team AITQIP

Performance Review Meeting

Children & Young People


East London Foundation Trust

Non executive Director

Care Quality Commission

Likelihood x Consequence

Primary Care Network

Oversight and Assurance Group

Health Overview & Scrutiny Committee

Clinical Commissioning group

NHS England

NHS Improvement

Cost Improvement Plans

Business Continuity Plan

Sustainability & Transformation Partnership

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Freedom to Speak up Guardian Report BoD 21

st November 2019

Version 0.1

Author: Liz Keay

Page 1 of 4 Date produced: 7/11/19



Title of Report: Freedom to Speak up

Action Sought: For information


Author: Liz Keay, Freedom to Speak up Guardian


Executive Summary:

This report provides a summary and analysis of concerns raised to the Freedom to speak up Guardian (FTSUG) during September and October 2019.

There were 45 cases recorded in this period (23 in Sept, 22 in Oct) compared to 26 in the equivalent period of 2018/19 (4 in Sept, 22 in Oct).

The case study is an example of individual staff, their managers and support functions working together to resolve issues.

1.0 Case activity

September and October have been mostly taken up with the awareness raising tour of Speak up Month this began on 16th September and is running through until 13th November, though ‘mop up’ visits are planned.

During the period covered by this report the Guardian has visited 44 sites, wards and offices introducing the role, the person and gaining a better understanding of the day to day working life of the people who work at NSFT.

In line with the previous FTSUG report’s findings; individuals are finding the initial conversations helpful in resolving their concerns and 10 of these cases were able to be concluded and closed on the same day as the initial contact or within a few days afterwards.

Having the Care Group leaders in post is having a positive effect on actioning concerns raised with the FTSUG.

Date: 21st

November 2019

J Item: 19.138

12.2

Tab 12.2 Item 19.138: Freedom to Speak Up report



st November 2019

Version 0.1

Author: Liz Keay


Breakdown of cases by Care Group

% of head count

Attitudes & behaviours

Staffing levels

Staff safety

B & H Systems, procedures & process

Patient Safety

Patient experience

Leadership &

management

Other

N Nfk & Nch 1.00 1 2 3 1 1

W & S Nfk 1.69 1 1 1

GY&W 2.34 2 4 2

Corp / Spt serv 1.00 3 1 1 2

W Sfk 0.24 1

E Sfk 0.99 1 1 3 1

Wellbeing 0.74 2

CFYP 1.55 2 5 1

Secure 0.31 1

Sfk AAT 1.02 1

Themes and trends

Systems, procedures and process issues number highest for these two months. This theme covers a wide range of topics but the underlying issues are:

staff taking on tasks additional to their JD, necessary to get the work done when teams are stretched in terms of capacity, but with little recognition or recompense,

difficulties in understanding how to navigate internal HR/employment systems such as pensions or training, with unclear guidance or procedures for newly established services.

How people treat each other in the day to day working environment continues to be something that people at all levels need help resolving. Often people hold their own answers and it is encouraging that the role of the FTSUG is going some way to enabling staff to feel more confident to address situations themselves using a coaching style conversation.

Next steps are to continue engagement with staff through speak up clinics in different areas one or two days a week.

Case Study

A member of staff contacted the FTSUG about their partner who also works in the organisation. They both had flexible working agreements in place however the spouse felt their line manager wasn’t taking the flexible working agreement into account and was finding their shifts were being rostered outside of the agreed times/days and each week was having to renegotiate when they would be at work. This was causing the partner a great deal of stress not knowing from week to week when they were going to be working and felt overwhelmed. As a result, they

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st November 2019

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Author: Liz Keay


were off sick for a period of time, this in turn had a knock-on effect on the person calling seeing their partner in distress. The partner received no return to work interview and no supervision at this time which fed their view that they weren’t valued and came at the bottom of the list when looking at being able to work flexibly.

The caller, in support of their partner, had arranged a meeting with the service manager and HR to discuss the situation but felt very pessimistic that their views and needs wouldn’t be listened to. They felt that the meeting would focus solely on the flexible working agreement and not the wider context of how the perceived lack of support from the line manager had made the partner feel worthless. In their view the outcome of the meeting was cut and dried.

During the conversation, the FTSUG was able to help the caller to explore all the options that they and their partner could come up with to be able to negotiate their position. The FTSUG contacted the HRBP to let them know of the wider worries for these members of staff and ask that they might facilitate a broader conversation.

The HRBP had developed an excellent working relationship with the service manager and was able to facilitate the meeting so that all parties had a good outcome. The partner has been assured of line management support and a structure by which they will receive it alongside a renegotiated flexible working agreement.

This felt like a good collaborative piece of work from all parties. Allowing the service to function as it needs to, the individual to balance their work and home life and feel able to contribute and be supported within their team. This also demonstrates the value of strong links between clinical and corporate/support teams.

Upcoming Activity

Working with the members of the Board to complete an update the NHSI self-assessment tool.

To develop the recording/reporting function to enable Care Groups to have a more granular view of the activity in their area whilst reflecting the changes being made to the culture and evidencing learning and improvement.

To complete a full gap analysis of the recommendations in the National Guardians Office case reviews and formulating an action plan alongside senior leaders to ensure we are learning from the recommendations made to other organisations

The service is to be audited in the coming weeks

The Speaking up policy is to be reviewed in the late Autumn of this year.

2.0 Financial implications

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No current financial implications


Encouraging people within the organisation to speak up when they see things that aren’t right and thanking them when they do, is crucial to preventing situations similar to those reported in the press over recent years.

4.0 Equality implications

The Trust must ensure that minority groups within the staff cohort are supported and encouraged to raise concerns without discrimination. The FTSUG role is discussed and contact details shared, in Equality and Diversity training settings and the FTSUG is invited to BME, Equality Leads and Disability Group meetings. The guardian attends the disability group regularly but has not been able to schedule regular attendance at other meetings as yet.


Continued work to ensure staff feel able to speak up and are listened for when they do will assist the Trusts objective to be in the top quartile of trusts for safety and quality and staff engagement by 2023. The work of the FTSUG is referenced in BAF risks 1.1 and 1.2

Liz Keay

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People and Performance Report Trust Board 21 November 2019

Version 6

Author: Charlotte Stewart/Jenn Parfitt Department: Human Resources

Page 1 of 15 Date produced: 29.10.19 Retention period: 20 years

Report To: Trust Board

Meeting Date: 21 November 2019

Title of Report: People and Workforce Performance

Action Sought: For information and assurance


Author: Charlotte Stewart, HR Business Intelligence Manager; Jenn Parfitt, Head of HR Business Partnering; Sarah Goldie: Head of Human Resources

Director: Mark Gammage, HR Advisor to the Board

Executive Summary:

This report provides information and an update on key people issues, particularly

focused on our People Plan Priorities, as well as workforce performance.

The following are key highlights:

Equality, Diversity and Inclusion – Our Workforce and Disability Equality Scheme performance for the year to the end of April 2019 were published at the end of September, in line with our obligations. The results and a proposed Equality, Diversity and Inclusion Strategy which brings together all actions in this area, including harassment and bullying towards those with protected characteristics, are presented to the Board under a separate agenda item. Leadership Review – The induction programme for the new Care Group senior leadership teams was undertaken in September 2019. The teams are now focusing on the priorities they have identified, aligned to the Trust’s Strategy, as well as reviewing the supporting leadership structures within their areas. Consultation for the next phase is likely to start in the new year. Recruitment and Retention – Vacancies are down to 8% of funded establishment (342 full time equivalent posts). This is partly due to a decrease in establishment but also an increase in the number of unregistered clinical staff resulting a 0% vacancy rate overall. 65% of the increase in unregistered nurses are Assistant Practitioners, Senior Clinical Support Workers and staff waiting their registration pin numbers in order to practice as registered nurses. Medical vacancies have reduced. This has been supported by a number of locum doctors moving on to Trust contracts. Clinical Directors have been really supportive in engaging locums to achieve this.


K Item: 19.139

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A new Recruitment Manager role has been recruited to as part of the Human Resources restructure. This role will be focused on working alongside professional leads to develop and implement innovative and impactful approaches to attracting and securing quality staff and ensuring the delivery of a great recruitment experience for all those involved in the process. Voluntary turnover – This has increased slightly with the highest number of leavers since the twelve months to the end of February 2019. Work-life balance is the highest reason, followed by early retirement, although quite a large number of people are choosing to return to work following retirement. Feedback from staff is that the issue with work-life balance is more about the demands of work than about a lack of flexible working opportunities. Time to hire - Following a review, for the reporting period from October 2019 onwards, a revised key performance indicator (KPI) will be used which can be automated through the applicant management system (TRAC) and can provide useful data broken down by process elements (e.g. advert close to shortlist etc). This will provide more meaningful data for the Recruitment Team and operational managers to focus on improvement. The new KPI is the number of calendar days from authorisation to recruit to actual start date using a 12 month rolling average. The target is 62 days based on our service level agreement timeframe. Sickness absence – The annualised sickness absence rate has reduced for the fifth consecutive month and is now 4.94%. Subject to the current trend continuing, the target rate of 4.63% should be achieved by April 2020. A detailed sickness deep dive has been provided to the Oversight and Support Meeting (OSM) and the Overview and Assurance Group on 12 November 2019. This shows that our performance is in the median range for comparator Trusts and has mirrored the national trend. Human Resources Business Partners are supporting Care Group leadership teams to better understand their local sickness issues. A senior HR review of the most significant absence cases is being undertaken. Work is also being taken forward on improving access to reasonable adjustments and exploring clearer pathways and fast track processes to support staff requiring mental health support. Appraisals and supervision – Rates continue to be well below target and are of concern. Detailed reports are sent to managers on a fortnightly basis to support managers in taking remedial actions. These have been well received by managers but are having little impact in achieving improvements. The Head of Human Resources has liaised with Care group leaders regarding a focus on improvement in this area. Registered Nurse Fill Rate – This fell to the lowest rate it has been in 12 months to 82.4% in September. Safe staffing was supplemented by the use of additional Clinical Support Workers over-establishment and through the multi-disciplinary teams and clinical managers. The Chief Nurse and Chief Operating Officer are currently running rostering clinics to review rostering practices and actions are being taken as a result to make better use of the clinical staffing resource available. Culture Programme – The ‘Discovery’ phase of the NHSI Culture Improvement Programme will be completed by January 2020 following which we will move into the design and delivery stages. Current focus is on the Board interview diagnostic.

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People Before Process – The work of the People Before Process Working Group is progressing. Investigating officer job descriptions have been drafted and it is anticipated recruitment will commence in November 2019. The group is also developing a set of questions to ask at the outset of disciplinary cases to ensure only those entirely appropriate to be managed through a formal process do so. Work on improving the management of bullying and harassment has also now been brought into the remit of this group. Partnership work is being undertaken on learning from the experience of staff on what would have made a difference so that this informs the approach going forward. Pension Flexibilities – A letter has been received from NHS England and NHS Improvement to request that NHS Trusts implement pension flexibilities in light of issues with the impact of the annual and lifetime allowances on higher paid NHS staff. The immediate concern relates to the pending winter pressures and availability of senior clinical staff. A small working group will explore options to take this forward. Feedback on the depth, breadth and content of this new style report would be welcome.

1.0 Introduction

1.1 This report provides information and an update on key people issues, particularly focused on our People Plan Priorities, as well as workforce performance.

1.2 Figures presented are those that relate to performance as at 30th September

2019. A copy of the Trust’s Workforce Performance Dashboard can be seen in

Appendix 1. The main source of the data is the Electronic Staff Record. The

information was taken during October 2019 (between 1st and 12th October 2019)

to allow for data processing.

2.0 People Plan

2.1 Equality, Diversity and Inclusion

2.1.1 In line with our obligations, our Workforce Race Equality Scheme and Disability Equality Scheme performance for the year to April 2019 was published at the end of September 2019. The results are set out in a separate report on the Board’s agenda. These findings and wider intelligence and feedback have informed our Equality, Diversity and Inclusion Strategy which is presented to the Board for approval. Objective 1 of the strategy includes our approach to managing concerns of harassment and bullying towards staff with protected characteristics.

2.2 Leadership Review

2.2.1 A comprehensive induction programme was implemented for the Care Group senior leadership teams in September. They are now focusing on the priorities they have identified, aligned to the Trust’s Strategy, as well reviewing the supporting

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leadership structures within their areas. This work is taking a little longer than initially anticipated to ensure an appropriate level of consistency in approach and principles being applied balanced with tailoring structures that meet local needs and affordability. Consultation on the next phase is likely to start in the new year.

2.3 Recruitment and Retention 2.3.1 At the end of September 2019, there were 342 whole time equivalent (wte) vacant

posts, equivalent to 8.0% of our funded establishment. This is an improvement of 1.1% points (45 wte vacancies) in the month, partly due to a reduction in the overall establishment, which includes a reduction in budget of 10 wte registered nurses and 12 unregistered nursing staff but partly offset by an increased in the establishment for 6 wte social workers. Alongside this reduced budget, there has been increase in overall staff in post which is mainly centred on an increase in the number of unregistered clinical staff with a net increase of 18 wte compared to August. Almost 65% (18 members of staff) of new starters in September who are in unregistered clinical roles are working either as Assistant Practitioners, Senior Clinical Support Workers at Band 4 or are awaiting their nursing PIN before being able to operate as registered nurses.

2.3.2 Whilst the number of nursing and medical vacancies continue to be of greatest

concern, there has been some improvement with the vacancy rate at the end of September with 21.9% of medical posts vacant. This equates to 53 wte vacant posts. The improvement has been supported by a number of locums having moved on to Trust contracts. Clinical Directors have been particularly supportive in engaging locum colleagues in this regard. As demonstrated in the table below, 16.41 wte vacancies are covered by locums. Factoring this cover in reduces the vacancy rate to 15%.

2.3.2 A small group is being set up to develop a new template for our medical job

descriptions and to review our adverts to ensure these are as attractive as possible. 2.3.3 Health Education England is visiting on 28 November 2019 to review clinical

education provision. This will include reviewing the position in regard to our improvement plan for Medical Trainees. Good progress has been made although we have experienced a number of payroll issues since the change in payroll provider. Human Resources has been working closely with Trainees, Finance and Payroll to support the resolution of these. Interviews are scheduled for the Guardian of Safe-working position with the current Guardian having given notice to stand down having taken on a new job within the Trust.

Establishment Staff In Post Vacancies Vacancy Rate

Locums in

Post

Vacancies

including

agency

locums

Vacancy

Rate

including

agency

locums

Consultants 113.54 90.78 22.76 20.05% 11.41 11.35 10.00%

SAS Doctors 41.26 24.58 16.68 40.43% 5 11.68 28.31%

Junior Doctors 86.2 72.9 13.3 15.43% 0 13.3 15.43%

Total 241 188.26 52.74 21.88% 16.41 36.33 15.07%

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2.3.4 There has been an improvement in registered nursing vacancy rates which are now at 14.3% compared to 14.8% in August 2018 (0.5% point improvement). This equates to 193 wte vacancies as at end September 2019. Behind this headline is an increase in the establishment for band 6 nurses and an increase in staff in post, but the position for band 5 nurses is very different with a reduction in establishment and a reduction of staff in post. This has arisen from local skill mix changes to create career progression opportunities to support retention and to help attract experienced staff. There is a 33.5% vacancy rate for Band 5 nurses. See graphs below.

2.3.5 Use of other registered clinical staff continues to mitigate low band 5 nursing

vacancy rates. The number of clinical support staff continues to increase and we now have no Support Worker vacancies overall. The establishment for qualified Allied Health Professional (AHP) roles continues to increase, in line with our AHP Strategy, now at 655 wte. Whilst recruitment is underway, there has been an associated increase in vacancies (now 40 wte).

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2.3.6 A new Recruitment Manager role has been recruited to as part of the updated Human Resources structure. This role will be focused on working alongside professional leads to develop and implement innovative and impactful approaches to attracting and securing quality staff and ensuring the delivery of a great recruitment experience for all those involved in the process.

2.3.6 Senior nursing colleagues led an event on 18 October 2019 for student nurses. The event was very well attended with lots of interest in working for the Trust. Assessment days are being held on 18 and 19 November for newly qualified nurses.

2.3.7 Whilst there are some positive signs of improvements with vacancies, staff turnover

has slightly increased. Voluntary turnover is 10.8%, 0.5% higher than the same time last year and 2.3% points above the target rate. 487 people left the Trust for a voluntary reason in the last 12 months, the highest number of leavers since the 12 months to end February 2019. The main reasons given for leaving the Trust are voluntary resignation – work life balance (121 leavers), followed by retirement age / voluntary early retirement (97 leavers) and voluntary resignation – relocation (59 leavers. Particularly where the leavers are registered nurses or doctors, Lead Nurses / Clinical Directors are encouraged to undertake local leavers discussions in order to fully understand issues and trends.

2.3.8 An internal nursing transfer scheme is being explored with Lead Nurses to support

development, engagement and retention. If successful, it will be rolled out more widely. The first ‘transfer window’ is likely to be in the new year.

2.3.9 Work continues in terms of nursing development and preceptorship. 2.3.10 On the dashboard at appendix 1, time to hire (TTH) is reported at 67 days against

a target of 56 days. This measures the time from the advert closing to the actual start date. This particular measure was adopted in April 2019 as it is the measure used by the Model Hospital. However, on examining the Model Hospital data more closely, there is very significant variation in performance (the Trust’s performance is around the middle of the pack). We have also identified that the formula that was being used to calculate the TTH was not correctly capturing all new starters, adversely impacting our TTH averages (data has now been amended). Further, it became apparent that the measurement was not especially helpful in highlighting the ‘true’ issues within the recruitment process.

2.3.11 After much consideration, and taking account of some of the work being led

nationally by the NHS Streamlining Operational Group on developing more effective TTH measures, we have changed our TTH key performance indicator (KPI), which will be effective from October 2019, so that this is based on ‘authorisation to recruit’ to ‘actual start date’ on a rolling twelve month average. Student nurse appointments will be excluded from the measure as these have a much longer lead in time which skews the data. The applicant management system we use (TRAC) enables automatic reporting of this data, including a breakdown by stage of the recruitment process. This is a more accurate way of reporting than with the previous KPI which required manual calculation and also enables more meaningful data to be available for consideration by the Recruitment Team and appointing managers in regard to where delays might be happening (e.g. advert close to shortlist; shortlist to interview) to support more targeted actions to improve. The target has been adjusted to

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62 days; this is based on our non-medical recruitment service level agreement factoring a one month average notice period. The medical recruitment service level agreement will be reviewed over the next couple of months.

2.4 Core Workforce Metrics

2.4.1 Sickness Absence

2.4.1.1 As at the end of September 2019, the Trust’s absence rate was recorded at 4.94% on an annualised basis (rolling 12 months) and at 4.94% on an in-month basis.

2.4.1.2The annualised cost of absence is estimated at just over £6 million in lost capacity (excluding backfill costs). This is equal to 185 full-time equivalent staff not attending work for a year. The true cost is higher factoring in bank, agency and other staff cover to keep services safe.

2.4.1.3The Statistical Process Control Chart (SPC) chart below shows that the Trust has

had a decreasing annualised absence rate since May 2019 and is currently 0.31% away from our target rate of 4.63%.

2.4.1.4 Whilst the values are still above the average and outside the upper control limit,

on the current trajectory, we can anticipate reaching the target by April 2020, as

below:

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2.4.1.5 Reasons for absence due to stress, anxiety, depression or other mental health

issue decreased to 1.39% from 1.42% in September; this is equivalent to a reduction of 1,603fte days lost in the month. This is the lowest level of stress, anxiety, depression and other mental health related absence for over 12 months.

2.4.1.6 A ‘deep dive’ sickness analysis has been presented to the Oversight and Support (OSM) Meeting and the Overview and Assurance Group Meeting on 12 November 2019. This shows that, based on the latest national benchmark information available from NHS Digital, which is for the period to the end of June 2019, whilst our rate of 4.86% was above the national average for mental health / learning disability Trusts, it is in the median range of comparator Trusts and our absence pattern is mirroring the national pattern. The graphs below demonstrate:

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2.4.1.7 This report provides updates on a number of areas of work to develop a more

compassionate, inclusive and supportive culture. Where staff feel more supported, this will positively impact staff sickness. Shorter term actions include: local ‘deep dives’ so new Care Groups better understand their local issues; a senior HR review of the most impactful absences; work on improving access to reasonable adjustments, implementation of regular management reports highlighting staff who have met thresholds under our Attendance at Work Policy; and a review of mental health support for staff, including exploring fast track processes. The flu vaccination campaign is also underway.

2.4.2 Appraisals and Management Supervision 2.4.2.1Non medical appraisal rates are unchanged at 79%, below the target of 90%.

Medical appraisal rates are on target (90%). 2.4.2.2 Whilst there has been an improvement in September of just over 5% in

management supervision rates, this simply recovers the position that deteriorated by the same amount in August. 67% is significantly below the target of 90% and below the performance of 12 months ago (79.8%) which is concerning.

2.4.2.3A detailed report has been sent to supervisors on a fortnightly basis to highlight

performance and who is outstanding for appraisals and supervision. Whilst managers are feeding back that this is helpful, there has been little impact on improving rates since its introduction. Further, we know from the Pulse Surveys that have been run monthly between April and September 2019 that 81% of staff responding say that they have regular management supervision meetings. 82% report having had an appraisal in the last 12 months. This suggests an ongoing issue of under-reporting. The Head of Human Resources has been liaising with Care Groups leaders regarding a focus on improvement in this area.

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2.4.3 Registered Nurse shift fill rates 2.4.3.1 Registered nurse shift fill rates fell in August and September 2019 to the lowest

they have been over the last year at 84.2%. In September 2019, a total of 12 wards fell under the target for Registered Nurse day shifts and 8 wards for Registered Nurse night shifts. Four units fell below 80% Registered Nurse fill for day and night shifts: Beach Ward, Foxhall House, Southgate Ward & Whitlingham Ward.

2.4.3.2 In the above situations, additional Care Support Workers were used to provide

additional capacity (fill rates of 120.65% for days and 131.68% for nights). Additionally, safe staffing was supported by the use of Assistant Practitioners, Occupational Therapists, Social Workers and clinical managers.

2.4.3.3 A report is sent to Care Groups Leads on a daily basis regarding the number of

shifts unfilled for their areas. An additional daily report is sent to the Chief Nurse, the Chief Operating Officer and the Deputy Chief Nurses providing further detail on areas with unfilled shifts of five or above, together with further detail of the wider multi-disciplinary team also on shift for the day in order to ensure visibility and supportive action where required.

2.4.3.4 The Chief Nurse and Chief Operating Officer are currently undertaking rostering

clinics within all of the Care Groups to review rostering practices to ensure safety and the most efficient use of the available staffing resource, including the wider multi-disciplinary team. The unnecessary rostering of excessive numbers of staff on some shifts in some areas has been identified, which is being addressed, as is an issue with the amount of management time clinical managers have away from direct clinical care.

2.5 Leadership Development

2.5.1 We have started reviewing our leadership development offering for the next couple

of years but will await the outcome of the culture programme diagnostics which are

due in January 2020 to inform the final proposals. The Board has previously

expressed interest in what will be available for ‘middle’ managers. Current

considerations include a ‘First Leaders’ programme for Bands 4 and above with

supervisory responsibilities that would run alongside completing the NHS Edward

Jenner on-line leadership programme and a Compassionate Leaders Programme

for Bands 7 and above.

2.5.2 Interim proposals are to be considered by the Executive Team, which includes team

coaching for the new Care Group leadership teams to support them operating as

effectively as possible within the new model. Away days are also being arranged.

2.6 Pulse Surveys

2.6.1 Attached at Appendix 2 is a summary of the results of the Pulse Survey that we

have been running since April 2019 to gain feedback on a number of key metrics.

These are Trust level results but Care Group and Service Line information has been

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provided to Care Groups. The survey has been sent to a randomly selected

800 staff per month. The response rate was 20.4% in September 2019.

Unfortunately, there is little notable improvement at this stage.

2.7 Executive Walkarounds

2.7.1 Executive Walkarounds are a chance for staff to tell an Executive Director about

the things they are really proud of, the things that stop them from delivering high

quality care, and to share ideas on how our Trust might do things differently.

Themes include a sense of pride in their work, a commitment to focusing on

improvements and an appreciation of their teams. Concerns include waiting lists,

caseloads, capacity (in regard to activity and vacancies), some environmental

issues and a desire for closer working with social care in the absence of a section

75 agreement in Norfolk.

2.7.2 The Chief Executive has also been holding breakfast / lunch sessions with staff.

He’s picking up lots of positive feedback about the impact of the new Care Groups

and how staff are liking having decision makers closer to them. As with the wider

Executive Walkarounds, issues are also being raised regarding staffing and

workload pressures.

2.8 Culture Programme

2.8.1 The Culture Steering Group programme is progressing well. We are following the NHSI Culture Improvement programme and we are being actively supported by colleagues from NHSI and NHS England. We are currenting in the ‘Discovering’ stage of the programme with our synthesis meeting taking place in January 2020 to bring together the analysis from the 6 different diagnostic tools being used. Following this meeting, the Culture Steering Group will share its findings with the Board. The next steps are the ‘Design’ and ‘Delivering’ stages of the programme. During November and December 2019, the focus is on the Board Interview diagnostic. The interviewers are members of the Culture Group and other staff volunteers who have received skills training to undertake the interviews.

2.9 People Before Process

2.9.1 The work of the People Before Process Group is progressing. Investigating Officer

job descriptions have been developed in partnership. It is anticipated that the

recruitment process will commence in November 2019. The group is also

developing a set of questions to ask at the outset of disciplinary processes which

will help ensure only those cases that are absolutely appropriate to go through a

disciplinary process are pursued through that route. The group is also looking at

how the wellbeing of staff affected by employment processes is at the forefront of

how things are managed.

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2.9.2 Work on improving the management of bullying and harassment concerns has now

also being brought into the remit of the People Before Process Group. Work in

partnership is being undertaken to review feedback from staff who have

experienced bullying and harassment on what might have made a difference for

them and to use this to feed into a review of how concerns can be raised, how these

will be explored and support.

2.10 Brexit

2.10.1 Monitoring and contingency planning regarding the potential workforce implications

of the United Kingdom (UK) leaving the European Union (EU) are ongoing. We

have 178 staff from the EU within clinical and non-clinical services and there have

been no notable negative impacts to date in terms of EU staff leaving.

2.11 Pension Flexibilities

2.11.1 In light of the impact of annual and lifetime allowances on taxation which have

resulted in significant tax bills for some higher paid NHS staff, most notably medical

Consultants, the Government has been consulting on potential pension flexibilities

to mitigate the impact. Pending this outcome, however, in light of pending winter

pressures and concerns about the availability of senior clinical staff across the NHS,

a letter has been received from Pauline Philip, National Director for Emergency and

Elective Care, NHS England and NHS Improvement and Ann Radmore, Regional

Director. The letter requests that all Trusts implement pension flexibilities. NHS

Employers has issued some guidance. The letter received draws particular

attention to what some refer to as ‘recycling’ where a proportion of the value of what

would be the employer’s pension contribution is paid to the employee if they choose

to opt out of the pension scheme. A small working group is being set up to explore

options and to propose a way forward pending national arrangements being

available.

3.0 Financial implications (including workforce effects)

3.1 Focus in the areas set out above will positively impact financial performance (directly and indirectly).

3.2 Some aspects of the People Strategy are likely to require some investment which will be explored with the Executive Team as necessary.


4.1 Focus on the areas set out in this report support the delivery of the Trust’s Strategy and improved experience for our staff and service users.


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5.1 Equality, diversity and inclusion is a key element of our People Strategy.


6.1 Risks and mitigation in relation to strategic workforce issues are presented throughout this paper and the associated workforce elements of the Business Performance Report.

6.2 The report relates to BAF risk 1.1 and 1.2

7.0 Recommendations

7.1 The Board is recommended to note the contents of this report, including actions and progress being made.

7.2 The Board is asked to advise on any further steps it requires to be assured that the issues highlighted are being managed effectively.

7.3 Any comments on the depth, breadth and content of this new format report are welcome.

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Appendix 1 – Workforce Performance Dashboard

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Tab 12.3 Item

19.139: People and W

orkforce report

96 of 181B


ublic - 21st Novem

ber 2019-21/11/19


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Appendix 2 – Pulse Survey Summary

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Board of Directors Public Meeting - 21st

November 2019

Equality Diversity and Inclusion

Version 1.0 Author: Nina Amoo; Karn Purvis

Department: Human Resources


Date: 21st November 2019 LItem: 19.140

Report to: Board of Directors – Public


Title of report: Equality, Diversity and Inclusion Strategy

Action sought: For Approval


Author: Nina Amoo, HR Consultant; Karn Purvis, Equality Adviser

Director: Mark Gammage, HR Advisor to the Board

Executive Summary:

Building an inclusive culture is a key aspect of achieving our Trust’s vision of supporting people to live their hopes, dreams and aspirations and our mission to be in the top quartile for safety and quality by 2023. One of our Trust priorities is engaging and inspiring our staff. Building on our Values of Positively, Respectfully and Together, developing a positive, inclusive culture that embraces diversity is therefore a core area of focus for our People Plan over the current and forthcoming years.

This paper sets out the findings from the 2018/19 Workforce Race Equality Scheme (WRES) and Workforce Disability Equality Scheme (WDES), which were published at the end of September 2019. It also asks the Board to consider and approve the Equality, Diversity and Inclusion (EDI) Strategy. The strategy brings together all of the equality related objectives held in other strategies1 and the WRES and WDES action plans. This strategy enables us to see and be accountable for the steps we need to take to create the inclusive organisation we want to be.

Our WRES data for the 2019 reporting year shows progress against some of the standards - for example, the likelihood of BME staff to be appointed or to be subject to formal disciplinary processes compared to white staff - but there is significant progress still to be made. Our WDES data also shows significant differences in experiences for disabled and non-disabled staff which we must address.

The Equality, Diversity and Inclusion Strategy takes account of feedback from the Staff Survey, WRES and WDES performance and wider sources, including intelligence from our staff network groups. It includes four core objectives which are proposed as the main areas of focus over the next two years:

1 NSFT Strategy, People Strategy.

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Tab 12.4 Item 19.140: Equality and Diversity Strategy



November 2019





• To eradicate behaviours that are not aligned to our Values towards people from diverse backgrounds and underrepresented groups within the Trust

• To remove inequalities and inadvertent barriers from our internal processes

• To improve progression and development opportunities and the retention of staff from underrepresented groups

• To integrate equality and diversity actions into the day to day work of our clinical Care Groups and Services.

There is a conscious decision to particularly focus on race and disability over the next two years given the very persuasive evidence that we need to address issues in these areas. Research shows that by improving the experience for one protected group, this has a positive impact on other groups also. However, a focus of the strategy is to also strengthen the role of our network groups, supporting other protected characteristics of the Equality Act 2010, so they are better able to identify priorities and lead on work to deliver positive change. To assist this, each group is supported by an Executive Director.

A high level delivery plan is at Appendix A of the strategy. Delivery of this plan will be overseen by a newly established Equality and Diversity Steering Group.

It is recommended that the Board endorses the proposed strategy and plan and provides feedback to help inform the final version of the strategy.

1.0 Introduction

1.1 Building an inclusive culture is a key aspect of achieving our Trust’s vision of supporting people to live their hopes, dreams and aspirations and our mission to be in the top quartile for safety and quality by 2023. One of our Trust priorities is engaging and inspiring our staff. Building on our Values of Positively, Respectfully and Together, developing a positive, inclusive culture that embraces diversity is therefore a core area of focus for our People Plan over the current and forthcoming years.

1.2 This paper sets out the findings from the 2018/19 Workforce Race Equality Scheme (WRES) and Workforce Disability Equality Scheme (WDES) which were published at the end of September 2019. It also asks the Board to consider and approve the Equality, Diversity and Inclusion (EDI) Strategy. The strategy brings together all of the equality related objectives held in other strategies and the WRES and WDES action plans. This strategy enables us to see and be accountable for the steps we need to create the inclusive organisation we want to be.

2.0 WRES and WDES

2.1 Under the NHS Workforce Race Equality Scheme (WRES), as an NHS Trust, we are required to publish data on how we are performing in regard to various indicators and to take action where the data identifies discrepancies in the treatment of black and minority ethnic (BME) staff compared to their white colleagues. This year, for the first time, we

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have also been required to publish data in regard to the new Workforce Disability Equality Scheme (WDES). This data relates to the period April 2018 to March 2019.

2.2 Our WRES data for this reporting year, including 2018’s data for comparison, can be found at Appendix 1 and our WDES data can be found at Appendix 2.

2.3 The headlines from our WRES data are:

∑ 6.9% of our total workforce is made up of black and minority ethnic staff but with an over-representation in Bands 3 and 5 and amongst medical staff but with under-representation in bands 6 and above, with the exception of Band 8a where representation has improved over the last year. Appreciating differences in the local populations across the country, overall, BME staff make up 19.1% of the workforce in NHS Trusts2, much higher than in our own.

∑ White staff are 1.52 times more likely to be appointed than BME staff. There has been significant improvement in this indicator over the last year from 2.04 times more likely and this is now closer to the national benchmark of 1.45.

∑ BME staff are 2.39 times more likely to enter a formal disciplinary process. This has reduced from 3.57 times more likely in the previous year but continues to be well above the national average of 1.24 times.

∑ BME staff continue to experience higher levels of harassment, bullying or abuse from patients, relatives or the public (45% BME compared to 33% white). This has reduced from 54% over the last year, however, the rate has increased in regard to harassment, bullying or abuse from staff to 35% from 29%.

∑ Whilst BME staff are more likely to access non-CPD related training compared to white colleagues, they have lower belief in that the Trust provides equal opportunities for career progression or promotion (60% BME compared to 81% white staff believe there is equal opportunity). This is a lower level of confidence for both BME and white staff than the national benchmark (71.5% BME and 86.6% white).

∑ 19% of BME staff believe they have experienced discrimination from a manager or colleagues in the last 12 months compared to 10% white staff.

∑ We lack diversity on our Board.

2.4 The headlines from our WDES data are:

∑ 5% of our staff have declared they are disabled within the Electronic Staff Record. There are lower levels of disabled staff within senior roles (8a and above).

∑ Non-disabled staff are 1.39 times more likely to be appointed compared to disabled staff.∑ Non-disabled staff are 4.25 times more likely to enter a formal capability process than

disabled staff.∑ Disabled staff are more likely to experience harassment, bullying or abuse than non-

disabled colleagues most notably from other colleagues (26.2% disabled compared to 19.2% non-disabled) and from managers (20.8% disabled, 14.1% non-disabled).

∑ Disabled staff are more likely to report concerns of harassment, bullying or discrimination than non-disabled colleagues (57.2% compared to 54.7%) but the rate of reporting is still low.

2 NHS Workforce race Equality Standard: 2018 Data Analysis Report for NHS Trusts (January 2019)

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∑ Disabled staff have less confidence that the Trust provides equal opportunities for career progression or promotion than non-disabled staff (72.8% compared to 81.7%).

∑ 10% more disabled staff have felt pressure to attend work when they have not been well enough to perform their duties than non-disabled staff (27.2% compared to 17.8%).

∑ Disabled staff feel slightly less valued in their work than non-disabled staff (36% feel the organisation values their work compared to 39.6%).

∑ 74.5% of disabled staff feel adequate adjustments have been made to enable them to undertake their work.

2.5 As this is the first year that WDES has been reported, there is not currently any national benchmark information to compare to.

3.0 The Equality, Diversity and Inclusion Strategy

3.1 Attached at Appendix 3 is the Equality, Diversity and Inclusion Strategy, presented to the Board for approval.

3.2 There is a significant body of evidence through the NHS Staff Survey and the research of experts such as Professor Michael West that demonstrates a strong association between getting diversity and inclusion right, better employee experience and better patient care and outcomes.

3.3 The strategy focuses on four primary objectives:

∑ To eradicate behaviours that are not aligned to our Values towards people from diverse backgrounds and underrepresented groups within the Trust

∑ To remove inequalities and inadvertent barriers from our internal processes∑ To improve progression and development opportunities and the retention of staff from

underrepresented groups∑ To integrate equality and diversity actions into the day to day work of our clinical Care

Groups and Services.

3.5 These objectives are proposed as priority areas for focus over the next two years and takeinto account feedback from the Staff Survey, our Workforce Race and Disability Equality Scheme performance and other sources, for example, through our staff network groups. It also takes account of national best practice. It brings together all of the equality related objectives held in other strategies and the WRES and WDES action plans. The strategy enables us to see and be accountable for the steps we need to take to create the inclusive organisation we want to be.

3.6 There is a conscious decision to particularly focus on race and disability over the next two years given the very persuasive evidence that we need to address issues in these areas. Research shows that by improving the experience for one protected group, this has a positive impact on other groups also. However, a focus of the strategy is to also strengthen the role of our other network groups, covering other protected characteristics, so they are better able to identify priorities and lead on work to deliver positive change. To assist this, each group is supported by an Executive Director.

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3.6 A high level plan for delivery is at Appendix A of the Strategy. An Equality, Diversity and Inclusion Steering Group will be established to oversee the implementation, to be chaired by the HR Advisor to the Board.


4.1 It is possible that aspects of the strategy will require some investment, for example, to support training provision. Business cases will be developed and presented to the Executive Team for approval where necessary.


5.1 As above, there is an evidenced correlation between staff experience and patient experience. A focus on improving staff experience, particularly for our staff with protected characteristics, will therefore have a positive impact on patient experience and the quality of the services we provide. It will also support the recruitment and retention of quality staff.


6.1 This report is solely dedicated to equality. Where proposals offer an advantage to a protected characteristic group there is an evidence-based inequality which the measure is attempting to mitigate.


7.1 The delivery of this strategy has a significant bearing on the successful delivery of our Trust Strategy, particularly in regard to engaging, developing and inspiring our staff and, through this, maximising the positive experience and outcomes for our service users. In order for the strategy to be as successful as possible, engagement in the principles and delivery of the strategy by leaders at all levels of the organisation is critical. A committed and consistent approach across the Trust is essential. The work links to BAF risk 1.1.

8.0 Recommendations

It is recommended that the Board endorses the proposed strategy and plan and provides feedback to help inform the final version of the strategy.

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Appendix 1 – Workforce Race Equality Standard (WRES) Analysis

Metric Description Data for reporting year 2019(Graphs on Appendix 2)

Data for previous reporting year 2018(Graphs on Appendix 3)

1 Percentage of BME staff in each of the AfC Bands 1-9 and VSM (including executive Board members) compared with the percentage of BME staff in the overall workforce. Organisations should undertake this calculation separately for non-clinical and for clinical staff.

Band Clinical%BME

Non-Clinical%BME

1 0.00% 0.00%2 0.00% 4.32%3 13.11% 3.94%4 8.04% 2.23%5 13.03% 0.00%6 5.34% 2.15%7 4.81% 1.37%8a 7.48% 5.08%8b 3.23% 4.76%8c 5.26% 0.00%8d 10.00% 0.00%9 0.00% 33.33%VSMConsultantSASTrainee

0.00%35.5%54.5%17.6%

0.00%

6.95% of total workforce is BME

Band Clinical%BME

Non-Clinical%BME

1 0% 0.00%2 0% 3.23%3 12.76% 3.41%4 8.36% 1.79%5 11.62% 0.00%6 6.13% 3.09%7 3.33% 4.41%8a 6.30% 4.35%8b 5.36% 8.00%8c 5.00% 0.00%8d 0.00% 0.00%9 0.00% 50.00%VSM 0.00% 0.00%

Consultant 30.6%SAS 60.6%Trainee 60%

6.9% of total workforce is BME

2 Relative likelihood of BME staff compared to white staff being appointed from shortlisting across all posts.

White staff are 1.52 times more likely to be appointed then BME

White staff are 2.04 times more likely to be appointed then BME. Higher than the national benchmark of 1.45.

3 Relative likelihood of staffentering the formal disciplinary process, as measured by entry into a formal disciplinary investigation. This Metric will be based on data from a two year rolling average of the current year and the previous year

BME staff are 2.39 times more likely to enter the formal disciplinary process.

BME staff are 3.57 times more likely to enter the formal disciplinary process.

4. Relative likelihood of staff accessing non-mandatory training and CPD.

White staff are 0.67 times more likely to access training then BME staff

White staff are 0.92 times more likely to access training then BME staff. National benchmarks in 2018 were 1.15)

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5. Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months.

BME 45%

White 33%

BME 54%

White 33%

2017 national benchmarks BME 29%White 28%

6. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months.

35% 29%

7. Percentage believing that Trust provides equal opportunities for career progression or promotion

BME 60%White 81%

BME 65%White 80%

8 In the last 12 months have you personally experienced discrimination at work from any of the following Manager/team leader or other colleagues

BME 19%White 10%

BME 19%White 10%

9. Percentage difference between the organisations’ Board voting membership and its overall workforce.

BME -1%White 6.7%

BME -8.4%White -8.5%

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Appendix 2 – Workforce Disability Equality Standard (WDES)

Metric Description Data for reporting year 2019(Graphs on Appendix 5)

1 Percentage of staff in each of the AfC Bands 1-9 and VSM (including executive Board members) compared with the percentage of staff in the overall workforce. Organisations should undertake this calculation separately for non-clinical and for clinical staff.

Cluster 1 (bands 1 – 4) 5%Cluster 2 (bands 5-7) 6%Cluster 3 (bands 8a – 8b) 3%Cluster 4 (Bands 8c – 9 & VSM) 1%Medical: 4%Other: 0%All staff: 5%

2 Relative likelihood of Disabled staff compared to non-disabled staff being appointed from shortlisting across all posts.

Non-disabled staff are 1.39 times more likely to be appointed than disabled staff

3 Relative likelihood of Disabled staff compared to non-disabled staff entering the formal capability process, as measured by entry into the formal capability procedure. Note:

i. This Metric will be based on data from a two-year rolling average of the current year and the previous year.

ii. This Metric is voluntary in year one.

i) Non-disabled staff were 4.25 times more likely to enter the formal capability process than disabled staff.

4A. Percentage of Disabled staff compared to non-disabled staff experiencing harassment, bullying or abuse from:

i) from a service-user, relative or other members of the public

ii) from a manager

iii) from other colleagues

i) Disabled 35.7%, Non-Disabled 33.6%ii) Disabled 20.8%, non-disabled 14.1%iii) Disabled 26.2%, Non-disabled 19.2%

4B Percentage of Disabled staff compared to non-disabled staff saying that the last time they experienced harassment, bullying or abuse at work, they or a colleague reported it.

Disabled 57.2%

Non-Disabled 54.7%

5. ii. Percentage of Disabled staff compared to non-disabled staff believing that the Trust provides equal opportunities for career progression or promotion.

Disabled 72.8%

Non-disabled 81.7%

6. Percentage of Disabled staff compared to non-disabled staff saying that they have felt pressure from their manager to come to work, despite not feeling well enough to perform their duties.

Disabled 27.2%

Non-disabled 17.8%

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7. Percentage of Disabled staff compared to non-disabled staff saying that they are satisfied with the extent to which their organisation values their work.

Disabled 36.0%

Non-disabled 39.6%

8 Percentage of Disabled staff saying that their employer has made adequate adjustment(s) to enable them to carry out their work.

74.5%

9. a) The staff engagement score for Disabled staff, compared to non-disabled staff and the overall engagement score for the organisation.

b) Has your Trust taken action to facilitate the voices of Disabled staff in your organisation to be heard? (Yes) or (No)

a) Organisation average 6.5

Disabled 6.2

Non-disabled 6.6

b) Yes. The Disability Employee Network group has co-produced the WDES action plan.

10 Percentage difference between the organisation’s Board voting membership and its organisation’s overall workforce, disaggregated.

By voting membership of the Board: Voting membership - Overall Workforce: -5

By Executive membership of the Board: Executive membership - Overall Workforce: -5

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Appendix 3 – Equality, Diversity and Inclusion Strategy

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Equality, Diversity and Inclusion Strategy

2019 to 2021

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Introduction One of our trust’s priorities is engaging and inspiring our staff. There is no shortage of evidence that shows that a culture that is diverse and inclusive creates a better working environment and the better our staff experience, the better our patient experience.

Since the 60 engagement sessions run in 2019, we have been working hard towards addressing our concerns around our organisational culture. We now have a greater understanding of what it is like to work at NSFT, and we realise there is a lot more work to be done to create the culture we all want with NSFT being a genuinely compassionate place to work and receive treatment. We are driven by our ethical duty to tackle inequality and improve internal fairness so that we can progress towards providing a genuinely compassionate place to work and receive treatment. Our challenge here will be measuring feelings of inclusion, which is more difficult to do than quantifying diversity, which is only representation. We will use the Staff Survey and Pulse Survey to help measure how well we are doing.

Our overarching diversity and inclusion aims2 remain; to create a culture that values diversity and inclusion with a culturally competent workforce that reflects and is sensitive to the needs of the communities we serve. Simply said, to treat people as we would like to be treated.This strategy has four primary objectives, each with a set of priorities that encompass the existing diversity and inclusion ambitions and associated workstreams. While the principles of the strategy apply to all protected groups, we have made a conscious effort to ensure we are doing targeted work to support specific groups of staff where there is evidence that this needs particular attention.

Jonathan Warren Chief Executive

Marie Gabriel OBEChair

1 A recent NHS England report using national NHS Staff Survey data 2 Workforce Strategy 2016-2021

Marie Gabriel OBE

Jonathan Warren

Carol BriggsStaffside officer

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Our Challenge

We know that organisational culture will be the most significant influencing factor in our efforts to tackle our concerns around diversity and inclusion. As it stands, we are faced with challenging the ingrained attitudes and behaviours of some and individual perceptions about the need for change.

We want NSFT to be a place where people want to come to work and where people are respected irrespective of their

role or characteristics, yet we know that building a truly inclusive organisation will be a journey. We are also mindful that our efforts are executed in the right way and not seen as a one-off project, but instead, woven into the broader cultural transformation programme. Embedding diversity and inclusion into “the way we do things around here” means looking at our strategies, policies and practices, including customer service and patient care. This requires a long-term commitment and dedicated resource.

While the principles of the strategy apply to all protected groups, we have made a conscious effort to ensure we are doing targeted work to support specific groups of staff.

To eradicate behaviours that are not aligned to our Values of Positively, Respectfully and Together towards people from diverse backgrounds and under-represented groups with the Trust

objectivesand challenges

Our

Objective 1

Did you know?

National data around NHS Trusts shows that mental health trusts have the second-highest percentages of staff reporting discrimination, Ambulance trusts being the highest.

NSFT Diversity and Inclusion Strategy 2019-2021 3

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What have we done so far?

Priorities - What will we do next?

• The People Strategy presented to the Board in July 2019 underpins our cultural change programme. The programme sets the tone of the organisation and the behaviours expected of us. We have also set up a Culture Steering Group comprising of staff and service user volunteers from across the organisation, to feed into the development of the strategy

• We have introduced Executive Walk-arounds to ensure executives are visiting different localities and services in the Trust and speaking with and meeting frontline staff

• Reverse Mentoring, a programme where our Executive Director (mentee) is assigned a mentor (frontline member of staff) who can explain what it feels like to work here

• As part of our Diversity and Inclusion objectives in the Workforce Strategy 2016-20121, we are proposing a new leadership development offering. This will equip our leaders to be allies who listen to the experience of staff in all protected characteristic groups, appreciate their unique experiences, and amplify their voices in order to build a truly inclusive culture

• We have hosted the Black History Month Conference

• We have introduced LGBT+ Rainbow badges with over 25% of staff pledging to be LBT+ allies and to support service-users and colleagues in those communities

• Our employee network groups have been reinforced with support and sponsorship from our executive team

1. Zero Tolerance

We intend to adopt a zero-tolerance approach to discrimination, harassment and bullying. All employees, workers, contractors, and visitors are expected to be treated, and to treat each other, with dignity and respect regardless of role or personal characteristics3.

Zero tolerance is our statement of approach. This means:

i. We will always take action, and

ii. The action will be proportionate to the circumstances of the case

We aim to adopt this approach while balancing our ambition to create a culture, where we seek to improve and learn from our mistakes continually. In practical terms this approach may seem contradictory to our move away from a blame culture – a ‘Just and Learning’ Culture. To us, Zero Tolerance does not mean ‘one strike and you’re out’ unless this is the proportionate outcome given the severity of the situation. It means that learning is at the forefront of our considerations and that there will be a proportionate response to concerns. This means that harassment or bullying will be taken seriously. In serious situations, therefore, this could result in disciplinary action, including dismissal.

3 age, disability, gender identity, marriage and civil partnership status, pregnancy and maternity, religion or belief, sex, sexual orientation, socio-economic background, political beliefs and affiliations, family circumstances or other irrelevant distinction.

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2. Develop a greater cultural awareness

We want to change the narrative around diversity and inclusion and appreciate the positives of diversity through greater cultural awareness. We will work with diversity partners such as Stonewall and Disability Confident to develop a stronger understanding of the different needs of our workforce. This means actively seeking to utilise the resources made available to us through Disability Confident to achieve Level 3. We know that our upbringing and environment impacts on our world view, so we intend to provide practical tools and techniques to our managers, HR team, equality leads and staff to enable them to engage and adapt across cultural differences confidently.

For new employees joining us, we want to ensure that through our induction

and orientation processes, we are more explicit about what our values mean in practice and the behaviours we expect.

3. Support and report

We know that some staff may be hesitant to report incidences of discrimination. We want our staff to feel free to report their concerns free from fear of victimisation.

We intend to strengthen our reporting processes and make clear that whoever is reporting will be listened to and proportionate action is taken. To enable this to happen, we will make it easier for staff to report an incident about themselves or on behalf of someone, either anonymously or through a trained adviser. We will be clear on the process and options available to the staff reporting the incident.

How will we know we have succeeded?

• We take proportionate action whenever there is an incident of discrimination, bullying or harassment, resulting in an improvement in staff satisfaction levels on how we deal with their complaints

• Our People Before Process Group continue to work with our Staff Side to ensure any grievances, disciplinaries, and bullying and harassment cases are managed in line with the NHS Resolution Being Fair and the principles of a ‘Just and Learning’ Culture

• Managers are open-minded, recognise their limitations and open to feedback. They feel confident and feel supported to

tackle unwanted behaviours within their teams and have difficult conversations

• Staff feel they can report concerns without fear and are treated with respect when they do. Staff know how to raise a concern, the process and options available to them

• New starters are clear on the Trust values and expected behaviours and “how we do things around here.”

• We have reduced the gap between BME and non-BME Staff Survey and WRES results around bullying

• Our employee network groups will feed back on progress against our action plan

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Our Challenge

Policies and procedures govern our internal processes; many of them have been through an Equality Impact assessment to remove inadvertent bias. However, the dataspeaks for itself. The underlying reasons forinequality are complex, and evidenceshows that personal characteristics and individual behaviours play a part.

A disproportionate number of BME staff are involved in disciplinary hearings. It is notoriously difficult to capture all informal cases on performance and conduct. Often the HR department will be unaware of action or lack of action taken in the

services, thus making it difficult for us to get an accurate picture of what is happening across the Trust.

Most of the time, poor behaviour doesn’t operate in a vacuum, and there are likely other individuals or circumstances supporting it.

To measure the scale of the issues we need to capture the frequency of staff incidents by triangulating the number and type of contacts made with our Freedom to Speak Up Guardian, HR Business Partners, managers, and Equality Leads.

Remove any inequalities and inadvertent barriers from our internal processes


• we have delivered unconscious bias training through our Equality Level 2 training to the majority of our staff.

• A deep dive review of our disciplinary cases concluded that the rationale for progressing to formal procedures appeared to be justified. This may be the case, but we are aware that we may not be capturing conduct or behaviours, involving non-BME staff, that have perhaps been managed informally

• In May 2019, the WRES Expert Programme reviewed our WRES results recommending that we prioritise Indicator 3 – the relative likelihood of BME staff to enter formal disciplinary hearings

• We have also brought in an additional resource to support with addressing our Equality Diversity and Inclusion (EDI) concerns

Fact

Our WRES results, published in September 2019, highlight significant concerns around black and minority ethnic [BME] staff representation at disciplinary hearings, who are reported to be 2.39 times more likely to enter formal disciplinary proceedings than their white counterparts

Objective 2

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1. Building cultural competence into the heart of our processes

We want to embed measures of inclusion in our performance framework, scrutinise and discuss them routinely. To start this off and in line with our “People before Process” mantra, we will facilitate an Inclusive Workplace session, specifically designed for relevant members of the HR team and Equality Leads.

The session will involve a legal update, revisiting the concerns around the recent WRES and Staff Survey results, exploring a further Equality Analysis or Quality Improvement systems for our employee relation processes and how we can build in accountability for inclusion. The session also seeks to provide tools and strategies to support our managers with having difficult conversations about equality an diversity and to introduce the concept of the Diversity Champions / Cultural Ambassadors programme.

2. Building inclusive leadership

Developing our cultural competencies is key to the success of this strategy, and in line with our ambition to build a Just Culture, we will work with our managers to reduce the level of inequalities in BME representation at formal disciplinary meetings.

We believe that by increasing the informal dialogue between managers and their team members will provide more opportunity for formative feedback. We want to support our managers to address issues in a timely way, with confidence, without fear of accusations of discrimination. We know that more diversity awareness training may be counter-productive and it will be more impactful to provide our managers with tools and strategies for managing the challenges they face and creating an inclusive work environment. We will review our leadership development offerings and will ensure compassion and inclusion are themes that run through these.

“We cannot all succeed when half of us are held back.”Malala Yousafzai

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3. Understanding cultural issues

We intend to adapt and pilot the RCN’s Cultural Ambassador (CA) programme within all our operational services to support a culture of inclusion and anti-discrimination. This programme aims to train cultural ambassadors as interlocutors in employee relations processes and reduce the number of formal disciplinaries and grievances of BME staff.

This programme aims to train cultural ambassadors to identify and challenge discrimination and cultural bias using their skills as a neutral observer within employee relations processes involving staff

from backgrounds to reduce the number of formal disciplinaries and grievances involving these staff. We hope that by introducing this role, staff will have more confidence in our grievance, discipline and selection processes and that fewer cases will go to formal hearings, thus supporting our Just Culture ethos.

We will seek to appoint CAs from our Employee Network Groups as they are best placed to understand and identify cultural issues. This will also put our Employee Network Groups (ENGs) in the driving seat of creating change.


• We capture more data around performance and conduct concerns managed informally

• We have reduced the gap between BME and non-BME Staff staff entering formal disciplinary proceedings

• Our minority staff groups report greater levels of confidence in our internal processes

• We have several fully trained and engaged CAs who can disseminate their learning amongst colleagues

• We have embraced and actively seek out CAs to participate in all investigations and formal panels relating to underrepresented staff

• In line with our Just Culture Strategy, we ‘keep things simple’ and systematically review the use of CAs, our policies and procedures to ensure they are workable and fit for purpose

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This means:

Improve progression and development opportunities and retention of staff from under-represented groups

Fact

Our 2019 WRES results show that BME staffare 1.52 times less likely to be appointed fromshortlisting compared to their white colleagues

Our challenge

Representation of BME staff has remainedconsistent for the past three years, with justunder 9% of staff from a BME background. These staff are under-represented at higher bandings. To achieve the representation recommended in NHSI’s ‘Implementing the NHS Workforce Race Equality Standard (WRES) leadership strategy’ we will be providing increased support for staff in protected characteristic groups to develop their careers. Our aspiration is to appoint two more BME band 8b staff within the span of this strategy.

Due to current efforts to target non-mandatory training, our data show that BME staff are more likely to access this. Only 65% BME staff as opposed to 80%white, believe that the Trust provides equalopportunities. This is reflective of thefeedback from our BME Employeenetwork group.

Our WDES 2018 data indicated thedistribution of staff is unbalanced inmedical staffing and roles above a band8a. We are also aware of concernsraised by the Disability ENG relating to

parking accessibility and delays accessingequipment to support with reasonableadjustments to the work environment.Our challenge is around supporting ourmanagers to have meaningful conversations about career development, particularly with those staff that, for whatever reason, theyhave not yet had such discussions.

Additional challenges we anticipate will bein supporting our minority groups to putthemselves forward for stretch assignmentsand existing development programmes aswell as and providing mentors and sponsorsto support their progression. If we takepositive action, we are likely to be facedwith issues around tokenism.

We know that our exit data may not accurately reflect the true reason for leaving. Reasons for leaving cited in resignation letters such as “relocation”,“career progression” and “personalreasons” and that exit interviews carriedout by the line manager do not provideus sufficient information - we need to do more to explore to understand our staff retention.

Objective 3

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• We have clear processes around accessing training, development and progression opportunities

• Our HR Team analyse and report through our governance structures on workforce data relating to internal promotions, appraisal and training and development and leavers

• We are proposing a Leadership and Management Offering to include a plethora of internal and external courses for aspiring managers and leaders to Executive Team level, including promoting the NHS Leadership’s Academies offerings such as Stepping Up


1. Developing careers

We want to support our workforce with career development. Therefore we will review how our appraisal processes enable meaningful conversations around career development, even when there is not a defined career pathway.

2. Leadership

We will actively promote our leadership development offerings, highlighting that this includes a Stepping Up and Ready Now Programme for BME staff at local service level and through our ENGs. We will also reserve a number of places on our internal leadership development programmes for staff from groups that are under-represented in leadership roles.

3. Recruitment, training and development

We recognise that it is often an inability to evidence experience rather than

competence that is a barrier to progression for some staff. Therefore, we will also review our processes around recruitment and access to training and development opportunities, including less formal opportunities, such as projects, secondments and workplace-shadowing to ensure there is no inadvertent bias.

4. Reasonable adjustment

We will carry out a review of the procurement process relating to requests for reasonable adjustment equipment, which will include the creation of a new central fund and policy to improve the lead time for its provision.

5. Parking review

We will re-assess the parking provision on two Trust sites and implement recommended actions and use the learning from this as a ‘blue print’ to support similar reviews elsewhere on Trust sites. >>

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6. Employee Network Groups

We will engage the support of our Employee Network Groups and revisit the terms of reference, making it clearer that they are empowered to provide support, education and mentoring to those who need it and to lead some of the work in taking forward this strategy.

7. Diversity characteristics data

We will continuously improve the quality of our data, further dissecting it, to report, where possible, on the different diversity characteristics (exit data, Friends and Family Test and Staff Survey results), to further understand how it feels for our diverse staff groups to work here.


• Our WRES and WDES data will show an increased representation of staff from underrepresented groups in more senior-level roles across the organisation and we are actively monitoring all protected characteristic groups

• We periodically audit, analyse and report on our diversity data, particularly around internal and external candidate appointments, appraisal, training and exit data

• We have a diverse workforce, reflective of the population that we serve and who report higher levels of engagement and employee experience in our annual survey, pulse and Friends and Family results

• We have a more accurate understanding of our employee experience, including why people join us and why they leave

“We did not come here to fear the future. We came here to shape it.” Barack Obama

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• We have put in place support for Care Groups by creating the Equality Lead role, who are trained to support Care Groups to carry out equality action plans for the services

• We have created a People Participation Lead so that each locality has a service user voice at the heart of its decision-making

Fact

One in seven LGBT people (14%) avoid seeking healthcare for fear of discrimination from staff. ref: LGBT in Britain – Health Report (2018), Stonewall

Integrate equality and diversity actions into the day-to-day work of our Care Groups / services

Our challenge

Our Trust already carries out a Trust-wide equality analysis using the Equality Delivery System, but we need to go much further in ensuring that the service-user experience in every service line lives up to the expectations laid out in the Public Sector Equality Duty. Our services need to be designed from the ground up to ensure that they provide the best care for all of the diverse communities we serve, and to be accessible to all.

To do this we need to both empower managers in our localities (and in our new structure, the Care Groups who lead them)

to analyse and understand the issues, create effective action plans to eliminate inequality, and provide the highest standards of assurance in our governance.

Improving recording of equality monitoring data of our service-users and of our staff is important so we can be sure our services and staff are truly representative of the diversity of our communities.”

We also recognise that this is a quickly evolving landscape and that Care Groups need to remain responsive to issues as they arise.

Objective 4

12.4





1. EDI lead in clinical services

Essential investment is needed to create a new EDI Lead role to provide expertise and support to Clinical Care Group leaders and immediately start work around equality and diversity governance, service access, and delivery within our clinical services. Using the EDS2 to ensure they fit into our governance framework, we will define aset of Key Performance Indicators related

to equality and diversity and measure our services against these.

2. Equality as Quality Improvement

We will support our leaders and managersto conduct an Equality Analysis to identifywhere a service or service change may havea negative impact on a particular group ofpeople, and then to develop action plans toaddress them using the QI framework.


• Localities report on the delivery of sustainable QI equality plans

• We are using the data available to us to drive discussion and to develop action plans that embed improvements into both staff and patient experiences

• Our services will deliver assurance on Quality Improvement project progress, informing how we assess progress against the Equality Delivery System objectives

• Services embrace, value, and promote the role of the Equality Leads

“...There is no test for progress other than its impact on the individual.” Aneurin Bevan

12.4



We recognise that placing the management of equality into our governance structure is a pre-requisite for success. Our Governance arrangements will ensure that the Trust Board receives regular assurance that the Trust is meeting its Public Sector Equality Duty and, equally important, our progress towards becoming a more inclusive employer.

his strategy demonstrates a two-yearforward view; however, given thechallenges faced by the Trust and

current climate within the NHS over recentyears, it is important to review the strategy ona yearly basis to ensure it remains fit for purpose.To ensure that there is a triangulation of strategy,the Action Plan (Appendix A), along with theWRES and WDES data, will be reported to the Trust Board and in the Annual Report, as well as regular updates to the Quality Committee and Service Delivery Board.

The governance structure for equality can be seen in the EDI Policy (HRP013).

NSFT has the following Employee Network Groups (ENGs). These groups inform our approach and will hold us to account for our performance against our goals:

• Equality Leads Network• BME• LGBT+• Spirituality and Faith• Disability• Mental Health - Lived Experience

They will shortly be joined by a Women’s ENG and a Carer’s ENG.

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“Revolution is not a one-time event” Audre Lord

what we are doingGovernance behind

12.4



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Norfolk and Suffolk NHS Foundation Trust values and celebrates the diversity of all the communities we serve. We are fully committed to ensuring that all people have equality of opportunity to access our service, irrespective of their age, gender, ethnicity, race, disability, religion or belief, sexual orientation, marital or civil partnership or social and economic status.

NSFTrust

@NSFTtweets

nsft.nhs.uk

01603 421421Trust Headquarters: Hellesdon HospitalDrayton High RoadNorwich NR6 5BE

Patient Advice and Liaison Service (PALS)

NSFT PALS provides confidential advice, information and support, helping you to answer any questions you have about our services or about any health matters.

If you would like this leaflet in large print, audio, Braille, alternative format or a

different language, please contact PALS and we will do our best to help. Email: [email protected] call PALS Freephone 0800 279 7257

12.4




[2 s

ides

- f

old

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No Action Link Strategy / report WRES WDES Desired impact

1 Review appraisal processes to incorporate and monitor career discussions

EDI Strategy - Objective 3 N N More meaningful conversations around career development, even when there is not a defined career pathway.

2 Actively promote our leadership development offerings at local level and through ENGs, including Stepping Up and Ready Now

EDI Strategy - Objective 3 N N Raised awareness on opportunities

3 Work towards further dissecting our exit and survey data, where possible on the different diversity characteristics to further understand how it feels to work here

People Stratedy 2019 Workforce Priority 3 EDI Strategy - Objective 3

N N Data is easily accessible, we have a greater understanding of what it feels like for our underrepresented groups to work here

4 Explore the feasibility of appointing an EDI Lead role within service governance

EDI Strategy - Objective 4 N N A designated resource to focus on supporting our services with equality and diversity governance, service access and delivery

5 Support our managers to conduct EIAs EDI Strategy - Objective 4 N N We are routinely assessing where a service or service change may have a negative impact on a group of people, and then to develop action plans to address them

6 Develop Inclusive leaders and explore ways to increase the informal dialogue between managers and their teams, broadening the conversations beyond the "to do list"

EDI Strategy - Objective 2, WRES Action Plan 2019 - Indicator 3

Y N To support our managers to address issues in a timely way, with confidence, without fear of accusations of discrimination.

7 Pilot the Cultural Ambassador Programme EDI Strategy - Objective 2. WRES Action Plan 2019 - Indicator 3

Y N We have cultural ambassadors to act as interlocutors in employee relations processes and reduce the number of formal disciplinaries and grievances of BME staff

8 Introduction of Equality Leads to Interview Panels

WRES Action Plan 2019, Indicator 1,2,7

Y N Reduction in unconcious bias in the recruitment process

9 Update the new starter induction to include a greater emphasis on our values, the importance of EDI and other relevant information to support a positive experience

People Strategy 2019 Workforce Priority 1, 3, 5 EDI Strategy - Objective 1

N N An improved employee experience where new starters are clear on what is expected of them

10 Review our processes around recruitment, our gender pay gap and access to training and development opportunities to ensure there is no inadvertent bias

People Strategy 2019 Workforce Priority 6. EDI Strategy - Objective 3. WDES Action Plan 2019 indicator 5 and 9

N Y We are reassured that there is no room in our processes for inadvertant bias

11 Review the procurement process relating to requests for reasonable adjustment equipment, which will include the creation of a new central fund and policy to improve the lead time for equipment.

People Strategy 2019 Workforce Priority 6 EDI Strategy - Objective 3, WDES Action Plan 2019 indicator 7,8 and 9

N Y Increased declaration of disability status and engagement for disabled staff.

12 Reassess the parking provision on two Trust sites and implement recommended actions

EDI Strategy - Objective 3, WDES Action Plan 2019 indicator 7,8 and 9

N Y Increased declaration of disability status and engagement for disabled staff.

13 Link in with Disability Confident to review expert resources and and training available to enable us develop a stronger understanding of the different needs of our workforce. Including achieving L3 Disability Confident

EDI Strategy - Objective 1 &2, WDES Action Plan 2019 Indicator 1,2,5,9

N Y We have an increased understanding of our workforce needs and have developed a comprehensive and easily accesible management toolkit that provides support, practical tools and strategies for creating an inclusive working environment

14 Launch a high visibility Zero Tolerance Approach to discrimination, Bullying and Harrasment led by Senior Leaders. This will include additonal ED training for all staff

EDI Strategy - Objective 1; WRES Action Plan 2019 - Indicator 5 and 6, WDES Action Plan 2019 - indicator 4,5,6,7,9

Y Y All employees, workers, contractors, and visitors are expected to be treated, and to treat each other, with dignity and respect regardless of role or personal characteristics

15 Review our processes relating to reporting an allegation of discrimination, bullying and harrassment, ensuring the individual and accused receives adequate support. This will include promoting the role of the Freedom to Speak Up Guardian.

People Strategy 2019 Workforce Priority 1, 3, 5 EDI Strategy - Objective 1, WRES Action Plan 2019 - indicator 3 and 6, WDES Action Plan 2019 - indicator 4 and 9

Y Y A clearer and easier process to report an incident relating to themselves or on behalf of someone, either anonymously or through a trained adviser.

16 EDI Workshop for HRBPs People Strategy Workforce Priority 7 EDI Strategy - Objective 2, WRES Action Plan 2019, Indicator 3 and 8, WDES Action plan 2019 - Indicator 3,4,6 and 9

Y Y Our HR team are enabled and encouraged to support the organisation achieve its EDI goals.

17 Revisit the ENG's terms of reference, making it clearer that they are empowered to provide support, education and mentoring to those who need it.

EDI Strategy - Objective 3, WRES Action Plan 2019 - Indicator 7, WDES Action Plan 2019 - Indicator 9 and 10

Y Y ENGS are clear on their role and are actively providing support to those who need it. They are positioning themselves to be in the driving seat of change

18 Continue with Reverse Mentoring of our Trust’s executives by members of the BME ENG

WRES Action Plan 2019, Indicator 6, WDES Action Plan 2019 indicator 7 and 9

Y Y Our Board have a greater awareness of what it is like for our underrepresented groups to work here. These groups have the opportunity to voice their concerns to the board.

Appendix A - EDI Strategy - Action Plan

Key: WRES = n WDES = n Both = n

Please see WRES and WDES guidance for an explanation of these Indicators referenced at: https://www.england.nhs.uk/wp-content/uploads/2017/03/wres-technical-guidance-2019-v2.pdf and https://www.england.nhs.uk/wp-content/uploads/2019/01/wdes-metrics.pdf

12.4



“We should indeed keep calm in the face of difference, and live our lives in a state of inclusion and wonder at the diversity of humanity.” George Takei (Actor, LGBT+ activist)

Last updated 21 February 2019 14

The following design assets are also free to use for creation of any other materials to support your Rainbow Badge initiative. We only ask that they are only used in support of this initiative and in a way that adheres to the overall principles of this model. Chalk badge design Chalk rainbow

Statistic bubbles with statistics relevant to both adults and young people

NHS Rainbow Badge implementation toolkit

The Rainbow Badge initiative gives healthcare staff a way to show that their place of work offers

open, non-judgemental and inclusive care for all who identify as LGBT+ (lesbian, gay, bisexual,

transgender, the + simply means inclusive of all identities, regardless of how people define

themselves).

The initiative originated at Evelina London Children’s Hospital and community services, part of Guy’s

and St Thomas’ NHS Foundation Trust. Its simple objective is to make a positive difference by

promoting a message of inclusion.

This toolkit provides information about the initiative, and some tools to facilitate adoption across

other NHS organisations. It may also be a useful resource for organisations outside of the NHS, with

small adaptations to the badge and materials.

This toolkit includes the following:

Key principles of the Rainbow Badge initiative

Funding advice

Information on badge production

Supporting design materials

Template materials:

o Intranet copy/sign-up information

o External website copy – can be found at evelinalondon.nhs.uk/rainbowbadges and

guysandstthomas.nhs.uk/rainbowbadges

Template materials:

o Staff leaflet

o Posters

o Rainbow badge brand assets

Rainbow badges graphic

Rainbow corners

Statistic bubbles

Roll-out case study – Evelina London

Support from RCPCH &US (Royal College of Paediatrics and Child Health & Us) – the voices of

young people.

12.4



<Board> - <18.11.19>

<EPRR>

Version <0.3>

Author: <Amie McGrory>

Department: <Operations>

Page 1 of 5 Date produced: <05.11.19> Retention period: 20 years

Date: 21st November 2019 M Item: 19.141


Meeting date: 18th November 2019

Title of report: Emergency Preparedness Resilience and Response (EPRR)



Author: Amie McGrory, Resilience Manager

Director: Stuart Richardson, Chief Operating Officer

Executive Summary:

Emergency Preparedness Resilience and Response (EPRR) is subject to an annual audit against the NHSE Core Standards Framework. At the 2019 audit, compliance was only agreed against 40 of the 54 standards; at 74%, NSFT was granted an overall rating of “non-compliant”.

An action plan was defined to improve compliance and information on this was provided to the Board in September 2019. Improvements are being made continually and at an extraordinary meeting with NHSE Regional Head of EPRR on 4th October 2019 to discuss NSFT-compliance, the Trust was already found to have increased compliance to “partially-compliant”.

A new approach to Resilience is now being encouraged throughout the Trust: to address non-compliance with business continuity planning, a new commitment to align to ISO 22301* is underway. Therein, a new Business Continuity Management System (BCMS) was launched on the 25th October 2019 alongside an ISO 22301 briefing to Senior Managers followed by a workshop for the completion of new documentation arising under the new System. All Care Groups are being supported to set their own smart objectives for Resilience which focus on the completion and testing of business continuity plans. A Resilience Group has been established, reporting to the Service Delivery Board, to push this work forward at pace.

In line with agreed actions to improve Resilience at NSFT, the attached Statement of Intent, as a precursor to the Resilience Policy and the Business Continuity Management System, has been adopted by Trust. It was agreed with NHSE Regional Head of EPRR that this Resilience Policy Statement shall be reviewed by the Board; this is presented in this paper.

*the international standard for Business Continuity Management, to which alignment is required under the EPRR Framework.

13.1

Tab 13.1 Item 19.141: EPRR update


<Board> - <18.11.19>

<EPRR>

Version <0.3>




Contents

1.0 Financial implications (including workforce effects)......................................................... 2

2.0 Quality implications ......................................................................................................... 2

3.0 Equality implications / summary of consultation .............................................................. 2

4.0 Risks / mitigation in relation to the Trust objectives ......... Error! Bookmark not defined.

5.0 Recommendations .......................................................................................................... 2

6.0 Background papers / information .................................................................................... 4


1.1 There are no financial penalties associated with non-compliance to Core Standards. There may be a minor increase in expenditure across the Trust due to increase in activity. Additional resources may be requested once resilience is embedded, for example resourcing new operational business continuity plans (grab bags, back up equipment etc), but these costs should spread evenly throughout the Trust and have little impact on individual Teams or Services.


2.1 The preparations underway to improve and embed Resilience in all clinical and corporate teams is a positive step towards improving the quality of all NSFT services.

3.0 Equality implications / summary of consultation

3.1 No specific equality implications were previously identified.

3.2 Moreover, the preparations underway to improve and embed Resilience across NSFT is positive for equality; sub clauses of the ISO22301 present the need to understand the context of the organisation and analyse the requirements and expectations of our stakeholders. By completing these activities equality will be integrated in to the development and delivery of EPRR.


4.1 Substandard Trust Resilience creates the potential for substandard response to a business continuity incident thus compromising our ability to deliver our core business objectives. Furthermore, if a Major Incident were to occur the needs of the community may not be met. This risk is unknown but reduces consistently with our improvement process, becoming obsolete within 1 year – this is the elected timeframe by which NSFT reaches a level of adequate resilience.

4.2 This improvement is being managed by the implementation of a new Trust Resilience Group; the first meeting of the Group is scheduled for 21st November 2019 at which the ToRs will be approved.

4.3 The Emergency Preparedness Resilience and Response Group, known simply as the Resilience Group shall be a sub-group of the Service Delivery Board. It is responsible for overseeing the development of all systems and processes for all functions relating to emergency planning, business

13.1



<Board> - <18.11.19>

<EPRR>

Version <0.3>




continuity and major incident response, as detailed by NHS England’s Emergency Preparedness, Resilience and Response Framework (EPRR Framework).

4.4 The Group will enhance NSFT resilience, enabling better progress in this area by including, supporting and educating senior staff whilst assigning responsibility to Care Groups and Corporate Services (as per the Business Continuity Management System).

4.5 Care Groups are encouraged to add risks relating to Resilience to their risk registers and work in this area supports BAF risks 2.2 and 4.1.

5.0 Reporting and Assurance

5.1 Care Groups and Specialist Services will be required to provide regular updates on progress via their risk on the Corporate Risk Register. A Corporate EPRR risk is also kept and reviewed regularly by the Resilience Manager.

5.2 It was agreed that progress reports on risk associated with Business Continuity Management and relating to improvement against the EPRR Core Standards Framework will be presented to the Risk and Audit Committee at 6 and 12 month intervals following the Audit in August 2019, and in relation to preparation with EU Exit. The first has been completed early (at 3 months) with a report submitted to the Audit and Risk Committee sitting on the 5th November 2019.

5.3 It was also agreed that a further report will be provided to the Board in 12 months to provide assurance that all areas of partial compliance have been addressed; this remains accurate and

13.1



<Board> - <18.11.19>

<EPRR>

Version <0.3>




today’s report allows for the Board to have sight of the Policy Statement as an interim update on progress as requested by NHSE.

6.0 Recommendations

6.1 To note the content of the report.

6.2 To review the Resilience Policy Statement


7.1 Resilience Policy Statement

13.1



<Board> - <18.11.19>

<EPRR>

Version <0.3>




Emergency Preparedness, ‘Resilience’ and Response (EPRR)

Resilience Policy Statement At Norfolk and Suffolk Foundation Trust (NSFT), Resilience is the term used for the effective combination of Business Continuity Management and Emergency Planning; this is referred to in the health community as Emergency Preparedness, Resilience and Response (EPRR). The 2015 EPRR Framework stipulates that the NHS needs to plan for and be able to respond to a wide range of incidents that could impact on health or patient care; from large civil emergencies that require the declaration of a Major Incident and an integrated civil response, to small internal incidents that requires the internal declaration of a Business Continuity Incident and an operational response. In respect to the Civil Contingencies Act (2004), mental health trusts are expected to plan for and respond to incidents in the same way as category one responders, in a manner which is proportionate to the scale and services provided. For NSFT this mandates the additional provision of post incident psychological support to those experiencing psychological injury as a result of a Major Incident occurring within Norfolk or Suffolk. The Trust hereby recognises that action is required to protect our community, service users, staff and resources: With that recognition, we commit to take a realistic view on the preparations that are required, to make our Trust resilient against the incidents which could arise and apply ourselves to being able to respond to the needs of the community and ourselves as a Foundation Trust. This commitment shall manifest at all levels of the Trust and be established through the design, implementation, maintenance and review of a Business Continuity Management System (BCMS) in alignment to the ISO standard 22301. This BCMS shall deliver NSFTs Resilience Policy and assigns all activity regulated by the EPRR Core Standards, thus bringing in to scope Emergency Planning and ensuring our duties under the Civil Contingencies Act 2004 and the Health and Social Care Act 2012 are met. The Resilience Policy shall further define;

Trust Resilience scope and objectives

The context of the Organisation

Specific roles including responsibilities, competencies and authorities

The risk management process

Resource requirements including training

Communications and engagement strategy, and

Commitment to stakeholders. The overall development and integration of this system throughout the Trust will be managed by the Resilience Team in consultation with a trained and competent core of Senior Managers combining to form the Norfolk and Suffolk Foundation Trust Resilience Group. The Group shall be led by the Deputy Chief Operating Officer on behalf of the Accountable Emergency Officer.

XStuart Richardson

Accountable Emergency Officer

13.1



Public BoD - 21.11.19Quality Assurance RO Revalidation

Version <0.1> Author: B SolomkaDepartment: RO




Title of Report: Quality Assurance for Responsible Officers and Revalidation:

Annual Board Report and Statement of Compliance.

Action Sought: For Approval

Estimated time: 10 Minutes

Author: Bohdan Solomka

Director: Bohdan Solomka: Responsible Officer

Executive Summary:

An updated format for reporting Revalidation quality has been issued in February 2019 byNHS England and NHS Improvement.

One issue arose with our AoA submission; the definition of Unapproved/Incomplete Appraisal numbers. Our threshold was lowered following a review to improve our performance on delays, but on reflection, these were delays rather than failures to engage. We therefore reported a falsely high number of 19 (10%) of doctors. Having taken advice from the General Medical Council and the Responsible Officer Lead Appraiser Network, the RO and LA for NSFT will use the up to date advice before submitting next year’s Annual Audit of Appraisal (AoA). Currently we have 3 doctors who can be defined as ‘non-engaging’ with appraisal resulting in ‘unapproved’ appraisal, and all three have been reported to the GMC for their delays and have management plans in place.

Appendices:

Annex D Document attached

Date: 21st November 2019 NItem: 19.142

13.2

Tab 13.2 Item 19.142: Statement of Compliance revalidation


OFFICIAL

NHS England and NHS Improvement

A Framework of Quality Assurance for Responsible Officers and Revalidation

Annex D – Annual Board Report and Statement of Compliance.

13.2



A Framework of Quality Assurance for Responsible Officers and Revalidation

Annex D – Annual Board Report and Statement of Compliance.

Publishing approval number: 000515

Version number: 3.0

First published: 4 April 2014

Updated: February 2019

Prepared by: Lynda Norton, Claire Brown, Maurice Conlon

This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. Please contact Lynda Norton on [email protected].

13.2



Contents

Introduction: ............................................................................................................... 3

Designated Body Annual Board Report...................................................................... 5

Section 1 – General.................................................................................................... 5

Section 2 – Effective Appraisal................................................................................... 6

Section 3 – Recommendations to the GMC ............................................................... 7

Section 4 – Medical governance ................................................................................ 8

Section 5 – Employment Checks ............................................................................... 9

Section 6 – Summary of comments, and overall conclusion ...................................... 9

Section 7 – Statement of Compliance ...................................................................... 10

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Introduction:

The Framework of Quality Assurance (FQA) for Responsible Officers and Revalidation was first published in April 2014 and comprised of the main FQA document and annexes A – G. Included in the seven annexes is the Annual Organisational Audit (annex C), Board Report (annex D) and Statement of Compliance (annex E), which although are listed separately, are linked together through the annual audit process. To ensure the FQA continues to support future progress in organisations and provides the required level of assurance both within designated bodies and to the higher-level responsible officer, a review of the main document and its underpinning annexes has been undertaken with the priority redesign of the three annexes below:

∑ Annual Organisational Audit (AOA):

The AOA has been simplified, with the removal of most non-numerical items. The intention is for the AOA to be the exercise that captures relevant numerical data necessary for regional and national assurance. The numerical data on appraisal rates is included as before, with minor simplification in response to feedback from designated bodies.

∑ Board Report template:

The Board Report template now includes the qualitative questions previously contained in the AOA. There were set out as simple Yes/No responses in the AOA but in the revised Board Report template they are presented to support the designated body in reviewing their progress in these areas over time.

Whereas the previous version of the Board Report template addressed the designated body’s compliance with the responsible officer regulations, the revised version now contains items to help designated bodies assess their effectiveness in supporting medical governance in keeping with the General Medical Council (GMC) handbook on medical governance1. This publication describes a four-point checklist for organisations in respect of good medical governance, signed up to by the national UK systems regulators including the Care Quality Commission (CQC). Some of these points are already addressed by the existing questions in the Board Report template but with the aim of ensuring the checklist is fully covered, additional questions have been included. The intention is to help designated bodies meet the requirements of the system regulator as well as those of the professional regulator. In this way the two regulatory processes become complementary, with the practical benefit of avoiding duplication of recording.

1 Effective clinical governance for the medical profession: a handbook for organisations employing,contracting or overseeing the practice of doctors GMC (2018) [https://www.gmc-uk.org/-/media/documents/governance-handbook-2018_pdf-76395284.pdf]

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The over-riding intention is to create a Board Report template that guides organisations by setting out the key requirements for compliance with regulations and key national guidance, and provides a format to review these requirements, so that the designated body can demonstrate not only basic compliance but continued improvement over time. Completion of the template will therefore:

a) help the designated body in its pursuit of quality improvement,

b) provide the necessary assurance to the higher-level responsible officer, and

c) act as evidence for CQC inspections.

∑ Statement of Compliance:

The Statement Compliance (in Section 8) has been combined with the Board Report for efficiency and simplicity.

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Designated Body Annual Board ReportSection 1 – General:

The board / executive management team – [delete as applicable] of [insert official name of DB] can confirm that:

1. The Annual Organisational Audit (AOA) for this year has been submitted.

Date of AOA submission: 23/04/2019

Action from last year: no specific actions

Comments: see box 2.2 below

Action for next year:

2. An appropriately trained licensed medical practitioner is nominated orappointed as a responsible officer.

Action from last year: None

Comments: Yes

Action for next year: New Responsible officer from 2020 will require training

3. The designated body provides sufficient funds, capacity and other resources for the responsible officer to carry out the responsibilities of the role.

Yes


Comments:


4. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is always maintained.


Comments: Yes


5. All policies in place to support medical revalidation are actively monitored and regularly reviewed.


Comments: Yes


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6. A peer review has been undertaken of this organisation’s appraisal and revalidation processes.


Comments: Yes


7. A process is in place to ensure locum or short-term placement doctors working in the organisation, including those with a prescribed connection to another organisation, are supported in their continuing professional development, appraisal, revalidation, and governance.


Comments: Yes


Section 2 – Effective Appraisal

1. All doctors in this organisation have an annual appraisal that covers a doctor’s whole practice, which takes account of all relevant information relating to the doctor’s fitness to practice (for their work carried out in the organisation and for work carried out for any other body in the appraisal period), including information about complaints, significant events and outlying clinical outcomes.


Comments: Yes


2. Where in Question 1 this does not occur, there is full understanding of the reasons why and suitable action is taken.

Action from last year:

Comments: Yes. One issue arose with our AoA submission; the definition of Unapproved/Incomplete Appraisal numbers. Our threshold was lowered following a review to improve our performance on delays, but on reflection, these were delays rather than failures to engage. We therefore reported a falsely high number of 19 (10%) of doctors

Action for next year: Revalidation team will meet before submission of AoA to go through every appraisal that is delayed and agree thresholds in each case.

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3. There is a medical appraisal policy in place that is compliant with national policy and has received the Board’s approval (or by an equivalent governance or executive group).


Comments: Yes


4. The designated body has the necessary number of trained appraisers to carry out timely annual medical appraisals for all its licensed medical practitioners.


Comments: Yes


5. Medical appraisers participate in ongoing performance review and training/ development activities, to include attendance at appraisal network/development events, peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers2 or equivalent).


Comments: Yes


6. The appraisal system in place for the doctors in your organisation is subject to a quality assurance process and the findings are reported to the Board or equivalent governance group.


Comments: Yes


Section 3 – Recommendations to the GMC

1. Timely recommendations are made to the GMC about the fitness to practise of all doctors with a prescribed connection to the designated body, in accordance with the GMC requirements and responsible officer protocol.


Comments: Yes

2 http://www.england.nhs.uk/revalidation/ro/app-syst/2 Doctors with a prescribed connection to the designated body on the date of reporting.

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http://www.england.nhs.uk/revalidation/ro/app-syst/


2. Revalidation recommendations made to the GMC are confirmed promptly to the doctor and the reasons for the recommendations, particularly if the recommendation is one of deferral or non-engagement, are discussed with the doctor before the recommendation is submitted.


Comments: Yes


Section 4 – Medical governance

1. This organisation creates an environment which delivers effective clinical governance for doctors.


Comments: Yes


2. Effective systems are in place for monitoring the conduct and performance of all doctors working in our organisation and all relevant information is provided for doctors to include at their appraisal.


Comments: Yes


3. There is a process established for responding to concerns about any licensed medical practitioner’s1 fitness to practise, which is supported by an approved responding to concerns policy that includes arrangements for investigation and intervention for capability, conduct, health and fitness to practise concerns.


Comments: Yes


4. The system for responding to concerns about a doctor in our organisation is subject to a quality assurance process and the findings are reported to the Board or equivalent governance group. Analysis includes numbers, type and outcome of concerns, as well as aspects such as consideration of protected characteristics of the doctors3.

4This question sets out the expectation that an organisation gathers high level data on the management of concerns about doctors. It is envisaged information in this important area may be

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Comments: Yes


5. There is a process for transferring information and concerns quickly and effectively between the responsible officer in our organisation and other responsible officers (or persons with appropriate governance responsibility) about a) doctors connected to your organisation and who also work in other places, and b) doctors connected elsewhere but who also work in our organisation4.


Comments: Yes


6. Safeguards are in place to ensure clinical governance arrangements for doctors including processes for responding to concerns about a doctor’s practice, are fair and free from bias and discrimination (Ref GMC governance handbook).


Comments: Yes


Section 5 – Employment Checks

1. A system is in place to ensure the appropriate pre-employment background checks are undertaken to confirm all doctors, including locum and short-termdoctors, have qualifications and are suitably skilled and knowledgeable to undertake their professional duties.


Comments: Yes


Section 6 – Summary of comments, and overall conclusion

- No specific outstanding actions from 2018/19

- Current Issues have been noted with NSFT thresholds for Unapproved / Incomplete Appraisals.

requested in future AOA exercises so that the results can be reported on at a regional and national level.4 The Medical Profession (Responsible Officers) Regulations 2011, regulation 11: http://www.legislation.gov.uk/ukdsi/2010/9780111500286/contents

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New Actions: Appraisal / Revalidation team has met and reviewed the current cases and found 3 rather than 19 to meet criteria. There will be a meeting prior to submission of the potential Unapproved / incomplete cases before submission of 2019/20 AoA

Overall conclusion:

There is full compliance with the necessary appraisal and revalidation process. There is a plan to ensure correct reporting of unapproved delays in appraisal.

Section 7 – Statement of Compliance:

The Board of Norfolk and Suffolk NHS Foundation Trust has reviewed the content of this report and can confirm the organisation is compliant with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013).

Signed on behalf of the designated body

[(Chief executive or chairman (or executive if no board exists)]

Official name of designated body: Norfolk and Suffolk NHS Foundation Trust

Name: Jonathan Warren Signed:

Role: Chief Executive Officer

Date: 30 September 2019

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BoD - 21 Nov 2019 BoD ToR

Version 0.1

Author: Jean Clark Department: Corporate

Page 1 of 4 Date produced: October 2019 Retention period: 20 years



Title of report: Board of Directors Terms of Reference

Action sought: For Approval


Author: Jean Clark, Trust Secretary


Executive Summary:

The purpose of this report is to review the Terms of Reference of the NSFT Board of Directors.

1.0 Authority 1.1 The Board of Directors (BoD) is established and authorised by the Norfolk and Suffolk

NHS Foundation Trust (‘the Trust’) Constitution under the NHS Act (2006) and the Health and Social Care Act (2012), as amended by the Council of Governors and Board of Directors from time to time.

1.2 The BoD may delegate any of its powers to committees or executive directors, with

the exception of discharge of patients under section 23 of the Mental Health Act 1983 (as amended by section 45 of the Mental Health Act 2007), which can be delegated to authorised people who are not Executive Directors.

1.3 For the avoidance of doubt, should any ambiguity or contradiction arise between

these terms of reference and the Trust’s constitution, it is the constitution that has sole primacy.

2.0 Purpose 2.1 The general duty of the Board of Directors and of each Director individually, is to act

with a view to promoting the success of the Trust so as to maximise the benefits for service users, carers, members of the Trust as a whole and for the wider public.

2.2. The principal purpose of the Trust is the provision of goods and services for the

purposes of the health service in England.

2.3 The Trust will not fulfil its principal purpose unless, in each financial year, its total

income from the provision of goods and services for the purposes of the health


O Item: 19.143

13.3

Tab 13.3 Item 19.143: Board Terms of Reference



Version 0.1



service in England is greater than its total income from the provision of goods and

services for any other purposes.

2.4 The Trust may provide goods and services for any purposes related to:

the provision of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness, and

the promotion and protection of public health.

3.0 Role of the Board of Directors 3.1 The Board of Directors has three general roles:

1. To formulate strategy to delivery safe, high quality, patient-centred care, 2. To ensure accountability by holding the account for the delivery of the strategy

through seeking assurance that systems of control are robust and reliable, and 3. To establish the values of the Trust, shaping the culture by promoting these in the

way that the Board does business and interacts with the rest of the Trust and external stakeholders.

3.2 The Board of Directors supporting principles:

To provide active leadership of the Trust within a framework of prudent and

effective controls which enables risk to be assessed and managed.

To be responsible for ensuring compliance by the Trust with its terms of

authorisation, its constitution, mandatory guidance issued by the regulators,

relevant statutory requirements and contractual obligations

To set the Trust’s strategic aims, taking into consideration the views of the Council

of Governors, ensuring that the necessary financial and human resources are in

place for the Trust to meet its objectives and review management performance.

To be responsible for ensuring the quality and safety of healthcare services,

education, training and research delivered by the Trust and applying the

principles and standards of clinical governance set out by the Department of

Health, the Care Quality Commission, and other relevant NHS bodies.

To ensure that the trust exercises its functions effectively, efficiently and

economically.

To set the Trust’s values and standards of conduct and ensure that its obligations

to its members, patients and other stakeholders are understood and met.

To approve and monitor the programme of risk management

4.0 Membership 4.1 Membership and voting arrangements are as set out in the Constitution. 4.2 The BoD consists of the Chair, Non-Executive Directors, and Executive directors

which include a Chief Executive (CEO), a medically qualified and licensed director, a nursing or midwifery qualified and licensed director and a Director of Finance.

13.3




Version 0.1



4.3 The Chair and the Non-Executive Directors are appointed by the Council of Governors.

4.4 The CEO is appointed by the Chair and the Non-Executive Director members of the

Appointments & Remuneration Committee, with the approval of the Council of Governors.

4.5 The Executive Directors are appointed by the Appointments & Remuneration

Committee, which for this purpose includes the CEO. 4.6 The BoD will appoint one of the Non-Executive Directors to be the Senior

Independent Director (SID) who may also be the Deputy Chair of the board. The Deputy Chair / SID will take on the Chair’s duties if the Chair is absent for any reason.

4.7 When an Executive Director is absent, deputies may attend BoD meetings but may

not vote unless they have been specifically appointed as interim voting directors by the Appointments & Remuneration Committee.

4.8 Any BoD member who has a conflict of interest on any item of board business must

declare this before the item is discussed and absent themselves from the discussion. For this purpose the member does not count towards the quoracy of that part of the meeting.

5.0 Administrative arrangements 5.1 The Company Secretary will act as Secretary to the Board and ensure that

appropriate administrative support is available to support board members. 5.2 Board papers of meetings held in public will be published on line at www.nsft.nhs.uk. 5.3 Governors will receive agendas for BoD meetings held in public in advance of

meetings, and approved minutes as soon as practical afterwards. 6.0 Meeting arrangements 6.1 Meetings will be held in public. 6.2 A resolution may be passed to exclude the public from a private session of the Board

for special reasons including the confidential or commercially sensitive nature of the item to be discussed.

6.3 Board papers will be sent to members no later than 5 days before the date of the BoD

meeting (except in an emergency), although any failure of a Board member to receive the papers will not invalidate the meeting.

6.4 Any Board member may request that an agenda item be put forward by giving

15 days’ notice in writing to the Chair. 6.5 The standing orders for the functioning of the BoD are set out in full in the Constitution

and take precedence over the Terms of Reference. 7.0 Quorum

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http://www.nsft.nhs.uk/


Version 0.1



7.1 No business shall be transacted at a meeting unless at least one-third of the whole number of the Chair and members (including at least one Executive Director and at least one Non-Executive Director) is present.

7.2 An Officer in attendance for an Executive Director but without formal acting up status

may not count towards the quorum. 8.0 Accountability 8.1 The Council of Governors holds Non-Executive Directors to account for the

performance of the BoD. 9.0 Review 9.1 These terms of reference will be reviewed annually by the BoD. Version Control BoD review 21st November 2019 BoD Reviewed 27th Apr2017 Updated and approval at BoD 28th April 2016 Original BoD Approved: 23rd April 2015

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BoD Governance architecture 21/11/2019

Version 0.1 Author: Jean ClarkDepartment: Trust Secretary

Page 1 of 1 Date produced: 01/11/2019 Retention period:



Title of Report: Governance Structure




Director: Mason Fitzgerald, Deputy CEO/Director of Strategic Partnerships

The governance structures of the Trust have been revised, following the ELFT governancereview in February and March 2019.

The Board has focused on the improvement necessary to become a “well led” Board, and the role of the Board and committees in supporting this.

The terms of reference of the Board sub-committees have been reviewed in line with best practice, the context of the Trust and its priorities, and were approved by the Board in May.

Since then, the whole governance architecture has been revised, with consultation and co-production with Care Groups. This is presented to the Board for final sign off.

There will be a sixth month review planned and a full review after one year to ensure the committees are working effectively and robust information flows from ward to board to ward.

Recommendations

The Board is asked to approve the new governance structure.


PItem:19.144

13.4

Tab 13.4 Item 19.144: Governance Structure


NSFT Board and Board Committees September 2019 V5.2

Quality Committee

OSMard of DirectorsCouncil of Governors

MH Act Committee

Chair: TSExec: BS

Membership

CommitteeChair: TNExec: DH

Remuneration Committee

Chair: TSExec: JC

Audit & Risk CommitteeChair: AMExec: DC

People Participation CommitteeChair: PCExec: DH

Finance & Business

Investment CommitteeChair: AMExec: DC

Service Delivery

Board (SDB)Chair: JW

Quality

meetings(QPM)

Nominations & Conduct CommitteeChair: MG

Exec: JC

Charitable Funds Committee

Chair: TSExec: DC

Trust Leadership

Forum

M

B MB

B

Q

B

Medical Staff

Committee

Committee

BB

BA

Q

H&S

IG Sub-Committee

M

Interventions Committee

Serious Incident/Mortality

Review Group

M M B

Digital Improvement

Group

Q

Governor sub-groups

Control Committee

Committee

Drugs & Therapeutics Committee

BQ

Content Assurance

Group

Q

Chair: JW

Group

Patient Flow Group

M

Care Groups

“Business Meeting”

ClinicalGovernance Committee

Professional Leadership

Forums

Clinical Networks

Key:

= monthly

= bi-monthly

= quarterlyQ

M

B

N&W STPSuffolk & NEE ICS

Corporate services

M

M

M

Cabinet

Q B

M

MQ

Trust Partnership

Board

Culture Steering Group

Group

M

WeeklySafety

Huddles

13.4

Tab 13.4 Item

19.144: Governance S

tructure

148 of 181B


ublic - 21st Novem

ber 2019-21/11/19

FBICCharitable Funds Report

Version v1 Author: Jean Clark, Trust Secretary




Title of Report: Charitable Funds Annual Report and Accounts 2018/19




Kathy Walsh, Assistant Director of Finance

Director: Daryl Chapman - Director of Finance

Executive Summary:

The purpose of this report is to present to the Board the Norfolk and Suffolk NHS Foundation Trust Charitable Funds 2018-19 Annual Report and Accounts for approval.

The Finance, Business & Investment Committee will review the accounts at its meeting on 15th

November 2019. The Committee will also receive the Chair’s Report from the Charitable Funds Committee held on 19th September 2019.

Accounts Overview – Income and Expenditure

The level of charitable income from voluntary donations and legacies received in the year was £30k, a reduction of £10k compared to 2017-18 (£40k).

Total expenditure for the year was £34k. (£20k in 2017-18).

Administrative and support costs including the Independent Examiner’s fee have been borne by the Trust due to a lack of investment income or interest from cash deposits during the year which has traditionally been used to fund these costs.

Accounts Overview – Balance Sheet

Total funds decreased slightly by £4k during the year due to the excess of expenditure over income received in the year.

No funds were closed during the year.

The accounts have been compiled in accordance with the relevant accounting standards and have been reviewed by Ensors Accountants LLP. The independent Examiner’s report is included within the Annual Report.

The Chair of the Trust and one other Trustee will be required to sign off the Accounts at a Board of Directors meeting prior to submission.

Date: 21st November 2019 QItem: 19.145

13.5

Tab 13.5 Item 19.145: Charitable Funds Annual Report and Accounts approval





Following the Board’s approval, the accounts will be signed by the Independent Examiner and submitted to the Charity Commission on or before the final deadline of the 31 January 2020.

Recommendations

The Board is asked to approve the Charitable Funds Annual Report and Accounts 2018/19.

13.5






1.0 Charitable Funds Committee Meeting

1.1 The Committee met on 19th September 2019 and was chaired by Adrian Matthews. Present were Daryl Chapman, Director of Finance and Jean Clark, Trust Secretary.

1.2 The Committee received the Income and expenditure report April 2019 – August 2019.

1.2.1 There are 24 charitable funds held and the total expenditure in this period was £10K. the total balance of all funds as at 31st August 2019 was £309K. In general, funds are related to fund raising which is collected and then spent – all under £10K; some very small amounts.

1.2.2 There had been a legacy received in period of £80K for the benefit of Insight Magazine.

1.2.3 There had been no requests for Charitable funds £10,000 and above in this period.

2.0 Charitable Funds Annual Report and Accounts 2018/19

2.1 Accounts Overview – Income and Expenditure

2.1.1 The level of charitable income from voluntary donations and legacies received in the year was £30k, a reduction of £10k compared to 2017-18 (£40k).

2.1.2 Total expenditure for the year was £34k. (£20k in 2017-18).

2.1.3 Administrative and support costs including the Independent Examiner’s fee have been borne by the Trust due to a lack of investment income or interest from cash deposits during the year which has traditionally been used to fund these costs.

2.2 Accounts Overview – Balance Sheet

2.2.1 Total funds decreased slightly by £4k during the year due to the excess of expenditure over income received in the year.

2.2.2 No funds were closed during the year.

2.3 Approval of the Annual Report and Accounts

2.3.1 The accounts have been compiled in accordance with the relevant accounting standards, and have been reviewed by Ensors Accountants LLP. The independent Examiner’s report is included within the Annual Report.

2.3.2 The Chair of the Trust and one other Trustee will be required to sign off the Accounts at a Board of Directors meeting prior to submission.

2.3.3 Following the Board’s approval, the accounts will be signed by the Independent Examiner and submitted to the Charity Commission on or before the final deadline of the 31 January 2020.

3.0 Recommendations3.1 The Committee is asked to note the report from the Charitable Funds Committee and to

recommend the charitable Funds Annual Report and Accounts 2018/19 to the Board of Directors for approval.

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Norfolk and Suffolk NHS Foundation Trust Charitable Funds Annual Report April 2018 to March 2019 1

Annual report and accounts

April 2018 to March 2019

nsft.nhs.uk

Charitable fund and other related charities

Corporate Trustee:Norfolk and Suffolk NHS Foundation TrustRegistered address:Hellesdon HospitalDrayton High RoadNorwichNR6 5BE

Registered Charity Number: 1103563

Created by the governing document, the Trust Deed, dated 1 April 2004

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Norfolk and Suffolk NHS Foundation Trust Charitable Funds Annual Report April 2018 to March 20192

13.5




Contents

Corporate Trustee and Advisers 4 – 5

Report of the Corporate Trustee 6 – 8

Statement of Responsibilities of the Corporate Trustee 9

Independent Examiner's Report 10

Statement of Financial Activities 12

Balance Sheet 13

Statement of Cash Flows 14

Notes forming part of the financial statements 15 – 23

13.5




Corporate TrusteeNorfolk and Suffolk NHS Foundation Trust is the sole Corporate Trustee, with members of the Trust’s Board acting as ex-officio trustees of the Charitable Funds.

The Board of Directors of Norfolk and Suffolk NHS Foundation Trust who served during the financial year were as follows:

Chair

Gary Page (to 27.11.18) Marie Gabriel (from 01.02.19)

Non-Executive Directors Jill Robinson (to 31.12.18) Ian Brookman (to 31.12.18) Tim Newcomb Marion Saunders (to 31.8.18) Pip Coker (from15.10.19) Ken Applegate (from15.10.19) Adrian Matthews

Executive Directors

Julie Cave – Interim Chief Executive (to 30.11.18) Antek Lejk - Chief Executive (from 01.05.18 to 31.3.19) Bohdan Solomka – Medical Director Daryl Chapman – Interim Director of Finance Josie Spencer – Interim Chief Operating Officer (to 30.6.18) Stuart Richardson – Chief Operating Officer Dawn Collins – Interim Director of Nursing (from 01.08.18 to 30.11.18) Duncan Forbes - Director of Human Resources and Organisational Development (from 20.08.18) Diane Hull - Chief Nurse (from 21.11.18)

The Corporate Trustee has delegated, within written terms of reference, day to day management of the funds to the Charitable Funds Committee. The Committee was formed on 13 September 2002 and operates with the following membership:

Membership• A Non-executive Director will chair the Committee. The membership of the Committee shall be:

From 18.02.19

– Non-executive Director (Chair)

– The Director of Finance (or delegated nominee)

– Company Secretary

All committee members may delegate a suitable representative.

• Nominated Representatives: Norfolk and Suffolk NHS Foundation Trust

– Tim Stevens, Non-executive Director

– Daryl Chapman Interim Director of Finance

– Robert Nesbitt, Company Secretary (to 06.06.18)

– Jean Clarke - Company Secretary (from 18.02.19)

– Michael Jones - Company Secretary (from 13.06.18 to 31.12.18)

• No business shall be transacted at a meeting of the Charitable Funds Committee unless at least three representatives are present.

Charitable Funds Committee attendance 2018/19

26 April 2018

25 Oct

2018 (Stood Down)

22 Nov 2018

24 April 2019

Tim Stevens Non-executive Director 3 3 3

Daryl Chapman Interim Director of Finance

3 3 3

Robert Nesbitt Company Secretary To 06 June 2018

3

Michael Jones Company Secretary From 13.06.18 to 31.12.18

3

Jean Clarke Company Secretary From 18.02.19

3

Corporate Trustee and Advisers

13.5




Registered Address

The Registered Office of the Charitable Fund is:

Norfolk and Suffolk NHS Foundation Trust Hellesdon Hospital Drayton High Road Norwich NR6 5BE

Telephone: 01603 421120

Principal Professional Advisers

Bankers:

Barclays Bank plc P.O. Box 885 Mortlock House Histon Cambridge CB24 9DE

Independent Examiner:

Helen Rumsey Ensors Accountants LLP Cardinal House 46 St. Nicholas Street Ipswich Suffolk IP1 1TT

13.5




The Corporate Trustee submits its Annual Report on the affairs of the Charity, together with the financial statements and independent examiner's report for the year ended 31 March 2019. The financial statements have been prepared in accordance with the accounting policies set out on page 15, and comply with the Charitable Fund’s trust deed, the Charities Act 2011 and Accounting and Reporting by Charities: Statement of Recommended Practice applicable to charities preparing accounts in accordance with the Financial Reporting Standard applicable in the UK and Republic of Ireland (FRS 102).

Charitable Objectives

The Charity is an NHS umbrella charity registered with the Charity Commissioners for England and Wales. The objectives of the umbrella charity are for the Trustee to apply the income, and at their discretion, so far as may be permissible, the capital for any charitable purpose or purposes relating to the services provided by:

• Norfolk and Suffolk NHS Foundation Trust

The funds are used to meet the objectives of the original donations or bequests, so far as is reasonably practicable. Where there are no specific objectives, the funds are used by the Charity for such purposes relating to services provided by them under the National Health Service Act 1977. The Charity meets the legal requirement of applying the funds for public benefit by ensuring that they are spent on the Trust’s service users and the staff who care for them.

Specific Restrictions

The funds are managed in accordance with the conditions set out in the Trustee Investments Act 1961 and the governing document. All the Charity’s funds are regarded as designated funds for general purposes to particular NHS hospitals or locations and are accounted for in accordance with the latest Guidance for NHS Charities from the Charity Commission. Twenty two funds are accounted for as unrestricted funds where the donor has made known their non-binding

wishes to a particular area. The Trustee has adopted a policy of designating funds within the unrestricted funds in order to respect the wishes of our generous donors wherever possible.

Structure, Governance and Management

The Charitable Funds Committee is a formal non-executive committee of the Trust’s Board of Directors and has no executive powers, other than those specifically delegated to it in its Terms of Reference.

The Charitable Funds Committee, a committee of the Corporate Trustee, met three times during the year and makes recommendations to the Corporate Trustee on:

• Fund governance

• Investment policies

• Fundraising

• Expenditure policies and procedures, and

• Reporting arrangements

Designated Directors and Managers manage the funds within the umbrella Charity on behalf of the corporate trustee.

The funds are overseen by fund holders who can make recommendations on how to spend the money within their area. These recommendations are generally accepted, provided they meet a charitable principle and also correspond to the criteria of the purpose of the fund.

The accounting records and day to day administration of the funds are dealt with by the Assistant Financial Accountant, 2nd Floor Purple, Endeavour House, Russell Road, Ipswich IP1 2BX.

The registered office of the Charitable Fund is: Norfolk and Suffolk NHS Foundation Trust, Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE.

Report of the Corporate Trustee

13.5




Future Plans

The trustee does not expect any significant changes in the objectives of the Charity in the forthcoming year, and will continue to receive and expend funds for the benefit of the Trust and its service users, and to support staff and service development where other sources are unavailable.

Principal Activities

Activities and achievements for public benefit

During the year the funds continued to support a wide range of charitable and health related activities benefiting both service users and staff. In doing so the Trustees have had regard to the Charity Commission's guidance on public benefit and in general they are used to purchase additional equipment and services that the NHS is unable to provide from other sources.

There are three principal areas of activity within the Charity:

• Contributions to the NHS – where funds are received and expended for the benefit of the NHS

There were no Contributions to the NHS received or expended during 2018/19. (2017/18, Nil)

• Patients’ welfare and amenities – where funds are received and expended for the benefit of service users

Total expenditure for the year under this activity was £27,000 (2017/18, £20,000) of which the main expenditure is summarised below:

A total of £6,000 was spent on providing a therapeutic garden area for the service users at the Dragonfly Unit in Carlton Colville. The staff at the unit had fundraised to finance the creation of the garden £3,000 was spent on the Reach for the Skies - Young Carers event. This event was held with the aim of giving young people aged 12-15 and who care for someone with a mental health condition a break from their caring duties. In addition to an overnight stay, activities included archery, a zip wire, music and barbeque

The Charity also spent £2,000 on a garden project for the Day Treatment Centre at the Older People's Dementia Unit on the Julian site providing a pleasant outdoor space for service users

Another £4,600 was spent on Christmas presents and festivities for the service users on the wards

The remaining expenditure was given for smaller requests for the benefit of service users to enhance their experience

• Staff welfare and amenities – where funds are received and expended for the benefit of staff

Expenditure for the year under this activity amounted to £7,000 (2017/18, £600) of which the main expenditure is summarised below:

A total £4,700 was spent on the Staff Awards event at Trinity Park

The remaining expenditure was made up of Staff Away days and Staff Christmas meals

Grant Making Policy

The Charity awards grants on an informal basis and in accordance with the objectives of the individual funds. The needs of the relevant hospital departments are considered and grants are awarded in the circumstances where the NHS would not normally provide the equipment or service, and where there is a benefit to service users in the provision of the equipment or service. A Charitable Fund request form is completed in the first instance and is considered on its own merits with regard to service user needs and provision of sufficient public benefit. Fund holders are entrusted with making decisions on grant making and will decide the appropriateness of each application.The Charitable Funds Committee monitors income and grant making on a quarterly basis.

Fund holders are able to authorise grants up to £1,000. Approval from Service Managers is required for requests between £1,000 and £5,000. The Director of Finance is required to approve requests between £5,000 and £10,000. Applications over £10,000 need to be approved by the Charitable Funds Committee acting on behalf of the Trust Board.

13.5




The Charity also occasionally accepts grants from other charities for the benefit of service users and transmits the donation on their behalf ensuring that the request of the donor is honoured. During the year, no grants were donated from other charities for service user benefit (2017/18, Nil).

Financial Review

As shown in the following statement of financial activities, the total value of funds held by the Charity decreased from £240,000 to £236,000. A total of £30,000 was given to the Charity in the form of donations and legacies. This was £10,000 less than last year. The Charity has not made any further investments in 2018/19 due to the lack of return and the need for available cash to discharge grants.

Expenditure has increased from last year by £14,000 to £34,000. The independent examination fee for the year was £1,760.

In April 2018 the Charitable Fund Committee agreed two proposals. The first was to amalgamate the Minsmere, Whitwell and St Clements and Woodlands funds into one fund and a total of £70,000 has been transferred over to the newly created Suffolk East General Mental Health Fund. The second proposal was to re-designate the Northgate Fund into the Great Yarmouth Fund and a total of £6,000 has been transferred over to this fund.

The Charity encourages fund-raising by volunteers but does not depend on donations in kind to achieve its objectives. The Trust held a Summer and Christmas Fetes during the year which generated a total of £5,000. This is to be used for the benefit of service users at the Trust to support exercise and wellbeing.

Reserves Policy

The Charity has been mindful of the need to reduce the level of reserves held and the Trustees will continue to review the balances held in the designated funds and encourage an appropriate level of expenditure. There are no target reserves as it is not the policy of the charitable fund to hold reserves. The fund holders are encouraged to spend monies on good causes rather than allowing funds to accumulate. The Charitable Funds Committee monitor any requests over £10,000 thereby anticipating the need to withdraw any investments that may be needed to fund approved grants.

Risk Management

Major risks to which the Charity is exposed have been identified and procedures have been put in place to mitigate those risks. All funds are checked and an assessment is undertaken before a payment is made to ensure that there is money available to meet expenditure. Procedures are in place to safeguard the receipting of donations and the banking of cash and cheques. The Charitable Funds Committee monitors income and expenditure on a quarterly basis. The Trustees have taken a cautious approach to investment by ensuring that assets are invested in low risk ethical funds and kept as cash holdings. Cash holdings that are set aside for day to day transactions are kept to a minimum.

Investment Policy

It is the policy of the Charity to ensure:

• Effective and secure investment of charitable monies

• Maximisation of investment income, and

• Maintenance of appropriate working cash balances for day-to-day transactions

No investments were held within this current year due to poor interest return. 13.5




Under charity law, the Trustees are responsible for preparing the Trustee Annual Report and the financial statements for each financial year, which show a true and fair view of the state of affairs of the Charity and its incoming resources and application of resources for that year.

In preparing these financial statements, generally accepted accounting practice entails that the Trustees:

• Select suitable accounting policies and then apply them consistently

• Make judgements and estimates that are reasonable and prudent

• State whether the recommendations of the Statement of Recommended Practice have been followed, subject to any material departures disclosed and explained in the financial statements

• State whether the financial statements comply with the Trust deed and rules, subject to any material departures disclosed and explained in the financial statements

• Prepare the financial statements on a going concern basis unless it is inappropriate to presume that the Charity will continue its activities

The Trustees are required to act in accordance with the Trust deed and the rules of the Charity, within the framework of trust law. They are responsible for keeping proper accounting records, sufficient to disclose at any time, with reasonable accuracy, the financial position of the Charity at that time, and to enable the Trustees to ensure that, where any statements of accounts are prepared by them under section 132(1) of the Charities Act 2011,

those statements of accounts comply with the requirements of regulations under that provision. They have general responsibility for taking such steps as are reasonably open to them to safeguard the assets of the Charity and to prevent and detect fraud and other irregularities.

Thank You

On behalf of the staff and service users who have benefited from the donations and legacies given, the Corporate Trustee would like to thank all service users, relatives, staff, and the general public for their generosity.

Further information:

If you require further information about the work and operation of the Fund, please contact the Director of Finance, Norfolk and Suffolk NHS Foundation Trust, Hellesdon Hospital, Drayton High Road, Norwich, Norfolk NR6 5BE.

By order of the Trustee

Signed:

Marie Gabriel Chair Date:

Daryl Chapman Interim Director of Finance and Trustee Date:

Statement of Trustee responsibilities in respect of the Trustee Annual Report and the financial statements

13.5




Independent examiner’s report to the trustee of Norfolk and Suffolk NHS Foundation Trust Charitable Fund and Other Related Charities

I report to the trustee on my examination of the accounts of the Norfolk and Suffolk NHS Foundation Trust Charitable Fund and Other Related Charities (the Charity) for the year ended 31 March 2019.

Responsibilities and basis of report

As the trustee of the Charity you are responsible for the preparation of the accounts in accordance with the requirements of the Charities Act 2011 (‘the Act’).

I report in respect of my examination of the Charity’s accounts carried out under section 145 of the 2011 Act and in carrying out my examination I have followed all the applicable Directions given by the Charity Commission under section 145(5)(b) of the Act.

Independent examiner’s statement

I have completed my examination. I confirm that no material matters have come to my attention in connection with the examination giving me cause to believe that in any material respect:

1) accounting records were not kept in respect of the Charity as required by section 130 of the Act; or

2) the accounts do not accord with those records; or

3) the accounts do not comply with the applicable requirements concerning the form and content of accounts set out in the Charities (Accounts and Reports) Regulations 2008 other than any requirement that the accounts give a ‘true and fair view which is not a matter considered as part of an independent examination.

I have no concerns and have come across no other matters in connection with the examination to which attention should be drawn in this report in order to enable a proper understanding of the accounts to be reached.

Signed:

Mrs H Rumsey FCAEnsors Accountants LLPCardinal House46 St Nicholas StreetIpswichIP1 1TT

Date:

13.5




Annual accounts

for the year ended31 March 2019

nsft.nhs.uk

13.5




Statement of Financial Activities for the year ended 31 March 2019

Unrestricted Funds

Restricted Funds

Endowment Funds

2018/19 Total

Funds

2017/18 Total

Funds

Notes £000 £000 £000 £000 £000

Income from

Donations and legacies 2 30 - - 30 40

Total income 30 - - 30 40

Expenditure on

Charitable Activities 3 (34) - - (34) (20)

Total expenditure (34) - - (34 (20)

Net (expenditure) / income (4) - - (4) 20

Transfer of funds - - - - -

Net movement in funds (4) - - (4) 20

Fund balances brought forward at 1 April 2018

240 - - 240 220

Fund balances carried forward at 31 March 2019

236 - - 236 240

All income and expenditure is derived from continuing activities.

All gains and losses recognised in the year are included in the Statement of Financial Activities.

The notes on pages 15 to 23 form part of these accounts.

13.5




Balance sheet as at 31 March 2019

Unrestricted Funds

Restricted Funds

Endowment Funds

Total 31 Mar 2019

Total 31 Mar 2018

Notes £000 £000 £000 £000 £000

Current Assets

Cash at bank and in hand

236 - - 236 240

Net Current Assets 236 - - 236 240

Total Assets 236 - - 236 240

Liabilities

Net Current Liabilities - - - - -

Total Assets Less Current Liabilities

236 - - 236 240

Funds of the Charity

Unrestricted: Income Funds

7 236 - - 236 240

Total Funds 236 - - 236 240

The notes on pages 15 to 23 form part of these accounts.

These financial statements were approved by the Corporate Trustee on Date: and signed on their behalf by

Daryl Chapman Interim Director of Finance and Trustee Date: 13.5




Statement of cash flowsNote Total Total

31 March 2019

31 March 2018

£000 £000

Cash Flows from operating activities:

Net cash used in operating activities 8 (4) 20

Cash flows from investing activities:

Proceeds from sale of investments - -

Net cash provided by investing activities - -

Cash in change and cash equivalents in the reporting period

Cash and cash equivalents at the beginning of the reporting period

8 240 220

Change in cash and cash equivalents in the reporting period (4) 20

Cash and cash equivalents at the end of the reporting period 8 236 240

13.5




Notes forming part of the financial statements

1 Accounting Policies

1.1 Basis of preparation and assessment of going concern

The financial statements have been prepared under the historic cost convention. The financial statements are prepared in sterling, which is the functional currency of the Charity. Monetary amounts in these financial statements are rounded to the nearest thousand £. The financial statements have been prepared in accordance with the Statement of Recommended Practice: Accounting and Reporting by Charities applicable to charities preparing their accounts in accordance with the Financial Reporting Standard applicable in the UK and Republic of Ireland (FRS 102) issued on 16 July 2014 and the Financial Reporting Standard applicable in the United Kingdom and Republic of Ireland (FRS 102) and the Charities Act 2011 and UK Generally Accepted Practice as it applies from 1 January 2015. The financial statements are prepared on a going concern basis and the principal accounting policies have been applied consistently throughout the year. The trustees consider that there are no material uncertainties about the charity's ability to continue as a going concern.

The Charity constitutes a public benefit entity as defined by FRS 102. The accounts have departed from the Charities (Accounts and Reports) Regulations 2008 only to the extent required to provide a true and fair view. This departure has involved following the Statement of Recommended Practice for charities applying FRS 102 rather than the version of the Statement of Recommended Practice which is referred to in the Regulations but which has since been withdrawn.

1.2 Critical accounting estimates and judgements In the application of the charity's accounting policies, the Trustees are required to make judgements, estimates and assumptions about the carrying amount of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from these estimates.

The estimates and underlying assumptions are reviewed on an ongoing basis. Revisions to accounting estimates are recognised in the period in which the estimate is revised where the revision affects only that period, or in the period of the revision and future periods where the revision affects both current and future periods. 1.3 Financial Instruments The Charity has elected to apply the provisions of Section 11 'Basic Financial Instruments' and Section 12 ' Other Financial Instruments Issues' of FRS 102 to all of its financial instruments.

Financial instruments are recognised in the Charity's balance sheet when the Charity becomes party to the contractual provisions of the instrument.

Financial assets and liabilities are offset, with the net amounts presented in the financial statements, when there is a legally enforceable right to set off the recognised amounts and there is an intention to settle on a net basis or to realise the asset and settle the liability simultaneously. Basic financial assets

Basic financial asssets, which include debtors and cash and bank balances, are initially measured at transaction price including transaction costs and are subsequently carried at amortised cost using the effective interest method unless the arrangement constitutes a financing transaction, where the transaction

13.5




is measured at the present value of the future receipts discounted at a market rate of interest. Financial assets classified as receivable within one year are not amortised.

Basic financial liabilities

Basic financial liabilities, including creditors are initially recognised at transaction price unless the arrangement constitutes a financing transaction, where the debt instrument is measured at the present value of the future payments discounted at a market rate of interest. Financial liabilities classified as payable within one year are not amortised. Debt instruments are subsequently carried at amortised cost, using the effective interest rate method.

Derecognition of financial liabilities

Financial liabilities are derecognised when the Charity's contractual obligations expire or are discharged or cancelled.

1.4 Fund Accounting

The Charity maintains a general unrestricted fund which represent funds which are expendable at the decision of the Trustees in furtherance of the objects of the Charity. Such funds may be held in order to finance both working capital and capital investment.

Restricted funds are provided to the Charity for particular purposes, and it is the policy of the Board of Trustees to carefully monitor the application of those funds in accordance with the restrictions placed upon them.

Endowment funds are subject to specific conditions by donors that the capital must be maintained by the Charity.

2 Income

2.1 Income is generated from voluntary donations, legacies, fundraising events and interest on cash at bank. The charity does not undertake charitable trading.

a) All income is included in full in the Statement of Financial Activities as soon as the following three factors can be met:

i) Entitlement - control over the right or other access to the economic benefit has passed to the charity

ii) Probable - where it is more likely than not that the economic benefits associated with the transaction or gift will flow to the charity

iii) Measurement - the monetary value or amount of the income can be measured reliably and the costs incurred for the transaction and the costs to complete the transaction can be measured reliably

b) Legacies

Legacies are accounted for as incoming resources either upon receipt or where the receipt of the legacy is probable.

This will be once confirmation has been received from the representatives of the estate that probate has been granted, the executors have established that there are sufficient assets in the estate to pay the legacy and all conditions attached to the legacy have been fulfilled or are within the charity's control.

If there is uncertainty as to the amount of the legacy and it cannot be reliably estimated then the legacy is shown as a contingent asset until all of the conditions for income recognition are met.

c) Investment income

The Trust implements a charitable funds investment policy to ensure:

i) Effective and secure investment of charitable monies

ii) Maximisation of investment income

iii) Maintenance of appropriate cash balances for day to day transactions

There was no investment income received during this current year. 13.5




3 Expenditure

These financial statements have been prepared in accordance with the accruals concept.

The corporate trustee recognises liabilities in the accounts once they have incurred either a legal or constructive obligation to expend funds.

Expenditure for patient welfare, staff welfare and other contributions to the NHS are included in Charitable Activities. Expenditure is incurred directly by the charity in support of the NHS and is allocated to the appropriate fund.

Expenditure was incurred as follows:

Total Total

31 March 2019

31 March 2018

£000 £000

Other patients welfare and amenities

27 19

Other staff welfare and amenities

7 1

34 20

No audit fee or administration fee was charged in 2018-19 as the 22 funds held fall under the management of Norfolk and Suffolk NHS Foundation Trust. All charges were therefore met by Norfolk and Suffolk NHS Foundation Trust. The independent examination fee for the year was £1,760 (2017-18, £1,700).

4 Related party transactions

During the year none of the members of the key management staff or parties related to them have undertaken any material transactions or received any remuneration from the charitable fund (2017-18, Nil).

The charitable trust has made no revenue or capital payments to Norfolk and Suffolk NHS Foundation Trust. There were no outstanding balances at year end.

At any one time Norfolk and Suffolk NHS Foundation Trust holds balances for debtors and creditors relating to the transactions it processes on behalf of the Charity, which are normally settled within the following month.

5 Grants made to institutions Grants are made in furtherance of the charitable objectives of the fund in accordance with the governing document which established the charity for purposes relating to the NHS.

During the year no grants were paid (2017-18, Nil).

6 Grants paid to individuals

During the year the charity made no small grants relating to patients welfare (2017-18, Nil).

7 Summary and structure of funds

The report of the corporate trustee describes the structure of the funds. A summary of the funds as at 31 March 2019 is given below.

The charity adheres to a policy that no transfers are made between funds unless in exceptional circumstances, for example where a fund is being wound up and the remaining balance is transferred to a comparable fund.

If no restriction is conveyed by the donor, funds are placed in the designated area that the donation is gifted. No endowment or restricted funds were held during the current year.

Total Total

31 March 2019

31 March 2018

Unrestricted: £000 £000

NHS Great Yarmouth and Waveney CCG

- 6

Norfolk and Suffolk NHS FT

236 234

236 240

13.5




NHS Great Yarmouth and Waveney CCG - Unrestricted Funds:

Balance 1 April

2018

Income Expenditure Transfers Gains and Losses

Balance 31 March

2019

Material Funds

Nature and Purpose of Fund

£000 £000 £000 £000 £000 £000

Northgate General

General purposes for services provided by SMHP at Northgate Hospital

6 - - (6) - -

Total 6 - - (6) - -

Norfolk and Suffolk NHS FT - Unrestricted Funds:

Balance 1 April

2018


Balance 31 March

2019Material Funds


£000 £000 £000 £000 £000 £000

Minsmere House

General purpose fund for old age psychiatry

2 - - ( 2) - -

St Clements Hospital

General purpose for St Clements Hospital

12 - - (12) - -

Whitwell Fund

General purposes for East Suffolk Mental Health

56 - - (56) - -

Wedgwood Patients

General purpose fund for Wedgwood patients

1 - - - - 1

Central Cluster Older

General purpose fund for older people and dementia

44 5 12 - - 37

Chatterton House

General Purpose fund for Chatterton House

48 - - - - 48

Great Yarmouth

General purpose fund for Great Yarmouth Services

- - - 6 - 6

Trust Wide General purpose fund for Trust Wide services

5 12 7 - - 10

West Norfolk

General purpose fund for services in West Norfolk

6 - - - - 6

Suffolk East General Mental Health

General purpose for the benefit of service users in the Suffolk East location

- - 1 70 - 69

Others (15 funds)

60 13 14 - - 59

Total 234 30 34 6 - 236

7 Summary and Structure of Funds (continued) - 2018-19 Material Funds Unrestricted Funds by Trust:

13.5




Material Funds - Unrestricted Funds by Trust:

NHS Great Yarmouth and Waveney CCG - Unrestricted Funds:

Balance 1 April

2017


Balance 31 March

2018Material Funds


£000 £000 £000 £000 £000 £000

Northgate General

General purposes for services provided by SMHP at Northgate Hospital

6 - - - - 6

Lowestoft Hospital

General purpose fund for Lowestoft Hospital

5 - 5 - - -

Total 11 - 5 - - 6

Norfolk and Suffolk NHS FT - Restricted Funds:

Balance 1 April

2017


Balance 31 March

2018Material Funds


£000 £000 £000 £000 £000 £000

Whitwell Endowment Fund

Charitable purposes for mentally ill patients (interest only can be used and transferred to St Clements Fund)

56 - - (56) - -

Total 56 - - (56) - -

7 Summary and Structure of Funds (continued) - 2017-18 Material Funds - Restricted Funds by Trust:

13.5




Norfolk and Suffolk NHS FT - Unrestricted Funds:

Balance 1 April

2017


Balance 31 March

2018

Material Funds


£000 £000 £000 £000 £000 £000

Minsmere House

General purpose fund for old age psychiatry

2 - - - - 2

St Clements Hospital

General purpose for St Clements Hospital

14 1 3 - - 12

Whitwell Fund

General purposes for East Suffolk Mental Health

- - - 56 - 56

Wedgwood Patients

General purpose fund for Wedgwood patients

- 1 - - - 1

Central Cluster Older

General purpose fund for older people & dementia

48 1 5 - - 44

Chatterton House

General Purpose fund for Chatterton House

38 10 - - - 48

Great Yarmouth

General purpose fund for Great Yarmouth Services

1 - 1 - - -

Trust Wide General purpose fund for Trust Wide services

3 6 4 - - 5

West Norfolk General purpose fund for services in West Norfolk

4 3 1 - - 6

Others (17 funds)

43 18 1 - - 60

Total 153 40 15 56 - 234

13.5




8 Analysis of Net Assets between funds

Unrestricted Funds

Restricted Funds

Endowment Funds

Total 31 March

2019

Total 31 March

2018

£000 £000 £000 £000 £000

Fixed assets: investments (at market value)

- - - - -

Current assets - Cash at bank and in hand

236 - - 236 240

Debtors - - - - -

236 - - 236 240

Monies placed on deposits ranging from 6 months to 12 months have been classified above and in the balance sheet as investments.

7 Summary and Structure of Funds (continued)

Summary

Total Total

31 March 2019 31 March 2018

£000 £000

Endowment funds - -

Restricted Funds - -

Unrestricted Funds 236 240

Total Funds 236 240

Funds have arisen from a variety of sources principally legacies and donations.

13.5




Analysis of Bank Deposits and Investments

Total 31 March

2019

Total 31 March

2018

Interest Received 2018/19

Interest Received 2017/18

£000 £000 £000 £000

Barclays - - - -

Scottish Widows - - - -

Bank of Scotland - - - -

Total Funds - - - -

Analysis of Cash and cash equivalents

Total 31 March

2019

Total 31 March

2018

£000 £000

Cash in hand 236 240

Total cash and cash equivalents 236 240

Cash and cash equivalents

Cash and cash equivalents include cash in hand, deposits held at call with banks, other short-term liquid investments with original maturities of three months or less, and bank overdrafts.

Reconciliation of Net (expenditure) / income to net cash flow from operating activities

Current Year

Prior Year

£000 £000

Net (expenditure) / income for the reporting period (as per the statement of financial activities)

(4) 20

Adjustments for:

Decrease in debtors - 7

(Decrease) in creditors - (7)

Net cash (used in) / from operating activities (4) 20

13.5




Norfolk and Suffolk NHS Foundation Trust values and celebrates the diversity of all the communities we serve. We are fully committed to ensuring that all people have equality of opportunity to access our service, irrespective of their age, gender, ethnicity, race, disability, religion or belief, sexual orientation, marital or civil partnership or social and economic status.NSFTrust

@NSFTtweets

nsft.nhs.uk

01603 421421Trust Headquarters: Hellesdon HospitalDrayton High RoadNorwich NR6 5BE

Patient Advice and Liaison Service (PALS)

NSFT PALS provides confidential advice, information and support, helping you to answer any questions you have about our services or about any health matters.

If you would like this leaflet in large print, audio, Braille, alternative format or a

different language, please contact PALS and we will do our best to help. Email: [email protected] call PALS Freephone 0800 279 7257

13.5



Board of Directors – Chair’s report on QA

Version 1.0

Author Tim Newcomb, NED, Jean Clark Trust Secretary




Title of Report: Chair’s report to BOD in respect of the Quality Assurance Committee meeting held on 28th October 2019



Author: Tim Newcomb – Non-Executive Director (Vice Chair Suffolk)

Jean Clark, Trust Secretary

Executive Summary: This report provides an update to the Board on the meeting of the Quality Assurance Committee (QAC) held on the 28th October 2019. Care Group Quality and Safety Report The meeting received a report from the North Norfolk and Norwich Care Group, presented by the Lead Nurse and People Participation Lead, in the absence of the Service Director. The Committee was impressed by the quality of the informative and honest report. Key areas of challenge were discussed such as capacity issues in the face of heavy demand. The Committee were assured that a review into caseloads and supervision was underway. Issues in relation to the Liaison Service at NNUH were raised and solutions discussed – this will retain senior executive oversight as we work forward with STP partners. The Committee heard about the development of plans for the second stage of the leadership review and acknowledged the effect of delay and uncertainty for staff. The great improvement in the number of OOA placements for this Care Group was noted and expectations that these will be sustainable. The proposed schedule of bi-monthly NED visits aligned with Care Group presentations to QAC is now well underway in order that contemporary triangulation and ‘context’ can be applied to the business of the committee. The Trust Secretary has agreed to arrange on-going coordination of this schedule and following a November round to CFYP, visits will now be planned for IDT’s in December/January. Quality Improvement Plan The Committee reviewed the latest plan which was now 53% business as usual. A high level dashboard is under development for better monitoring of performance. The Committee will want to review this in due course. The concerns and actions to address delayed transfers of care for older people was discussed. Patient safety and Serious Incident Report The committee discussed the current SIs and the new SI and Mortality Group which has been widened to include Care Groups to improve local ownership and learning. Explanations were provided on the NRLS data and the STEIS system and officers were requested to review the threshold for uploading of incidents. Research and Development Annual Report

Date: 21st November 2019 R Item: 19.146i

14.1

Tab 14.1 i. Quality Assurance Committee Chair's report


Board of Directors – Chair’s report on QA

Version 1.0

Author Tim Newcomb, NED, Jean Clark Trust Secretary


Positive progress with R&D was presented to the Committee. The key performance indicators determined by the Department of Health and National Institute of Health were met in the last financial year which resulted in increased funding, and there has been an increase in people recruited into studies. The department’s target of being awarded 3 grants a year have already been surpassed with 8 grants awarded to date. Restrictive Interventions The committee received a deep dive presentation on Restrictive Interventions and welcomed the improving picture in trust-wide performance in respect of keeping our service users and staff safe whilst in our care. A sustained ‘step-change’ in performance and quality was particularly evident on those wards that are part of the NHS pilot work with improvements seen in some locations. The Committee discussed how to maintain and spread good practice without being seen to ‘impose’ best practice. It is believed wards will be enthusiastic about embracing change when encouraged and supported with QI methodology. Quality Committee Chair’s Report It was evidence from the report that the Quality Committee is still under development and that the underpinning structure is still immature and in some cases the groups are only one or two meetings into their new cycle. This means that the key ‘feeds’ into the Committee still need to improve in terms of clarity and focus and assurance was given by the Chief Nurse and Medical Director that this is in hand for the next meeting and strong progress will be evident. Board Assurance framework (BAF) risks The committee reviewed the relevant quality and safety risks and was pleased that the BAF now explicitly aligns with the new NSFT Strategy and the analysis of potential risks to its implementation. The Committee requested ‘deep dive’ reports in relation to two red risks - the priority should be waiting times and medicines management. The committee agreed to regularly ensure alignment of BAF risks and ‘Hot’ issues with the agenda of the meeting. What is the impact on Service Users: The committee found that reporting this month remained service user oriented and genuinely focussed on improving the service delivered.

Recommendation The Board is asked to note the report.

14.1

Tab 14.1 i. Quality Assurance Committee Chair's report


Board of Directors – Chair’s report on A&RC

Version 1.0

Author Adrian Matthews NED, Jean Clark Trust Secretary




Title of Report: Chair’s report to BOD in respect of the Audit and Risk Committee meeting held on 5th November 2019



Author: Adrian Matthews, Non-Executive Director; Jean Clark, Trust Secretary

Executive Summary: This report provides an update to the Board on the meeting of the Audit and Risk Committee held on the 5th November 2019. External Audit The new contract commenced from 1st October 2019 and the auditors are starting their planning procedures for the year end 2019/20 audit. The committee requested more emerging governance issues from the sector in future reports. Internal Audit and Counter Fraud The committee voiced its concerns with the lack of progress with the internal audit plan. This had been due to delays in Trust officers responding to audit recommendations and delays in auditor escalation. The committee requested more executive grip on the audit plan and audit recommendations in future, as it was unacceptable that recommendations that identified governance risks were being left with no response to for many months. The Executive needs to ensure completion of the plan by year end and expected significant progress by the next meeting. Assurances were given that this is now integral to the re-set of the new governance processes. The committee received the final report on Clinical Incidents with a Partial Assurance audit opinion and challenged the action plans to address the recommendations. This report will be reviewed by the Quality Assurance Committee in more depth. The Committee requested more proactive work by counter fraud and more raising awareness with all staff on reporting potential fraud. The Executive and the external providers for Internal Audit and Counter Fraud were requested to reset their relationships and interfaces to heighten the control of governance issues that were being highlighted. Risk Management The Board Assurance Framework and Corporate Risk Register were reviewed. More challenge with Care Group risk reporting was required. The committee requested further conversations on risk appetite at a board development session. Compliance Reports were received on Information Governance and on Losses, special payments and use of single tender waiver and requested the Finance, Business & Investment Committee conduct a deep dive of the procurement process.

Date: 21st November 2019 S Item: 19.146ii

14.2

Tab 14.2 ii. Audit & Risk Committee Chair's report


Board of Directors – Chair’s report on A&RC

Version 1.0

Author Adrian Matthews NED, Jean Clark Trust Secretary


The Register of Seals and Register of Interests were reviewed by the Chair of the Committee on 14th November 2019. The register of seals was all in order, and there had been significant progress on the register of interests which needed a complete review following the recent senior management restructure. Emergency Planning The committee received the annual self-assessment against the Emergency Preparedness Resilience and Response (EPRR) Core Standards and asked for assurance on business continuity and the testing of plans for both Care Groups and corporate services at the next meeting.

Recommendation The Board is asked to note the report and to schedule a risk appetite session for the Board at the earliest opportunity

14.2

Tab 14.2 ii. Audit & Risk Committee Chair's report


Board of Directors – Chair’s report on PPC

Version 1.0

Author , Jean Clark Trust Secretary




Title of Report: Chair’s report to BOD in respect of the People Participation Committee meeting held on 15th October 2019




Executive Summary: This report provides an update to the Board on the meeting of the People Participation Committee held on the 15th October 2019. The Committee heard feedback from each of the People Participation Leads for the Care Groups with their areas of progress and concerns. Key themes were:

How to make services less fragmented internally and working with external colleagues.

PPLs have equal status amongst the care group leadership

Gathering evidence and listening to other’s voices

PPLs are developing their own strategies and workplans

PPLs are thinking about early intervention by linking in with schools.

Travelling is an issue.

The People Participation Strategy is in development building on the strategies and workplans of the PPLs. It was agreed to carry out a more formal evaluation of the role as it was unique amongst most Trusts. The Governors will be holding an election on who will attend for the service user governor role on the committee. The Committee reviewed the relevant BAF risk 2.1 – poor engagement with service users and cares and other stakeholders will mean that their views are not heard and responded to. A number of the members had attended a recent East of England New Models Collaborative Launch Day and gave their feedback on the event.


Date: 21st November 2019 U

Item: 19.146iv

14.4

Tab 14.4 iv. People Participation Committee Chair's report


Board of Directors – Chair’s report on Appts & Remco

Version 1.0

Author Jean Clark Trust Secretary




Title of Report: Chair’s report to BOD in respect of the Appointments & Remuneration Committee meeting held on 25th September 2019




Executive Summary: This report provides an update to the Board on the meeting of the Appointments and Remuneration Committee held on the 25th September 2019. Further to the meeting on 4th June which discussed the arrangements for the appointment of new executive directors, the meeting in September confirmed the appointment and remuneration of the Chief Medical Officer and the Director of Strategic Partnerships, who will also be the Deputy CEO.


Date: 21st November 2019 V Item: 19.146v

14.5

Tab 14.5 v. Appointments & Remuneration Committee Chair's report


board of directors public session meeting to be held on ... · mason fitzgerald (mf) elft, director...

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