unconfirmed minutes of the board of directors – public ... · page 1 of 10 date produced: 26 jan...

Board of Directors - Public - 22 Jan 2015 – Unconfirmed Minutes

Version 1.0 Author: Claire Harber Department: Trust Secretariat

of 10 Date produced: 26 Jan 2015 Retention period: 30 years

Unconfirmed

Minutes of the Board of Directors – Public Session

held on 22nd January 2015 at 9.30am

In the Main Hall, Hellesdon Hospital, Drayton High Road, Norwich, NR6 5BE

Present:

Gary Page, Trust Chairman (Chair)

Alison Armstrong, Director of Operations, Suffolk

Graham Creelman, Non-Executive Director

Tim Newcomb, Non-Executive Director

Andrew Hopkins, Director of Finance

Leigh Howlett, Director of Strategy & Resources

Peter Jefferys, Non-Executive Director

Brian Parrott, Non-Executive Director (in part)

Dr. Jane Sayer, Director of Nursing, Quality & Patient Safety

Marion Saunders, Non-Executive Director

Michael Scott, Chief Executive Officer

Stuart Smith, Non-Executive Director

Dr. Bohdan Solomka, Medical Director

Debbie White, Director of Operations, Norfolk & Waveney

In attendance:

Claire Harber, Acting Assistant Trust Secretary (minutes)

Lisa Mungham-Gray, Head of Communications

Robert Nesbitt, Trust Secretary

There were 9 members of public present

Meeting commenced at: 9.35am

15.01 Chair’s welcome, apologies for absence and notification of any urgent

business

The Chair (Gary Page) welcomed the Board and others present and introduced

Alison Armstrong as the new Director of Operations for Suffolk. He reminded those

Date: 26th February 2015

A Item: 15.25




present that this is a Board meeting in public rather than a public meeting, so priority

would be given to questions and comments from Board members.

The Chair advised the Board of one additional item (Service User and Carer

Involvement Strategy Progress Report) for the agenda to be heard under Any Other

Business. The Chair also advised the Board of the additional report from Stuart Scott,

relating to item 15.07vii, tabled due to the meeting taking place on Tuesday 20th

January. The Board were advised that the quality report under item 15.07ii was to be

withdrawn from the agenda due to an issue with the report and that this item would

be discussed at the next Board meeting.

Apologies from Adrian Stott, Non-Executive Director, were noted, and the Board

were informed that Brian Parrott had been delayed.

15.02 Standing Item: Declarations of Interest

John Brierley presented a declaration of interest to the Board as a Trustee of Mind,

Norwich.

The Board noted the declaration of interest.

15.03 To approve the minutes of the previous public meeting held on 18th December

2014

The Board showed concern over the number of typing errors and recommended that

these be checked. In addition, the following amendments were requested:

• Page 3, item 14.171i, first paragraph, fourth line: the word ‘acquitting’ should

be replaced with ‘acquiring’.

• Page 9, item 14.172i, fourth paragraph, first line: should read ‘Organisational’

rather than ‘Operational’.

• There was a question around the accuracy of the penultimate paragraph of

item 14.173ii, and whether ‘access to medicine’ should read ‘access to

medical advice or input’, but it was decided that the minutes were a correct

reflection of the discussion.

15.04 Matters arising from the meeting in public held on 18th December 2014

Robert Nesbitt said that action 14.173ii(a) was not an action for Jane Sayer and that

this has now been corrected. This action is to remain open. To be carried forward.

Bohdan Solomka confirmed that action 14.173ii(b) is still outstanding. To be carried

forward.




15.05 Chair’s Report (Gary Page)

The Board noted the report

15.06 CEO Report (Michael Scott)

Michael Scott introduced this reporting and provided updates on a number of issues.

The CQC Quality Summit is due to take place on 2nd February 2015 and the

subsequent report is due to be issued on 3rd February 2015.

The Haymills building in Stowmarket is scheduled for occupancy in the autumn.

Planning issues have caused some delays to this project.

In response to a question from a governor of the Trust, Michael Scott advised that

the lead governor is welcome to attend the CQC summit.

The number of Out of Area placements had fallen to 13 and Thurne Ward was due to

open in March 2015 with 12 beds.

Stuart Smith expressed concern over the large amount of referrals coming in,

especially in the fourth quarter of last year. Michael Scott confirmed that in October

and November 2014 there was a huge spike in demand for mental health services.

Acute hospitals reported a similar problem. It was also noted that community case

loads are high with actions underway to address this.

Brian Parrott joined the meeting at this point.

The Board noted the paper.

15.07i Patient Safety and Quality Report (Dr. Jane Sayer)

An increase in Serious Incident (SI) reports since 2012 was reported. It is thought

that the main cause of this numerical increase is due to the new NRP contract. The

Board were informed that NRP figures will be reported separately in future.

Additionally, all unexpected deaths are reported initially as SI’s, but are often

downgraded at a later date.

Marion Saunders requested charts for Duty of Candour and it was agreed that these

will be included in future.

Jane Sayer added that although the report quotes no incidents of Noro-virus, there

had subsequently been an outbreak at Willows, where 11 patients and many staff

were affected. She reported that all the usual precautions have been taken.




In response to a discussion on learning from complaints, Jane Sayer said that this

was a focus for a number of actions including a proposal to carry out random checks

that lessons have been embedded. Bohdan Solomka added that learning from

complaints and SI’s is a key part of Doctor’s appraisals and that this is recorded and

forms part of a Doctor’s target for the following year. He also informed the Board that

Doctors need to be revalidated every 5 years, and lessons learnt is a key part of this.

There was a question from the audience whether this ‘lessons learnt’ appraisal

system is in place for everyone and the Board responded that it is a regulated GMC

requirement for Doctors but not for nurses; it is due to become a requirement for

nurses in 2016.

Jane Sayer reported that guidance on Duty of Candour thresholds in unclear, so the

Trust may be over-reporting. The Department have been asked for clarification but

there is no timescale for a response.

Regarding SI’s, Brian Parrott asked if meeting with Chairs of the Safeguarding Adults

Board in Norfolk and Suffolk would be helpful. Jane Sayer advised the Board that the

Care Act was coming into force this year and that safeguarding will be picked up by

her and Saranna Burgess.

Summarising the discussion Gary Page said that embedding learning from incidents

and complaints was a consistent theme. It was agreed that a report is to go via the

Service Governance Committee and come back to the Board between March and

May 2015.

Action 15.07i

a. A report on how learning is formally embedded currently and a plan to show how this will be improved in the future to come to the board in March 2015 if feasible or May 2015 at latest. (Jane Sayer)

Jane Sayer drew the Board’s attention to paragraph 5 on safe staffing and advised

that the trends shown on the graph are average fill rates. She reported that a working

group is being pulled together to look at staffing. Tim Newcomb stressed that this had

a significant financial impact on the Trust and asked for clarification as to whether

demand is as expected, but staff are being overused, or whether it is that demand is

higher? Jane Sayer responded that past activity has been analysed and that it was

recognised that staffing creates a cost pressure, but they were looking at how to

effectively use the workforce. One issue is patients requiring 1:1 support: any

reduction in this type of support needed to be authorised at a senior level, but the

Trust was reviewing how best to maintain patient safety with appropriate

authorisation.




Action 15.07i

b. An analysis of whether the over-supply of CSWs shown in safer staffing is due to extra demand or whether there is evidence of over-staffing. Financial implications to be included. The executive team to review, agree date for this to come to the Board, and report this date at the next meeting. (Jane Sayer)

It was agreed that the graphics showing the ‘dials’ for satisfaction will be included in

future reports and that the Director of Operations should address the issue that the

current Family and Friends return is only 16%.

Action 15.07i

c. Friends and Family Test ‘dials’ to be included in future reports. (Jane Sayer)

A carer in the audience asked whether there is a Friends and Family Test for carers.

The Board responded that the test is ready for patients, and once that is fully

implemented, the Trust will then consider including carers.

Approved.

15.07ii Quality Account Quarterly Report (Dr. Jane Sayer)

Withdrawn – to be considered at the February 2015 meeting.

15.07iii Equality Objectives Quarterly Report (Robert Nesbitt)

Robert Nesbitt introduced the paper.

In response to a number of questions about monitoring, Robert Nesbitt explained

that there was still a low level of awareness of the importance of monitoring in

relation to the Trust’s public sector equality duty, however a plan was being

developed in relation to staff training and complaints.

In response to a question from a member of the audience Robert Nesbitt reported

that the team consisted of Ravi Seenan (Equality and Engagement Manager), two

spiritual leads from Norfolk and Suffolk and a Membership and Engagement Officer.

In relation to training Robert Nesbitt explained that options to take equality training

out to teams were being explored and that this might form one of the refreshed EDS

objectives for 2015/16.

Approved.




Action 15.07iii

Consideration to be given to the inclusion of E&D training plans as one of the updated E&D objectives for 2015/16 in April 2015. (Robert Nesbitt)

15.07iv Board Assurance Framework (Robert Nesbitt)

The report was taken as read. Each section was discussed in turn.

1 (Staffing) – there were no comments

2 (System Confidence) – Stuart Smith confirmed that this section would be reworded

(as an action from the Finance Committee) with Andrew Hopkins and this would be

forwarded to Robert Nesbitt.

Action 15.07iv

System confidence theme to be revised by Stuart Smith with Andrew Hopkins for reporting in February 2015 BAF. (Stuart Smith / Andrew Hopkins)

3 (Quality) – there were no comments

4 (Staff Morale)

Michael Scott reported that ‘April Strategy’ are taking forward work to support staff

engagement.

5 (Maintaining and Growing Business)

Stuart Smith confirmed that the Finance Committee have picked this up and that he

would come back to the Board with recommendations for improvements in this area.

6 (Maintaining a CoSRR of 3 in 2014-15)

Stuart Smith confirmed that the Finance Committee discussed this at their meeting

earlier this week and that he and Andrew Hopkins have a meeting scheduled to

update the risk.

7 (ICT Weaknesses)

Stuart Smith agreed to speak with Leigh Howlett following discussions at the Finance

Committee on this element.

15.07v Finance Report M09 (Andrew Hopkins)

Andrew Hopkins introduced the report and noted a slight deterioration from M08 due

to increases in temporary staffing partly due to the holiday period.

Andrew Hopkins reported that members of the Finance team met with Monitor on

Monday 19th January 2015, and Gary Page and Michael Scott subsequent to that, to




understand the reason for the Trust’s financial deterioration. OOA placements were

noted as the main contribution along with temporary staffing and actions are

continuing to address these pressures.

15.07vii Finance and Performance Committee Chair’s Report (Stuart Smith)

The Chair’s report from the Finance Committee was tabled due to the meeting being

held only two days ago. Stuart Smith talked through the executive summary and

confirmed that the current financial year position was as explained by Andrew

Hopkins in his report. For the next financial year, the Finance Committee noted

evidence of a firm approach being taken by contract negotiators. Stuart Smith

reported that, in terms of financial recovery, £7.85m of CIP savings for next year

have been identified and that this figure may be revised as contract negotiations are

made.

Stuart Smith reported focus on, and activity around, budget setting for next year, and

close working relationships with finance professionals and managers. It was stressed

that department managers must take ownership of their budgets, particularly

managers moving into fresh areas. Alison Armstrong reported that a new financial

business partner is working closely with locality managers in Suffolk and that there

was evidence that ownership is being taken of budgets. Debbie White reported a

similar situation in Norfolk.

The Board were informed that Monitor require an operational annual plan draft by

27th February 2015 on how the Trust plans to achieve a CoSRR of 2 whilst ensuring

that the standard of care is maintained.

Graham Creelman added that the Trust needs to be realistic about cost

improvements and predicted savings and need to be confident it can deliver on

predicted savings. Andrew Hopkins reported that sensitivity analysis will be done and

that finance will be looking at scenarios. This is the first year the Trust has failed to

meet its plan. However, it was noted that the Trust would have a lower CIP target for

2015/16 if additional funding was secured.

There was a break from 11:00 to 11:15

15.07vi Business Performance Report (Andrew Hopkins)

Andrew Hopkins introduced this report. Following a discussion regarding delayed

transfers of care (detoc) it was agreed to forward a detailed anonymised report to

Adrian Stott

Action 15.07vi

a. The detailed detoc report that Veno Sunghuttee provides to be sent in anonymous format to Adrian Stott before next meeting. (Debbie White)




Graham Creelman asked what the cost implications of delays were for detocs and

Andrew Hopkins agreed to include rolling costs of delays in future reports.

Action 15.07vi

b. The detoc report to include financial costs for the Trust. (Andrew Hopkins)

The Board were informed that trends in the workforce statistics are all positive. Gary

Page advised that a note will go out to Governors. Brian Parrott endorsed the good

progress in this area and added that monitoring needs to be maintained.

Approved.

15.07ix Monitor Compliance Framework Quarterly Declarations (Andrew Hopkins)

Andrew Hopkins reported that all governance targets are green. The Board were

informed that a paper on the CQC report will be presented once the CQC issue their

final report. It was noted that in relation to the LD declaration, the board had received

a report in 2014 on this matter which confirmed compliance.

Referring to appendix 1, Andrew Hopkins reported the Trust is looking at a CoSRR of

2 for the current and next financial year. Following discussion it was agreed that the

Board should declare that it could not confirm a 12 month CoSRR of 3 and that the

narrative below would set out the rationale for this.

Approved

15.07x Amendment to Constitution (Partner Governors) (Robert Nesbitt)

Robert Nesbitt introduced the report which recommended that time limited partner

governor appointments be made by Suffolk Family Carers and Suffolk User Forum.

Approved.

15.07xi Policies that Require Board of Director Approval (Robert Nesbitt)

The board approved the proposal and asked that the existing policies be mapped

onto the meeting structure.

Action 15.07xi

A list of policies, mapped on to the groups that approve them to be requested from Helen Oatham for circulation to the Board before the next meeting. (Robert Nesbitt)




15.07xii Terms of Reference for Revised Committee Structure and Transition Plan to

April 2015 Implementation (Robert Nesbitt)

Robert Nesbitt introduced the paper explaining that the changes to the structure

reflected those agreed by the Board at its meeting in November 2014.

Stuart Smith reported that the Finance Committee had agreed the inclusion of the

work of the Investment Committee but that oversight of performance required further

discussion. Michael Scott stressed the importance of monitoring integrated

performance at committee level.

Action 15.07xii

a. The Finance Committee’s Terms of Reference to be amended by Stuart Smith with input from Andrew Hopkins to remove oversight of performance, to come back to February 2015 Board for approval along with a recommendation as to how performance is scrutinised in the new structure. (Stuart Smith)

Peter Jefferys pointed out that the Terms of Reference for the Service Governance

Committee in this paper (Nviii) were the previous version.

Leigh Howlett, referring to the Committee structure chart in Ni, provided an example

that the Flexible Workforce Board feeds into two Committees so they are producing

duplicate reports. It was agreed that as a principle, there should only be one line of

accountability.

Action 15.07xii

b. Committee diagram to be amended so that no group reports into more than one committee and so that all professional lead groups show as reporting to OD&WF. (Robert Nesbitt)

15.08 Items for Debate

i Impact of s.75 Changes in Norfolk (Debbie White)

Debbie White reported that since the report was written, she has met with the Head

of Social Care and they have reported the recruitment of more staff, including

additional Band 6’s. She also reported that some issues have come to light around

CHRT which have posed an opportunity to do things differently. Debbie White

advised the Board that it is expected that case load transfers will be complete by the

end of March 2015.

Noted.




15.09 Items for Information

i. Update on System-Wide Action Plan for MH Concordat (Debbie White)

Debbie White advised that there were two action plans for the two counties. The

Norfolk plan is complete and has been shared with Suffolk colleagues and Suffolk

were in the process of devising their plan.

In response to a question from Brian Parrott, Andrew Hopkins confirmed that

psychiatric liaison had been funded by CQUIN for two years. After this two years, it

should move to mainstream funding. The Board were informed that CCGs recognise

that psychiatric liaison was something they needed to fund and Debbie White

confirmed that the current CQUIN funding for this ends in 2016.

15.10 Any Other Business

The paper ‘Service User and Carer Involvement Strategy Progress Report’ was

discussed and it was noted that whilst the themes were broadly correct they needed

to be translated into a clearer plan. It was also necessary to ensure the strategy was

aligned with Trust plans on IMROC.

It was agreed that Jane Sayer will arrange the production of a final document during

January and February 2015 to be taken to the Service User and Carer Trust

Partnership before coming back to the Board to approve in March 2015.

Action 15.07xi

A fully worked up strategy, incorporating the overarching themes agreed, to come to the March 2015 Board. (Jane Sayer)

Meeting closed at: 12.30

Chair: ……...…..…………………

Date: ……....…………………………….

of 2

Carried Forward from 2014

Action 14.173ii (LD Strategy)

a. Cost implications for the LD strategy (including capex) to be included in the report to F&PC next committee. (Andrew Hopkins)

A paper is due to go to committee on 24 Feb 2015.

b. Email note to be circulated to the BoD on the context and organisational boundaries for mental health services for people with a LD in Norfolk. (Bohdan Solomka)

Complete

Matters Arising from Public BoD 22nd January 2015


B Item: 15.26

Action 15.07i (Patient Safety and Quality Report)

a. A report on how learning is formally embedded currently and a plan to show how this will be improved in the future to come to the board in March 2015 if feasible or May 2015 at latest. (Jane Sayer)

On agenda planner

b. An analysis of whether the over-supply of CSWs shown in safer staffing is due to extra demand or whether there is evidence of over-staffing. Financial implications to be included. The executive team to review, agree date for this to come to the board, and report this date at the next meeting (Jane Sayer)

c. Friends and Family Test ‘dials’ to be included in future reports. (Jane Sayer)

Action 15.07iii (Equality Objectives)

Consideration to be given to the inclusion of E&D training plans as one of the updated E&D objectives for 2015/16 in April 2015. (Robert Nesbitt)

On agenda for April 2015.

Action 15.07iv (BAF)

System confidence theme to be revised by Stuart Smith with Andrew Hopkins for reporting in February 2015 BAF.

BAF reporting aligned with risk register this will come back in May 2015

of 2

Action 15.07vi (Business Performance Report)

a. The detailed detoc report that Veno Sunghuttee provides to be sent in anonymous format to Adrian Stott before next meeting. (Debbie White)

Complete

b. The detoc report to include financial costs for the Trust (Andrew Hopkins)

Included in this month’s report

Action 15.07xi (Policies Requiring Board Approval)

a. A list of policies, mapped on to the groups that approve them to be requested from Helen Oatham for circulation to the board before the next meeting. (Robert Nesbitt)

Copy of policy mapping appendix sent to BoD on 03.02.15

b. The finance committee’s terms of reference to be amended by Stuart Smith with input from Andrew Hopkins to remove oversight of performance, to come back to February 2015 board for approval along with a recommendation as to how performance is scrutinised in the new structure.

Complete

c. Committee diagram to be amended so that no group reports into more than one committee and so that all professional lead groups show as reporting to OD&WF. (Robert Nesbitt)

Complete (note that E&D does report to both SGC for service and ODWF for staff issues.

Action 15.10xii (Service User and Carer Strategy)

A fully worked up strategy incorporating the overarching themes agreed, to come to the March 2015 Board. (Jane Sayer)

On agenda planner

Board of Directors – 26 Feb 15 Chief Executive Update

Version 1.0

Author: CWC Department: Corporate

Page 1 of 2 Date produced: 15 Feb 15 Retention period: 30 years

Report To: Board of Directors – Public

Meeting Date: 26th February 2015

Title of Report: Chief Executive Update

Action Sought: For Information

Estimated time: 10 minutes

Author: Michael Scott, CEO

Director: Michael Scott, CEO

Executive Summary:

This report provides an update on the main issue, insights, observations and activities undertaken by the Chief Executive for the month.

1.0 Monitor:

1.1 We have held several meetings and telephone calls with Monitor to discuss

current and future financial position. I have also held an introductory call with Kath Cawley who has recently taken over as Regional Director from Adam Cayley.

1.2 Both the Chair and I met with Alan Yates who will be joining us as an Improvement

Director for the Trust, appointed by Monitor. The Board will all meet Alan during his time with the Trust both in meetings and on an individual basis.

1.3 Monitor additionally requested that we meet the team at Birmingham and Solihull

Mental Health NHS Foundation Trust, several members of the workforce including the Chair, myself and a governor visited the Trust and met our counterparts who were very generous in showing us key areas and enlightened us on their achievements.

2.0 CQC update:

2.1 We met with the CQC and local partners at the quality summit earlier in the month. We have been proactive in dealing with any issues which the CQC had highlighted and are currently well underway in dealing with actions from the summit.

2.2 Staff have been kept informed of the current position and took the opportunity at the Senior Management Forum to relay our presentation to the CQC.


C Item: 15.27

Board of Directors – 26 Feb 15 Chief Executive Update

Version 1.0

Author: CWC Department: Corporate

Page 2 of 2 Date produced: 15 Feb 15 Retention period: 30 years

2.3 We have also invited staff member, governors and stakeholders to events being held next month at Lynford Hall to discuss Strategic Priorities. They have already received a copy of the Board Strategy session outcomes which will form the basis of the event. As a result of feedback we are laying on a third event which is more accessible by public transport.

3.0 Junior Doctor Faculty Event:

3.1 I was invited to participate as a panel member for the faculty of postgraduate psychiatry in a question and answer session which was well attended by trainees. As a result, key concerns were raised by trainees which are now in the process of being addressed.

4.0 Recruitment Video:

4.1 Both Jane Sayer and I have participated in a video to encourage recruitment to the Trust. The video is aimed at potential external candidates and promotes the career opportunities and professional development together with staff benefits when joining the Trust.

5.0 FACT and AFI Model: 5.1 I visited the Resource Centre at Northgate in Great Yarmouth to meet with the

teams who run the Flexible Assertive Community Treatment and the Assessment and focussed Intervention Team. Both the teams were very busy but were very positive about the new models they have developed.

6.0 Waiting times in Mental Health.

6.1 NHSE have released new standards for waiting times particularly for Early Intervention in psychosis. This is the result of concerted national efforts to raise the profile of mental health services through the establishment of waiting times standards. Full details are attached.

7.0 Risks / mitigation in relation to the Trust objectives:

7.1 None.

8.0 Recommendations:

8.1 The Board is asked to note the content of this report.

Michael Scott Chief Executive

AW Guidance – NHS England Letter

Gateway reference: 03023 Commissioning Operations &

Medical Directorates 6th Floor Skipton House 80 London Road SE1 6LH

To: CCG Clinical Leaders CC: CCG Accountable Officers

12 February 2015 Dear colleagues, Re: Publication of guidance to support the introduction of access and waiting time standards for mental health services in 2015/16 We are writing to advise you that the above guidance is to be published today on the NHS England website (http://www.england.nhs.uk/resources/resources-for-ccgs/#times). The guidance follows the October publication of Improving access to mental health services by 2020 which outlined a first set of mental health access and waiting time standards for introduction during 2015/16. The commitment to introducing the new standards was reaffirmed in the NHS Mandate and reflected in the joint planning guidance for 15/16. Improvements towards meeting the first standards will come into effect from 1 April 2015 for achievement by 1 April 2016 and are focused in three areas where timely access to evidence-based care is of particular importance in improving longer term mental health, physical health and recovery-focused outcomes and in reducing the distress experienced by individuals and their families:

More than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. Most initial episodes of psychosis occur between early adolescence and age 25 but the standard applies to people of all ages in line with NICE guidance.

75% of people referred to the Improved Access to Psychological Therapies programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral. This standard applies to adults.

£30m investment to is to be targeted on effective models of liaison psychiatry in a greater number of acute hospitals. From 15/16, when the Care Quality Commission (CQC) rates acute services, it will include a specific focus on liaison mental health services and mental health care, as well as the quality of treatment and care for physical conditions.

The guidance published today builds on the joint planning guidance published in December and is intended to:

http://www.england.nhs.uk/resources/resources-for-ccgs/#times

http://www.england.nhs.uk/resources/resources-for-ccgs/#times

1. Clarify the requirements of each of the new 15/16 mental health access and waiting time standards and associated expectations of CCG commissioners in line with the planning guidance.

2. Outline the intention to implement access and waiting time standards for eating

disorders in community CAMHS from 2016. 3. Update commissioners, providers, commissioning support units, regional and sub-

regional teams and wider system stakeholders regarding the national programme of support for implementation of the new access and waiting time standards.

4. Signpost the above stakeholders to helpful sources of regional support for

implementation of the early intervention in psychosis (EIP) standard. Please can you ensure that the guidance is disseminated to key leads within your organisations to support their work to develop local plans to enable delivery of these 2015/16 NHS Mandate commitments. The Five Year Forward View underlined NHS England’s commitment to delivery of the new standards and ensuring parity of esteem for people affected by mental illness. This was further reinforced by the planning guidance which requires each CCG’s spending on mental health services in 2015/16 to increase in real terms and grow by at least as much as each CCG’s allocation increase. The new guidance reinforces the clear the expectations of CCGs set out in the planning guidance:

For early intervention in psychosis (EIP) and improving access to psychological therapies (IAPT) commissioners are required to agree service development and improvement plans (SDIPs) as part of their 15/16 contract with mental health providers, setting out how providers will prepare for and implement the new standards during 2015/16 and achieve them on an ongoing basis from 1 April 2016.

For liaison psychiatry commissioners will be required to agree SDIPs with acute providers, setting out how providers will ensure there are adequate and effective levels of liaison mental health services across acute settings. Supplementary planning guidance1 made clear the expectation that all acute trusts should, by 2020, have in place effective models of liaison psychiatry (all ages, appropriate to the size, acuity and specialty of the hospital).

For IAPT CCGs will be also be required to submit plans setting out how they

will meet the new waiting time standards and these will be monitored throughout the year. Compliance will be assessed in the final quarter of 2015/16.

We would particularly draw your attention to the specific requirements of the early intervention in psychosis standard. The standard is ‘two-pronged’ and both conditions will have to be met for the standard to be deemed to have been achieved, i.e. 1. A maximum wait of two weeks from referral to treatment; and

1 http://www.england.nhs.uk/wp-content/uploads/2014/12/plan-guid-nhse-annx-231214.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/12/plan-guid-nhse-annx-231214.pdf

2. Treatment delivered in accordance with NICE guidelines for psychosis and schizophrenia - either in children and young people CG155 (2013) or in adults CG178 (2014).

Our expectation is that the additional £40m recurrent EIP funding being made available should be invested recurrently in EIP services to support sustainable delivery of the new access and waiting time standard. EIP services are subject to local agreement on pricing and commissioners will need to ensure that increases in the level of local investment take into account baseline performance against both elements of the EIP standard Please contact the central programme leads if you have any queries regarding the new guidance: EIP and liaison mental health – [email protected] IAPT – [email protected] Eating disorders – [email protected] Many thanks for your support for this work that will make a very real difference to the lives of people affected by mental illness and their families and carers. The introduction of the new standards offers a landmark opportunity to improve the timeliness, quality and effectiveness of NHS care. Yours faithfully,

Dr Sarah Pinto-Duschinsky Director of NHS Operations and Delivery

Dr Martin McShane Director of Long Term Conditions

Dr Geraldine Strathdee National Clinical Director for Mental Health

CC: NHS England regional directors, medical and nursing directors

NHS mental health provider chief executive officers, medical and nursing directors

http://www.nice.org.uk/guidance/CG155

http://www.nice.org.uk/guidance/CG178

mailto:[email protected]



Board of Directors – Public 26Feb2015 - SID Appt

Version 1.1

Author: Gary Page Department: Corporate

Page 1 of 4 Date produced: 13Feb2015 Retention period: 30 years

Report To: Board of Directors - Public


Title of Report: Appointment of Senior Independent Director (“SID”) and Deputy Chair

Action Sought: For Approval


Author: Gary Page, Chair

Director: Gary Page, Chair

Executive Summary:

The report seeks approval for the appointment of Marion Saunders as the Senior Independent Director and Deputy Chair.

1.0 Summary of Report 1.1 Graham Creelman, the current SID and Deputy Chair, is standing down from the

Board on 28.02.15 and consequently we need to appoint one of the NEDs into this role.

1.2 My recommendation is that Marion Saunders should be appointed to this role from

today, 26.02.15. 2.0 Role of the SID and Deputy Chair

2.1 The role description was reviewed and approved by the Nominations Committee at its meeting on 01.12.14 as is attached to this report. The role has a number of responsibilities:

• To deputise for the Chair when he is unavailable to attend meetings of the BOD, BOG and Remuneration Committee.

• To carry out the appraisal of the Chair after consultation with members of the BOD and the Governors.

• To act as a sounding Board for the Chair

• To be the person that Governors can go to in order to address and concerns regarding the Chair.


D Item: 15.28i


Version 1.1



2.2 In order to fulfil the role the individual needs to have good chairing skills, be acceptable to the Governors and the Board of Directors and to be someone that the Chair can work closely with.

3.0 Marion Saunders

3.1 Marion joined the Trust in 2014 as a Non-Executive Director and is an experienced operator at Board level including being a previous Chair of a Primary Care Trust. She is a member of the Nursing and Midwifery Council Fitness to Practice Committee and a specialist advisor on safeguarding matters to the Care Quality Commission (CQC).

3.2 I have discussed this appointment with Governors at the Nominations Committee on December 1st 2014 and there was unanimous support for the appointment.

3.3 Marion has extensive NHS experience outside of NSFT and in view of the considerable challenges which the Trust is currently facing I believe Marion brings a fresh external perspective which will be of considerable value to me and the wider organisation. She also has a good mix of public and private sector background which will compliment my predominantly private sector career.

4.0 Recommendation

4.1 I recommend the appointment of Marion Saunders as the SID and Deputy Chair with immediate effect, and seek the approval of the Board.

Gary Page Chair 31

st January 2014

Background Papers/Information 1.0 Senior Independent Director and Deputy Chair 1.1 Purpose

The principal responsibilities of the Senior Independent Director and Deputy Chair are to:

• Support the Chair in leading the Board of Directors, acting as a sounding board and source of advice.

• Support the Chair in the role of Chair of the Board of Governors.

• Chair the Board of Directors or Board of Governors when matters concerning the Chair are considered and in the Chair’s absence

• Act as a conduit to the Board for the communication of member and governor concerns when appropriate

• Chair the Nominations Committee of the Board of Governors


Version 1.1



• Ensure that the annual performance evaluation of the Chair is effectively conducted and reported to the Nominations Committee

• Be available to members, Directors or Governors who wish to meet in confidence.

1.2 Reporting Line

The Senior Independent Director/ Deputy Chair is appointed by the Board of Directors in consultation with the Board of Governors. S/he is required to meet the independence criteria set out in the Combined Code. The role is accountable to the Chair.

1.3 Areas of Responsibility

In addition to his/her responsibilities as Non-Executive Director of the Trust, the specific areas of responsibility of the Senior Independent Director / Deputy Chair are: Leadership

• To act as the lead Non-Executive Director.

• To convene and Chair any meeting of the Board or part of a Board meeting at which matters concerning the Chair are considered.

• To act in the Chair’s absence Governors and Members

• To be available to governors or members if they have concerns which have not or cannot be resolved through contact with the Chair, the Chief Executive, or the Trust Secretary or for which such contact is inappropriate.

• To attend sufficient meetings with governors and members to gain a balanced understanding of the issues which are important to them and any concerns they may have, as well as an understanding of governors’ views on key strategic and performance issues facing the Trust.

1.4 Performance Evaluation

To ensure the annual process to appraise the performance of the Chair is undertaken effectively, including leading a meeting of NEDs without the Chair’s presence. To ensure that the outcome of the appraisal is reported to the governors’ Nominations Committee. In the event of there being any concerns about the performance of the Chair, the SID will provide support and guidance to the Board of Governors (in liaison with the lead governor) so as to resolve concerns, or in the absence of a resolution, to take formal steps


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1.5 Communication

To communicate the issues and concerns of governors and members to the non-executive directors and, where appropriate, the Board of Directors as a whole

1.6 Meetings with Other NEDS

In addition to leading the meeting with other NEDS for the purposes of the annual appraisal of the chair, to hold such other meetings with the NEDS on such occasions as are deemed appropriate.

Board of Directors – Public 26Feb 2015 Quality Account

Version 1.0

Author: Sue Barrett Department: Governance

Page 1 of 11 Date produced: 13th

January 2015 Retention period: 30 years



Title of Report: Quality Account Update



Author: Sue Barrett: Head of Governance

Executive Dr Jane Sayer: Director of Nursing Quality and Patient Safety

Executive Summary:

This paper updates the Board of Directors (BoD) on the progress made towards achieving the Quality Account priorities 2014/15 approved by the Board in February 2014. The paper also suggests quality improvement priorities for 2015-16 identified in the CQC report and from service user feedback via the annual survey. The Board is asked to approve the quality improvement priorities.

1.0 Summary

This paper provides an update on the quality priorities which will be reported in the annual Quality Account due for publication in June 2015.

2.0 Progress against Quality Account priorities – Quarter 3 2014/15

Priority 1: Patient Safety 2013-14 To implement a system which ensures that all patients in contact with mental health services access relevant physical healthcare screening and services. (2013-14) Board Lead: Jane Sayer, Sara Fletcher Q3 Update The Trust now has a physical health strategy group chaired by Dr Kapil Bakshi


E Item: 15.28ii


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and this group coordinates physical health initiatives across the Trust. This includes:

• Linking with the recovery college to produce a physical health module

• Links with public health leads to address physical health needs of community patients

• Physical Health monitoring in Clozapine Clinics and for depot injections

• Cardio-metabolic assessment for patients with schizophrenia as required from the National Audit of Schizophrenia.

• Supporting the use of the Rethink document. The East Norfolk pilot scheme that was originally proposed in response to the first round of the National Audit of Schizophrenia, has been subsumed into the physical health strategy group work. Specific work liaising with GPs was undertaken as part of the public consultation. This priority arose from round one of the National Audit of Schizophrenia, published in 2012. In 2014-15, this priority was clarified as the implementation of the Lester Tool and adopted as a National CQUin. Results of round two of the National audit identified that the Trust performance in monitoring the Five cardio-metabolic health risk factors had improved and the Trust had moved from 53rd position to 39th position out of the 64 organisations taking part. Although this identifies an improved position nationally, the completion of all five elements of the tool has only risen from 29% to 33%. In response to the National CQUIN, the Trust has focussed on the implementation of the Lester tool and submitted data to a further National audit in January, the results of which will be published in March.

Progress RAG rating AMBER In response to the priority stated “to implement a system” this priority has been achieved. However, as noted above, little tangible progress has been made in areas that will improve outcomes for service users. It is therefore proposed to take physical health monitoring forward to a new priority in 2015-16 worded in such a way as to demonstrate outcome based improvements that benefit service users rather than changes to processes.

Priority 2: Patient Safety 2014-15 Being able to access services quickly Board Lead: Operations Directors Q3 Update


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Following discussion with the informatics team, the following format will be included in the Quality Account. This format is designed to give a view of the waiting times which will be accessible for the public in the terms that are usually referred to.

Complete waits for treatment - 2014 - 2015 Q3

Secondary Care Services - seen within 18 weeks of referral

Month GT Yarmouth & Waveney Norfolk Suffolk Trust

Oct 99.45% 99.52% 98.66% 99.23%

Nov 99.51% 99.59% 99.84% 99.65%

Dec 99.74% 99.54% 98.92% 99.40%

Qtr 99.57% 99.55% 99.14% 99.42%

Complete waits for treatment - 2014 - 2015 Q3

IAPT Services - seen within 28 days of referral

Month GT Yarmouth & Waveney Norfolk Suffolk Trust

Oct 90.16% 80.71% 99.50% 89.04%

Nov 75.28% 79.38% 99.41% 86.07%

Dec 72.84% 80.08% 99.39% 85.42%

Qtr 79.50% 80.06% 99.44% 87.03%

Progress RAG rating AMBER The data presented will be updated for inclusion in the Quality Account but the current levels of compliance are poor in Norfolk and Gt Yarmouth and Waveney compared to Suffolk and this has the effect of lowering the Trust average significantly. A rationale for the dip in performance in GTY&W and the overall low compliance in Norfolk will be included in the Quality Account along with an explanation as to how the underlying problems are being addressed and an analysis of the level of confidence that improvement will be achieved.

Priority 3: Patient Safety 2014-15

Being confident that the Trust learns from mistakes and puts in plans to reduce similar risks

Board Lead: Jane Sayer, Michael Lozano Q3 Update


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The priority stated that this would be evidenced from the introduction of the Duty of Candour policy, which is now in place and reported on by the patient safety team. The second aspect of the priority was regular reporting on the implementation of action plans arising from serious incident investigations. The quarterly patient safety report submitted to Service Governance Committee provides statistical data and identifies trends emerging from incidents. Actions identified from RCAs are also monitored by the patient safety team and locality managers reminded of the need to complete the actions. The report presented in January identifies that there are 258 recommendations outstanding from 98 serious incident reviews. This is clearly a risk and identifies that learning may not be put in place. In addition the CQC reports have identified that learning at all levels of the organisation is not taking place and all teams will be required to share learning from incidents that occur in all areas of the Trust, not just their own area. This will be followed up as part of the CQC quality improvement plan. The patient safety team have reflected on the current processes and identified further actions that are required to ensure learning takes place.

• Communicating learning

• Supporting managers to enhance their understanding and role within Patient Safety

• Connection with localities

• Assurance learning has reached all levels

• Actions/interventions

Progress RAG rating AMBER

While the implementation of the policy has been achieved, it is clearly not the case that staff can identify how they learn from incidents. This priority will therefore need to continue to be worked on for achievement in 2015-16. The board will receive a specific paper setting out the current arrangements for applying learning, as well as the ways in which these will be improved so as to meet CQC requirements. This paper will come to the board by May 2015 at the latest.

Priority 4: Patient Experience 2014-15 Being able to contact a mental health worker out of hours.

Board Lead: Operations Directors Q3 Update


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Access to a support line in Norfolk Following negotiations with MIND and CCGs for funding to ensure that all Norfolk areas will be covered, the support line commenced on the 26th January 2015. This service will be evaluated and if successful, ongoing funding sought in Norfolk and a business case presented in Suffolk to extend the service.

The inclusion of emergency contact details in crisis plans for service users subject to CPA or contingency plans for those on non CPA

Criteria GTY&W E.

Suffolk

W.

Norfolk W. Suffolk

Central

Norfolk

There is a crisis / contingency

planning document for audit 47% 73% 42% 86% 45%

CPA ONLY

There is a crisis plan 35% 81% 75% 100% 38%

The crisis plan includes

specific personalised advice

for the SU regarding

telephone contact details out

of working hours in case of

emergency

86% 63% 100% 50% 60%

NON CPA ONLY

There is a crisis / contingency

plan 67% 29% 35% 58% 48%

The crisis / contingency plan

includes specific personalised

advice for the SU regarding

telephone contact details out

of working hours in case of

emergency

75% 50% 29% 17% 23%

The audit results demonstrate that compliance with this requirement is poor and even where it shows that contact details are included, the audit shows that not all service users actually have a crisis plan. The 100% compliance shown for two measures (in West Suffolk and West Norfolk) indicates that the targets are achievable. With the implementation of Lorenzo it should be possible to provide more up to date timely information on the status of crisis plans but without a specific management focus on making practice changes, progress will not be made. A follow up audit will take place in February/March to demonstrate any improvements made.


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Progress RAG rating RED It is proposed that this priority is rolled forward, that actions are agreed to change clinical practice, and that further evaluation of the crisis line and improvements in crisis plans takes place in 2015-16

Priority 5: Patient Experience 2013-14

All inpatient areas will have a programme of activities which will be available over seven days and include evenings

Board Lead: Operations Directors

Q3 Update This requirement has been met as all in patient areas have an activity programme consisting of both structured and unstructured activity including evenings and weekends. Daily meetings enable service users to discuss activities for the day and for the staff to tailor the programme accordingly. However, the expected level of activity is subjective and dependent on the individual and so an individual monitoring form will be introduced for all in patients (appendix 1). This will demonstrate the activity that is available and taken up by the service user and may also be used in reviews to identify changes in mental state. The requirement in the CQC quality improvement plan to ensure that there are enough staff includes one measurement that demonstrates that activities have been available. This priority will therefore be monitored through the improvement plan and a quarterly audit of the monitoring forms.

Progress RAG rating AMBER

Priority 6: Patient Experience 2014-15 Having carers needs taken into consideration. Implementation of the Triangle of Care Board Lead: Jane Sayer Q3 Update This is being implemented through the Triangle of Care and is reported in the Director of Nursing update. A full summary of achievement will be presented in the Q4 update

Progress RAG rating GREEN


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The Trust is on track to submit the required number of self -assessments within the required timescale. As this measure is reported to board and monitored through the carers leads advisory group, as well as local groups, it is proposed that this priority is included as business as usual and not rolled forward in the Quality Account.

Priority 7: Clinical Effectiveness 2013-14 When a new medication is prescribed, the prescriber should always discuss this with the service user first. Information leaflets should be given and this should be recorded in the service user’s record. Board Lead: Medical Director Q3 Update Dr Solomka has taken over this priority as the new medical director and will take the lead role in ensuring that prescribers comply with the requirement. An audit is currently underway and will be reported in the end of year report. There is a risk that this priority will not have made progress. An audit carried out in June identified that only 47% of service users notes had a record of new medication being discussed. The community service user survey 2014 identifies that the Trust score of 5.8 for people given information in a way that they could understand was the lowest score obtained in all Trusts. The National Audit of Schizophrenia found that 74% of NSFT service users (71% National sample) said they felt involved in decisions about their medication but only 42% said they received information (National sample 48%) This evidence indicates that NSFT is discussing medication changes and performing better than the National average, but this conversation is not being recorded. It also indicates that written information is not being provided in a way that service users can understand.

Progress RAG rating AMBER This priority has already been rolled forward from 2013-14 and discussion with prescribing staff indicates that they have the conversation with the service user but that this is not recorded in the medical record. Medical staff also report that part of the problem is that service users are seen in a variety of locations where leaflets are not available. At present, no action is being taken to improve compliance with this priority and it seems unlikely that the audit to be published in March 2015 will show a significant increase in compliance., A clear plan for improvement is required which addresses the issue at the point of prescribing and includes a mechanism for checking that the information has been given.


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Priority 8: Clinical Effectiveness 2014-15 Having a care coordinator who gets to know you and can ensure continuity of your care. Board Lead: Operations Directors Q3 Update As reported in the October 2014 report, there is no obvious metric with which to report achievement of this priority, however, a starting point is that there should be an allocated care coordinator and this is reported here. Following discussion with Informatics, the regular reports regarding unallocated cases are received and the current figures for Norfolk are as follows:

Unallocated cases

Locality Number of cases (Dec 14)

Number of cases (Jan 14)

Central adult 283 270

Central youth 96 119

Coast adult 79 109

Coast DCLL 33 53

Coast memory team 29 43

West adult 163 174

West Youth 0 20

West DCLL 0 51

To date the figures for Suffolk have not been collected in a systematic way but this is now due to commence. It is known however that the figures are much lower than in Norfolk. In Norfolk a variety of actions have been put in place to reduce the number of unallocated cases and to mitigate the risks inherent in the unallocated cases. This includes the identification of an additional 12 band 6 care coordinator posts and an additional 5 band 4 posts. To mitigate the risk, cases are open to the team and the service user can contact the team at any time for support. The timeframe for reducing the number of unallocated cases is however dependent on the recruitment of staff.

Progress RAG rating RED It is suggested that a consistent downward trajectory towards a target of zero unallocated cases would enable this priority to be completed. The timeframe for this to be identified according to staffing levels and this will continue to be addressed as part of the Quality Improvement Plan.


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3.0 Quality Priorities for 2015-16

3.1 The Department of Health guidance for the production of Quality Accounts requires that priorities are identified from service user and carer engagement. In the past five years, NSFT has consulted both by quality events and surveys.

3.2 Unfortunately responses have been very limited and this response cannot be seen as representative of service user and carer opinion. The Trust board has therefore agreed that for 2015-16, the priorities will be identified from the 2014 community service user survey, the National audit of Schizophrenia and the comprehensive CQC inspection which included feedback from the public.

3.3 The Quality account requires at least one priority from the three headings of patient safety, service user experience and clinical effectiveness. It is important that the priorities agreed are SMART, to ensure that the Trust can clearly demonstrate achievement to all stakeholders.

The proposed priorities are as follows:

Patient safety (CQC Domain Safe) Seclusion- There will be a reduction in the number of prone restraints. (Measured via Datix) and the target for this will be agreed as part of the implementation plan. Lead will be Jane Sayer as this is already in process. This will link to the Quality Improvement Plan - “The trust must ensure that seclusion facilities are safe and appropriate and that

seclusion and restraint are managed within the safeguards of national guidance and the

MHA Code of Practice”

Physical health - 95% of service users admitted to the ward where they stay for more than 24 hours will have a physical health check. This will be recorded on Lorenzo along with the action plan where a physical health need is identified “The Trust must ensure that all physical healthcare monitoring forms are completed and

acted upon where relevant”

Patient experience (CQC Domain-Responsive) 95% of care plans will reflect the direct views of the patient. (Measured via audit/Lorenzo) Leads to be operations directors but will also need implementation leads to ensure action is taken and embedded in teams. “The Trust must ensure that all risk assessments and care plans are updated consistently

in line with multi-disciplinary reviews”

“in conjunction where appropriate with the service user or carer”

Clinical effectiveness (CQC Domain-Effective) All staff will report that they are aware of learning from incidents (Measured by mock CQC inspections/survey) Leads to be operations directors but will need managers to ensure action is taken and respond to information coming from the patient safety team. “The trust must have an effective system to share learning from incidents in order to

make changes to patients care and reduce the potential for harm to patients”


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4.0 Quality Implications

4.1 The quality account provides an important tool for the Trust to measure improvements in the safety, experience and effectiveness of our services. Board members should therefore be confident that the chosen priorities are aligned with the Trust’s quality priorities, expressed in a way that is achievable but challenging, properly resourced and clearly measurable

4.2 Due to the roll-over of quality priorities from 2013-14, there is an imperative that progress is made in 2014-15. A failure to do so will mean that opportunities to improve quality for service users and carers will be missed.

5.0 Risks / Mitigation in Relation to the Trust Objectives

5.1 As noted above, a failure to deliver the quality priorities will have a negative impact on the reputation of the Trust and the Trust aim to “improve our focus on quality”

Commissioners in response to the Quality Account published in June 2014, commented on the Trust failure to deliver some of the quality priorities and the governors have also recently raised concern about a lack of progress.

The risk can be mitigated through a determined focus on the objectives in the final months of the financial year, particularly with regard to priorities 2, 4, 7 and 8.

6.0 Recommendations

6.1 The board is asked to approve the suggested priorities for 2015-16.

Sue Barrett Head of Governance

Background Papers / Information Appendix 1

Re

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ns fo

r n

on

-atte

nd

an

ce:

A =

Asle

ep

C =

Co

mm

un

ity L

ea

ve

M =

In

a m

ee

tin

g

PI

= P

hysic

al Illn

ess

SC

= S

essio

n C

lash

SL

= S

taffin

g le

ve

ls

DM

H =

De

teri

ora

tio

n in

Me

nta

l H

ea

lth

S =

Se

clu

sio

n

O=

Oth

er

– P

lea

se

Sp

ecify

Ap

pen

dix

1

Pa

tie

nt

Initia

ls:

Ward

:

Da

te:

Se

ssio

n O

ffe

red

: A

tte

nd

ed

Y o

r N

R

ea

so

n if

did

no

t a

tten

d:

(see

Ke

y)

Sta

ff I

nitia

ls

Off

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Board of Directors, 26th February

2015 Quality Improvement Plan Version 1.0

Author: Jane Sayer Department: Nursing and Governance

Page 1 of 2 Date produced: 12th February

2015 Retention period: 30 years



Title of Report: Quality Improvement Plan



Author: Jane Sayer, Director of Nursing and Quality

Director: Jane Sayer, Director of Nursing and Quality

Executive Summary:

This report outlines the process by which implementation of the actions from the recent Care Quality Commission and Foresight Partnership reviews will be monitored. The Board is asked to note the content of the Quality Improvement Plan, assess if the suggested processes for monitoring progress on implementation are sufficiently rigorous, and agree the escalation process to the Board. It is vital that the Board retains oversight of the delivery of the Quality Improvement Plan and directs action to mitigate risks if required, as successful delivery of the actions impacts on quality of services.

1.0 Report Contents

1.1 Background

1.2 Implementation and monitoring

2.0 Background

2.1 The comprehensive inspection of Trust services by the Care Quality Commission (CQC) was published on 3rd February 2015. A number of actions were identified in the report as ‘must dos’, with other issues identified as ‘should dos’. In addition, an action plan was in place to address the concerns raised by the CQC in their letter of 31st October 2014. The Trust Board had also developed a plan in response to the Foresight Review of September 2014, implementation of which was underway at the time of the CQC inspection.

2.2 Rather than hold a number of action plans, it has been decided to combine all actions in response to the CQC and Foresight Partnership reports into one Quality Improvement Plan (attached).


F Item: 15.28iii

Board of Directors, 26th February

2015 Quality Improvement Plan Version 1.0

Author: Jane Sayer Department: Nursing and Governance



3.0 Implementation and Monitoring

3.1 The implementation of the Quality Improvement Plan has commenced, and a number of actions are already completed. Implementation will continue as planned and assurance evidence will be collated centrally. Actions will be identified as Trustwide, locality or service-based, and assurance will be sought at the relevant level.

3.2 The central plan will be held by the Governance Department, who will collate evidence and update regularly. The plan will be delivered locally through Locality Governance Groups.

3.2.1 Monthly monitoring of progress on the actions will be undertaken by the Executive Group. Monthly escalation reports will be provided to the Quality Governance Committee and bi-monthly to the Board of Directors.

3.2.2 Mock CQC visits will commence in March 2015, with a focus on the areas of concern identified by the CQC, and incorporating all core standards. These visits will be led by senior governance and nursing staff, and will involve CCGs, a small group of governors and service users and carers. The findings from these visits will contribute to assurance on delivery of the plan, and gaps in assurance will be discussed with Locality Managers, and escalated to Performance Review Groups if required.

3.3 In addition to delivering specific actions, it will be important to check that we are addressing quality improvement and creating a culture of improvement rather than just signing off completed actions. It will be the role of the Quality Governance Committee to focus on this aspect, as agreed at the Quality Workshop held in December 2014.

4.0 Risks / mitigation in relation to the Trust objectives

4.1 Delivery of actions to improve quality of Trust services is at the core of the Trust’s objectives. Any barrier to implementation of the actions must be identified and addressed in order to progress improvement. Regular oversight of progress by the Board of Directors through the Quality Governance Committee and the Executives’ group will identify and remedy any barriers to quality improvement.

5.0 Recommendations

5.1 It is recommended that the Trust Board approves the Quality Improvement Plan, the implementation and monitoring arrangements, and its role in owning and overseeing quality improvement.

Dr Jane Sayer Director of Nursing and Quality

Background Papers / Information - Quality Improvement Plan

Version 1.2 18/02/2015

CQC Domain or

Regulation

Actions to be taken Accountabilities &

Responsibilities - Exec

Lead

Accountabilities &

Responsibilities - Delivery

Lead

Milestones &

Timescales

Actual Outcomes Sustainability

Risk register ref

Assurance Monitoring

Committee/

Group

Progress

(RAGB

rating)

Date

Completed

Safe, Effective,

Caring, Responsive,

Well-led

Plans to prevent reoccurrence/ make

improvements

Who is going to ensure

improvements are made?

Who is going to deliver

them?

These could be staged

or final end point and

need to be realistic.

(not 'ongoing')

Have the actions been completed

and how can this be

demonstrated?

E.g. % of staff trained has

increase to %

Are the actions / improvements

sustainable? (Consider CIPs)

e.g. Yes - once guidelines are fit

for purpose there will be

capacity in mandatory training

for updates

How will we be assured

the actions deliver

improvements and are

sustainable?

E.g. Annual clinical

audit programme or

monthly metrics

Strategic/

operational

Risk register 1145 Mock CQC audits Quality

governance

committee

(QGC)

Locality managers

Service managers

End March 2015 Minutes of relevant meetings will

be available

Spotchecks will be implemented

to ensure staff have received the

information

Minutes of meetings

Spotchecks

Local

governance

group (LGG)

Locality managers

Service managers

End March 2015 All relevant staff will report that

debriefing has taken place

following a serious incident.

Logs will demonstrate that all

staff have had the opportunity to

attend debriefing

Evidence from

attendance log

LGG

Michael Lozano We will know by:

Reduction in the number of

recommendations that are

repeated across Serious Incidents

and complaints, checking with

frontline staff that they are able

to described their learning from

incidents in their own and other

areas.

NSFT: Our Quality Improvement Plan

1. The trust will

have an effective

system to share

learning from

incidents in order to

make changes to

patients care and

reduce the potential

for harm to

patients.

The Trust currently has a system to

provide feedback and learning from

incidents which includes

Patient safety newsletter

patient safety group meeting

Nurse leadership forum.

In addition the following are planned at

corporate level-

Tips booklet for managers

Increase frequency of pt safety

newsletter to bi monthly

E bulletin for managers

Improvements to the intranet page

Consider other media

Locality managers must ensure that

processes are in place to disseminate this

information to all staff via staff meetings,

bulletin boards, availability of staff

meeting minutes

Debriefing sessions must take place for all

staff in accordance with policy Q11

Serious Incidents

Staff will invited to attend debriefing

sessions

Managers will maintain a log to identify

attendees or reason for non attendance.

Log to be developed and included in

policy

End April 2015Jane Sayer/ Director of

Nursing

Debbie White-Alison

Armstrong/

Operations directors

Att Fi - Action plan 18 02 15 inc corp gov

Locality managers

Service managers

End March 2015 Minutes of relevant meetings will

be available

Spotchecks will be implemented

to ensure staff have received the

information

Minutes of meetings

Spotchecks

LGG

2.1 The current management of

medicines policy is being reviewed by the

drug and therapeutics committee.

2.2 Locality managers must ensure that

staff are aware of the medicines policy

C112 and that they adhere to the policy

A simple monitoring checklist for the

storage of medication will be developed

as part of this process

2.3 Ward paharmacists will check that

temperatures are recorded and action

taken where required

2.4 Weekly matrons audit will check that

medication is prescribed and

administered in accordance with policy

Where breaches are found these will be

raised to the team leader/manager and

immediate action taken.

Any persistent breaches of the policy will

be dealt with as part of the performance

management process

Dr Solomka/medical

director

Jane Sayer/DoN

Esther Johnston 01/04/2015

July 2015

2.1 Simple operational

procedures will be in place

2.2 Managers and team leaders

will ensure that all staff keep

updated with policy

2.3 ward pharmacists will check

that temperatures are recorded

and actions taken where

necessary

2.4 Matrons will undertake

spotchecks of medicine cards on a

weekly basis

Ward pharmacists already visit

the wards regularly

Monitoring boooks will

evidence that checks

have taken place

Matrons Audit

Drug and

therapeutics

committee

Matrons audit will

demonstrate

compliance

Mock inspections will

demonstrate

compliance

Jane sayer Dawn Collins

2. The trustwillt

ensure that

medicines

prescribed to

patients who use

the service are

stored,

administered,

recorded and

disposed of safely.


processes are in place to ensure all staff

receive feedback from complaints via

staff meetings, bulletin boards and

availability of staff meeting minutes

Competency checks for registered nurses

in medicines administration will be

implemented

RN's will be signed off as

competent

Jul-15


The Trust maintenance department has a

service level agreement which sets out

required response times . Response times

are calculated using a software

programme and are based on level of

risk.

An emergency scenario would receive an

immediate response and many situations

are completed on the day.

Leigh Howlett/ Director of

strategy and resources

Mark Kittle

Richard Bloom

Process in place response times are monitored Process is already in place Compliance with SLA

monitored and

statistics produced

QGC

the wards at the Julian Hospital will be

reviewed to ensure they are as dementia

friendly as possible and Blickling Ward

(dementia assessment) will move to

Beach ward at Hammerton Court

review the accomodation on the

remaining ward to utilise the additional

space.



Mark Kittle 30/04/2015 Blickling ward will move to a new

environment specifically designed

for the care of people with

dementia

Move will take place Trust board

The environment at Walker Close will be

reviewed to ensure that disturbed

patients are managed appropriately.



Kae Donnellan service

manager

review to take place

leading to action plan.

Feb 2015

The review will identify what

action is required to ensure

disturbed patients are managed

in an appropriate environment

This review will identify the

actions required

QGC

3. The trust will

ensure that action is

taken so that the

environment does

not increase the

risks to patients’

safety.


4. The trust will

ensure that action is

taken to remove

identified ligature

risks and to mitigate

where there are

poor lines of sight.

4.1 The Trust has a plan to undertake

annual ligature audits and to produce

an action plan to remove ligatures.

Where ligatures cannot be eliminated

immediately, this is known to the

ward staff and actions taken to

mitigate the risk- team leaders to

ensure that all staff are aware and

that ligatures and mitigating actions

are discussed at ward staff meetings

4.2 Ligature action plan in place

All staff aware of the ligature action

plan and the need to take mitigating

action

4.3 Each ward area will undertake an

assessment to identify lines of sight

Where poor lines of sight are

identified and action plan or plans for

mitigation will be put in place.



Service managers

team leaders

4.1 March 2015 4.1 All wards have a ligature audit

and the results of the audit are

known to staff

4.2 A ligature action plan is in

place where required and all staff

are aware of this

4.3 All wards will have an

assessment of lines of sight in

place and this will be shared with

all staff. An action plan will be in

place to improve lines of sight or

mitigate the risk.

Risk 1136 and 928 QGC

Personal alarms will be ordered and a

stock retained to ensure alarms are

always available

Matrons Alarms ordered and in place.

Process implemented to ensure

that alarms are not removed from

the wards or are replaced if

necessary Dec-14

The Trust policy Q23 health and

safety states that annual checks will

be made by the risk management

team and any actions required

identified.


the assessments are completed and

actions followed up.

Jane Sayer/DoN

Operations directors/

Debbie White, Alison

Armstrong

Risk manager

Locality managers

Service managers

Feb-15 All areas will have a H&S check

Action plan to be discussed at

locality governance group

Item is already on LGG agenda,

business partners to ensure that

it is discussed

Evidence of check

available

Minutes of LGG

QGC

Trust policy C46 CPR states that

checks must be made and provides a

checklist.


checks are carried out in accordance

with policy

Operations directors/


Armstrong

Locality managers

service managers

Mar-15 Checklist will be available to

evidence that checks have taken

place

This will be added to the

matrons walk round schedule

and to the mock compliance visit

checklist

Matrons will undertake

regular checks

Mock compliance visits

will check that this has

happened.

QGC

5. The trust will

ensure there are

enough personal

alarms for staff and

visitors and carry

out and

document regular

checks of

emergency

equipment.


A review of the estate will be undertaken

and proposals to remedy any issues

drawn up.

Female lounges on Poppy/Avocet- the

provision of lounges will be discussed

with service users to identify their

preferences. When this is known a plan

for implementation will be drawn up


Strategy and resource

Paula Clarke Apr-15 Female only lounge to be

provided in accordance with

service users preferences

Evidence of service

user involvement

QGC

Southgate ward- seclusion accessed via

female corridor.

Process in place to manage privacy and

dignity

Mike Seaman

Bedroom on Sandringham Ward- To be

formally decommissioned

Micki Munro Bedroom to be decommissioned

Review of seclusion areas within the Trust

to take place and plans for improvements

developed

Leigh Howlett/Director of

strategy and resource

review to take place

leading to further

action plan

review by March 2015

Further action plan to

be determined

Review of seclusion facilities

across the Trust available

Action plan available

Review document

Action plan available

Exec team

6. The trust will

ensure that all

mixed sex

accommodation

meets guidance and

promotes safety

and dignity.

7. The trust will

ensure that

seclusion facilities

are safe

and appropriate and

that seclusion and

restraint are


7.1 Review policy to ensure that all

guidance is included as required. This will

include liaison with other Trusts for

clarity.

7.2 Seclusion that lasts in excess of 48

hours will be classified as long term

segregation and reported to the Director

of Nursing and Medical Director

7.3Undertake monthly review of

seclusion data and governance team to

work with localities to ensure all staff are

aware of the requirements and

definitions.

7.4 Training package being developed

following the changes to the Code of

Practice

7.5 Ward teams to work with governance

to identify areas of poor performance and

take action to improve.

7.6 The Trust will implement the

recommendations in "Positive and

Proactive Care" and develop a restrictive

practice reduction plan

7.1 Jane Sayer/DoN

7.2 Jane Sayer/Bohdan

Solomka

7.3 Jane Sayer/DoN

7.4 Jane Sayer/DoN

7.5Operations directors/


Armstrong

7.6 Jane Sayer/DoN

7.1 Sue Barrett

7.4 Michael Lozano

7.5 Locality and service

managers

7.6 Michelle Allott

7.1 28th february 2015

7.2 Direction in place

7.3 In place and

ongoing

7.4 31st march 2015

7.5 Ongoing

7.6 Milestones as per

schedule

Completion 2016

7.1 Policy will meet all National

criteria

7.2 Everyone secluded for 48

hours will be reviewed

7.3 Evidence will show that pts

are managed in accordance with

best practice

7.4 All relevant staff will

undertake training

7.5 Evidence will show that

patients are managed in

accordance with best practice

7.6 Recommendations will be

implemented

Risk 1169 Policy in place

Evidence of review in

patient record

Staff training records

Reduction in prone

restraint

QGC

Action will be taken to address 'restrictive

and punitive practice'

-Implement formulation driven care

-Review of induction training

-Individualised care planning

-service user engagement

Enhanced pre admission assessment of

need

Debbie White/Operations

director

Karen Clements

8. The trust will

ensure there are

sufficient staff at all

times to provide

care to meet

patients’ needs.

The Trust has implemented the safe

staffing guidance and is actively recruiting

to all posts.

Where vacancies exist, NHSP and agency

staff are used

Activities take place as planned

Patient leave is not cancelled due

to staff shortages

All patient care needs are met

Numerous entries to specific

teams on risk register

Ward rostas OD and

Workforce

Trust board

managed within the

safeguards of

national guidance

and the MHA Code

of Practice.

Debbie White

Alison

Armstrong/operations

director


The implementation of Health roster will

enable the Trust to monitor staffing in

real time and move resources to reflect

need

Locality and service

managers

Inpatient wards

complete by 31st

October 2015

Community teams

complete by

November 2016

Wards will be staffed according to

the safer staffing guidelines and

staff moved to ensure optimum

availability

Action plans and board

reports

Staff rostas

Additional funding has been identified to

provide 12 additional band 6 care

coordinator posts and 5 band 4 support

worker posts

Locality managers

service managers

Staff will be in post

Unallocated will be reduced

Data will demonstrate

reduction in

unallocated cases

The Trust is working with the third sector

to provide additional support services to

maintain people in their own homes.

Policies to be reviewedand any changes

made to reflect the needs of specific

groups

All staff should notify the governance

dept if the policy does not reflect their

working practice due to changes in

service

reminder to be communicated via staff

bulletin

1.DoN Jane Sayer Sue Barrett 31st March 2015 Lone worker policy will be robust

and relevant to all teams across

the Trust

Evidence of policy

Lone worker policy in place-Q17

Locality managers must ensure that all

staff adhere to policy

Debbie White

Alison Armstrong/

operations directors


managers

May-15 Policy can be amended if required

due to changes in practice

Mock compliance

checks will identify

compliance

Thurne ward assesment model to be

developed

Debbie White

Alison Armstrong/


John Devenney Mar-15 10 bedded ward opened to

perform an assessment and

discharge function

risk 1062 Trust board

There will be a clear pathway in

place for 24 hour access to

services. This may be provided by

specialist teams or by access and

support from other

teams/services

services to be evaluated and

funding continued if service

considered to be beneficial to

improve patient care

9. The trust will

ensure that there

are robust policies

and procedures that

keep staff and

patients safe in the

community.

10. The trust will

ensure that people

receive the right

care at the right

time by placing

them in suitable

placements that

meet their needs

and giving

them access to 24

Work with CCG's to develop a model for

the provision of DIST and CAMHS out of

hours crisis response.

All staff to be aware that where

appropriate other services can be utilised

eg social care services and specialist

Jane Sayer/DoN

Operations Directors/


Armstrong


managers

QGC

West Norfolk MIND project 40 hours per

week

Central Norfolk Julian Support 80 hours

week

Stonham Homegroup 4wte support

coordinators in central CRHT

Gary Hazelden Services in place, to be

reviewed by April 2015

Community service users are

supported to remain in their own

homes

Reports

Senior

operational

team


10A The trust will

review it's

procedures for

admitting young

people to services

out of area

placement

arrangements

A procedure has been developed in

Suffolk in conjunction with

commissioners.

Staff have been made aware of the

procedure and a monitoring system

introduced by the clinical lead for the

youth pathway

Alison

Armstrong/Operations

director

Paul Cathmoir In Place Implementation of a system that

can identify when a young person

is placed out of area, ensuring

continuity of care and clarity for

commissioners

Procedure available LGG Feb-15

Currently in place

11.1-12th June 2015

11.2- Central

implementation

March 2015

11.1 Reports and action

plans

11.2 FACT model can

be demonstrated in

practice

teams/services

Patients are able to access

suitable placements.

Risk 103311.1- Simon Gatehouse

11.2- Vanessa Wragg

(West)

Peter King (Central)

11.1 Meeting with GP's to

develop a collaborative model

new model implemented by June

2015

11.1-Review of the access and assessment

function with a plan to deploy staff into

community teams, produced

collaboratively with GP's

11.2- Introduction of the Flexible

11. The trust will

review the

unallocated cases in

community services

and ensure that

hour crisis teams.eg social care services and specialist

advice available for younger people or

older adults within the adult teams.

Alternative to admission places are

utilised for people who do not need

access to a hospital bed but may need

time away from the home environment

Ashcroft 4 decant beds

West Norfolk 2 beds

Central Norfolk 2 Beds

GTY&W 3 beds

Gary Hazelden

Operations

director/Debbie White

Trust board


Organogram in place

Staff are able to describe the

relationship between teams and

the process for moving service

users between teams.

Organogram

Staff will demonstrate

awareness at mock

inspections

SGCPaula Clarke

Veno Sunghuttee

11.3.1 End April 2015

11.3.2 End July 2015

11.3.3 End October

2015

11.4- Commenced

26/1/15

11.5 currently being

recruited

Aug-15

practice

11.3 Model is in place,

reports

11.4 Crisis line is in

place and active/

reports

11.5 Staff records/

unallocated cases data

11.3- Clare Lussignea

11.4- Del Mitchell

11.5 service managers

11.2 FACT to be introduced to the

final 2 localities in the Trust that

have not already implemented

11.3 Implementation of the

Waves model as part of a

personality disorder strategy

11.4 Crisis line in Norfolk in

placeand evaluated

11.5 Staff in post

11.2- Introduction of the Flexible

assertive community treatment (FACT)

model to localities that have not yet

implemented (Central and West Norfolk)

11.3- Introduction of the Waves model

for service users with a personality

disorder

=identify funding as part of budget

setting

=identify lead person and third sector

partner

=Work together to develop

implementation plan, learning lessons

from Suffolk pilot

=further steps to be identified following

implementation plan

11.4- Crisis support telephone line in

Norfolk

telephone service to be evaluated and

possible business case presented to

Suffolk for funding in Suffolk localities.

11.5- Investment in community staffing

funding agreed for an additional 12 band

6 nurses and 5 band 4 nurses

and ensure that

there is an

allocated care

coordinator

12. The trust will

ensure that a

‘standard operating

procedure’ is

introduced to

manage effectively

the

interface between

the various

community services

provided.

As part of Lorenzo implementation a

Standard operating procedure is in place

Work is ongoing to embed the procedure

across clinical services

This will include the production of an

organogram demonstrating the

relationships between teams for easy

reference

Debbie White

Alison Armstrong



Debbie White

Alison

Armstrong/operations

directors


managers

Dices Training march

2015

Audit will demonstrate that:

Service users are engaged in the

process

Risk assessments are completed

involving the service user and

using the Trust tool

Care plans are written involving

the service user and reflecting

their views

Risk assessments and care plans

are reviewed in the timeframes

set out in policy or as needs

change.

Quarterly audit

currently provides data

demonstrating

compliance with this

requirement.

The implementation of

Lorenzo in April 2015

will enable data to be

accessed more

frequently to ensure

that progress is made

in a timely way. This

data will be available

monthly

PRG

14. Outcome

measurement tools

will be used to

assess

appropriateness and

effectiveness of care

and treatment

provided

The wards for people with a learning

disability will engage in the national

development of outcomes for this client

group and implement them as

appropriate.

Currently in the absence of validated

tools, outcomes are set with the

involvement of the service user/carer on

an individualised basis and these can then

be measured

Alison


director

Paula Clarke Outcome tools will be

implemented in line with national

guidnace

Staff will be able to

discuss and

demonstrate the use of

the tools.

QGC

PRGAudit will show that service users

have been involved in the writing

of the care plan.

Audit will show that care plans

have been updated and reviewed

according to policy

31st may 2015

All patients will have a physical

health assessment

All patients with a physical health

issue will have this included in

their care plan

Audit

Training records

QGCAll staff must ensure that patients receive

a physical health check on admission

Where the patient is too unwell or

refuses, this should be documented in the

health record and further attempts


managers

Debbie White/Alison

Armstrong-operations

directors

30th June 201515. The Trust will

ensure that all

physical healthcare

monitoring forms

are completed and


managers

13. The trust will

ensure that all risk

assessments and

care plans are

updated consistently

in line with

multidisciplinary

reviews.

Debbie White/Alison

Armstrong-operations

directors

All staff should ensure they follow the

CPA policy C98

This policy requires service users to be

involved in the planning of their care and

assessments of risk

Risk assessments and care plans must be

updated regularly according to policy

Risk assessment revised for Lorenzo-

COMPLETE

DICES training booked to commence in

March 2015

As above


Sep-15 All staff will complete training Risk 1162 Data produced and

provided to Trust board

Trust board

Oct-15 All patients will have a record of

their capacity with regard to

specific decision making

Audit will demonstrate

that capacity

assessments have been

completed

QGC

All staff should complete stat/man

training as set out by their manager in

their training template

Staff will book to attend training and be

supported to attend by managers

Stat/man training compliance will be

discussed at monthly supervision to

identify where training compliance is not

met

Staff will be supported by managers to

ensure they have time to attend training


managers

Sep-15 All staff will know which training

they are required to undertake.

Staff will book training

Compliance with stat/man

training will improve

Risk 1115

Risk 1056

Training data is

presented to the Board

Trust board

their care plan

Staff will have attended

physiological workbook training


managers

health record and further attempts

offerred.

The relevant physical health monitoring

record must be completed in full

Where physical health problems are

identified, these should be addressed and

the relevant actions taken.

All relevant staff must undertake

physiological workbook training

16. The trust will

carry out

assessments of

capacity and

record these in the

care records

17. The trust will

ensure all staff

including bank and

agency staff have

completed

statutory,

mandatory and

where relevant

specialist training

acted upon where

relevant

Debbie White Alison


directors

Debbie White/Alison

Armstrong- Operations

directors

All staff must undertake MCA/DOLS

training to ensure they understand the

importance of establishing capacity

Capacity must be recorded in the patient

notes


TEMPORARY STAFF

The Trust only uses temporary staff

procured via the East of England

procurement hub. This system ensures

that only agencies who have staff trained

in the statman requirements are

procured and utilised.

The EoE hub also maintains responsibility

for ongoing checks

Random checks on staff will be

introduced

Jane Parris


managers


managers

18.1 New policy in place

18.2 All staff records show that

they have had supervision

18.3 All staff records show that

they have had an annual appraisal

This is currently Trust policy and

should be in place.

Risk 1170

Data will provide

evidence of compliance

QGC

Add to matrons walk

round

Mock compliance

inspection

QGCWritten information in easy read

or foreign language formats will

be made available for service

users.

Clinical effectiveness group will

consider the need to produce

OD and

workforce

cttee

Trust policy Q14 identifies how Trust

information should be produced.

Individual services should identify the

specific needs of their service users and

ensure that appropriate information is

Trust policy Q16b identifies that all staff

should have clinical supervision and an

annual appraisal

18.1 Supervision policy to be reviewed

18.2 Locality managers should ensure

that all staff including regular

NHSP/agency staff receive clinical

supervision in accordance with policy

18.3 Locality managers should ensure

that all staff receive an annual appraisal

in accordance with policy

17A The Trust will

review its provision

of duty and crisis

services for young

people to ensure

that staff

underatking

assessments have

the appropriate

skills to ensure this

is carried out to an

appropriate

standard

19. The trust will

ensure that they

provide people with

the right

information about

18. The Trust will

ensure all staff

receive regular

supervision and

annual appraisals 18.1 DoN/ Jane sayer

18.2 Operations

directors/ Debbie White

Alison Armstrong

18.3 Operations directors

Debbie White

Alison Armstrong/


01/09/2015Locality and service

managers

Staff will be supported to

undertake training relevant to

their current needs and

development for future roles.

All appraisals

completed

All training needs met

SPECIALIST TRAINING

Specialist training will be identified by all

staff at appraisal

Staff will book training as agreed by their

manager

Where specific teams have training

needs, these will be discussed with the

training department and a training

package commissioned or other forms of

development identified.

Debbie White/Alison

Armstrong operations

directors

Jane Sayer/DoN


managers

Ongoing

April 2015


Mock compliance

inspection

QGCconsider the need to produce

documents in other formats when

the document is approved.

Information leaflets will be

reviewed in accordance with

service changes and published

dates

Law forum

All detention documentation will

be correct/lawful and available

for scrutiny

Trust Audit/

matrons audit

Monthly MHAA checks

will identify breaches

Reports to law forum

Law Forum

Section 17 documentation is

completed in full

Service users/carers and staff are

aware of the leave requirements.

Processes are currently in place

ensure that appropriate information is

made available

Individual services should regularly

review the information given to service

users to ensure it is up to date and

accurate. In accordance with Q14 all

documents should have a date of

publication

A leaflet will be produced that informs

service users and staff how to access

information in other languages or easy

read formats

=Sign off at readers panel

=Translation and easy read versions

developed

=Leaflets printed

=Distribute to all services

information about

services and that

this is in

the right format for

the individual.

20. The trust will

ensure that proper

procedures are

followed for

detention under the

Mental Health Act

and that the

required records

relating to patient's

detention are in

order.

21. The trust will

ensure that

arrangements for

patients

taking section 17

leave are clear for

their safety and

that of others.

The Trust has a robust system for

ensuring that detention records are in

order, monitored by the central MHA

team

Copies of documents are printed on

Green paper and sent to the ward for

filing

MHA adminstrators will undertake

monthly checks to ensure that all

paperwork is in place and filed correctly

Bi monthly monitoring report to law

forum and shared with managers for

action

Ward admin staff must ensure that

documents are filed correctly and the

current papers available.

Trust secretary/Robert

Nesbitt

Lynn Harvey

Ward managers

=Feb 15

=March 2015

=April 2015

=April 2015

Jun-15

Robert Nesbitt

Section 17 leave policy is in place

Responsible clinicians should ensure that

leave details are recorded in full on the

documentation

Matrons should check forms are

completed and return to RC if there are

omissions.

Patient leave status should be easily

available to all staff

MHA administrators to check

documentation

Medical director/Bohdan

Solomka


Nesbitt

Ward managers Jun-15


Leaflets available

Checked by MHAA

16th Feb

2015

Posters available

Add to Mock

compliance visits

checklist16th Feb

2015

24. The trust will

ensure that there

are systems in place

to monitor quality

and performance of

the teams

The trust has a structure of meetings

that reviews the quality and performance

of teams. This includes performance

review group, locality governance groups,

business meetings and the quality

governance committee

This structure will be enhanced by the

development of quality metrics

Jane Sayer/DoN Apr-15 A comprehensive dashboard of

quality metrics will be available to

all localities to inform their

discussions.

dashboard available

Evidence of actions

taken to improve

quality

QGC

Feb-15 Law forumLeaflets will contain the contact

details for CQC

Posters will be available on all

wards

Trust board

Trust Board

The Trust currently faces a number of

challenges with numerous patient record

systems. This is currently being replaced

by the Lorenzo system which will be

implemented from April 2015

This electronic system will ensure that

current records are available to all staff

across the Trust and old records will be

scanned in.

In the interim this is being addressed by

the medical records team

Director of strategy and

resource/Leigh Howlett

Dave Huggins 30th April 2015

Evidence of events and

attendance

Lorenzo will be available to all

Trust staff from April 2015

Lynn Harvey

Sue Barrett

The information leaflet given to detained

patients will be changed to include the

contact details for CQC

Posters advising how to contact the CQC

will be available on all wards

Medical director/Bodan

Solomka


Nesbitt

23. The trust will

review the delivery

of their vision and

values to ensure

they are understood

and owned by all

staff.

25. The trust will

review its

procedures for

maintaining

records, storage and

accessibility

including out of

hours provision.

22. The trust will

ensure that patients

who are

detained under the

Mental Health Act

have

information on how

to contact the CQC.

Risk 1163Sep-15Paul JohnsonExternal support to underpin review

April consultancy events with staff


resource/Leigh Howlett

Events to take place with staff

across the Trust

The outcomes of the events will

inform strategic development,

recruitment and appraisal


26. The Trust will

review their

engagement

processes for young

people, staff and

others for the

planning and

delivery of specialist

community mental

health services for

children and young

people across the

trust

"Hearing from Young People" event for

governors

Norfolk and Suffolk services to implement

a new forum specifically to look at

children family and young peoples service

needs and ensure this is clinically led

having a clear remit to communicate and

engage with staff.

Each locality to pursue their locality

management structures ensuring that

staff feel able to engage in governance

and quality issues.

Alison Armstrong/Debbie

White

Operations directors


managers

12/03/2015

DATE?

Ongoing

Event will take place

Forum will be in place and staff

will be able to communicate that

they have been kept

informed/involved

Staff will be able to state that

they have been engaged.

Poster available

Attendance list

Checks to be made as

part of mock

inspections

27. The Trust will

review their

engagement

processes for staff

and others for the

planning and

delivery of

Trustwide

services/specialised

eating disorder

services

AWAIT STATEMENT FROM ALISON Alison Armstrong/

operations director

28. The Trust will

ensure that there is

a clear admission

criteria for the

service

All wards will have an operational policy

or clear statement of admission criteria

Alison Armstrong

Debbie White/Operations

directors

service managers Jun-15 Admission criteria will be clearly

stated

Mock Inspections

Evidence to be

provided to

governance team

QGC


29. The Trust will

take steps to

address the low

morale of staff

29.1-Locality staff engagement and

wellbeing plans in place and monitored

monthly, including

Have your say days

29.2-Central Norfolk project to explore

engagement issues

29.3-Exec/non exec and senior

management visits to all sites

29.4- Healthy and engaged worker

project including

Healthy worker courses

29.5-Talent management and

Leadership strategy

29.6 Introduction of an email box direct

to CEO


resource/leigh Howlett

29.1 Alison Thomas

29.2 Amy Eagle

29.3 Liz Keay

29.4 Alison Thomas

29.5 Paul Johnson

29.1 In place

29.2 Complete

29.3 Programme of

visits in place

29.4

29.5

29.6 Complete

An improvement in morale will be

evidenced by staff reporting that

they feel listened to and able to

contribute to Trust discussions.

Risk1164 Staff FFT results

Staff survey results

QGC

Trust board

30. The Trust will

ensure that all staff

working with

vulnerable adults

and children have a

DBS check

completed

All staff commencing work with the Trust

currently have a DBS check.

The Trust will explore the options for

undertaking regular DBS checks for all

staff in post

Locality managers will ensure that all staff

receive their checks in accordance with

agreed Trust process

DoN/Jane Sayer Sarah Ball Jul-15 All staff must have a current DBS

check before commencing in post.

A process for rechecking DBS will

be in place to ensure that checks

are undertaken at regular

intervals.

Staff Records OD&W

31. The trust will

ensure that patients

and staff are fully

informed about the

timeline for the

closure of the ward

and the new model

of care at Carlton

Court

The Trust should

communicate the

future of learning

disability services to

staff

Staff should be informed of the CCG plans

as soon as the information is available.

Staff meetings should include regular

updates on progress and minutes of

meetings should be available for any staff

not able to attend the meetings.

The Trust is currently awaiting the

outcome of discussions with the CCG's

An update will be sent to all staff

informing them of the current position

Further updates will then be sent as

appropriate or at 3 month intervals

Operations

director/Debbie White

Operations director/

Alison Armstrong


managers

End february 2015

End february 2015

All staff will be aware of the

plans for the transfer of

services

Minutes of meetings

Copy of communication

available

Trust Board


32. The Trust will

improve staff

understanding of

the governance

structures

32.1-Workshop to be held to explore the

relationships and future model

32.2-Implement business partner model

32.3-Standardised locality governance

agenda

32.4-Locality managers and clinical leads

to attend service governance committee

meeting

32.5-Masterclasses in nursing academy

32.6- reconfiguration of the matron

model and implementation of

development sessions

DoN/Jane Sayer 32.1Jane Sayer

32.2-Sue Barrett

32.3-Sue Barrett

32.4-Jane Sayer

32.5-Michelle Allott

32.6-Jane Sayer/Sue

Barrett

02/12/2014

1st january 2015

1st January 2015

January 2015

April 2015

July 2015

Staff will be able to articulate how

governance structures work in the

Trust, particularly in relation to

practice changes in their areas of

work.

Feedback from staff

will be sought.

Service

Governance

Committee

32.1-2nd Dec

2014

32.2 1st jan

2015

32.3- 1st jan

2015

32.4 1st jan

2015

32.5 1st Jan

2015

33. The Trust

should ensure they

review the out of

hours arrangements

with the

commissioners for

young adults age 14-

18

TO BE CLARIFIED WITH CQC AS NO DETAIL

IN THE REPORT MATCHES THIS

STATEMENT

Debbie White

Alison Armstrong/


34. The Trust will

improve staff

engagement as

many staff in mental

health community

teams felt

disconnected from

senior managers and

the leadership of the

Trust

34.1 Programme of exec team walk

rounds

34.2 April consultancy events

34.3 Central Norfolk engagement event

COMPLETE

34.4 Boardroom bulletin introduced

COMPLETE

34.5 Ask Michael email box to be

introduced

Directors 34.1 Liz keay

34.2 Paul Johnson

34.1 February 2015

34.2 September 2015

34.3 Complete

34.4 Complete

34.5 Complete

Community staff will identify

that they are involved and able

to contribute to the work of

the Trust.

Survey monkey Trust board


35. The Trust will

ensure that physical

healthcare needs

are monitored and

managed

Implementation of the physical health

strategy.

Physical health checks will be undertaken

for all inpatients, and community patients

will be supported to seek regular health

checks.

Reinforce the importance of physical

health at each intake of junior doctors

Trial of rethink document "My Physical

Health" in West Suffolk

Jane Sayer/DoN

Medical director/Bohdan

Solomka

Jane Sayer/DoN

Sara Fletcher


managers

Sara Fletcher

July 2015

Ongoing

April 2015

Physical health checks are

correctly recorded

Physical checks are completed

and necessary actions taken

Physical health issues are

included in the action plan

The tool will be utilised across the

Trust

Audit

Supervision records.

audit

audit

Availability of

evaluation report

The Physical

Health

Strategy Group

36. The Trust will

look at contingency

arrangements in the

autism diagnostic

service for Suffolk to

manage the build up

of the waiting list to

this service

There is currently nobody waiting

longer than the 15 week target

A contingency plan has been developed

Alison Armstrong Nettie Burns Apr-15 All people referred will be seen

within the 15 week waiting time

target

Waiting times data PRG

data provided

to

commissioners

37. The trust must

address the

identified

environmental

health and safety

concerns in the

health-based places

of safety.

1. Mariner House- The concerns are

known and a plan is in place.

Implementation of the plan is

currently awaiting the landlords

permission. The £305k budget

has been identified and planning

permission will be applied for

2. Visible entrances

3. Non frosted glass

4. Furniture

5. Anti barricade doors

Leigh Howlett Mark Kittle 1. The reception area will

meet the health and safety

needs of staff and service

users


38. The trust will

review the provision

of in-patient beds

to ensure that the

needs of the local

population are met

Finance director to discuss with

CCG's

10 bed unit to open (Thurne ward)

Alternative to admission provision is

available working with the third sector.

This includes in patient beds for

alternatives to admission and discharge

facilitation as well as additional support

in the community provided by third

sector organisations

Finance director/ Andrew

Hopkins


Debbie White

Gary Hazelden

March 2015

March 2015

In place

Decision to be made on the

number of in patient beds to

be available in each area

No further service users to be

placed out of area due to lack of

beds

Trust Board

39. The trust will

ensure that the

good example of

health-based place

of safety monitoring

information

seen at one unit is

used throughout this

service.

Associate director to ensure good

practice is shared as part of the

review of 136 placements

following the 'Safer Place to Be '

report


Debbie White

Veno SunghutteeJuly 2015

Good practice noted will be

implemented across the Trust

Acute service

Forum

40. The trust will

review the provision

of their single

bedded health

based place of

safety units in the

light

of the potential

demand for this

service.

Following the implementation of a

new team based with the police, the

data shows that the use of the 136

suites has decreased.

This data will continue to be

monitored and triangulated with police

data.

Following this monitoring a report will be

produced which will inform the TRust

about the need to appraoch

commissioners for further additional

suites.


Debbie White

Veno Sunghuttee Aug-15 A report will be produced to

demonstrate the use of the

suites and the requirements

for future provision

Report will be

available

Acute

services

forum

Corporate Governance Improvement Plan


Develop a lessons learnt document

relating to TSS and recent strategy

implementation from the

perspective of the Board.

What would we do differently?

Leigh Howlett Complete

Dec-14

Share Board 'lessons learnt' with

governors, service users / carers,

Senior management forum and

staff, external stakeholders

Leigh Howlett Feb-15

Away day to agree annual strategic

planning cycle and compelling

narrative

Leigh Howlett Complete

Jan-15

Resource plan

Realistic view on resourcing of the

strategy function

Leigh Howlett Nov-14

Reshape ToR of investment

committee to give robust oversight

of delivery of strategy

Leigh Howlett IC now integrated into Finance

cttee

Jan-15

Clarify and provide a rationale for the

operational model

-how is accountability held?

-What are the parameters of freedom

and accountability?

-Processes for locality interface

-Clinical leader accountability

-Management of medical staff and

alignment with work around AHP and

nurse leader roles

-Right balance of resources

--corporate versus locality

--in tandem with corp, reorganisation.

Michael Scott Dec-14 Model agreed

Implementation now in place

(Might want to say what that

is and when it will be complete)

development of locality staff to

support this model (via SMF)

-Ensuring that there are right people and

processes to manage effectively.

Michael Scott

refresh board reporting format to

include narrative, analysis

improvement actions and

trajectory to 'green'

Robert Nesbitt

Jan-15


Explore committee rationalisation Robert Nesbitt

Dec-14

refresh the Board and committee

cycle and the reporting arrangements

between committees and the board

to ensure that business is only done

once in the right place

Robert Nesbitt Apr-15

Refresh service governance terms

of reference and ensure that lead

clinicians within localities are

represented

Jane Sayer

Oct-14

Refresh locality performance review

process to ensure increased and

explicit focus on quality

-include focus on learning across

the Trust, peer to peer support and

challenge and asssurance

Jane sayer

Engage with staff, service users and

carers to build quality governance

arrangements at locality level that ensure

appropriate accountability at that level-

Make meaning of IMROC principles

Jane Sayer Workshop took place in

december 14

Dec-14

Dovetail with overall operating

model work in priority 2

Jane sayer

Consider rationalisation ofcttees

below service governance

Jane sayer Investment cttee and

communications cttee

disestablished

Check that risks to quality are aligned to

the refreshed BAF

Jane sayer

Nov-14Att Fi - Action plan 18 02 15 inc corp gov

Further facilitated board sesssion Gary Page Session has taken place with

further board development

priorities identified

do we add these to the plan?

Oct-14

refresh existing NED-ED role

descriptions- ensure that this

undrestanding is broadly shared

Robert Nesbitt Portfolios updated

review and refresh existing stake

holder engagement plan

-Existing 'health of relationships'

evaluation may be helpful

-active monitoring of relationships

-include the role of governors

-Systematic approachincluding

stakeholder register

-make use of NED networks and

experience as appropriate

Michael Scott Feb-15

Ensure that user/carer perspectives

at the heart of the process

Engagement strategy principles

agreed at Board Jan 15

Jan-15

Action incomplete within timeframe

Action on track for completion

Action complete

Action complete and signed off by Trust Board


Board of Directors - 26th February

2015 Month 10 Financial Performance Report

Version 1.0

Author: Adrian Brooke Department: Finance

Page 1 of 3 Date produced: 13th February 2015 Retention period: 30 years



Title of Report: 2014/15 Financial Performance Report (for the 10 month period ending 31st January 2015)



Author: Adrian Brooke – Business Accounting & Reporting Manager

Director: Andrew Hopkins – Director of Finance

Executive Summary:

The purpose of this report is to inform the Committee of the Trust’s financial performance for the period 1 April 2014 to 31 January 2015. Key headlines for the month include:

• A deficit in the month of £0.21m, increasing the year to date deficit at month 10 to £3.98m. The Trust has secured additional income in line with recovery plan expectations, so that a year-end deficit of £3.75m remains achievable.

• A reported Continuity of Service Risk Rating (COSRR) of 2 for January which is forecast to continue to the end of the year based on the financial recovery actions being addressed.

• Temporary staffing expenditure levels reduced in the month £1.95m (£2.10m December). The year to date expenditure now stands at £20.92m.

• The cash position is slightly ahead of plan by £0.4m as at the end of January. This favourable position however is set to turn adverse during March due to the current operating levels of the Trust, with a year-end forecast position anticipated to be £8.8m behind plan, at £12.6m.

• A reduction in the number of bed days for acute out of area (OOA) placements is once again reported in the month. Forecast assumptions have been revised as a result of this change and to account for the effect of the opening of the Assessment Ward.

• Year to date capital expenditure of £4.40m against a revised plan of £7.7m.


G Item: 15.28iv



Version 1.0



1.0 Financial Position

The following power-point document details the overall Trust Financial Performance

as at the end of January 2015. (Please see attached).

2.0 Risks

The forecast deficit is close to the threshold at which the COSRR would hit “1”. The

Trust has made some gains with additional income and in reducing temporary pay

and out of area spend, but there remains a significant risk that this threshold might

be breached in Month 12, if these indicators rise again over the next two months.

3.0 Recommendations

The Board is asked to review and note the report.

Adrian Brooke Business Accounting & Reporting Manager 13th February 2015



Version 1.0



Appendix 1

Actual PlanVariance

(adverse)Forecast Plan

Variance

(adverse)

Jan-15 Jan-15 Jan-15 Mar-15 Mar-15 Mar-15

£m YTD YTD YTD FY FY FY

Operating Income 175.6 170.6 5.0 211.0 204.3 6.8

Pay Costs (137.0) (130.9) (6.1) (164.7) (156.3) (8.4)

Drug Costs (3.1) (2.6) (0.5) (3.6) (3.1) (0.5)

Other Costs (29.9) (26.6) (3.3) (35.0) (31.5) (3.4)

EBITDA 5.6 10.5 (4.9) 7.8 13.3 (5.6)

Depreciation (5.5) (5.7) 0.3 (6.6) (6.9) 0.3

Net interest (0.8) (0.8) 0.0 (0.9) (1.0) 0.1

Other (3.3) (2.9) (0.4) (4.0) (3.5) (0.5)

(4.0) 1.0 (5.0) (3.7) 1.9 (5.6)

Exceptionals - - - - - -

Net surplus / (deficit) (4.0) 1.0 (5.0) (3.7) 1.9 (5.6)

EBITDA margin 3.2% 6.1% (3.0%) 3.7% 6.5% (2.8%)

Actual PlanVariance


Variance

(adverse)



Non-Currrent Assets 135.3 146.3 (11.0) 136.9 142.7 (5.8)

Current Assets 30.8 18.7 12.2 26.7 26.9 (0.1)

Current Liabilities (28.8) (22.6) (6.2) (27.1) (29.2) 2.1

Non-Current Liabilities (22.4) (23.2) 0.8 (21.4) (20.2) (1.2)

TOTAL ASSETS EMPLOYED 115.0 119.2 (4.3) 115.2 120.1 (4.9)

Public dividend capital 81.5 80.6 0.9 81.5 80.6 0.9

Retained Earnings (Accumulated Losses) 8.5 12.9 (4.5) 8.7 13.8 (5.2)

Revaluation reserve 25.0 25.7 (0.6) 25.0 25.7 (0.6)

Donated asset reserve - - - - - -

TOTAL FUNDS EMPLOYED 115.0 119.2 (4.3) 115.2 120.1 (4.9)

Actual PlanVariance


Variance

(adverse)



EBITDA 5.6 10.5 (4.9) 7.8 13.3 (5.6)

Change in working capital (3.1) 0.4 (3.5) (2.2) 3.9 (6.1)

Cashflow from operations 2.5 10.9 (8.4) 5.6 17.3 (11.7)

(3.8) (8.1) 4.3 (6.4) (4.9) (1.5)

Financing and other (3.3) (2.8) (0.5) (6.0) (5.1) (0.9)

Net cash inflow / (outflow) (4.6) (0.0) (4.6) (6.8) 7.3 (14.1)

Closing cash and cash equivalents 14.7 14.2 0.6 12.6 21.4 (8.8)

Net cash inflow / (outflow) from investing

activities

Statement of

Comprehensive Income

(SOCI)

Statement Of Financial

Position (SOFP)

Statement of Cashflow

(SOCF)

Financial Performance for the Period ending January

2015


Index

Slides 1 - Executive Summary

Slide 2 - Finance Dashboard

Slide 3 - Statement of Comprehensive Income (SOCI)

Slides 4 – 6 - Income – Clinical and Non Clinical

Slides 7 - 11 - Expenditure – Pay & Non Pay

Slide 12 - Capital

Slide 13 - Balance Sheet

Slide 14 - Cash flow

Slides 15 - COSRR

Executive Summary

The monthly deficit level improved this month against the forecast expectation. January

deficit was down to £0.21m pushing the YTD deficit to £3.98m. The YTD variance against

original Annual Plan is now adverse by £4.97m. The year-end forecast expectation has

been reduced further to £3.7m to reflect initiatives previously identified in terms of financial

recovery for the year-end and the improvement reported this month.

The improved deficit position reported this month is predominantly due to the advanced

release of Lorenzo Initiative income (0.2m) in this financial year, together with reduced Pay

costs due to lack of recruitment to vacancies across the Trust and the delay in the opening

of the new Assessment Ward.

As a result of the YTD position the Trust reports a COSRR (Continuity of Service Risk Rating) of 2

again this month. This rating of 2 is expected to remain through to year end, in part due to

the above and the improved cash position forecast.

A reduction in the Acute out of area placements is reported again this month with the new

assessment ward due to open in the coming weeks that is hoped will drive further

reductions in this area. These assumptions have been factored into the revised forecast

position.

Temporary staffing levels reduced slightly this month, bringing monthly expenditure below

the £2m mark.

Cash forecast position has improved significantly this month (see Cash-flow and Finance

Dashboard pages).

1

Finance Dashboard

3

Statement Of Comprehensive Income (SOCI)

4

Statement of Comprehensive Income (SOCI)-Year to date Full Year SOCI

Annual Actual Variance to Annual Forecast Variance

Plan Annual Plan Plan

£'000 £'000 £'000 £'000 £'000 £'000

Operating Income (170,589) (175,567) 4,978 (204,251) (211,048) 6,797

Pay Costs 130,892 137,023 (6,132) 156,306 164,708 (8,402)

Drug Costs 2,592 3,057 (465) 3,097 3,604 (506)

Other Costs 26,630 29,896 (3,266) 31,524 34,970 (3,446)

EBITDA 10,476 5,591 (4,884) 13,324 7,766 (5,557)

Depreciation 5,731 5,480 251 6,928 6,604 324

Net interest 3,745 4,087 (341) 4,495 4,911 (416)

Other

Exceptionals

Net surplus / (deficit) 999 (3,975) (4,975) 1,901 (3,749) (5,649)

EBITDA margin 6% 3% 7% 4%

Income – Summary

7

Year to date Income position Full Year Income position

Annual Actual Variance to Annual Forecast Variance

Plan Annual Plan Plan

£'000 £'000 £'000 £'000 £'000 £'000

Block contracts 145,723 145,695 (28) 174,868 174,999 131

Clinical Partnerships 10,266 9,890 (376) 11,863 11,540 (323)

Clinical income-Secondary Commissioning 1,852 1,865 13 2,222 2,238 16

Other clinical income 3,365 4,320 956 4,038 5,219 1,182

NHS Mental Health activity Income, Total 161,206 161,770 565 192,991 193,996 1,005

Research and Development 744 1,538 795 892 1,746 854

Education and Training 2,794 2,940 146 3,353 3,538 186

Misc. Other Operating 5,846 9,319 3,473 7,015 11,767 4,752

Other Operating income, Total 9,383 13,797 4,414 11,260 17,052 5,792

Operating Income, Total 170,589 175,567 4,978 204,251 211,048 6,797

Income – Clinical

Block Contracts – (£28k) lower than plan:

• (£397k) under-occupancy provision for CAMHS Tier 4 and Secure Services,

• (£585k) CQUIN underachievement provision, and (£151k) budget phasing

• £463k of Additional Observations for Suffolk CCG’s,

• £336k Additional Income for QEH Liaison and winter pressures

• £306k of other contract variations and budget phasing.

Clinical Partnerships – (£376k) lower than plan:

• (£170k) reduction in the Section 75 NCC and NRP contracts, and

• (£69k) reclassifying of NCA monies to a block contract with Cambridge & Peterborough CCG

• (£172k) re-phasing of NRP innovation monies. The latter will be recovered at the end of the year and

• £35k of other contract movement.

Other Clinical Income - £968k increase to plan: key contributors are:

• £562k agreed contracts over original Annual Plan assumptions

• £394k – Other contract variations including Norfolk Constabulary and System Wide CQUIN

8

Income – Non Clinical income The graph below shows the breakdown of miscellaneous other income against plan.

In bringing forward the utilisation of Lorenzo income from that originally planned, the

programme has recognised a further £200k receipt during January.

Deferred/other income variance continues to be due to the conservative assumptions

when setting the Annual Plan. All income is matched with pay and non pay expenditure.

ICT trading accounts also reflect increased activity of £840k against original planned

assumptions to which a profit of £128k has been achieved against the total level of

turnover generated in the year.

Estates trading income is below plan by £518k YTD due to lost contracts. Where this

applies, there are matching pay and non pay favourable variances to plan with no loss to

the Trust overall.

11

Expenditure – Summary Vacancy levels continue to remain high across the Trust. Whilst improvements had been

made in the last two months due to clinical and admin roles across the Trust being

recruited to, headcount levels remained static during January. The overall vacancy figure

now stand at 448 WTE’s. As previously reported this vacancy level does not take account

of any overtime or additional hours that are regularly worked and it is planned to capture

these for the new financial year so as to show the true level of vacant hours. It is

anticipated at this stage that this will not be material.

Temporary pay expenditure continues to exceed the funding available from the vacant roles

(see graphical presentation of forecast Pay position overleaf). Total temporary pay

expenditure has reduced slightly this month to £1.95m (£2.10m December), pushing up

YTD costs to £20.92m.

A decrease in bed days and costs for Out of Area Placements is reported once again this

month, which has prompted a further improved forecast position in this area as a result.

Other non pay expenditure categories remain broadly in line against original plan, with the

continued exception of Drugs, Public Dividend Capital and Depreciation (see non-pay

section).

14

Expenditure – PayAgainst original plan, Pay costs report an

adverse variance YTD of £6.13m.

Of the variance, total medical related roles

overspend accounts for £1.18m. A continual

review of the personnel and respective

vacancies is being carried out however

recruitment is proving to be particularly

difficult. As a result this area will remain over

spent with forecast overspend around

£1.5m. Without recruitment, this cost

pressure will continue into the next financial

year.

The chart shows total spend by pay type with

a forecast level of expenditure.

The forecast position accounts for the latest

plan and additional spend relating to the new

Assessment Ward.

The bank and agency ratio (excluding

medical locum agency) improved slightly this

month to 44%/56% respectively, with

increased spend on Bank staff against the

drop reported last month, coupled with

reduced Agency costs.

Non-trading account agency costs within

ICT reduced this month as the department

looks to further manage expenditure.

Agency staffing levels remain high however

to cover vacancies, infrastructure projects

and Service desk requirements. Underlying

spend in these areas for the month was

down to £0.11m. YTD Agency costs on

these non-trading accounts now stands at

£1.53m.

15

Expenditure – Non Pay 1

The YTD adverse position for Drugs increased again this month, to £0.47m, as further prior

month costs materialise together with an increase in the monthly expenditure levels.

Forecast expectation is £0.5m overspend against original plan. Of this, £0.2m is due to the

non-achievement against the original CIP target, with a remaining forecast overspend driven

by prior year costs not having been accounted for (£0.18m), and increase in spending levels

this year.

Routine investigation and review of drugs costs is now required to understand whether

increases going forward are price or volume driven.

Training and Education expenditure in the month was broadly in line with forecast

expectation, which is part of the agreed financial recovery plan to reduce non essential, non

mandatory expenditure level by £0.3m this year against original plan.

A further revision to the forecast out turn position for Public Dividend Capital (PDC) has

recently been recalculated. Expectation is that full year cost pressure will now be £0.5m and

constant review of this has been implemented given the financial position going forward.

The favourable position reported for depreciation continues to be due to the Capital

programme being considerably behind the Trust’s original plan. The favourable YTD position

is £0.25m with a forecast out turn favourable position of £0.32m, which is dependant on the

planned Q4 Capital expenditure levels.

16

Expenditure – Non Pay 2

(Specialist and OOA Placements)

Total spend on Specialist and Out of Area placements YTD now amounts to £5.31m.

Specialist placement expenditure in Norfolk accounts for £1.53m of this total. Costs have

remained relatively static throughout the year as placements have remained at a consistent

level. (see graph overleaf). The increase reported this month is due to the placement of

one adult admission in Central Norfolk, bringing the total number of placements up to 11, all

of which are considered longer term care.

A drop in the number of bed days for Out of Area (OOA) placements is once again reported

in the month. Total bed days were 512 in January (December 846, November 1,221) and

the expenditure level has fallen as a result to £0.27m for the month. There were 17

admissions during the month with 18 discharges. As at the end of the month patient

numbers totalled 16, all of which were in the Central locality. Due to the continued

improvement in this area and accounting for the latest plan regarding the opening of the

new Assessment Ward, the forecast position has again been revised. Total YTD costs now

stand at £3.00m with a full year forecast of £3.46m expected.

The one remaining patient on PICU was discharged during the month. YTD expenditure

therefore stands at £0.44m.

17

Expenditure – Non Pay 2 (Placements)

18

Capital

21

The cumulative capital position at the end of month 10 is 79% against the revised plan

(month nine - 55%).

The Trust capital expenditure must remain between £5.5m and £7.5m at year end in order

to meet Monitors acceptable range of 85%-115%. Based on the current risk assessments

being carried out it is expected that we will fall well within this range.

Currently £2.7m of the capital programme is forecast to be spent in the last two months of

the year, of which £1.5m (54%) relates to ICT expenditure. Whilst there will be a small

amount of slippage of some projects until the Lorenzo project is complete, it is still

anticipated that the majority of the ICT planned spend will be completed in the year.

Balance Sheet

At the end of month 10, the Trust held cash of

£14.6m, £0.4m higher than planned. The

variance against plan has reduced significantly

as capital expenditure has increased, and the

higher than planned level of agency staff

spend will utilise the remaining cash balance at

a higher rate than the initial plan, although

there has been an improvement in the month.

Please see further details on the cash flow

slide.

Net current liabilities continue to be higher

(£6.0m) than planned due to higher than

anticipated accruals and holding higher levels

of provisions being held for possible HMRC

liabilities.

Trade receivables are £4.1m ahead of plan.

This is due to a number of catch up invoices

being raised in the month and an £0.8m invoice

being raised in relation to Lorenzo project

funding. The longer outstanding debt relates to

outstanding CQUIN Invoices and amount due

from Norfolk County Council in relation to s75.22

Statement Of Position Actual Annual PlanVariance

(adverse)

Jan-15 Jan-15 Jan-15

£m YTD YTD YTD

Non-Currrent Assets 135.3 146.3 11.0

Current Assets 30.8 18.7 (12.2)

Current Liabilities (28.8) (22.6) 6.2

Non-Current Liabilities (22.4) (23.2) (0.8)

TOTAL ASSETS EMPLOYED 115.0 119.2 4.3

Public dividend capital 81.5 80.6 (0.9)

Retained Earnings (Accumulated Losses) 8.5 12.9 4.5

Revaluation reserve 25.0 25.7 0.6

Donated asset reserve - - -

TOTAL FUNDS EMPLOYED 115.0 119.2 4.3

Cash flow

The forecast cash position is currently £12.6m at 31st March 2015 against a plan of

£21.41m.

The year-end forecast position has improved from the previously forecast £8.7m year end

position (£3.9m) due to

Lorenzo Incentive funding agreed (£0.8m)

Revision of year end accruals figures based on current information (£1.2m)

Adjustment to accrued income year end forecast (£1.0m)

Other small reforecasting amendments based on the month 9 agreement of balances

review (0.9m)

23

COSRR forecast

24

Due to the improvement in the cash position

previously highlighted, and the improvement

in the deficit position, the year end COSRR

forecast has improved on both the capital

service cover and liquidity rating.

This forecast is based on the current forecast

plan, and takes into account the adjustments

to actual forecasts.

Board of Directors – Private 26

th February 2015

Business Performance Report

Version 1.0 Author: Tim Walsh Department: Informatics


February 2015

Retention period: 30 years

Report To: Board of Directors –Private


Title of Report: Business Performance Report – M10 2014/15


Estimated time: 10 Minutes

Author: Tim Walsh: Business Intelligence Manager

Director: Andrew Hopkins: Director of Finance

Executive Summary:

The Business Performance report shows that the Trust is compliant across all seven of the key performance standards under the Monitor Risk Assessment Framework. This is shown in the Monitor Targets section (section2). The key points for the board to consider in this paper are:

1. IAPT access rates are below the trajectory to meet the 15% target for quarter 4 in all but one of the localities. Section 3.4 outlines the performance and plans in place to address this and there has been an increase in access in January.

2. The access and assessment service in Norfolk is the subject of a contract query notice specifically for the 28 day access target which is not being achieved for over 18s. Section 4.4 provides further information. This presents a risk to service quality because 63% of service users with routine appointments are waiting longer than 28 days for an appointment.

This paper is for Approval and the Board is requested to consider the Trust’s performance as described within the Business Performance Report.

1.0 Report contents and Summary

The Business Performance Report is submitted to the Board for month 10 2014/15 and contains details of performance against key Monitor Compliance Framework targets and KPIs for Organisational Delivery, Quality, Safety & Experience and Workforce Development & Effectiveness.


H Item: 15.28v


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2.0 Monitor Targets

2.1 Monitor Performance Summary

Ref Measure Target Quarter 3 to Date (M10)

M01 CPA patients receiving follow up within 7 days of discharge

95% 100% 62 out of 62 discharges

M02 CPA patients having formal review within 12 months

95% 97% 1,945 out of 2,003 reviews

M03 Minimising Delayed Transfers of Care

7.5% 5.0% 686 delayed days out of 13,626 bed days

M04 Admissions to inpatient services had access to Crisis Resolution and Home Treatment (CRHT) teams

95% 98% 118 out of 120 admissions gate-kept

M05 Meeting commitment to serve new psychosis cases by Early Intervention teams

95% 142% 142 new cases against target of 201

M06 Data completeness: Identifiers 97% 99%

218,721 valid entries out of 220,194 possible data fields

M07 Data completeness: Outcomes 50% 82%

8,303 valid records out of 10,146 records

2.2 Director of Operations Norfolk and Waveney Summary

The main areas to highlight in Norfolk and Waveney are:

• Out of area placements decreased to 12 at the end of January and addressing the number of out of area placements remains a priority.

• DTOC remained below the 7.5% threshold in January reporting at 5.7% in Central Norfolk.

• The trust data on to systems within 3 working days improved in January.

• The IAPT service continued to report below the 15% access trajectory and significant work is taking place to ensure the access trajectory is met for quarter 4.


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• The locality is continuing to interview and recruit but they do have an issue with recruiting to certain staff bands which means that teams have to carry vacancies which increases pressure on the service. This is particularly an issue in the Access and Assessment service.

The following contract queries remain open:

• Norfolk Access and Assessment 28 day performance – This contract query could lead to withholding of funds. A remedial action plan was agreed with commissioners on 2nd February 2015.

• Norfolk IAPT Access rates below 15% target – The formal contract management meeting to discuss the Contract Query Notice is scheduled for 17th February.

2.3 Director of Operations Suffolk Summary

The main areas to highlight in Suffolk are:

• DTOCs in Suffolk East remain high at 8.4% in January however this is still a reduction from the position reported in December.

• Performance against the IAPT 15% access target in Suffolk is showing a further improvement in January and was achieved in West Suffolk.

The following contract queries remain open:

• Suffolk IAPT prevalence rates below the 15% target – An action plan is in place and this target is being met in West Suffolk. Whilst the performance in East Suffolk was below the target the service have seen an improvement in their access rates. The target will be based on the Quarter 4 performance only.

• Suffolk Non IAPT waiting times – There was agreement at the last contract meeting that this would be closed – NSFT are awaiting formal notice of this.

• Training MCA and DOLs training – NSFT have met the trajectory for the past two months which is positive. The service is working to ensure that this continues.

• Ligature points in Northgate (Wedgewood House) – The work has been completed and NSFT are awaiting a report to be released which should lead to the closure of this contract query.


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3.0 Financial implications (including workforce effects)

3.1 Minimising delayed transfers of care - DTOC (OD02)

In January the DTOC position for the trust got slightly worse and moved from 4.7% to 5.03%. This is below the 7.5% threshold but does have a financial implication because this signifies that beds which could be used to treat service users who are now out of area are instead being used for service users who could be discharged. In Norfolk on a weekly basis the DTOCs and potential DTOCs are discussed and agreed with operational staff and a social care lead. It has been identified that there is an insufficient number of beds outside of NSFT which causes pressure on NSFT acute areas. If NSFT look at discharging service users there is often a waiting list for accommodation that has been identified and this means that when funding is agreed the delay is still possible.

Suffolk East were reporting above the threshold at 8.4% however this is an improved position from 9.2% reported last month. In Suffolk the service is continuing to work in conjunction with Social services to look at the delays especially for service users who are awaiting placements in residential care particularly the Learning Disability patients.

Please refer also to Appendix 1 and Appendix 2. This item shows the financial cost of all of the delays reported in January 2015 and the attribution of delays as at 6th February 2015 for Norfolk, Great Yarmouth and Waveney and Suffolk.

3.2 Medium Secure Bed Occupancy Rate – (OD14) This indicator is related to the minimum occupancy of the medium secure beds that are commissioned by the East of England Specialised Commissioning Group. The figure is a minimum of 90% of all inpatients and includes those who are on leave from the units. Medium Secure bed occupancy reported at 81% in January, a dip from 85% the previous month. The implication of not meeting the occupancy of these beds is that NHS England will withhold funds (50% of bed day price for occupancy under 90%). The 2015/16 contract negotiation is expected to involve a reduction in medium secure beds.

3.3 Percentage of qualifying patients with a MHCT cluster (OD07)

In January the trust continued to report at 97% against a 99% target. Suffolk East and Suffolk West are the lowest performing localities against this metric at 95%. In Suffolk East and Suffolk West a number of data errors had been identified which are now being corrected by the locality business support manager. The locality will also be monitoring the referrals coming from AAT (Access and Assessment Team) into the IDT (Integrated Delivery Team) to ensure they have a cluster and to return to AAT if it is missing.


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The implications of the trust not meeting this target are that any activity not clustered under reports NSFT activity and this would have a significant financial impact if the trust were on a real tariff. At a point that NSFT move to an alternative payment system this would represent activity that NSFT would not receive payment for. At 97% this would mean that were the trust on a tariff, it would represent £3 million of activity that the trust would not be paid for, or the equivalent of 103 band 5 posts.

3.4 Percentage of IAPT patients who have depression and or anxiety disorders who receive psychological therapy (OD12)

Access rates continue to run below the target trajectory in January; however performance has improved since the position reported last month. The Local Area Team is monitoring the trust on the access rates for the IAPT service on a weekly basis. The 15% access rate is being monitored for Quarter 4 only.

In terms of the year to date position, West Suffolk were performing well in January. Central and West Norfolk were both well below the target trajectory. Action plans are in place across all localities to meet the 15% access rate for Quarter 4 2014/15. The access rates are being monitored on a weekly basis and a report to present the weekly performance is sent to commissioners and the Local Area Team. The access rate in Norfolk and Suffolk is the subject of a Contract Query Notice. The risk is that if the 15% target (3.75% for Quarter 4) is not achieved, there will be financial penalties imposed on the IAPT contracts. For the purposes of this report the monthly access rate has been plotted to demonstrate the performance of each of the NSFT IAPT services. The chart below outlines the month on month performance of the IAPT services in Norfolk, Suffolk and Great Yarmouth since April 2014.


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3.5 Bed occupancy, out of locality and out of area acute placements

There were 12 out of area placements reported in Norfolk and Great Yarmouth and Waveney as of the end of January. This figure has decreased further from the position reported in December. Assessors remain in place to review the out of area cases in Norfolk.

Bed occupancy in the adult acute service remained very high at 105%, this number reached 118% in GY&W suggesting that the adult acute beds are in high demand particularly in this locality. This high demand was also seen in the other inpatient adult acute areas. A similar high demand was also reported in the Older adult continuing care service line in Central Norfolk and GY&W, both of which reported at 100% for January.

The out of area placements represent a financial risk to NSFT because of the cost to place service users out of areas when NSFT beds are not available. This is a specific area that the Central Norfolk locality is working on to address and in Central Norfolk Thurne ward will be ready by the end of February and it is planned to open with four beds (recruitment for the ward is in progress).

3.6 Workforce - Vacancy Rate

More detailed workforce metrics are presented and discussed at the Trust’s bi-monthly Workforce and Organisational Development Committee. The workforce commentary highlights key issues and areas of assurance for the Board.

There is a continuing positive trend with the turnover rate continuing to reduce across the Trust. The current rate of 11.5% sits at just 0.28% over the in-month target level to reach 8% by the end of March 2016. The rate is 8.38% within Norfolk clinical services , 11.04% within Suffolk clinical services and 11.54% in Specialist Clinical services. Vacancies are highest within Corporate Services (19.09%) pending restructure and West Suffolk (17.24%).

Good progress continues in regard to the Recruitment and Retention Strategy. Net recruitment in the period to the end of December 2014 was 280 whole time equivalents, 249 of which were clinical.

Thirty-two registered nurses have been appointed following the introduction of a recruitment premium in hard to fill areas, including 10 for West Suffolk.

A recruitment ‘Twitter’ account has gone live (@nsftjobs) within the month.

The Trust has also appointed 12 ‘soon to be qualified nurses’ from University Campus Suffolk. These are due to start in the Trust at the end of February/March. These will be deployed amongst inpatient and community settings in Suffolk.


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Specific recruitment events have continued for Thurne Ward in Central Norfolk and a recruitment event is scheduled within Secure Services for the end of February.

3.7 Workforce - Employee Turnover

The Trust’s turnover rate has slightly increased in the month from 15.48% to 15.66%. The main areas of concern to highlight are within Central Norfolk and Suffolk West, where 27.4% and 29.4% (respectively) of all leavers failed to complete a years’ service with the Trust. A detailed analysis of reasons for leaving has been undertaken with actions being taken at locality level as well as via the over-arching retention and engagement strategies. The exit interview process has been reviewed to move to a resignation interview within one working day as well as an on-line survey. The proposed changes are currently being consulted on.

3.8 Workforce - Sickness absence

Overall, the Trust’s annualised sickness absence rate continues to reduce (7th consecutive month of reductions). In the month, it has reduced from 5.03% to 4.98%, the lowest level since the merger in January 2012. The reduction is attributable, in part at least, to the implementation of the Healthy and Engaged Worker Strategy which has a particular focus on prevention. This includes a series of locality based Wellbeing Weeks and break-time makeover challenges. A Healthy Worker training programme was launched in January which takes an evidence based approach to improve, in particular, short term absence. A regular employee wellbeing newsletter has also been launched.

3.9 Workforce - Appraisals

From April 2015, managers will be required to give positive assurance of performance in order for staff to be awarded pay increments. The Trust Partnership Meeting has agreed that the values aspect of the current appraisal criteria will be excluded from the assessment criteria for incremental pay purposes for 2015/16 in light of the review of the Trust’s values. Where staff have not had objectives set, the award of an increment will be assessed on general performance. The implementation of this policy is expected to assist in improving the appraisal rate and quality.

3.10 Workforce - Employee Relations

The Trust continues to have no active Employment Tribunal cases. There has been an increase in the active board appeals in the month, however, from 0 to 2. These relate to unconnected appeals against dismissal. The overall activity for sickness absence reviews is reducing which broadly correlates with the reducing Trust sickness absence rate.


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4.0 Quality implications

4.1 Data quality including timely entry (OD09)

The trust performance improved against this metric further for January, increasing from 93% to 95%. Performance in the Central Norfolk locality improved and was at 91% in January. The risk of late data is that decisions will be made, and finance data will be generated based on an incomplete data set. The reporting data will be extracted at the end of the 3rd working day of each month. If this data is not complete the reports that are generated will not be an accurate and fair reflection of the service activity. This will also affect the national datasets that are generated and submitted as part of the MHLDDS submissions.

4.2 Waiting times in completed pathways breaching standard and Number of incomplete pathways waiting over 18 weeks (QU04)

The number of 18 week waits rose to 80 in January from 72 in December. In Suffolk West, the number of 18 week waits was 23 in January. There were 17 service users waiting longer than 18 weeks in Central Norfolk and 19 in Great Yarmouth and Waveney. In Great Yarmouth and Waveney these waits are due to the ADHD referrals for which there is no dedicated service. This is being raised with the commissioners and a shared protocol is being agreed. The remaining 18 week breaches are being investigated by the services and this is being monitored at the monthly locality performance review meetings.

4.3 Percentage of long term (over 12 months) inpatients that have received an annual health check

The performance against this metric dropped from 98% in December to 92% in January. Secure services reported at 88% for January against a 100% target. Of the 5 breaches in secure services, 1 has now been confirmed to have been completed. The four remaining breaches are expected to have had the checks completed by 22nd February or an update provided to the locality manager. This will be addressed at the monthly performance review meeting.

4.4 Access and Assessment

Norfolk

The performance of the Access and Assessment service in December 2014 showed that 100% of emergency referrals were seen within 4 hours. 75% of the Urgent referrals were seen within 72 hours and 63% of the routine referrals were seen within 28 days. A contract query notice has been issued by Norfolk CCGs and an action plan has been submitted outlining actions being taken by the service to address the performance against the 28 day KPI. A review of the Access and Assessment service is taking place and this is making recruitment to vacancies


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within the service difficult . Further to this, the vacancies and sickness mean that the service is having to focus on the high priority referrals.

The 28 day breaches presents a risk to service quality because 63% of service users with routine appointments are waiting longer than 28 days for an appointment. The service are managing this risk but it is being reported for the Boards attention. The contract query represents a financial risk should the remedial action plan not be followed.

NSFT have been working with Commissioners and CCG colleagues to review the model for A&A, and have further meetings scheduled to look at moving to a new agreed model which will have a positive improvement on performance.

Suffolk

In Suffolk the Access and Assessment service reported a performance of 100% for the emergency referrals. For the urgent referrals the service reported at 100% and for the 28 day referrals the service reported at 98 %. The January information is not available at the time of writing. In the performance meeting with commissioners the good AAT performance was acknowledged.

4.5 Norfolk Recovery Partnership (NRP) and Suffolk Alcohol Service

The Norfolk Recovery Partnership are performing well at the moment. A remedial action plan that had been in place has now been signed off by the NRP commissioners. The service have had confirmation from Public Health recognising the hard work that has taken place in order to get the service meeting to local and national targets. There are concerns that the up-grade of Care Notes and new documentation may affect the quality of future reports if not corrected. This is being monitored at the Performance Review meeting with the service.

With regard to the Suffolk Alcohol Service, performance is robust and constant with no areas of concern. The contract finishes on the 31st March 2015.

4.6 Section 75 Suffolk

NSFT are currently rolling out tailored training for mental health practitioners on the new duties under the Care Act 2014; dates for this are scheduled up until April 2015. The content, and format, of this training is being developed with the involvement of Suffolk County Council (Workforce Development Team) and a small number of staff working in mental health services. The strategy is to target the delivery of the training directly into the Integrated Delivery Teams and Waveney Recovery Team using a similar approach to that taken to Personal Budget training in mid/ late 2014. There are 235 clinical staff that have either completed the training already or who are booked to attend one of the training days.

In parallel with this rollout of the training, the County Council and the Trust has commissioned the support of an external consultant to review and revise the


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existing S75 Partnership Agreement to accommodate the legislative reforms introduced by the Care Act. This work has commenced and will run through to late March 2015 and be overseen by the S75 Partnership Review Group.

Work is progressing between Informatics leads in Suffolk CC / NSFT and the Lorenzo Programme Team to ensure that new patient electronic recording system has the capacity to report out on the ‘Adult Social Care Outcome’ requirements for contract monitoring and national reporting requirements. A detailed data specification has been compiled and this is being mapped over to Lorenzo to influence the system design.

In summary, the partnership between Suffolk CC remains strong and we are jointly motivated to work closely together as we move through service developments. Our working arrangements continue to be overseen by the S75 Partnership Review Group that meets quarterly and has director level presence from both organisations.

5.0 Risks

5.1 For the purposes of this report the risks associated with each of the KPI items raised have been articulated in sections 3 and 4 of this document.

6.0 Recommendations

5.1 The Board is requested to consider the Trust’s performance as described within the Business Performance Report.

Tim Walsh Business Intelligence Manager 09

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Background Papers / Information

Appendix 1

The table below summarises the cost associated with all Bed Days that were a Delayed Transfers of Care in the month of January 2015 for NSFT for Norfolk, GY&W and Suffolk. The total cost is further broken down by attribution to Social Care, NHS or both.


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Appendix 2

The table below outlines the number of delays as at 6th February and their attribution - i.e NHS, social care or both.

These data show that 47% of the delays are attributable to Social Care.

Delayed Description Total

NHS - Awaiting public funding 2

NHS- Awaiting further non-acute care 5

Awaiting nursing home placement or availability

(attributable to NHS and Social Care) 1

Awaiting residential home placement/availability

(attributable to Social Care) 11

E Awaiting care package in own home 2

I Housing – patients not covered by NHS and Community

Care Act 1

TBC 1


January 2015 version 2.0

NSFT Informatics

1 BPR January 2014 v2.0/Front

Monitor

Ref Metric Period Value Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Actual 100% 98% 98% 100% 100% 99% 99% 99% 98% 100%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 98% 97% 97% 98% 98% 97% 97% 97% 97% 97%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 4.05% 4.87% 4.55% 3.58% 5.04% 5.14% 5.59% 5.01% 4.70% 5.03%

Target 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50%

Trend

Actual 100% 100% 100% 98% 98% 98% 100% 99% 98% 98%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 79% 89% 133% 140% 125% 131% 135% 133% 130% 142%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 100% 100% 100% 100% 99% 100% 99% 99% 99% 99%

Target 97% 97% 97% 97% 97% 97% 97% 97% 97% 97% 97% 97%

Trend

Actual 83% 83% 83% 83% 82% 82% 81% 82% 82% 82%

Target 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

Trend

Actual 6 6 6 6 6 6 6 6 6 6

Target 6 6 6 6 6 6 6 6 6 6 6 6

Trend

Performance is neither improving or worsening

Performance is worsening

Performance is improving

M01CPA patients receiving follow up within

7 days of discharge

Month

YTD

M03 Minimising delayed transfers of careMonth

YTD

M02CPA patients having formal review

within 12 months

Month

YTD

M04Admissions to inpatient services had

access to CRHT teams

Month

YTD

M08

Trend is calculated using Actual at Month 9 2014/2015 as compared to

the Actual in the current month

M05

Meeting commitment to serve new

psychosis cases by early intervention

teams

Month

YTD

M06 Data Completeness: IdentifiersMonth

YTD

Self-certification against compliance

regarding access to healthcare for

people with LD

Month

YTD

M07 Data Completeness : OutcomesMonth

YTD

2 BPR January 2014 v2.0/Monitor

Organisational Delivery


Actual 98% 97% 97% 98% 98% 97% 97% 97% 97% 97%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 4.05% 4.87% 4.55% 3.58% 5.04% 5.14% 5.59% 5.01% 4.70% 5.03%

Target 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50%

Trend

Actual 100% 100% 100% 98% 98% 98% 100% 99% 98% 98%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 79% 89% 133% 140% 125% 131% 135% 133% 130% 142%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 100% 100% 100% 100% 99% 100% 99% 99% 99% 99%

Target 97% 97% 97% 97% 97% 97% 97% 97% 97% 97% 97% 97%

Trend

Actual 83% 83% 83% 83% 82% 82% 81% 82% 82% 82%

Target 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

Trend

Actual 97% 97% 98% 98% 97% 97% 97% 98% 97% 97%

Target 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 100%

Trend

OD02 Minimising delayed transfers of careMonth

YTD

OD06 Data Completeness: OutcomesMonth

YTD

OD05 Data Completeness: IdentifiersMonth

YTD

% of qualifying patients with a MHCT

cluster

Month

YTD

OD01CPA patients having formal review

within 12 months

Month

YTD

OD04Meeting commitment to new psychosis

cases by EI

Month

YTD

OD03Admissions to inpatient services had

access to CRHT teams

Month

YTD

OD07

3 BPR January 2014 v2.0/Organisational Delivery

Organisational Delivery


Actual 91% 91% 89% 92% 93% 91% 92% 94% 93% 95%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Trend

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

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Trend

Actual 0.73% 1.60% 2.63% 3.69% 4.47% 5.44% 6.61% 7.88% 8.81% 10.06%

Target 1.25% 2.50% 3.75% 5.00% 6.25% 7.50% 8.75% 10.00% 11.25% 12.50% 13.75% 15.00%

Trend

Actual 51% 50% 53% 50% 46% 49% 44% 45% 46% 46%

Target 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40%

Trend

Actual 81% 82% 83% 79% 78% 83% 79% 79% 85% 81%

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Trend

Actual 85% 80% 79% 81% 87% 84% 86% 90% 94% 95%

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Trend

Actual 15 16 14 15 17 15 16 17 16 14

Target 28 28 28 28 28 28 28 28 28 28 28 28

Trend

Trend is calculated using Actual at Month 9 2014/2015 as

compared to the Actual in the current month

OD16Average Length of Stay - Adult Acute

Service

Month

YTD

OD10

OD13

% of IAPT patients who complete

treatment and 'move to recovery during

the month

Month

YTD

OD12

% of IAPT patients who have

depression and/or anxiety disorders

who receive psy therapy

Month

YTD

% of inpatient Finished Consultant

episodes during the period with an

ICD10 code

Month

YTD

OD09

Number of contacts recorded on Trust

systems within 3 working days of event

(Last 30 days)

Month

YTD

OD15Low Secure Bed Occupancy Rate

(including leave)

Month

YTD

OD14Medium Secure Bed Occupancy Rate

(including leave)

Month

YTD

4 BPR January 2014 v2.0/Organisational Delivery

Quality, Safety and Experience


Actual 100% 98% 98% 100% 100% 99% 99% 99% 98% 100%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 67 54 46 64 49 47 86 80 72 80

Target 0 0 0 0 0 0 0 0 0 0 0 0

Trend

Actual 92% 75% 91% 77% 83% 89% 95% 96% 97% 92%

Target 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

Trend

Actual 97% 100% 97% 100% 96% 95% 98% 97% 99% 98%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Trend

Actual 100% 100% 100% 100% 100% 100% 100% 98% 98% 92%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Trend

QU01CPA patients receiving follow up within

7 days of discharge

Month

YTD

QU04Waiting Times - Number of incomplete

pathways waiting > 18 weeks

Month

YTD

Waiting Times - % of CAMHS patients

seen within standard

Month

YTD

QU14Patient Safety Thermometer

(Development KPI)

Month

YTD

QU05

QU17

% of long-term (over 12 months)

inpatients that have received an annual

health check

Month

YTD

5 BPR January 2014 v2.0/Quality, Safety & Experience

Workforce Development and Effectiveness


Actual 5.59% 5.62% 5.55% 5.59% 5.41% 5.34% 5.26% 5.09% 5.03% 4.98%

Target 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76%

Trend

Actual 12.17% 11.38% 11.37% 11.36% 11.68% 11.52% 11.02% 9.78% 10.17% 10.20%

Target 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00%

Trend

Actual 11.84% 15.51% 11.96% 12.06% 11.50% 11.61% 10.90% 11.06% 10.89% 10.15%

Target 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52%

Trend

Actual 24.31% 24.13% 24.52% 25.04% 25.60% 26.02% 26.08% 26.38% 26.28% 26.26%

Target 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17%

Trend

Actual 61.60% 49.30% 46.20% 16.44% 25.72% 58.80% 39.50% 63.79% 65.71% 70.66%

Target 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Trend

Actual N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Target 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Trend

Actual 14 11 13 12 12 11 6 7 6 63.00%

Target 33 33 33 33 33 33 33 33 33 90% 90% 90%

Trend

Actual 11.84% 11.59% 12.06% 12.38% 11.97% 11.91% 11.80% 11.65% 11.54% 11.50%

Target 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00%

Trend

WD07

Mandatory/statutory training

compliance. Month

YTD

WD08 Vacancy RateMonth

YTD

WD05

% of staff with an appraisal since April

2013Month

YTD

WD06

% of medical staff compliance with

planned 2014/15 appraisal timetable

(Cohort 1)

Month

YTD

WD03% of sickness absence episodes > = 21

days

Month

YTD

WD04% of sickness absence days attributed

to Anxiety/stress/depression/etc.

Month

YTD

WD01 Annualised sickness absence rateMonth

YTD

WD02% of staff with 4 or more absence

episodes (WD2)

Month

YTD

6 BPR January 2014 v2.0/Workforce Development & Eff

Workforce Development and Effectiveness


Actual 15.65% 17.54% 15.69% 14.25% 17.37% 17.23% 17.86% 16.57% 15.48% 15.66%

Target 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00%

Trend

Actual 51.34% 49.91% 51.17% 52.27% 50.52% 47.51% 47.88% 47.51% 49.17% 51.15%

Target 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00%

Trend

Actual

Target

Trend

Actual

Target

Trend

Trend is calculated using Actual at Month 9 2014/2015 as

compared to the Actual in the current month

WD11Staff engagement - mini survey

(Development KPI)

Month

YTD

WD12Staff in post to caseload ratio

(Development KPI)

Month

YTD

WD09 Turnover RateMonth

YTD

WD10 % of resignations which are voluntaryMonth

YTD

7 BPR January 2014 v2.0/Workforce Development & Eff

Financial Management

Ref Metric Period Value Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15Full Year

Outturn

Actual 3 3 3 3 3 3 2 2 2 2

Target 3 3 3 2 2 3 3 3 3 3 3 3 3

Trend

Actual 3 3 3 2 2 2 1 1 1 1

Target 3 3 3 3 3 3 4 4 3 4 4 3 3

Trend

Actual 3 3 3 3 3 3 3 2 2 2

Target 2 2 2 1 1 2 2 2 2 2 2 3 3

Trend

Actual 10.30% 10.12% 19.48% 29.52% 18.47% 7.37% 7.75% 10.79% 24.42% 15.79%

Target 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%

Trend

Actual 5.10% 4.48% 5.41% 2.55% -0.85% 0.56% -0.27% -0.02% -0.48% -0.03%

Target 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%

Trend

Actual 2.02% 7.19% 11.32% 14.74% 17.01% 24.50% 30.25% 43.69% 53.78% 61.64%

Target 10.96% 22.30% 35.55% 46.25% 56.50% 64.97% 69.86% 75.34% 81.83% 87.21% 92.62% 100.00% 100.00%

Trend

Actual 51.91% 55.11% 55.11% 70.48% 61.62% 65.52% 67.32% 69.23% 70.70% 73.30%

Target 79.91% 81.65% 83.40% 85.15% 86.90% 88.65% 90.54% 92.43% 94.33% 96.22% 98.11% 100.00% 100.00%

Trend

FM01 Continuity of Service Risk RatingMonth

YTD

FM02 Capital Service Cover ratingMonth

YTD

FM03 Liquidity ratingMonth

YTD

FM04Debtors > 90 days past due account for

more than 5% of the total debtor base

Month

YTD

FM05

Creditors > 90 days past due account

for more than 5% of the total creditor

balances

Month

YTD

FM06 CAPEX % of plan spentMonth

YTD

FM07CIPs % of planned CYE (R&NR)

savings achieved

Month

YTD

BPR January 2014 v2.0/KPI Financials 14_15

<Audit & Risk Cttee & BoD> - <11 Feb 2015 & 26 Feb 2015> <SGC Chair’s report -27 Jan 2015>

Version 1.0 Author: <Peter Jefferys> Department: <Corporate>

Page 1 of 3 Date produced: 2 February 2015 Retention period: 30 years


Audit & Risk Committee

Meeting Date: 26th February 2015 (Board)

Title of Report: Chair’s Report – Service Governance Committee - 27th January 2015



Author: Dr Peter Jefferys, Non-Executive Director & Chair of SGC

Director: Dr Peter Jefferys, Non-Executive Director & Chair of SGC

Executive Summary:

First Service Governance Committee with enlarged locality membership (Lead Clinicians /Modern Matrons). Well attended. Key recommendation - re-name as Quality Governance Committee – to improve local and national recognition of Committee function.

• Timing (week prior to CQC publication) meant too early to share NSFT’s action plan – main focus for next meeting.

• Too early for improvements in locality governance – draft proposals for local structures await consultation & role clarification (Lead Clinician/Modern Matron/Deputy Matron/Locality Governance Practitioners/Governance Team Business Partners). External expertise may be needed.

• Governance work on CQC plan has delayed task completion on topics where SGC sought assurance. E.g., reports awaited on:

o Medical staff compliance with safeguarding training o Improved analysis of serious incident & complaint data. o Learning lessons from RCA’s including outcome following Coroner

recommendations o Rationalisation of groups / committees reporting to SGC. o Progress with plan to reduce use of restraint

• Work on clinical supervision policy needs to ‘return to basics.’


I Item: 15.28vi




1.0 Report from Service Governance Committee Meeting on 27th January 2015

Theme 1: Safe Services

1.1 Serious Incidents & RCA’s

1.1.1 Trend of apparent increase in community deaths continues. Detailed analysis with discussion requested. A number of RCA recommendations still not completed. Need to categorise and analyse recommendations more systematically. Similar methodology could be applied to complaint analysis. Locality engagement in process not consistently demonstrated.

1.1.2 ‘Learning lessons’ aspect of action plan following 2013 RCA audit of community deaths awaiting completion and report back. Needs to link with Coroner assurance work and action plan following West Norfolk CCG-commissioned audit.

1.2 Safeguarding

1.2.1 Compliance data on medical staff safeguarding training still not available (requested Sep 2104). Attention drawn to survey of postgraduate trainees in London Trusts by Education Leads. Serious risk of loss of approval as education provider unless remedied.

1.3 Clinical Supervision

1.3.1 Interim NSFT action plan following ‘weak assurance’ by Internal Audit discussed at length but withdrawn for re-drafting. Need to ‘go back to basics’ and clarify purpose of supervision and modes of delivery to fit clinical workforce in different settings.

1.4 Reduction in Use of Restraint

1.4.1 Verbal report only. Reference made to ‘Safer Wards’ initiative but unclear what progress has been made so far in NSFT on reducing use of restraint. Recent CQC interest in issue acknowledged and the CQC action plan will address this.

Theme 2: Caring & Responsive Services

1.5 Proposal to increase sample size for future Community & Inpatient Service User surveys supported (50%).

Theme 3: Effective Services

1.6 It was agreed to support the introduction of a programme of Basic Life Support training (Resuscitation) for community based clinical staff and to recommend that the Intermediate Life Support training for ward staff should be of one day’s duration. As the latter is mandatory, implementation needs consideration by




Organisational Development and Workforce Committee (OD&W). Course funding is already available.

Regulatory Compliance & Clinical Governance

1.7 Enhanced Locality Clinical Governance

1.7.1 Detailed proposals for re-structuring locality clinical governance are under discussion, linking with clarification about roles of modern matron / deputy modern matron / lead clinician and locality governance practitioners. It was suggested that external assistance may expedite the process.

1.8 Regulatory Compliance (CQC Report)

1.8.1 Ahead of publication of the CQC report detailed discussion of NSFT’s action plan was not possible. This will be the main focus for the next meeting. Jane Sayer accepts that most of the issues concerning the Committee will figure in the plan.

2.0 Financial Implications (including Workforce Effects)

2.1 Because of workforce implications and therefore the cost of mandatory training the recommendations on life support training are referred to the OD&W Committee


3.1 Given the CQC findings with respect to Safe Services, virtually the entire agenda of the Committee has quality implications. This means that effective action to improve quality and provide the necessary assurance will be key for NSFT.

4.0 Equality Implications - none


5.1 Effective action on a range of issues identified by SGC over the past year required to reduce risk and to demonstrate mitigation. It is hoped that the CQC / Quality Action Plan when finalised will provide the necessary assurance.

6.0 Recommendations

6.1 The Board is asked to approve change of title from SGC to Quality Governance Committee.

Dr Peter Jefferys Non-Executive Director, Chair of Service Governance Committee

Board of Directors-Public – 26 February 2015 – Risk Report

Version 1.0

Author: Neil Paull Department: Risk Management




Title of Report: Risk Register Progress Report



Author: Neil Paull: Risk Management and Security Lead

Director: Jane Sayer: Director of Nursing, Quality and Patient Safety

Executive Summary:

The attached table (appendix 1) highlights the current Trust Risk Register and the (appendix 2) mapping progress of identified risks. This paper identifies Risk Register progress using a mapping tool and the individual actions recorded on the Datix system. Risks have been grouped into categories. Whilst some overarching risks are shown as headline risks, i.e. clinical staffing, there are also Operational risks that arise and these are shown to ensure appropriate focus is given to the risk at each level. Each recorded risk is reviewed within the Risk Management team weekly and assurance is gathered from the Service Manager of progress. Outcomes of significant risk are discussed with the Trust Board Secretary and recorded on the Board Assurance Framework.

1.0 Risk Movement

1.1 There have been 37 risks archived as reaching their target between 1st February 2014 and 31st January 2015.

1.2 There are currently 77 live risks being monitored within the Datix system of which 35 are rated as 12 or above.

1.3 The Risk Management team reviews these risks weekly and follow up management responses on a monthly basis. The audit trail used within the system has identified that there are currently seven that have past their review date. The Head of Risk Management and Security is to meet with these Risk Owners to ensure the system is understood to ascertain if there are any obstacles in managing the risk review.


L Item: 15.30i

Board of Directors-Public – 26 February 2015 – Risk Report

Version 1.0

Author: Neil Paull Department: Risk Management


2.0 Risk Development

2.1 The most recorded risks remain staffing and indeed there are still high levels of staffing concern recorded on the Datix incident system. This is currently being reviewed with the staff level returns reported to ensure risks are focused on appropriately.

2.2 The Ligature programme is being reviewed with the Head of Risk Management

and Security, Head of Strategic Estates and Deputy Director of Nursing and Quality to ensure the programme reflects the concerns of active risks in in-patient and community areas.

2.3 Performance review group documents and dashboard presented to the Service Managers highlight the current risks recorded, the most recent incident reporting trends and current complaints compliance.

2.4 Training in the Datix system has been offered to the newly appointed Deputy Director of Nursing and Director of Operations in Suffolk.

2.5 The Head of Risk Management and Security is to meet with Service Managers to ensure that the dashboard used within the Datix system has been set up and to identify whether managers are using the system so that it can be used locally to assess emerging risks.

3.0 Risks / Mitigation in relation to the Trust Objectives

3.1 To ensure a best practice approach Risk Management and Patient Safety will co-ordinate engagement with Service Managers on a monthly basis to triangulate risks coming from Complaints, SI and incident reports.

3.2 The Executive team are advised of risks upon scoring by the Head Risk Management and Security and review the table monthly. The meeting considers whether the action plan for the risks are sufficient given the impact on the overall business of the Trust, whether they are accepted risks or concerns and if any further risks have been highlighted.

4.0 Recommendations

4.1 That the Board accepts the updated report on progress.

Neil Paull Head of Risk Management and Security

Background Papers / Information Risk Register, current register attached January 2015 Trust Overview Risk Profile

record

ID

Name of risk Risk description Locality (Team) Svs / Dept Lead Update on Controls in place Opened Risk

Current

Action Plan /Lead

1100 Disaster

Recovery

Capability

The existing infrastructure

design does not include

effective disaster recovery

measures.

ICT Services (Risk

Register)

Director of

Stratergy and

Resources

ICT are in discusion with Mircosoft

about using Azure as a solution.

We will update progress as talks

progress.

07/02/2014

reviewed

17/12/2014

20

ICT will formulate

and procure a

solution that will

meet its long term

needs. This work

will be completed

by 31 July 2014.

1101 Data Backup

Capability

The existing infrastructure

design is not effective enough

to ensure that all business

critical clinical and corporate

data is reliably backed up

ICT Services (Risk

Register)

Director of

Stratergy and

Resources

A project mandate has been

produced to audit and develop the

backup stabilisation plan that

meets recognised industry

standards and methodologies.

07/02/2014

reviewed

17/12/2014

10

Project work will be

completed by 31

July 2014.

1095 ICT

Infrastructure

Failings in aspects of our core

ICT Infrastructure may result

in network, application or

service failures that could

result in a breach in the

availability or integrity of all

clinical or corporate data.

ICT Services (Risk

Register)

Director of

Stratergy and

Resources

Service Improvement Plan in

place, on schedule to complete by

year end

reviewed

12/11/2014

12

Linked with

Infrastructure

Rectification

Programme PID.

Risk reviewed at

ICT Programme

Board

885 Stability of

ePEX

The historical level of stability

of ePEX gives ICT sufficient

concern that it is prone to

prolonged disruptions that

would result in the non-

availability of clinical records

to its users.

ICT Services (Risk

Register)

ICT Security

Manager

In proactive monitoring tool to be

installed to help ICT monitor

problems. This is not a fix but will

minimise likelihood of disruption.

The monitoring tool has

demonstrated a period of recent

stability

10/04/2012

reviewed

9/10/2014

12

No change - ePEX

will be monitored

until its

decommissioning in

2015.

863 Patient

Administration

systems

(Formerly

Lorenzo

Programme)

Likelihood score raised to a 3

by the Lorenzo programme

board as a result of the

increased risk of network

capacity not being sufficient,

caused by additional

requirements (eg WinDIP,

enhanced resilience).

Corporate (Risk

Register)

Director of

Stratergy and

Resources

A fully governed programme exists

to ensure that the work is actively

managed. This includes

governance from HSCIC as part of

the Department of Health's

involvement and provision of

funding. A full risk register is

maintained by the programme and

circulated to the risk team on a

monthly basis.

13/02/2012

reviewed

8/1/2015

12

Regular update

reports are

provided

ICT RISKS

1

record

ID


Current

Action Plan /Lead

1164 Low staff

morale risks

quality of care

Low staff morale may affect

staff engagement and good

will which may in turn have a

detrimental effect on patient

care.

Corporate (Risk

Register)

Director of

Strategy and

Resources

Staff engagement strategy

including a wide range of

initiatives. Locality staff and

wellbeing plans are in place.

17/11/2014

reviewed

17/12/2014

20

Links to the action

plans chased.

1116 Inability to

deliver clinical

services safely

due to high

number of

vacancies

The Trust currently has

484.72 wte vacancies, 432 of

which are being actively

recruited to. 324 of those

vacancies are within clinical

services (146.45 wte Norfolk,

133.34 Suffolk and 44.73

Specialist).

Human Resources

(Risk Register)

Director of

Strategy and

Resources

Good progress with Recruitment

Strategy. Net recruitment of 261

new staff from Jan to end

November. Turnover remains an

issue and is impacting net

recruitment. Recruitment Strategy

Project extended to include

retention strategy. Clinical

vacancies 10% to end Nov 14.

24/04/2014

updated

19/12/14

12

Staffing Strategy -

Reported via

Workforce

Development

1141 Inability to

deliver

corporate

services safely

due to high

number of

vacancies

There is a vacancy rate of

20.08% within corporate

services (Dec 14). The level

is particularly high as

vacancies are being managed

to minimise redundancies

pending a restructure.

Human Resources

(Risk Register)

Director of

Strategy and

Resources

A number of corporate services

are now consulting on their

proposed changes (Finance,

Communications and Trust

Secretariat). Work is ongoing with

the org design of the remaining

services. Consultation anticipated.

reviewed

19/12/2014

9

Vacancies are

being covered by

temporary staff

(fixed term, bank,

agency).

Relevant Executive

Directors engaged

in developing plans

for their corporate

areas and ensuring

adequate interim

cover.

1103 Secure

services - Use

of medical

Locums at all

grades.

Secure Services currently has

a number of locum medical

staff. 3 Consultant posts while

the recruitment process takes

place. 3 CT posts due to

vacancies on the rota and 1

staff grade.

Secure Services

(Risk Register)

Service

Manager

This risk was reviewed by the

Clinical Governance Forum on

19.01.15. 2 new Consultant

Psychiatrists in post now which

has reduced our need for 2 locum

consultants so reducing the

likelihood. We have another

consultant retiring at the end of

Feb 15. Junior doctor posts will be

remain the same until March when

all but 1 CT posts are filled. Due

date changed to reflect this.

25/02/2014

reviewed

22/1/2015

9

All locum posts

remain consistant.

A businss case is

being developed

with finance

Headline HR RISKS

Sub HR RISKS

2

record

ID


Current

Action Plan /Lead

1065 Post TSS

impact of

increasing

locality

boundary on

level of patient

demand and

available

service

capacity.

Excess service demand

poses risk of; breach of

external waiting time target,

waiting lists (internal and

external), waiting list risks,

reduced capacity to handle

high risk patients, reduced

work quality, lower priority

work deferred (GP meetings,

group work), reduced morale,

increased patient incidents

and patients / GP / carer /

commissioner complaints,

and long working hours an

staff stress, sickness and

turnover

West Norfolk (Risk

Register)

Service

Manager

Regular tracking of patient referral

numbers, status and plans by

senior service team. Develop case

for appropriate staff level and plan

to implement. Fill vacancies with

agency staff in interim, explore

creating interim supernumerary

staff .

20/11/2013

reviewed

22/12/14

12

CMHT caseload

145% of target.

DIST caseload has

increased

Risk mitigation plan

continues to be

implemented

1072 Breaches AAT

Central and

West

Risk of SI/compromise to

patient safety/contract

breaches AAT Central and

West

Central Locality

(Risk Register)

Service

Manager

No significant change, vacancy

levels remain high wich are

impacting in ability to complete

tasks required in a timely manner.

Saturday Assessment clinics

cancelled to provide critical mass

Monday to Friday, CTL and DSM

are being pulled into numbers

which is not a long term solution.

Different ways of recruitment are

being considered including shared

roles with ASL Community Teams.

11/12/2014

reviewed

29/1/2015

12

CQN is in place

due to ongoing

breaches of 72 &

28 day breaches.

AAT review is

underway by the

Trust.

1133 Unable to

delivery patient

care due to

high number of

vacancies and

inability to

cover these

with temporary

staffing

NHSP are unable to fill the

shifts required when put on

the system resulting in unsafe

staffing levels on occasion

across west inpatient areas.

Centralised recruitment

process has impacted on

ability to be able to recruit to

vacancies.

West Suffolk (Risk

Register)

Service

Manager

Agencies being contacted directly

to block book staff. Recruitment to

be managed at local level We

have appointed to some

vacancies.

14/07/2014

reviewed

13/1/2015

12

Continuing to

actively recruit to

vacancies.

942 Lack of PMA

trained NHSP

staff

Inability to supply flexible

workers with full PMA training

via NHSP or agency to meet

demand

Human Resources

(Risk Register)

Director of

Patient Safety

and Quality

The Trust has provided two

intiatives to support the number of

staff provided by NHSP/Agencies.

1.Offered training courses to

agencies to undertake Trust PMA

training. 2.Creation of further

virtual PMA training team to create

greater capacity/places.

27/07/2013

reviewed

6/1/2015

12

Gaps in available

training places

3

record

ID


Current

Action Plan /Lead

1090 Overall CIP

delivery.

Financial risk review Corporate (Risk

Register)

Director of

Finance

A financial recovery programme

has been established with the first

meeting of the new CIP Steering

Group scheduled for 17

September 2014. A Programme

Director has been appointed who

with the support of a small team

will work with managers to identify

additional CIP plans, review

existing CIP performance and work

with managers to reduced current

run-rates.

24/12/2013

discussed at

Execs mting

17/12/2014

20

Monthly updates

DoF updating CIP

targets

1084 Financial

improvements

of TSS

2014/15

Operational plan 2014/15 -

Inability to deliver financial

improvements of Trust

Service Strategy and identify

suitable alternatives to

shortfall

Corporate (Risk

Register)

Director of

Finance

Financial controls as part of SFIs

and scheme of delegation.

discussed at

Execs mting

17/12/2014

20

CIP plans are

reported on a

regular basis to the

Finance and

Performance

Committee

highlighting

achievement on

projects.

1062 Bed Pressure Use of 'red leave' bed's,

demands on staffing to

manage high turn over of

service users as well as

protracted time periods

required to manage

applications for OOA

placements as well as

transport issues.

Time periods spent in S136

suite.

Central Locality

(Risk Register)

Deputy Director

of Operations

Norfolk

Increased demand on beds has

led to increased OOA placements.

Measures as detailed put in place

to ensure gatekeeping is of

required quality. CRHT

establishment and ability to

perform necessary functions under

examination by Service Manager.

15/10/2013

discussed at

Acute

Service

Forum

20/01/2015

12

NHSP temporary

staffing being used.

NHSP currently

attempting to find

staff who will be

block bookable for

three month

periods to improve

continuity whilst

awaiting staff to

return from

maternity leave.

1040 Delivery of

Acute services,

Norfolk West

Increased sickness is evident,

therefore putting pressures on

existing staff. Shifts are not

safely covered without using

NHSP or equivalent

West Norfolk (Risk

Register)

Service

Manager

CTL due a phased return. Current

secondment to CRHT Band 8a.

Unable to cover shifts on both

ward and CRHT

19/06/2013

reviewed

17/12/2014

16

Recent interviews

secured 1.6 Band

6. 2 Band 4. 1 Band

3

PATIENT SAFETY

FINANCIAL RISKS

4

record

ID


Current

Action Plan /Lead

1169 Positive and

Proactive Care

The Trust may not be able to

fully implement the guidance

in a timely way due to

unfunded activity and

vacancies in the PMA team,

and the difficulties of

implementing fundamental

practice change in such a

short time.

Corporate (Risk

Register)

Director of

Patient Safety

and Quality

Restrictive interventions working

group have developed a plan for

engagement of key staff in rolling

out positive behaviour support

training and approaches, the Safe

Wards approach is being

implemented in East Suffolk and

this approach will be

recommended across the Trust.

08/12/2014

reviewed

20/1/2015

15

Recording of data

allows for more

analysis of areas

that require

additional support,

and the Trust is

developing greater

ability to use data

for this purpose.

1170 Lack of

provision and

use of clinical

supervision

Internal audit has identified

that the Trust has weak

assurance on its compliance

with the clinical supervision

policy.

Corporate (Risk

Register)

Director of

Patient Safety

and Quality

Policy is being reviewed by the

governance team, and will be

discussed at SGC

08/12/2014

reviewed

20/1/2015

16

Actions from

Service

Governance

27/1/2015

1033 Inability to

provide an

individual

practitioner to

every Service

User in Central

Adult

Community

There are a growing number

of unallocated clinical cases

in the Central Locality who

require Care Coordination or

Lead Care Professional

alignment which could result

in a lack of timely intervention

if required.

Central Locality

(Risk Register)

Locality

Operations

Manager

recruitment to an additional 12

band 6 and 4 band 4 staff is

underway, once recruited it is

predicted the risk associated with

the unallocated cases will reduce

to a level where the risk can be

closed

24/05/2013

reviewed

29/12/2014

15

Weekly reporting

and monitoring

continues with

actions in place to

increase discharge

to enable capacity

to be built into the

teams.

1123 High demand

for community

services.

Volume of referrals is greater

than rate of discharges from

services, equating to

increasing demands on the

team. Care coordinator and

lead professional capacity not

sufficient to pick up and work

with all new referrals to team.

West Norfolk (Risk

Register)

Service

Manager

Currently interviewing to fill

vacancies. May need to

readvertise, but vacancies will be

greatly reduced.

10/07/2014

reviewed

25/1/2015

9

Monthly monitoring

5

record

ID


Current

Action Plan /Lead

1142 No access to

physio or SALT

in acute

inpatient

services

Inpatient teams are unable to

directly access SALT or

physio where these are

identified needs for patients

Suffolk Access &

Assessment Team

(Risk Register)

Locality

Operations

Manager

CCG continuing to identify SALT

provision,discussions being held

with IDT manager with possibilty of

SALT input from IDT's.

15/08/2014

reviewed

20/1/2015

12

Director of Infection

Prevention and

Control, Physical

Health Team

Leader

commencing action

plan with the ward.

No progress made.

CCG continuing to

identify SALT

provision- to be

raised at contracts

meeting

1125 System

confidence

A loss of system confidence

affecting sustainability of trust

Corporate (Risk

Register)

Chief Executive a) rules for meetings introduced,

follow up of actions and minutes in

a timely manner, b) more regular

contact with commissioners

established including clinical leads,

c) Access and Assessment service

being reviewed, d) Constructive

approach to dialogue with the

Campaign.

30/05/2014

reviewed

9/1/2015

15

Trust Secretary

reviews monthly

updates, currently

no change (9/1/15)

914 Compliance

with mandatory

training

Low compliance with

mandatory training resulting

in non-compliance with legal

obligations, NHSLA & CQC, &

poorer quality of care

Human Resources

(Risk Register)

Director of

Workforce and

OD

Project work to review and improve

relevance and access to stat/mand

training.

29/08/2012

reviewed

17/12/2014

16

1163 Weaknesses in

the "well-led"

domain may

impact on

quality and staff

engagement

The risk is that without clear

vision and strategy led by the

Board of Directors and Senior

Management team, and

supported by effective

governance mechanisms,

quality may be compromised.

Corporate (Risk

Register)

Chief Executive Action plans in response to the

external BoD evaluation and CQC

inspection are underway to

strengthen the well-led domain.

These include immediate and

medium term plans to build board

and senior capacity and capability,

and a staff engagement strategy.

17/11/2014

reviewed

17/12/2014

discussed

Service

Governance

27/1/2015

20

Action plans being

drawn up.

QUALITY and AUDIT

REGULATION

6

record

ID


Current

Action Plan /Lead

1144 Negative

impact of poor

CQC inspection

report

The CQC will inspect the

Trust under the new

inspection model in October

2014. There is a risk that not

all of the new standards will

be met and this will have a

negative impact on the Trust

Corporate (Risk

Register)

Director of

Nursing, Quality

and Patient

Safety

Following the draft report, this risk

remains high. Jane Sayer is

meeting with quality leads to

discuss the report.

19/08/2014

reviewed

14/01/2015

20

Action plans being

drawn up.

1160 Section 75

changes

Risk associated with the

changes to the way Health

and Social Care are provided

in the Central Locality (end of

the Section 75) the caseloads

need absorbed into the

workload.

Central Locality

(Risk Register)

Service

Manager

Transitional Plan written by NSFT

covering the need to facilitate safe

and timely transfer of caseload

between organisations. Agreement

to appoint a lead to manage this

safely between November 2014

and March 2015.

31/10/2014

reviewed

29/12/2014

16

Move to Monthly

reporting has not

supported continual

management of this

risk in terms of

numbers so move

back to weekly

reporting of

unallocated

commenced on

19/12/14.

1137 Reception area

Mariner House

Ipswich

Size and facilities of reception

area at Mariner House not fit

for purpose, due to increase

in number of services using

the building and therefore the

number of people attending.

East Suffolk IDT

(Risk Register)

plans have now been drawn up

and there are three options

currently being considered.

Awaiting planning approval and

landlord support.

01/08/2014

reviewed

22/1/2015

12

Landlord has taken

time to respond.

1136 Ligature

Programme

Clarity with the CTL that there

is common practice of

reducing risk dependant upon

the environment and the

services users access to

those risks.

Corporate (Risk

Register)

Risk

Management

and Security

Lead

CF1 for WAS and Northgate GY.

MK states Norvic and Churchill

completed

25/07/2014

reviewed

30/1/2015

12

Estates and Risk

will review with

Deputy Director of

Nursing programme

priority 13/2/2015

1112 Trust

Reputation/

Public

Relations

Current negative media

coverage; Request from CCG

in response to media

coverage and campaign.

Commercial

Development (Risk

Register)

Director of

Strategy and

Resources

Significant increase in positive

media coverage over recent

months.

Meetings with campaign members

undertaken to open

communication channels and

encourage balanced reporting

however negative and personal

reporting continues.

10/04/2014

reviewed

2/1/2015

12

Appointed outside

agency on

reputation recovery

through the Comms

team. Plan of action

progressed.

Key

Removed from current

register

Bold writing

Newly recorded or changes

to risk

COMMUNICATION

ENVIRONMENTAL

7

Headline risks:

1090

1163

1084

11441100

Actions on current risks

ID Name Responsibility ('To') Due date Done date

1136

Ligature

programme

Head of Risk

Management

and Security 18/02/2015

1141 30/03/2015

1116 30/03/2015

1170 Clinical Supervision. Change: Identified weakness in policy and compliance. Action: Policy development roled out

Trust Overview Risk Profile

1160 Section 75 changes. Changes: Lead to manage transfer until March 2015. Action: Move to monthly reporting

1069 Possitive and Proactive Care. Change: Working group rolling out Safe Wards approach used in East Suffolk. Action:

Benchmarking data.

1144 Impact of CQC inspection. Change: Quality leads working with DoN&Q. Action: Weekly review of action plan

1125

1169

1090 Overall CIP Change: Programme Director in place. Action: Monthly review

1084 Financial improvements of TSS 2014/15 Change: CIP plans developed in individual localities. Action: Reports to Finance

& Performance Committee

1163 Weakness in 'well led'. Change: Staff engagement strategy. Action: Planning from the CQC report.

1095 ICT Infrastructure. Change: No current activity. Action: Service implementation, due for completetion

1100 Disaster recovery plan. Change: No change. Action: Discusions with Mircosoft projected completion of works July 2015

1112 Reputation/Public relations. Change: Balanced media coverage. Action: Comms team responding to activity

1125 System confidence. Change: No change January 2015. Action: Trust Secretary reviews monthly.

0914

1160

1170

1136

1164

1116 Implementation of the Flexible workforce plan. Change: Good progress with Recruitment Strategy, rating reduced

August. Action: Maintain and monitor

1141 Vacancy rate of 19.86% within corporate services. Change: Vacancies are being covered by temporary staff (fixed term,

bank, agency). Action: Relevant Executive Directors engaged in developing plans. Consultation anticipated Feb/March 2015

1164 Low staff morale risks quality of care. Change: New risk identified detrimental effect on patient care. Action: Locality staff

and wellbeing plans are in place.

0863 Patient administration systems (Lorenzo). Change: Programme remains on track. Action: Monthly reviews by programme

board.

1136 Ligature programme. Change: CQC report identifies Ligature outside current plan. Action: Estates/Risk Management

reviewing with Deputy Director of Nursing

1062 Bed management. Change: Gatekeeping monitoring in place. Action: Bed management team working on persistent

request in Central Norfolk

0914 Compliance with mandatory training. Change: Education reviewing settings and access. Action: monthly reviews.

Concern: Low uptake on training places.

1141 1116

1112

0863

1095

1062

Teams are being engaged in the org design of the HR and WD functions in readiness for formal consultation to commence

end Feb.

Good progress with recruitment and retention strategy. 280 net recruitment in 12 months to end December. Clinical

vacancies under 10%. Recruitment premium in hard to fill areas has had positive impact (32 appointments since

introduction). Strealined vacancy management and invite to interview processes implemented.

Corporate

Implementation of

wider recruitment

strategy milestones

Clinical

Implementation of

wider recruitment

strategy milestones

Inability to

deliver

services

effectively

due to high

number of

vacancies

Director of

Strategy and

Resources

Description

Locality / Service: Corporate (Risk Register)

Locality / Service: Human Resources/Workforce Development (Risk Register)

Progress

Meeting with Head of Estates Strategy and Deputy Director of Nursing to ensure all environment is accounted for and staff

are aware of the controls and when changes will be addressed where necessary.

Investigate

discrepancy between

Trust priority ligatures

Board of Directors Meeting - 26th

February 2015 Chairs Report

Version <0.1>




Report To: Board of Directors Meeting - Public


Title of Report: Chairs Report


Estimated time: 5 Minutes

Author: Gary Page, Chair

Director:

Executive Summary:

The report details my most significant meetings and my key observations over the last month.

1.0 Interaction with External Organisations

1.1 Together with Michael Scott, I met with Under Secretary of State at the Department of Health and Suffolk MP Daniel Poulter and Suffolk Councillor and Cabinet member of Adult Social Care Alan Murray at the Woodlands Hospital.

1.2 Together with a number of the Board I attended the CQC Summit at which the Report was presented to a large group of stakeholders from Norfolk and Suffolk. In the afternoon Monitor led a session on how our stakeholders could help us to address the challenges we are facing.

1.3 Together with Michael Scott, Jane Sayer, Bohdan Solomka and Governor Catherine Wells, I visited Birmingham and Solihull Mental Health Trust as part of our Trusts Buddying. There were some useful ideas on how we could make our Board more effective, a couple of which I have already started to implement.

1.4 I am attending the Deans monthly breakfast group at Norwich cathedral where I will present on Mental Health.

2.0 Interaction with Services and Staff


M Item: 15.30ii



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2.1 I attended the newly constituted Service Governance Committee which now includes clinical representation.

2.2 I visited Bury St Edmunds and met with Locality Manager Paula Clarke and toured the wards at Wedgwood House.

2.3 I visited the Bury South IDT and met with the Deputy Service Manager and then spent time with each of the IDT pathways.

2.4 I met with Dr Santosh and Dr Emore (consultants at Carlton Court) and then visited the DCLL services at Carlton Court.

2.5 I met with the Integrated Delivery Team at Mariner House Ipswich.

2.6 I visited the Acle and Drayton Wards at the Norvic Clinic with Lady Dannatt. I subsequently met with some of the BME staff who presented at last month’s Board Meeting and spent some time with them on the ward.

2.7 I have met with two of the New Governors and have meetings scheduled with the others,

2.8 I am attending the PIPE opening at Wayland HMP.

2.9 I met with Paul Johnson from HR to kick start the process on the Ned appraisals.

2.10 I Chaired the interview panels for two new consultants at Hellesdon where we successfully made two appointments.

3.0 Interactions with Service Users

3.1 I was shadowed by a youth council member where we visited the services at Bury St Edmunds and then attended the Organisational Development and Workforce Committee.

3.2 I met with Kevin James, Governor and Chair of Norwich Service User Locality Group.

3.3 I attended two Service User and Carer involvement Strategy meeting to help to get the strategy ready for the March Board Meeting.

3.4 I met with Jo Stewart, new Chair of the North Norfolk Service User Locality Group.

4.0 Key Observations

The month has obviously been dominated by the CQC Report. It goes without saying that, like everyone else on the Board I was hugely disappointed by the Report. However I was massively heartened by the reaction from stakeholders



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who were enormously supportive of the new team we now have and very understanding of the challenges we have faced over the last two years. I was also incredibly proud of the Staffs responses – there was an understandable element of “ we told you so “ but an overwhelming desire to fix those things that we know are wrong and a big sense of injustice from many staff who felt feedback they had received was so inconsistent with the report. My message has been clear – we know what we have to fix, plans are in place in most areas and we have the team in place throughout the trust to deliver.

We are making some changes to Board Reporting to make our sessions more efficient and effective. This is being informed by how some other Trusts (including our Buddy Trust) operate. The Board Assurance Framework will now be bi monthly aligned with the Risk register. Our Quality Report will also be bi monthly and will alternate with the CQC Improvement Plan. We are still working on the exact arrangements around the governance around the CQC Plan and will announce that in due course once we have had a chance to discuss this with our Improvement Director.

I am conscious in writing this report that it has become more of a diary than a report. In future the Chairs Report will be more about my perspective on where we are as a Trust, where progress is being made and where we still have work to do. I will attach my diary as an Appendix for those who are interested

5.0 Recommendations

5.1 The Board is asked to note the report.

Gary Page Chair

Board of Directors-Public – 26February2015-A&R Chair’s Report

Version 1.0

Author: John Brierley Department: Non-Executive Director




Title of Report: Report of the Chair of Audit and Risk Committee from its’ Meeting on 11th February 2015.



Author: John Brierley – Non-Executive Director and Chair of the Audit & Risk Committee

Director: As Author

Executive Summary:

The key issues considered by the Committee and reported for the Board of Directors Information and attention are:

• The Committee reviewed and approved its’ work plan for 2015.

• Amendments were agreed for final accounts/ reporting timetable and plan.

• Section E of the Monitor Code of Governance in respect of Relations with Stakeholders was reviewed and agreed. A report on compliance with the Monitor Code of Governance will be made to the March meeting of the Board of Directors by the Trust Secretary.

• The Committee discussed ligature risk in the context of the CQC report and asked for a report back from the Risk Management and Security Lead on issues raised and actions being taken.

• The Committee reviewed and made amendments to the Trusts’ Standing Financial Instructions (SFIs) and Scheme of Delegation – Note decisions need to be made by the Board on the roles and terms of reference of its’ committees and the Board of Directors itself in respect of the monitoring of performance.

• The Committee approved the accounting policies to be adopted in the Trusts’ Financial Statements and Accounts for 2014-15.

• The Committee approved the Counter Fraud Annual Plan for 2015-16. This will be re-presented at the June Committee to which the Governors will be invited.


N Item: 15.30iii


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• The Committee discussed reported outcomes of individual internal audits and opinions given and sought clarification and explanation where appropriate. Concern was expressed over the number of reports that were concluding on the opinion on assurance ‘requires improvement’, which will be reflected in the Head of Internal Audit Opinion.

• The Committee considered the Draft Head of Internal Audit Opinion for 2014-15 which is likely to give a limited opinion on assurance which is worsening on previous years, in particular, governance and quality.

• The Committee noted that the assurance opinion on quality is likely to remain ‘requires improvement’, as is IM&T and HR and Workforce. Finance remains substantial. Performance is likely to improve from ‘requires improvement’ to ‘substantial’ but governance and risk may move from ‘substantial’ to ‘requires improvement’, which is of concern. It is proposed to draw to the attention of relevant Committees the assurance ratings when these are finalised.

• The Committee agreed and recommended for adoption the External Audit Plan and Fees for 2014-15, which are in line with the tender submitted by KPMG earlier in the year when they were re-appointed by the Board of Governors.

1.0 Report Contents

1.1 I do not propose to repeat the items referred to in the Executive Summary of the report which are self explanatory only those which require further comment or clarification. These are set out below.

1.2 Section E of the Monitor Code of Governance in respect of Relations with Stakeholders was reviewed and agreed. A report on compliance with the Monitor Code of Governance will be made to the March meeting of the Board of Directors by the Trust Secretary. The Committee have now reviewed all of the Sections of the Monitor Code of Governance. This has proven to be a useful exercise highlighting where improvements can be made by the Trusts’ existing arrangements.

1.3 The Committee discussed ligature risk in the context of the CQC report and asked for a report back from the Risk Management and Security Lead on issues raised and actions being taken. At our last meeting the Committee had asked why new ligature risks were being identified which had not been eliminated. We were advised that a programme of work was in place to carry out the work on a risk assessed basis and that remaining risks were being risked managed by the services concerned e.g. by observations. We were therefore concerned by the unexpected ligature related patient safety issues raised by the recent CQC report. The Committee asked for a report to its next meeting which addresses and explains the differences.

1.4 The Committee reviewed and made amendments to the Trusts’ Standing Financial Instructions (SFIs) and Scheme of Delegation. Note decisions need to be made by the Board on the roles and terms of reference of its’ committees and the Board of


Version 1.0



Directors itself in respect of the monitoring of performance. With the exception of those paragraphs relating to where the Trusts’ performance should be reported and considered the SFIs were amended and are recommended for approval by the Board of Directors. This review included the Scheme of Delegation and the associated financial limits. The SFIs and Scheme of Delegation and financial limits are being separately reported to your meeting for approval by the Director of Finance.

1.5 The Committee discussed reported outcomes of individual internal audits and the opinions given and sought clarification and explanation where appropriate. Concern was expressed over the number of reports that were concluding on the opinion on assurance ‘requires improvement’, which will be reflected in the Head of Internal Audit Opinion. The reports on the Appointments Procedure, Safeguarding, Remote Access-3rd Party Support and Risk Management/ Risk Register (draft opinion) were all given an assurance assessment of ‘Requires Improvement’. The main concern arising from the Appointments Procedure is that there were 40 new starters and or volunteers since February 2014 who have not brought in their DBS certificates for review. This is also one of safeguarding concerns highlighted in that report. It is of concern, as previously reported in previous reports, that some policies are not being followed and some basic and important control processes are not being completed or checked sufficiently. As this has been a theme across a number of Internal Audit reports during the year it is likely that the Head of Internal Audit’s opinion for 2014/15 is likely to be that only ‘Limited Assurance’ can be given to the Trusts’ control environment. Action plans for all of these audits are or have been agreed with management. The Committee will, as a matter of ongoing scrutiny, monitor the implementation of the action plans as reported to each of its meetings by Internal Audit. It will be a matter of concern to the Board that too many aspects of the Trusts’ control environment is in need of improvement.

2.0 Financial Implications (including Workforce Effects)

2.1 A weak control environment is potentially a problem for the management of the Trusts’ resources including its’ finances and workforce. It is clearly essential that the Trust operates a sound system of governance in all aspects of its work.


3.1 Of the three Internal Audit assessments completed this year, Complaints has an opinion of ‘substantial’ assurance, safeguarding ‘requires improvement’ and clinical supervision is ‘insufficient’ with an overall domain opinion likely to be ‘requires improvement’ at the year end. This is the same as last year for this domain. This would suggest concerted action is needed.

4.0 Equality Implications

4.1 There are no direct equality implications of this report although the lack of insufficient appointment controls on DBS checks could potentially put vulnerable people at risk and raise safeguarding issues.


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5.1 The risks posed by some of the control weaknesses raise concerns about the Trust governance arrangements which could impact on the achievement of Trust objectives. Action plans are either in place or are being developed to address these weaknesses.

6.0 Recommendations

6.1 The Board are asked to note the content of this report and the ongoing scrutiny the Committee will provide in monitoring the improvements identified.

John Brierley Non-Executive Director and Chair of the Audit & Risk Committee

Board of Directors-Public - 26February 2015-CF Chair’s report

Version 1.0

Author: Stuart Smith Department: Non-Executive Director




Title of Report: Charitable Funds Committee Chair’s Report



Author: Stuart Smith – Non-Executive Director

Director: Stuart Smith – Non-Executive Director

Executive Summary: Charitable Funds Committee – 9th February 2015 Stuart Smith stood in for Graham Creelman and took the opportunity to extend a vote of thanks to Graham for his considerable efforts in taking forward the Charitable Funds agenda. Graham retires as a NED and Chair of the Charitable Funds committee at the end of February. Adrian Stott will be the new chair of the Charitable Funds committee. As part of the ongoing search for a viable way forward with the Beccles Hospital legacy (c.£1.251m) members of the committee (including Kate Gill) are due to meet with the Chair of the Friends of Beccles Hospital soon. The total balance of Charitable funds at the bank was £1.784m as at 31 December 2014. Income for the period April to December 2014 was c.£160k with expenditure at c.£68k. Three large donations were received during this period comprising of £98k to Newmarket Hospital, £19k from the League of Friends and £10k for Chatterton House. A bid from Suffolk Mind and Quay Place was considered and upon the condition that the intention is to write, produce, perform and workshop an original play with a mental health component using co-production and recovery orientated techniques a contribution will be made.

Recommendation The Board of Directors notes the contents of this report. Stuart Smith Non-Executive Director


O Item: 15.30vi

OD&W Chair’s Report – BoD 26th

February 2015 Version 1.0

Author: Brian Parrott Department: NED

Page 1 of 3 Date produced: 30th January 2015 Retention period: 30 years



Title of Report: OD & Workforce Committee Chair’s Report


Estimated time: 5 mins

Author: Brian Parrott: Non-Executive Director

Director: Brian Parrott: Non-Executive Director

Executive Summary

The OD & Workforce Committee met on 28th January 2015. This report highlights the issues that need to be brought to the attention to the Board of Directors.

1.0 Introduction

The Committee adapted its usual agenda in view of the absence of Leigh Howlett and any of the senior workforce managers to focus time on a valuable and broad ranging discussion about (a) Medical (b) Nursing & AHP workforce and education matters without the benefit of written reports. The other item was the regular review of Workforce performance management information.

2.0 Medical Workforce and Education 2.1 Detailed clarification was sought about progress in achieving a robust appointment

process for both permanent and locum Consultant Psychiatrists. Progress has been made in just recent days involving the new Medical Director, Peter Jefferys and Sarah Rowe. It is expected that a clear defined systematised process will be mapped out over the next two weeks, be agreed between Bohdan Solomka, Leigh Howlett and the two Directors of Operations, with advice from Peter Jefferys, and then be made available to the next OD&WC committee. It was also confirmed that all permanent Consultant appointment panels should be chaired by a NED. If this is not possible the Trust Chair will be advised before any alternative arrangements are agreed. The Medical Director also assured the Committee that following a recent incident, candidates for consultant posts and locums coming into the Trust now have greater scrutiny around their past history.

2.2 The committee considered the number and location of Consultant vacancies (and

potential vacancies) in some detail. There is cause for serious concern about West Norfolk, with potential knock-on implication for the Deanery (now HEEoE) view of the locality's fitness for medical training. Urgent consideration is being given, including by the Medical Director and Director of Operations as to how best to address this.


P Item: 15.30vii





2.3 It was encouraging that the November Health Education East of England (HEEoE) visitors had been reassured about previous areas of concern. However, there are continuing potential causes for concern: for example, ensuring the benefit of the recent changes to the medical staffing function in HR designed to respond more effectively to medical staff's need, booking of study leave, supervision of junior trainees, mandatory training for Consultant and Specialty doctor appraisals, stat/man training for other doctors, and recent concerns expressed by some UEA medical undergraduates.

2.4 It was agree that outcomes of actions on the most important points (above) would

be reported to the next (March) meeting of the OD&WC. There would be fuller consideration in May with Dr Stephen Jones, Core Programme Director invited.

3.0 Nursing Workforce and Education 3.1 The Committee warmly welcomed Dawn Collins as the new Deputy Director of

Nursing with her responsibilities (delegated directly from the Director of Nursing) for all non-medical (including Nursing, OT, Psychology and other) education and development, professional standards and practice. She was supported by the Committee in wanting to address quickly some of the most immediate issues she highlighted to the committee and was asked to present a report to the next meeting. She would present a critical overview as an experienced newcomer to the role in NSFT. It would state what she considered as priorities, and those things, given all the current pressures, which were not.

3.2 The Chief Executive was asked by the committee to set out more fully his

demarcation of Executive responsibilities for (i) the OD & Workforce functions which were now the responsibility of Jane Sayer/Dawn Collins and (ii) the HR & Workforce functions which were the responsibility of Leigh Howlett. The Committee hoped that there would be no dual accountability or risk of ambiguity. It was agreed that in advance of the next meeting there will also be an OD&WC planning meeting of the Chair, Leigh Howlett and Dawn Collins together, perhaps with some others (e.g. Tim Newcomb) if available. Lucy Want will arrange.

3.3 More particularly, concern was expressed about the Trust's preparedness for two

Nursing and Midwifery Council visits in February, one across the Trust's whole area, the other focused on UEA which would also involve the Trust. It would be the first such visit since 2012. They would probably want to use the CQC report as a basis for some of their review. There might be concerns expressed about the NSFT mentor register, quality assurance rating level and approach to moderating nurse revalidations. The strong suggestion was made that the latter should be tied more directly to appraisals. Dawn Collins would be working with senior nursing colleagues to prepare as necessary.

3.4 The Committee felt it is important for the future that the OD&WC (and the Trust

Board as a whole) ensures, and appears to staff to be ensuring, that all the clinical professions represented in the Trust's employment or secondment arrangements are (and feel) appropriately valued and respected. There might be need to review the balance between professionally specialist and generic job descriptions. The committee chair emphasised a request that the new Deputy Director have early conversations about occupational therapy.





4.0 Workforce Management Performance Information 4.1 The workforce information presented to the Committee went part way to

highlighting, on the front page, the 5 (now 6) priority metrics - staff engagement, net recruitment - including clinical/corporate roles separately identified, turnover, sickness, appraisal and stat/man training, as requested at the last meeting by the Chief Executive. These are the elements central of the Trust's progress on improving staff morale and staff engagement generally. It is important that all can see how and where good progress is being made (or not). From the next meeting onwards one locality manager (by rotation) would be asked to attend to describe the progress being made locally on improving staff engagement.

4.2 The Committee welcomed a number of improvements in the headline figures for

vacancy levels, turnover and sickness - and the efforts which have clearly been made in localities/specialist services and corporately. Notwithstanding this, however, Committee members drew attention to: - the need to ensure that the targets set are benchmarked against comparable MH Trusts and are sufficiently challenging, - the question of how targets would be set for 2015/16 and the expectation that the Committee would be invited to comment at its next meeting, - graphs which showed a relatively flat line because of the extended axis range. If the latter were to be reduced it would be easier to identify actual significant movements up or downwards, - the considerable variation between localities/specialist services positions on sickness absence improvement over recent months, both absolute % and % change. Directors of Operations recognised the need to focus in detail on the way sickness absence was being addressed in different places and in different teams, - improvements in relation to appraisal, stat/man training and length of time to recruit, but that significantly more needs to be achieved, - in relation to stat/man training, the early planned review of statutory requirements, quantity of time required for training and priorities was welcomed. Dawn Collins was encouraged to be as ruthless as professionally appropriate in recommending reductions. This was a matter for the Executive team to come to a view about before any further OD&WC view is sought.

5.0 Next meeting

5.1 A revised date of Monday 16 March 2.00 - 4.30 in Ipswich was agreed. Lucy Want will consult urgently before dates are resolved for the rest of 2015. Future meeting agendas will include an explicit item on the Board Assurance framework, items 1 & 4.

Brian Parrott Non-Executive Director, Chair of OD&W Committee 28

th January 2015

unconfirmed minutes of the board of directors – public ... · page 1 of 10 date produced: 26 jan...

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