AGENDA - Pennine Care NHS Foundation Trust BOARD OF DIRECTORS PART I Wednesday 27 April 2016 To be held in the Boardroom, Ground Floor, Pennine Care Trust HQ, 225 Old Street, Ashton-under-Lyne,

AGENDA

BOARD OF DIRECTORS PART I Wednesday 27 April 2016

To be held in the Boardroom, Ground Floor, Pennine Care Trust HQ, 225 Old Street, Ashton-under-Lyne, OL6 7SR, commencing at 9.30 am

Presented by:

1. Apologies for Absence

Keith Walker, Michael Livingstone JS

2.

Declarations of Interest

Against any items contained within the agenda JS

3. Previous Meeting of the Board of Directors

3.1 Minutes of a meeting of the Board of Directors held on 30 March 2016 (PI) JS

4. Matters Arising and Action Plan

4.1 Action plan arising from meetings of the Board of Directors 4.2 Community teaching update 4.3 Investigation into the care and treatment of a service user

JS IT HT

5. Strategy

5.1 Chief Executive’s update: April 2016 5.2 Technology Steering Group highlight report: April 2016 5.3 Operational Plan 2016/17

MMc MR JT

6. Quality Governance

6.1 Implementation and development of Pennine Care NHS FT performance and assurance systems 6.2 Monthly performance highlight report: March 2016 6.3 Mental Health and Community Health Governance report: March 2016 6.4 Inpatient Quality Matrix (IQM) heat map 6.5 Freedom to Speak Up Guardian 6.6 Finance and performance dashboard: Mar 2016 6.7 Accounts preparation: Going Concern basis 6.8 Q4 2015/16 governance submission 6.9 Statutory registers report 2015/16 6.10 Naming of the Trust’s Charity

MMc EDs HT IT IT MR MR MMc MMc LB

7. Audit Committee

7.1 Highlight report and minutes from a meeting of the Audit Committee held on 16 March 2016

TB

8. Council of Governors

8.1 Council of Governors Terms of Reference JS

9.

Other Reports

9.1 Information circulated to Board since last meeting JS

10. Any Other Business

11. Patient story IT

12. Questions

At the Chairman’s discretion, questions may be invited from public attendees in relation to items on the agenda

Date and time of next meeting

The next meeting of the Board of Directors will take place on Wednesday 25 May 2016 in the Boardroom, Ground Floor, Pennine Care NHS Foundation Trust Headquarters, 225 Old Street, Ashton-under-Lyne, commencing at 9.30 am.

Exclusion of Press and Public: that publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted and that the public be now excluded

Minutes

Board of Directors Wednesday 30 March 2016 at 9.30 am Boardroom, Trust Headquarters PART I Present: John Schofield Chairman Michael McCourt Chief Executive Martin Roe Executive Director of Finance / Deputy Chief Executive Keith Walker Executive Director of Operations Ian Trodden Executive Director of Nursing and Healthcare Professionals Henry Ticehurst Medical Director Judith Crosby Director of Service Development and Sustainability Julie Taylor Director of Business Development Robert Ainsworth Non-Executive Director Joan Beresford Non-Executive Director Tony Berry Non-Executive Director Keith Bradley Non-Executive Director Michael Livingstone Non-Executive Director Paula Ormandy Non-Executive Director Sandra Jowett Non-Executive Director In attendance: Louise Bishop Trust Secretary Helen Taylor Communications Officer Dil Jauffur RHSD Directorate Manager Lindsey Baucutt Unit Manager, Specialist Services Governor representative: Dr My Staff Governor, Medical and Dental 1. Apologies for absence No apologies were received. 2. Declarations of interest There were no declarations of interest.

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3. Previous meeting of the Board of Directors 3.1 Minutes from a meeting of the Board of Directors

The Chairman presented the minutes from a meeting of the Board of Directors (PI) held on 24 February 2016 to the Board for approval. The minutes were approved as an accurate record.

4. Matters arising and action plan 4.1 Action plan arising from meetings of the Board of Directors

The Chairman presented the action plan arising from meetings of the Board of Directors to the Board for approval. The Board approved the action plan. With regards to item five on the action plan, community teaching, Mr Trodden advised that he would provide an update at the next meeting on discussions with the University of Manchester, Manchester Metropolitan University, and University of Salford.

5. Strategy 5.1 Chief Executive’s update: March 2016

Michael McCourt provided a verbal Chief Executive’s update for March 2016 to the Board for assurance. Mr McCourt reported on the series of communications to engage the organisation on its mental health strategy, integrated business plan (IBP), and Manchester Mental Health and Social Care NHS Trust (MMH&SCT). The Trust recognised the importance of engaging and involving staff in what was happening across the organisation. Arrangements were also being made for Mr McCourt and Dr Ticehurst to meet with the consultant psychiatrics regarding the mental health strategy and Manchester bid. The process to recruit to a substantive HR Director was underway and at the shortlisting stage. Interviews were scheduled for 18 April 2016. Further to Professor Jowett’s enquiry regarding the number of applications received, Mr Walker agreed to check and circulate this information outside the meeting. Mr McCourt added that this post would report to the Chief Executive but be line managed by the Executive Director of Operations. Mr McCourt noted that a letter from Jim Mackey (Chief Executive, NHS Improvement) had been circulated to Board members on 29 March 2016. The letter was a note of thanks to the organisation for its continued focus on financial performance, and maintaining a surplus. The letter would be shared with service, clinical, and professional leads across the organisation – it was important their hard work and the pressures they faced were recognised. Professor Ormandy suggested this could be developed into a positive news story for all staff. Mr McCourt agreed, adding that he would speak with the Communications department to process this proposal.

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Mr McCourt reported that he, Ms Taylor and Mr Berry had met regarding Corporate Social Responsibility (CSR) and were developing a proposal to adopt the GM ‘taking charge’ theme, promoting good health and self care amongst staff and their families. This would be discussed in more detail at the next meeting of the CSR Group as it would need resources to support it. Colin McKinless had completed his final report on the review of business planning / performance management, and would be presented to the next meeting. Mr Walker and his team would now take this project forward. The IPDRs for the Executive team were underway and due to be completed in the next two to three weeks. Mr McCourt met with Colin Scales (CEO, Bridgewater Community Healthcare NHS FT) on 26 February 2016 to discuss the development of local care organisations. Within Devolution GM, the Provider Federation Board had recognised the need for a more robust infrastructure to take its work forward and influence the DGM strategy. This was expected to need dedicated resources working on behalf of providers with shared investment to support this. Further meetings were planned to discuss. Mr McCourt met with Simon Wootton (new Chief Officer, HMR CCG) on 8 March 2016, which recognised past challenges but there was a positive approach to working together in the future. Mr McCourt, on behalf of the Provider Federation Board, spoke at a GM-wide health and social care event on 11 March 2016, and reaffirmed the positive progress made over the last year. Mr McCourt met with Mike Farrar (Independent Management Consultant) on 21 March 2016, who had been appointed as the independent chair of the review of the North East Sector, including the sustainability of Pennine Acute Hospitals NHS Trust. Referring to engagement with universities, Mr McCourt reported that the University of Manchester, Manchester Metropolitan University, University of Salford, and University of Bolton had signed a Memorandum of Understanding to work collaboratively on the provision of graduate and undergraduate training. It was acknowledged these institutions would still develop their own unique selling points and compete for business but, along with Mr McCourt as chair of the GM Local Workforce and Education Group, plus Health Education England; they would come together as a task and finish group to ensure that nursing and healthcare professional training remained attractive in the city region. As an employer, the Trust would also need to consider it arrangements for students, for example income / reward schemes, in order to attract people to future opportunities. The Trust held a positive discussion with Greater Manchester West NHS FT (GMW) and the Trust Development Agency (TDA) on 14 March 2016 regarding the Manchester Mental Health and Social Care NHS Trust (MMH&SCT) bid. Whilst the two organisations would submit competing bids for this opportunity, they agreed to devise a collaborative narrative regarding mental health services across the city region that would be overseen by an independently chaired strategic board. Lord Bradley enquired as to how this strategic board would relate to the DGM mental health strategic board. Mr McCourt responded that he envisaged they would come together as the structures developed.

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The Board noted the update.

5.2 Technology Steering Group highlight report: March 2016

Martin Roe presented the Technology Steering Group (TSG) highlight report for March 2016 to the Board for assurance. Mr Roe reported that the like-for-like roll-out of Paris had been completed in Bury, Oldham, and Specialist Services. HMR and Mental Health were on track for completion by July 2016. TSG discussed the strategy and timeline for the Electronic Patient Record (EPR), which was covered in more detail under item 5.3 of the Board agenda. Dr Ticehurst provided an update on the child health system. The Trust had been informed that NHS Wales was no longer able to support the provision of this system, and organisations would have to find an alternative. Paris did have a child health system but the work involved in the migration of data was significant and, because this work needed to be prioritised, it was impacting on the timescales for the like-for-like roll-out and the implementation of the 'choose and book' system. With regards to the latter, implementation had now been pushed back by a further three months to December 2016 and left the Trust with financial risk exposure amounting to £120k. Mr Roe added that NHS England had advised affected organisations to keep this issue on the risk register. Professor Ormandy enquired if there were any opportunities to utilise the £120k to support work now. Dr Ticehurst advised that this was being explored and could involve, for example, engaging additional staff to support data migration. Drawing attention to the section on Wi-Fi funding, Mr Roe noted that TSG discussed patient internet access to aid recovery, complement treatment, and satisfy a number of external requirements. TSG approved a request for funding to progress this programme. Mr Roe highlighted that Barbara Hoyle (ICT Director) had now retired. An Interim ICT Director, Iain Marsland, was in place under an initial six month contract. Mr Marsland would be assisting the Trust to develop its five-year IT Strategy, part of which would be to identify the type of Director needed to take the strategy forward. This strategy was expected to be ready for Board sign off in summer 2016. Dr Ticehurst added that the development of the strategy would also include consideration about the role and function of Performance and Information, and how all these support services might be brought together as part of an overall strategy. The Board noted the report.

5.3 Electronic Patient Record Strategy 2016-2018

Henry Ticehurst presented the Electronic Patient Record (EPR) Strategy for 2016-2018 to the Board for approval. Dr Ticehurst reported that the EPR Strategy had been reviewed by the Technology Steering Group, where it was acknowledged that the strategy would require regular review as the organisation flexed and responded to local and national priorities, and the changing landscape of GM devolution. The EPR timeframe in the strategy set out a phased programme for the delivery of a fully functioning integrated clinical system by March 2018. Dr Ticehurst highlighted that the definition of EPR would

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need to be explicit in the IT Strategy to reflect the fact that EPR was about data flows, algorithms of care, and care pathways. In terms of roles and responsibilities, Ian Marsland, the new Interim ICT Director was developing a paper on programme management methodology to ensure the skills required to take this work forward were clearly identified. Mr Marsland was also supporting the development of methodologies that would measure benefits realisation, and in turn this would form part of the EPR Strategy. Mr Roe cautioned against putting names against the roles and responsibilities until the department review was completed. Mr Ainsworth enquired as to what considerations had been given to the compatibility of the Trust’s EPR with the future direction of travel across GM. Dr Ticehurst replied that Mr Marsland had made contact with GMW, which also used Paris, to ensure systems were aligned as much as possible. MMH&SCT had a different system and so, irrespective of who was selected as preferred provider, it would migrate to Paris. The Chairman enquired whether the Trust had a clear picture from across its services of who was on like-for-like Paris, full Paris, and who was using mobile technology. In response, Ms Beresford suggested that it would be helpful for any future EPR updates to develop a dashboard for each DBU so progress against the EPR project could be seen ‘at a glance’. Dr Ticehurst advised that this suggestion would be fed back to Mr Marsland as part of the development of the strategy going forward. Professor Ormandy queried whether this project would be led by an experienced IT manager. Dr Ticehurst agreed that the project manager would need to be experienced in EPR, and these considerations would be picked up as part of the development of the strategy and departmental review. The Board approved the Electronic Patient Record Strategy 2016-2018.

5.4 Trafford Section 75 Partnership agreement

Keith Walker presented the Trafford Section 75 Partnership agreement to the Board for approval. Mr Walker reminded colleagues that the Trafford Section 75 Partnership agreement had been subject to a detailed Board development presentation by Richard Spearing (Interim Integrated Network Director, Trafford) on 16 March 2016. The Board papers contained a copy of the Section 75 agreement that would come into force on 1 April 2016 until 31 March 2018. This was an exciting development for the borough of Trafford through the bringing together of community health and social care services into one all-age integrated model. Pennine Care retained its statutory obligations (as did the local authority), but the Trust would now be responsible for the day-to-day operational management of services under the leadership of a director employed by Pennine Care (post currently occupied by the Interim Integrated Network Director). This director had a duel reporting line to Mr Walker and Jill Colbert (Corporate Director, Trafford Council). Management processes were overseen by the Trafford Integrated Provider Board; whilst the Trust’s quarterly assurance process would change in that the Trafford panel would be jointed chaired between Pennine Care and Trafford Council, and would look at the totality of provision. This would mean the Board would have line of sight of the total outputs of the integrated service. Professor Jowett requested an update on the status of the Integrated Network Director role, as this was not clear from the Section 75 agreement or the presentation at Board development. Mr Walker responded that the post had been appointed to in

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2015 on an interim basis – this was the most appropriate arrangement at the time because of the expediency required in developing the agreement. Mr McCourt added that the process to recruit substantively to this position would need to be developed, but it would be open, transparent, and competitive. Professor Jowett expressed concern that the status of the post was not referred to in the Section 75 agreement, and this might be misleading for people. Mr McCourt clarified that the Section 75 agreement was a stand-alone legal agreement between Pennine Care and Trafford Council; whereas the operational management structure, including arrangements for the lead post, would need to be clearly developed once the agreement took effect. Mr McCourt stressed that this was a significant achievement for the organisation and Trafford Council in that it was the first GM strategic partnership agreement for all-age community health and social care services. The Board approved the Section 75 partnership agreement between Pennine Care NHS FT and Trafford Council. Mr McCourt would sign the agreement on behalf of the Trust on 1 April 2016, and joint communications would follow thereafter.

6. Quality Governance 6.1 Performance and Quality Assurance Committee Terms of Reference

Henry Ticehurst presented the Performance and Quality Assurance Committee (PQAC) Terms of Reference (ToR) to the Board for approval. The ToR were discussed at PQAC on 23 February 2016. The Chairman advised that discussion had taken place in the NEDs pre-meeting regarding the quorum for the Committee (currently set at five), and that it did not include the requirement for a NED. Ms Bishop agreed to revisit this point, to ensure there was consistency across the ToR for other Board committees. Subject to the above amendment, the Board approved the ToR for the Performance and Quality Assurance Committee. The updated ToR would be circulated to Board outside the meeting.

6.2 Monthly performance highlight report

Michael McCourt presented the monthly performance highlight report to the Board for assurance. The report was circulated to Board members on 29 March 2016. Mr McCourt reminded colleagues of the progress made in improving the overall performance and assurance system. One of the areas that had needed to be strengthened was oversight by the Executive team – this was being addressed via the enhanced scrutiny of performance at the formal EDs business meeting every month. In terms of the issues highlighted in the report, Ms Crosby drew attention to information governance (IG) training compliance, which attracted a 95% target. Previously there had been a degree of latitude, with compliance expected over a reasonable period, which the Trust took to be three years. The requirements had now changed and the Trust was expected to be compliant with the IG training target by 31 March 2016. This meant that a large number of staff had to be trained in a very tight timeframe.

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Ms Crosby, Mr Walker, and members of the IG team had met to discuss and agree a process to achieve compliance across the Trust by the end of March 2016, which included paper-based training exercises because of the issues of access to computers for some people in wards and community teams. As of 24 March 2016, the compliance level was 88%; and by 30 March 2016 it was 94.3%. Work continued to improve the figures further. Mr McCourt added that the immediate issue was to address the required compliance levels but following on from this there would be a review of systems in order to learn from this experience, and ensure there was an appropriately phased approach to training going forward. Professor Jowett enquired as to the extent the issue was about access to equipment. Ms Crosby replied that the high volume of people requiring training in March did put pressure on the electronic system and, for example in ward environments, it was difficult for people to do individual e-learning. Some areas had therefore found it beneficial to undertake training in a team meeting, and so the Trust would look to adopt this as one of its methodologies for training in the future. The Board noted the report.

6.3 Mental Health and Community Health governance report: February 2016

Henry Ticehurst presented the Mental Health and Community Health Governance dashboard for February 2016 to the Board for assurance. Referring to the mental health dashboard, Dr Ticehurst noted that there had been one homicide case in the reporting period. This case related to an incident in Bury whereby a mother and adult daughter were assaulted, which resulted in one death and one serious injury. The alleged assailant had been referred to Trust services. An internal investigation was currently underway. Mr Trodden reported on a Regulation 28 letter, received from the Coroner on 29 February 2016. The case related to SG, who had informal stays on the ward in October and November 2014. SG had a history of anxiety, obsessive compulsive disorders, depressive traits, and suicide ideation. Upon discharge from the ward, SG took her own life and was found the following day. The Coroner’s R28 letter set out a number of concerns about the care and treatment of the patient, including the response to the ward team in terms of SG’s risk profile, and concerns about communication between the ward and family. Mr Trodden and Dr Ticehurst had met with SG’s brother to offer the Trust’s condolences; apologise on behalf of the organisation; and discuss his concerns, particularly in relation to engagement with the family and how this could have been improved, and the family’s concerns about the conduct issues of two nurses and their perceptions about the behaviour of the Consultant Psychiatrist in the court environment. Two nurses involved in this case had been referred to the NMC by the Coroner. During the inquest fresh evidence came to light from a transcript between the police and a nurse, of which the Trust was unaware. This nurse was subsequently suspended pending a full investigation. A second nurse was alleged to have made unprofessional comments and, although this could not be proved, the Coroner had referred the individual to the NMC. Mr Trodden added that neither of these nurses had previously been subject to fitness to practice concerns or complaints. In addition to the formal processes referred to above, Mr Walker was commissioning a piece of psychologically-based organisational development work / cultural support

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for the locality – it was hoped this model would also be appropriate for replication in other boroughs. Mr Livingstone queried the Trust’s assessment of its own review process in light of the Coroner’s findings. Dr Ticehurst replied that the alleged unprofessional comments by a nurse had been investigated as part of the internal review; however the recording by the police was not known about until it was submitted as evidence in court. Referring to safeguarding, Dr Ticehurst noted that there were two cases involving young people – one in Trafford and one in Rochdale – that were subject to investigations. The Specialist Services DBU was working in partnership with Papyrus, a national charity for the prevention of young suicide; and a programme had been initiated in Tameside and Glossop, and Stockport, whereby young people would undertake suicide prevention training and raise awareness in their communities. With reference to the community services dashboard, Dr Ticehurst commented on slips, trips, and falls, plus pressure ulcer reporting; adding that the majority of cases were low graded and the reporting culture remained healthy. The Board noted the report.

6.4 CQC preparation: Board update

Ian Trodden provided a verbal update on CQC preparation to the Board for assurance. Mr Trodden reported that the Trust had made two information submissions to the CQC thus far, and third evidence request was expected in due course. A Board development session was planned for 13 April 2016 regarding the CQC assessment process. A number of mock inspections had taken place in services across the organisation, the findings of which will be collated into themes / hotspots. The communications plan for the inspection was currently being reviewed to ensure there was an appropriate balance of information for, and engagement with, services. In terms of logistics, the inspection start date was 13 June 2016 however some activities, such as focus groups, were expected to take place before this date. The logistical plan was in the process of drawn up, and would be shared with Board at a Board development CQC update session. The Board noted the update.

6.5 Finance and Performance dashboard: February 2016

Martin Roe presented the Finance and Performance dashboard for February 2016 to the Board for assurance. Mr Roe reported that, as at month 11, the Trust had a year-to-date underspend of £2,234k against a budget of underspend of £1,515k. The end-year forecast was a surplus of £679k, which equated to 0.24% of Trust income. The combined CIP target for 2015/16 was £7,604k, all of which had now been achieved recurrently. A Board development session on 23 March 2016 provided a detailed review of next year’s plans, including the CIP requirement of £9m – of which £3.3m related to the loss of contribution to overheads.

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With regards to performance, ‘CPA (adults) having a formal review within 12 months’ was currently at 92% against a target of 95%; however the target was expected to be achieved by year-end. Work continued in relation to the achievement of the new IAPT targets. Professor Jowett enquired as the actual numbers involved in the CPA target. Mr Walker agreed to clarify this outside the meeting. Further to Ms Beresford’s enquiry about the new CPA policy, Mr Walker advised that this was now in place but it was too soon to see an impact; adding however that work had been undertaken to improve the process elements around CPA recording, although the fluctuations experienced with this target were most likely due to work flow and the prioritisation of work within the quarter. Referring to the new IAPT targets, Mr Walker clarified that although these were Q4 targets, not all commissioners had invested in 2015/16 to achieve these targets – some funding would not be available until 1 April 2016. The Board noted the report.

6.6 Monitor confirmation of Q3 2015/16 feedback

Michael McCourt presented Monitor’s confirmation of Q3 2015/16 feedback to the Board for assurance. Feedback confirmed that the Trust had a financial sustainability risk rating of ‘four’ and a governance rating of ‘green’ in the reporting period. The Board noted the report.

6.7 Agency: TDA and Monitor requirements

Keith Walker presented a report on the Trust Development Agency (TDA) and Monitor requirements regarding agency usage to the Board for assurance. Mr Walker reminded colleagues that Monitor and the TDA issued guidance in autumn 2015 regarding controls on agency expenditure. Technically, the guidance applied to those trusts receiving support or in breach of their licence for financial reasons; however Pennine Care decided to work in the spirit of the guidance. There were three areas of control in place: mandatory use of frameworks, price caps, and an expenditure ceiling. With regards to the mandatory use of frameworks, action had been taken to significantly reduce the use of off-framework agencies. In the last three months, only nine shifts within nursing had been worked off-framework (compared to 270 shifts between September and November 2015). In terms of price caps, there were on-framework agencies that did not comply with the price caps – this was a national issue recognised by Monitor / TDA whereby some agencies were refusing to support the agency rules. The Trust applied a ‘tiered’ system – tier one framework agencies were the preferred providers because they complied with the price caps; tier two framework agencies did not comply with the price caps however they could not be removed from the booking system because the tier one agencies alone could not meet the Trust’s demand. Tier two agencies currently accounted for approximately 25% of agency usage. Monitor was taking

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further action from 1 April 2016 in relation to the price caps, and agencies that did not comply with the price caps would be subject to a formal process – at the end of this process the agencies would either be off-framework or comply with the price caps. The final area of control was expenditure – a target of 4% (as a percentage of total nursing staff expenditure) for 2015/16 was set. Performance was currently at 3.9%. Referring to the data in the report, the Chairman commented on agency usage for Allied Health Professionals (AHPs) and enquired if this meant that there were not enough of these posts on the bank. Mr Walker acknowledged that the majority of developmental work with the bank in recent times had been for nursing posts; however the work patterns of AHPs reduced the ability of substantive staff to undertake extra hours (as opposed to the 24/7 nature of ward environments), and so the number of AHPs able to work on the bank was not sufficient to meet the Trust’s needs. Ms Crosby added that there were also wider national and regional issues of skills shortages and reduced numbers in training within AHP disciplines. Mr Roe noted that the Trust’s plans for 2016/17 included a CIP requirement relating to agency spend of £1m, which was borne out of national guidance and the Trust’s more effective use of the bank. The latest development on this issue was for Monitor to write to trusts with a proposal that included all agency staff, including locums, into a ceiling for 2016/17. For Pennine Care, the allocated ceiling was £7.8m; however given that forecast total agency expenditure for 2015/16 was £13.4m, the organisation considered the ceiling unrealistic. The Trust was trying to clarify the status of this target, given that the original targets in 2015 were mandated for organisations in deficit or subject to special measures and only advisory for trusts such as Pennine Care. An appeal against this target, which it was in the process of pulled together, would be submitted by 31 March 2016. The Board agreed to this approach, adding that whilst the organisation was committed to reducing agency expenditure, any target had to be realistic in the context of how it managed and maintained quality and safety as part of its workforce strategy. Professor Jowett noted the useful information in the report regarding the breakdown of nursing agency spend by DBU, and requested that this kind of information be provided across all other disciplines. Mr Walker agreed to circulate this information outside the meeting.

The Board noted the report. 6.8 Board self-assessment of collective performance: March 2016

Louise Bishop presented the Board’s self-assessment of collective performance as at March 2016 to the Board for approval. Ms Bishop reminded colleagues that foundation trust boards were expected to assess their performance annually, in line with the Monitor Code of Governance. Pennine Care had chosen to assess its performance against the provisions in the Code of Governance, and the report set out the requirements, the evidence against them, actions to address gaps, and the applicable ‘red / amber / green’ rating. When the exercise was carried out in 2015, the overall compliance score was 94% against 107 indicators. There were two ‘red’ rated areas. The first related to a statement of the responsibilities between Chairman and Chief Executive. This had since been developed and approved; hence this area was now ‘green’. The second ‘red’ provision concerned Governor and member engagement. The Trust had a

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Patient Experience Strategy however there was a risk that the focus on Governors and members might be lost if it was subsumed into this strategy. The matter had been discussed by the Executive team, where it was agreed that the Chief Executive would be the lead for all engagement. Ms Bishop, Zoe Molyneux (Associate Director of Quality Governance) and Kathleen Dixon (Communications and Marketing Manager) were to meet in April 2016 to ensure Governor and member engagement was highlighted as it should be going forward. This provision had now changed to an ‘amber’ rating. The self-assessment exercise had been revisited, and the performance rating was now 98%. The Board approved the contents of the report.

7. Audit Committee 7.1 Feedback from a meeting of the Audit Committee held on 16 March 2016

Tony Berry provided verbal feedback from a meeting of the Audit Committee held on 16 March 2016 to the Board for assurance. Mr Berry reported that the Committee received the results from a meeting feedback exercise conducted following the December 2015 meeting. This exercise would be conducted twice a year. The Committee received two detailed presentations regarding controls, systems and process – one for safeguarding, and the other for contracts. External audit provided an update on their workplan, and the Committee discussed the criteria for the value for money conclusion. The timetable for the annual accounts was noted, as was progress in relation to quality account indicator testing. KPMG presented progress updates in relation to the internal audit plan and counter fraud. The Committee approved the Internal Audit Charter plus the Counter Fraud Strategic and Operational Plan for 2016/17. The next meeting of Audit Committee would take place on 20 May 2016. The Board noted the update.

8. Council of Governors 8.1 Draft minutes from a meeting of the Council of Governors held on 2 February 2016

The Chairman presented the draft minutes from a meeting of the Council of Governors held on 2 February 2016 to the Board for information. The Chairman noted the Council’s enquiries regarding the provision of autism services by the Trust, advising that a development session was scheduled on 10 May 2016 for the Governors on the topic, which would be facilitated by Clair Carson (Assistant Director of Operations, Mental Health) and Jeremy Bentham (Clinical Manager). The Board noted the contents.

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9. Other reports 9.1 Briefing from a meeting of the Board Appointment and Remuneration

Committee held on 24 February 2016 The Chairman presented a briefing from a meeting of the Board Appointment and

Remuneration Committee held on 24 February 2016 to the Board for assurance. The Board noted the report. 9.2 Fit and Proper Persons guidelines Louise Bishop presented the Fit and Proper Persons (FPP) guidelines to the Board

for ratification. Ms Bishop reported that the FPP guidelines had been reviewed and discussed at the

Board Appointment and Remuneration Committee (ARC). The guidelines set out how the Trust would demonstrate FPP requirements; there was a code of conduct and declarations that Board members were expected to sign. There had only been one minor change to the guidelines submitted through ARC, which was to clarify that ‘any offence’ did not include driving offences.

The Board ratified the FPP guidelines.

9.3 Information circulated to Board since last meeting The Chairman presented a schedule of information circulated to the Board since the

last meeting.

The Board noted the report. 10. Any other business 10.1 Quality Strategy Mr Trodden noted that the Trust was currently reviewing its Quality Strategy. It was

continuing to support the ‘sign up for safety’ campaign; lead on suicide prevention work; and progressing with collaborative care planning and carer engagement in mental health and community services. The strategy would be reviewed by the Quality Group, and was expected to be presented to Board by summer 2016.

11. Patient Story Dil Jauffur and Lindsey Baucutt were in attendance to present a patient story. Mr Jauffur explained that the patient story had come about due considerations about

how to respond to the Friends and Family Test. The Rehabilitation and High Support Directorate (RHSD) held a series of focus groups with patients to gather information about their experiences, and this had helped to inform a new model for capturing patient experience.

Ms Baucutt provided background to the Tatton Unit, situated on the Tameside

General Hospital site. The unit opened in 2013 for males of adult age requiring a long-term low secure service. The cohort of patients comprised of people that had spent long periods of time in secure services and required long-term pathways. They

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could not be discharged due their risk profiles but could be cared for in a low secure environment. The aim of the unit was to deliver patient-centred rehabilitation by working closely with patients and their families. The multi-disciplinary team on the unit proactively supported service users with reintegration into local communities, with the goal of stepping them out of secure services.

Ms Baucutt described the story of patient ‘R’. ‘R’ was asked three simple questions

about his time on the unit, and his responses provided a wealth of information about patient experience such as the benefits of psychological therapies, group and individual therapeutic activities, plus medication. ‘R’ had been able to make friends, improve the relationship with his mother, and take leave away from the ward. His care and treatment had enabled him to better understand his feelings and symptoms, change his way of thinking and the way he used his time, utilise skills and techniques to manage difficulties, and make plans for the future. Overall ‘R’ was very positive about his experiences on the ward and the help he had received.

Mr Jauffur noted that the next step for ‘R’ would be a plan for discharge. Of the 16

patients that were admitted to the unit when it opened, five had been discharged in less than two years – this was a significant achievement for secure services, and the NHS England were interested in learning from the unit about stepping patients down though the pathway.

Mr Ainsworth enquired whether the levels of therapeutic interventions described were typical for RHSD. Mr Jauffur replied that all services in RHSD had access to psychological and occupational therapies, providing a range of activities. The minimum was 25 hours of activity per patient per week – this was difficult to record so at least once a year the directorate held a quality event to share narratives and patient stories. Professor Ormandy commented that the Trust-wide Patient Experience Steering Group was scoping out the range of ways services captured patient experience, adding that it was important the RHSD approach was described along with the impact it had made. Mr Jauffur added that the Specialist Services DBU were due to meet with Zoe Molyneux (Associate Director of Quality Governance) to discuss how patient narratives could be shared with other areas. The Board thanked Mr Jauffur and Ms Baucutt for sharing this patient story.

12. Questions No further business was discussed. 13. Date and time of next meeting The next meeting of the Board of Directors will take place on Wednesday 27 April

2016 in the Boardroom, Ground Floor, Pennine Care NHS Foundation Trust Headquarters, 225 Old Street, Ashton-under-Lyne, commencing at 9.30 am.

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ACTION SHEET PI Schedule of actions arising from meetings of the Board of Directors ACTION NO.

AGENDA ITEM DATE ADDED (BOARD MEETING)

ACTION REQUIRED FOR ACTION BY (TITLE)

FOR ACTION BY (DATE)

STATUS/PROGRESS

1. PI (5.4) Update on Paris PI (5.2) Update on Paris implementation PI (5.2) Paris update: Technology Steering Group highlight report PI (5.2) Technology Steering Group highlight report: June 2015

23 Dec 2014 28 Jan 2015 25 Feb 2015 29 July 2015

Monthly highlight report from the Technology Steering Group to be presented to Board. Exceptions against the monthly plan to be built into future reports.

Executive Director of Finance / Deputy Chief Executive. Executive Director of Operations / Medical Director / Executive Director of Nursing and Healthcare Professionals

Ongoing Ongoing Monthly updates to Board since January 2015. Next update in April 2016, agenda item 5.2.

2. PI (5.2) Technology Steering Group highlight report: October 2015

28 Oct 2015 EPR project and resource plan to be presented to Board in March 2016.

Medical Director / Executive Director of Nursing and Healthcare Professionals

Mar 2016 Complete EPR Strategy presented to Board in March 2016.

3. PI (4.1) Action plan arising from meetings of the Board of Directors

28 Oct 2015

Draft People and OD Strategy to be presented to Board.

Executive Director of Operations

April 2016 Pending Progress update to be presented to April Board, agenda item 5.3.

15

4. PI (5.1) Chief Executive’s update: October 2015 PI (4.2) Community teaching update PI (4.1) Action plan arising from meetings of the Board of Directors

28 Oct 2015 27 Jan 2016 30 March 2016

Further information on the Trust’s proposals to become a community teaching trust to be presented to Board.

Executive Director of Nursing and Healthcare Professionals

April 2016 Pending Update provided to Board in January 2016. Further update scheduled for Board in April 2016, agenda item 4.2.

5. PI (6.2) CQC preparation: Board update

22 Dec 2015 Monthly updates to Board. Medical Director / Executive Director of Nursing and Healthcare Professionals

Ongoing Ongoing Monthly updates to Board from January 2016. Additional Board development session scheduled for 27 April 2016.

6. PI (5.1) Chief Executive’s update: March 2016

30 March 2016 Number of shortlisted applications for HR Director post to be confirmed with Board.


April 2016 Complete Update circulated to Board on 14 April 2016.

7. Communication to staff regarding Jim Mackey’s letter to Pennine Care to be developed.

Chief Executive April 2016 Complete News story circulated at the beginning of April 2016.

8. Colin McKinless’ final report on Business Planning and Performance Management to be presented to Board.

Chief Executive April 2016 Pending Report to be presented to Board in April 2016, agenda item 6.1.

9. PI (5.2) Technology Steering Group highlight report: March 2016

30 March 2016 IT Strategy to be presented to Board. Medical Director Summer 2016 Pending Strategy to be presented to Board in summer 2016.

10. PI (6.1) Performance and Quality Assurance Committee Terms of Reference (ToR)

30 March 2016 Updated ToR to be circulated to Board.

Trust Secretary April 2016 Pending Updated ToR to be circulated to Board in due course.

16

11. PI (6.4) CQC preparation: Board update

30 March 2016 Logistical plan for CQC inspection to be shared with Board.

Executive Director of Nursing and Healthcare Professionals

May 2016 Pending Plan scheduled for presentation at Board development on 18 May 2016.

12. PI (6.5) Finance and Performance dashboard: February 2016

30 March 2016 Numbers relating to ‘CPA (adults) having formal review within 12 months’ to be confirmed with Board.


April 2016 Complete Information circulated outside Board on 21 April 2016.

13. PI (6.7) Agency: TDA and Monitor requirements

30 March 2016 Breakdown of agency spend by discipline to be shared with Board.


April 2016 Pending Information to be circulated outside Board.

14. PI (10.1) Any other business: Quality Strategy

30 March 2016 Refreshed Quality Strategy to be presented to Board.

Medical Director / Executive Director of Nursing and Healthcare Professionals

Summer 2016 Pending Strategy to be presented to Board in summer 2016.

15. PII (10.2) Investigation into the care and treatment of MD PII (4.2) Investigation into the care and treatment of MD

24 Feb 2016 30 March 2016

Further update and action plan to be presented to Board.

Medical Director April 2016 Pending Verbal updates provided to Board in February and March 2016. Report to be presented to PI Board in in April 2016, agenda item 4.3.

16. PII (5.1.2) Operational Plan 2016/17

30 March 2016 Summary version of the 2016/17 Operational Plan to be presented to PI Board.

Director of Service Development and Sustainability

April 2016 Pending Plan to be presented to Board in April 2016, agenda item 5.4.

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Report to the Board of Directors Wednesday 27 April 2016 Part I

Chief Executive Report: April 2016

Author Michael McCourt

Chief Executive Corporate Governance

Executive Sponsor Chief Executive Date of Report 19 April 2016 Action Required

The Board of Directors is asked to note the content of the report.

Key issues for Board discussion / approval

To provide an update on activity during the period.

Quality and patient care implications

N/A

Financial Implications N/A Amount of time required on the Board agenda

5 minutes

Report submitted by (if previously considered by a Group/Committee)

N/A

FOI Exemption (PI only) None This paper relates to the following strategic goals/high level targets – select all that apply (see key overleaf): LPC (Put local people and communities first)

LPC1

LPC2

LPC3

SE (Strive for excellence)

SE1

SE2 SE3

SE4

SE5

UR (Use resources wisely)

UR1 UR2 UR3 UR4

PC (Be the partner of choice)

PC1 PC2 PC3 PC4 PC5

GP2W (Be a great place to work)

GP2W1

GP2W2 GP2W3 GP2W4

18

Report to the Board of Directors Chief Executive Update April 2016 Overview Partnership with Trafford Council S75 Agreement was entered into on 1st April 2016 by Trafford Council and PCFT. This is Greater Manchester's first Strategic Partnership Agreement for Integrated All Age Community Health and Social Care Services. Director of Workforce The recruitment process has commenced for the Director of Workforce position within PCFT. CQC Inspection Revised CQC inspection timetable received:

• 31 May to 3 June: announced inspections of community services • 6 June to 17 June: announced inspections of mental health services,

scheduled interviews with key service leads and Board members and scheduled staff focus groups

• 20 June to 3 July: unannounced inspections across community and mental health services

• September/October 2016: outcome report due

HSJ Awards Three PCFT teams have been shortlisted in the HSJ Value in Healthcare Awards. The winners will be announced at the awards dinner in Manchester on Tuesday 24th May.

• HMR Wound Care Team for effectively embedding the Flo messaging system to support patient self-management - telehealth category.

• Oldham Community Services as part of the Urgent Care Alliance for introducing a SPRINT team to improve care for older people – emergency medicine category.

• Psychological Medicines Service for innovation in integration of mental health and physical health – mental health category.

19

Internal Activity The following internal meetings have taken place during the report period:

• Clinical Presence Visit to York House, Stockport Community Mental Health Team (1st April)

• Clinical Presence Visit to the Access and Crisis Team, Stepping Hill (7th April) • Executive Directors Service Development and Sustainability Group (11th April) • Board agenda planning (12th April) • Board Development Session to review MMHSCT procurement and

preparation for the forthcoming CQC inspection (13th April) • Director of Workforce interviews (18th April) • Executive Director IPDRs – throughout the month • Meeting with Executive Directors and Corporate Heads of Department to

review current capacity and workload (19th April)

External The following external meetings and activities have taken place during the report period:

• Meeting to discuss Clinical Leadership with Michael McCourt, Denis Gizzi, Keith Walker, Caroline Drysdale & Henry Ticehurst (31st March)

• Central Manchester Provider Partnership Board (31st March) • Provider Federation Board Support Meeting (1st April) • Meeting to sign Section 75 Agreement with Theresa Grant of Trafford Council

(1st April) • 1:1 meeting with Sir David Dalton, Chief Executive of Salford Royal NHS

Foundation Trust (7th April) • GM Reform Board (8th April) • 1:1 meeting with Gina Lawrence of Trafford CCG (13th April) • Review of NW Leadership Course with Kay Worsley-Cox, Deputy Director NW

Leadership Academy (12th April) • 1:1 meeting with meeting with Karen Howell, CEO of Wirral Community NHS

Trust (14th April) • Greater Manchester Health & Social Care Workforce Engagement Forum

(14th April) • GM NHS Trust Federation Board (15th April) • 1:1 meeting with Stuart North of Bury CCG (15th April) • GM H&SC Strategic Partnership Board Executive (15th April)

20

Recommendations That the Board note the report. Michael McCourt Chief Executive Pennine Care NHS Foundation Trust 20th April 2016

21


Technology Steering Group Highlight Board report (April 2016)

Author Clare Everett

Technology Programme Manager – Mental Health Executive Sponsor Martin Roe

Executive Director of Finance / Deputy Chief Executive Date of Report April 2016 Action Required The Board of Directors is asked to note the contents of the

report. Key issues for Board discussion / approval

The purpose of the report is to provide assurance to the Board on the range of work streams and developments in technology to support service change and transformation. The Board is asked to note the update.


N/A


5 minutes

Report submitted by Technology Steering Group FOI exemption None This paper relates to the following strategic goals/high level targets – select all that apply (see key overleaf): LPC (Put local people and communities first)

LPC1

LPC2

LPC3


SE1

SE2

SE3

SE4

SE5


UR1

UR2

UR3

UR4


PC1

PC2

PC3

PC4

PC5


GP2W1

GP2W2

GP2W3

GP2W4

22

Technology Steering Group Highlight Report April 2016

1. Objective of the Report

This report is intended to provide assurance to the Board on the range of work streams and developments in technology to support service change and transformation.

The priority focus of the Technology Steering Group since March 2015 has been the implementation of Paris. The remit of this group also includes mobile working, assistive technology, off line solutions, interoperability and the organisational development plan to support staff to change, embrace and embed new ways of working.

2. Technology Steering Group Membership The membership of the group was refreshed to ensure that it included key representation from across the Trust. It was acknowledged that membership of the group is likely to require further review following the completion of the IM&T strategy by Channel 3.

23

3. Update from the Information Technology Programme Group The Technology Steering Group received an update from the Information Technology Programme Group, chaired by Keith Walker. This update excludes any items that are also items on the TSG Agenda.

Oldham, Bury and HMR Community Services and Trust Specialist Services have all completed the Paris like-for-like roll out, with Trafford Community Services and Trust Mental Health Services on track for completion on 6th June and 23rd May respectively.

Paris Risks and Issues The current risks and issues are being proactively managed by the programme group, and two new risks have been added:-

• Amber Risk – The PARIS Child Health Module will not be linked to the national Patient Demographic Service (PDS) in time for go live in July 2016 which would risk immunisation and examination appointments being sent to the wrong address and / or scheduled for the wrong GP practice. It is planned to mitigate this risk by batch testing Child Health demographics against the PDS and then manually updating data as necessary. There will be sufficient resource to do this, as the three Child Health teams will be operating a single instance Child Health system.

• Amber Risk – The Paris Child Health data migration is behind plan. The

volume of data errors is significant due to the merging of 3 Child Health systems. Additional resources have been secured. 7 service and system specialist are now assigned to data migration. The Civica system specialists working with the Trust are moderately confident that the task will be completed within the programme timescales.

Bank Staff – Paris Training

A scoping exercise has been undertaken to establish how many Bank staff are Paris trained with a view to providing a solution for how this is funded and managed in the future. More information is being sought from HR and ICT in order to agree the best approach to take on training this staff group.

KS Helper/Optio Notification has been received from the supplier terminating their contract with the Trust following their lack of engagement and support. The Head of Information is progressing this with the supplier in terms of seeking a reimbursement.

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Mobile Working The 12 month forward planner has been developed and illustrates priority areas for roll out of devices. The Trust is seeking reimbursement from Dell to reflect the commonly held view amongst Trust staff that the Dell 10s were not fit for purpose. The Director of ICT is planning to meet with the UK Director for Dell. The Dell 10 will not be completely written off but instead may be directed to other areas where they can be utilised. A meeting has been arranged with KW, IM and JP to agree actions 4. Clinical Standards steering Group update

Currently there is lots of work being done to develop clinical docs in Paris. Concerns have been raised that as a Trust we are not best placed to develop documentation in house, and IM is looking to work with other PARIS Community and Mental Health sites such as GMW to collaborate and ask them to share their developments. There are also plans for IM to visit other long term users of Paris to build relationships and investigate what other developments can be sought out that will reduce the need for the Trust to develop the system from scratch. This approach will then shortcut the delivery time of EPR within PCNFT. Work is being undertaken to investigate the very high number of KPI’s that the trust are currently required to report on and to renegotiate with commissioners to reduce this figure to a more manageable and reasonable level.

5. Child Health System Update Paris Child Health – The programme started late and is supported by users from boroughs as well as product specialists from Civica to work on the data migration and testing. This will help ensure that the project works to time as there is no opportunity to extend. The project has recently also bought in some data cleansing capacity. A BCP is being considered with HSCIC to mitigate against the risk that migration is not achievable A report will be brought to the next Steering Group which will outline the full BCP and associated costings.

EMIS Child Health - EMIS have advised that they cannot migrate all historical data within the timeframe, this may be a show stopper so talks with HSCIC are imperative. An urgent meeting is to take place with the Trafford Service Director and CCG to discuss and progress way forward. 6. Dark Fibre Currently Trust contracts with Virgin for broadband services. IM updated that we have a unique opportunity to put in our own fibre cable to carry broadband services between the Trust’s two data centres, working collaboratively with Tameside Borough Council and New Charter Housing Association. The benefits of having our own fibre

25

are increased speed and reduced annual cost but more importantly it will enable us to ensure continued systems access in the event of a major issue which will mean we are in effect ‘Disaster Proof’. The cost to implement will be 153k which already includes a 50% discount. A business case will be drawn up for Board consideration together with the forthcoming IT Strategy.

7. Paris Connect FundingParis Connect has been purchased and latest version is being installed. Internal meeting planned in April to plan pilot in CCNT Oldham

8. IM&T Update from DEVO MancNew organisation 'GM connect' has been established. They will be looking at IG across Greater Manchester with a view to creating a GM wide information sharing agreement.

The recent NHS Digital Maturity Index compares all NHS organisations. PCNFT came out very weak in comparison to other Trusts. It was highlighted that this does have a positive element as the plan is to invest in the lower performing Trusts in order to bring up to the required standard so investment has been secured.

9. Channel 3 ReportICT Interviews are nearly completed and an outline ICT strategy will be submitted before the end of April. The Information interviews are underway with the Information Strategy planned for May.

Clare Everett Technology Programme Manager – Mental Health

26


Operational Plan 2016/17: Final (redacted) version

Author Heather Bell

Deputy Director of Business Development Executive Sponsor Judith Crosby

Director of Service Development & Sustainability Date of Report April 2016 Action Required

The Board of Directors is asked to note the contents of the report.


Changes made since final draft submitted to March Board meeting (included on page 1).


N/A

Financial Implications Financial planning section included. Amount of time required on the Board agenda

5 minutes


N/A


LPC1

LPC2

LPC3


SE1

SE2 SE3

SE4

SE5


UR1 UR2 UR3 UR4


PC1 PC2 PC3 PC4 PC5


GP2W1 GP2W2 GP2W3 GP2W4

27

Operational Plan 2016-17 Pennine Care NHS Foundation Trust (Pennine Care)

Summary of changes

The following provides a summary of any significant changes to Pennine Care’s Operational Plan since the submission of the draft plan on 8 February 2016:

Plan Narrative:-

• Section 1.0 – addition of Pennine Care’s strategic objectives for 2016-17; • Section 2.1 – updated to reflect updated contractual position and inclusion of

additional detail on the impact of procurement activity on the activity projections; • Section 3.1 has been updated to reflect the refreshed Quality Strategy for the

organisation 2016-18; • Section 3.2 – additional information provided based on Monitor feedback; • Section 4.0 – additional paragraph on Pennine Care’s approach to reducing bank

and agency usage during 2016-17; • Section 5.0 – refreshed section to include current financial planning information.

Financial Template:-

• No significant change to bottom line; • 15/16 figures now final outturn at M12; • Clarified safer staffing levels of funding and associated expenditure; • Updated CIP information to reflect latest position; • Updated contract values to include MH additional funding agreed at contract sign off; • Correction of the activity figures for HMR Community Services to reflect the loss of

several services from mid-May 2016; • Correction of the activity figures for Trafford Community Services to reflect the award

of the MSK contract from July 2016 (additional activity).

Heather Bell

Deputy Director of Business Development

28

Summary Operational Plan 2016-17

Pennine Care NHS Foundation Trust

(Pennine Care)

29

1.0 Pennine Care’s approach 2016/17 Pennine Care believes that adopting a whole person care approach will allow the organisation to to drive service transformation at pace and scale, meeting the care and financial challenges ahead. Pennine Care’s core purpose is to help communities to live healthy lives, acting with integrity and upholding our values. It means we will place the needs of patients and people at the heart of our service planning, working with local stakeholders to develop bespoke, place-based service offers that meet the needs of the six localities that we serve. Whole person care involves designing services in a way that provides holistic assessment and treatment, encompassing physical, mental and social health and wellbeing. It will help to improve quality of care, reduce fragmentation and duplication and have greater focus on prevention and recovery. In support of this, Pennine Care’s overarching vision is to deliver the best care to patients, people and families in our local communities, by working effectively with partners to help people to live well. We believe that the best type of care for the majority of patients is provided outside hospital wherever possible, placing the person and their own home as a central part of future service delivery. If providers can begin to manage demand better, they can start to edge upstream and towards more preventative models of care. Our mission is to be the leading provider of whole person care across Greater Manchester, shifting more care into the community. We will achieve this through our refreshed strategic goals and supporting objectives for 2016/17:-

1. Put local people and communities first; 2. Provide high quality whole person care; 3. Deliver safe and sustainable services; 4. Be a valued partner; 5. Be a great place to work.

This plan sets out Pennine Care’s approach to progress our transformation programme in line with the Five Year Forward View and the local system’s Sustainability and Transformation Plan (STP), whilst also continuing to deliver quality, financially viable services in line with the annual requirements set out by our local commissioning colleagues.

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2.0 Approach to activity planning

2.1 Activity plans 2016/17

In developing our activity plan for 2016/17, Pennine Care has been influenced by the following:

Commissioning requirements

Pennine Care has developed its assumptions based on the specified commissioner contractual requirements for 2016/17.

We are currently commissioned on a block contract basis across 15 CCGs, 6 Local Authorities, a range of NHS England contracts and associated contracts. A number of these contracts include indicative activity targets, against which performance is monitored. These are discussed and agreed as part of the annual contract negotiation process and monitored throughout the contract lifetime via a number of Contract Governance Forums. As part of recent contracting discussions with commissioning colleagues, there has been no indication that there will be any significant changes to contracted activity. Consequently, the plan has been forecast based on current levels of activity for 2015/16.

These assumptions are routinely monitored and adjusted in line with commissioner intentions, contract variations and tenders.

Trust contracts

Unfortunately during 2015/16 we have failed to retain a number of services as a result of formal procurement exercises. This will impact on the contractual position of the organisation with a number of our commissioners, both CCGs and Local Authorities.

While we are aware that a number of procurement activities for current service provision will occur during 2016/17, Pennine Care has modelled an ‘up-side’ position of service retention.

Current planning considerations

While we have a large scale programme in place to review our mental health strategy a number of options are being developed. This work stream will form part of the refresh of the organisation’s Strategic Plan, which is scheduled to conclude in July 2016. Therefore, in developing the activity plan, the assumption that occupied bed days will remain static during 2016/17 has been adopted.

2.2 Capacity and Demand

As an organisation, capacity and demand has become a regular part of performance assessment. On a monthly basis our service line reports provide information on staffing levels and activity, from which services are asked to identify any specific capacity and/or demand issues. Where concerns are raised over capacity and demand, the organisation has developed a suite of tools to support more in-depth analysis. These include historic data analysis, use of Statistical Process Control

31

Charts, pathway analysis or a review of staffing. We have also developed a robust process that will support a much larger piece of capacity and demand work when required. The process combines outputs from the tools defined, to provide an insight into the relationships between staffing configuration, current activity and service demand. This intelligence is then used as evidence for service redesign to reduce demand or improve utilisation of staff, or on some occasions as a case for increasing capacity.

Moving forward, demand and capacity modelling is taken place with commissioners, utilising national tools where available and developing local solutions where required.

Pennine Care is currently undertaking work to ‘un-pick’ its block contracting arrangements with commissioners. This involves working with CCGs/Local Authorities to identify if resources are allocated appropriately to meet demand. This will encompass areas where we are seeing growth in demand.

As an organisation, Pennine Care is committed to looking at new ways to deliver care, including working with third sector agencies to support increased capacity. Partnership approaches form a key part of our commercial strategy and while this is currently limited in terms of contractual arrangements, the organisation has some defined examples (for example, a contract with Age UK Oldham to deliver specified service elements) to build upon.

In summary, based on the current activity planning assumptions, as identified above, the Trust has a high degree of confidence that sufficient capacity is in place to deliver on the plan.

2.3 Key operational standards

There are no identified risks to Pennine Care maintaining its adherence to the applicable key operational standards. This specifically relates to the referral to treatment performance targets for our consultant-led pathways (Audiology and Community Paediatrics) and diagnostic waiting times for Audiology.

2.4 System resilience

During 2015/16, a number of system resilience schemes have been put into operation, including additional capacity for community teams (including our Children’s Community Nursing Teams and rapid response service) and our liaison psychiatry model (RAID) as well as additional bed capacity (5 beds, Bury) to support a ‘discharge to assess’ initiative.

Discussions continue with commissioners across our footprint as to whether system resilience schemes will continue into 2016/17. Some schemes (Children’s Navigator, Bury) will continue on a short term basis (to June 2016). In Oldham Community Services, the schemes will be rolled into April 2016 for review and evaluation pending ongoing investment or the identification of alternative provision.

Any known activity has been modelled into the supporting activity submission.

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2.5 Managing unplanned changes in demand

In the event of a significant shift in demand, services can call upon Pennine Care’s clinical and non-clinical temporary workforce, if additional capacity is required. This well-established temporary workforce covers all staff groups and represents the diverse range of professional staff Pennine Care employs. Pennine Care has recently invested in a full review of the temporary workforce, and its supporting systems and processes, to ensure it can continue to respond effectively and efficiently to unplanned staffing requirements. Pennine Care also has several NHS Framework agreements with employment agencies in place, whose workers form part of the wider flexible workforce.

Pennine Care operates across a wide and diverse geographical area and so has in place a large internal network of clinical and professional leads, who are able to be deployed to respond to changes in demand in a particular location/service as required. 3.0 Approach to quality planning 3.1 Approach to quality improvement Effective quality governance continues to underpin all existing service delivery and improvement. Pennine Care’s newly refreshed Quality Strategy 2016-18 describes the Trust’s approach to quality improvement. The purpose of the strategy is to act as a framework of accountability, outlining the direction planned to achieve quality excellence in relation to:-

• Patient Safety; • Patient Experience; • Clinical Effectiveness.

The strategy has been developed by working closely with service users, their carers, commissioners and local stakeholders to ascertain the priorities for those who use our services, in a co-produced manner, via our ‘Spotlight on Quality’ engagement event held in February 2016. Pennine Care’s strategy promotes our approach to providing safe, high quality care by measurement against the five key questions in the CQC inspection process. Our methodology is outlined in the project plan ‘Countdown to CQC’. This will provide a Trust-wide benchmark against the expected standards with targeted improvement plans for services. This methodology will be the organisation’s framework for quality improvement, along with the Trust’s strategic quality aim and objectives. The key aim of the strategy is to set the direction for further development and implementation of quality care delivered by Pennine Care over 2016-18. We will do this by implementing set objectives with implementation plans reporting to the Trust’s Quality Group and reporting by exception to the Performance and Quality Assurance Committee.

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Dr Ticehurst, Medical Director, has the lead role for quality meetings and committees within the Trust, in the capacity as Chair of the Quality Group. The new reporting structures, developed and implemented during 2015/16, have seen greater connection between quality and performance across all of the organisation’s six Divisional Business Units (DBUs). See Section 3.4 below. Additionally, the Trust Board provide scrutiny on quality indicators as a routine part of the monthly Board meeting. The governance structures will be the framework for the Quality Strategy assuring delivery of high quality care, promoting an open and fair culture, in line with the requirements of the CQC’s ‘Well-led’ Key Line of Enquiry. Pennine Care’s Patient Experience Strategy 2015-18 will underpin the work to ensure service users and their carers’ feedback influences service improvement. Our Quality Account contains the mandated quality sets that measure our performance against key national priorities and core standards, and articulates our quality priorities, as follows:-

• Sign up to Safety, including falls prevention; safe discharge transfer and leave; reducing hospital and community acquired avoidable pressure ulcers; and reducing omitted and delayed medications;

• Suicide Prevention; • Collaborative Care Planning.

These priorities have been finalised following consultation at the quality engagement event (‘Spotlight on Quality’), discussion at the Council of Governors, debate at the Quality Group and approval by the Board of Directors. The quality priorities will be monitored via progress reports to the Pennine Care’s Quality Group with exception reporting to the Performance and Quality Assurance Committee. Pennine Care is to be formally inspected by the CQC in June 2016. We remain in Band 4 of the CQC priority banding, which is the lowest risk. The CQC regularly publish their intelligence monitoring report; this has continued to record minimal risk for Pennine Care. Following the publication of the Mazar’s Report (Independent review of death of people with Learning Disability or Mental Health problems in contact with Southern Health) and in line with NHS England’s new Serious Untoward Incidents framework (March 15), Pennine Care has reviewed governance systems and processes relating to deaths of service users and subsequent investigations. Pennine Care has established a Mortality Review Panel and will commit to participate in the associated work regarding avoidable deaths. Pennine Care can provide assurance that the recommendations in the Academy of Medical Royal Colleges 2014 report ‘Guidance for taking responsibility: accountable clinicians and informed patients’ have been fully implemented.

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3.2 Seven Day Services

Our mental health services provide a seven day a week service, delivered through our Access and Crisis and RAID (liaison psychiatry) frameworks. These cover all ages at the point of access for service users who are either new to the service and require assessment, or are known to the service and experiencing a crisis or need support. These services have full access to junior and senior medical practitioners to support their risk assessments and decision making processes. The service is 24/7 and is further enhanced by the delivery of the street triage scheme and helpline systems. This ensures emergency services and service users/carers that require help at any day or time, have immediate access to a trained practitioner who will be able to provide appropriate advice and support.

Within our community services, we continue to work with commissioners to improve our out of hospital care offer, working in partnership with local stakeholders to improve integration and patient care. Ways in which we currently deliver on the out of hospital offer seven days a week include:-

• Adult Community Nursing service (24/7) – supporting people to be cared for in their own homes, preventing admissions and facilitating discharge;

• Community therapists in A&E - reducing inappropriate admissions, supporting timely discharge and follow up in the community;

• Intermediate care and enhanced intermediate care services (24/7) - strong partnership with social care staff based on site, facilitating effective packages of support in the community, including community IV services preventing hospital admission;

• Hospice Helpline (24/7) - for patients/carers and professionals, provides support and signposting to relevant agencies;

• Children's Community Nursing Team – for children with acute, chronic, complex and palliative needs. This helps to reduce secondary care attendances, acute in-reach and increase discharges into the community;

• Homeward Bound Initiative - supporting medically fit patients in the acute setting back home by the introduction of a seven day pathway (including seven day admissions to intermediate care). This is being managed with a small additional investment from system resilience funding.

Plans for 2016/17

We continue to work with our commissioning colleagues and local partners to understand how Pennine Care can support the ambition for extended healthcare provision to ensure all service users, regardless of age and need, will have their needs met despite the day or time these are presented.

‘Easy Access’ is a core principle of service delivery and ongoing service development/improvement processes. Services are constantly looking to improve access opportunities, and this includes trialling extended service offers i.e. evening and weekend provision. This is embedded within the individual business plans of our Divisional Business Units and Clinical Business Units for 2016/17. Any change of this manner is always undertaken based on engagement and feedback from users of the service and other key stakeholders.

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As part of the ongoing competitive tendering requirements, we are finding that extended provision is a common feature of new service specifications. Redesigned service models are developed in accordance with these requirements e.g. we have recently retained the Trafford MSK service via a competitive tendering process. This will have an extended access model, including weekend provision.

In mental health, we are active participants in the Greater Manchester Child and Adolescent Mental Health Service (CAMHS) forum and one of our senior managers is currently leading a work stream for crisis support and 24/7 care for under-16s. This work stream has recently been initiated with a clear project plan in place, however, it is envisaged that the work will span a 6-12 months period before any changes to provision are realised. This will focus attention on the tailoring of services to under-16 year olds, enabling services to be more responsive.

Additionally within our CAMHS service we will be mobilising two new services during 2016/17 – a community eating disorders service across all our six key boroughs, with seven day access, and an emotional health and wellbeing service for children and young people in Heywood, Middleton and Rochdale which will also be modelled across seven days.

In our Oldham borough, we are currently working as part of a formal alliance to develop a comprehensive urgent care offer with a paediatric programme budget approach across all acute paediatric providers, looking to ensure resources are targeted appropriately to allow children to be cared for in the right setting, at the right time, based on their needs. This has provided additional investment into Pennine Care services to enhance the existing Children’s Community Nursing team (currently 7 days, 8am-12midnight) by providing a “see and treat” facility for paediatric patients at the Royal Oldham Hospital. This will enable us to provide ambulatory care in a more effective way, preserving paediatric A&E for true accident and emergency patients.

During 2015/16, Pennine Care participated in a review of the Urgent Care Pathway in Bury. This includes the Prestwich Walk-In Centre (WIC), Bury Urgent Treatment Centre, out of hours provision, ambulatory care and extended GP hours. We are awaiting the outcome of the review and will respond as part of an alliance with partners to improve the pathway as identified.

During 2015/16 we were successful in procuring a new wound care service in Bury. This will be delivered over seven days to support a reduction in activity within the urgent care pathway. Weekend clinics are currently being trialled to monitor clinic utilisation and this will be supported by extended hours ‘drop-in’ sessions over the coming months.

Additionally, we are in discussions with Bury CCG and Bury Council regarding the development of intermediate care across the borough. Part of this strategy will be to understand how we can enhance the current seven day offer and dovetail to existing community and acute services.

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3.3 Quality impact assessment process Pennine Care has delivered financial efficiencies year-on-year since 2008. These have been achieved without significant disruption to service delivery and without detracting from the expectations of commissioners in respect of quality and value. However, the current financial climate and changes in commissioning expectations mean that Pennine Care has to adapt and develop a new strategy and associated Transformation Programme. The Transformation Programme is developing Cost Improvement Programme (CIP) schemes that deliver a step change in service redesign, underpinned by a set of the design principles for delivery of whole person care.

The Board takes responsibility for ensuring that a full appraisal of the quality impact assessments is completed and recorded and that arrangements are put in place to monitor work going forward. Given the dynamic nature of the CIP schemes, this exercise is part of the Trust’s core business and a feature of our Quality and Performance Governance Framework. This process has been informed in part by Delivering Sustainable Cost Improvement Programmes (Audit Commission/Monitor, Jan 2012) and Quality Impact Assess Provider Cost Improvement Plans (National Quality Board, July 12-Mar 13).

All appropriate CIP schemes are subject to an assessment of their impact on quality. This is undertaken and led by the relevant clinical team and covers an analysis of patient safety, clinical effectiveness and patient experience. The Quality Impact Assessment process has continued to be refined throughout this year; in particular improvements will be made to assess more effectively the cumulative impact of schemes across a pathway.

All CIPs are managed via a robust performance management process and require a named lead (in the majority of cases this will be a Service/Corporate Director). Regular reports on progress are made into Pennine Care’s assurance forums and actions taken promptly in response to any variance.

Additional scrutiny is also provided through the Quality Assurance Panels, with approval for all schemes via the Medical Director/Director of Nursing and AHPs. Specifically the Quality Group, chaired by the Medical Director, has a crucial role in reviewing the quality impact of CIPs and where quality risks are identified, ensuring effective mitigation plans are in place.

KPMG has also undertaken an internal audit of the CIP programme, including a review of the CIP governance system, review of 2014/15 and longer term schemes. Substantial assurance was reported and specific findings and recommendations were fed into the Trust Audit Committee in March 2015.

Externally all CIP plans for 2016/17 were formally presented at a joint CCG Commissioning Board prior to implementation (on 24 February 2016). This approach will ensure a consistent understanding across our local health economy. In addition, regular monthly reports are made into the CCG Mental Health and Community Quality Groups in respect of any impact on Clinical Effectiveness, Patient Safety and Patient Experience.

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Discussions have also taken place with CCG Quality Leads with an agreement to hold a quarterly sub-group with the aim of analysing the impact of certain 2015/16 schemes. This may involve a ‘patient story’ approach, as well as a forward looking discussion, with focus on 2016/17 schemes and beyond. 3.4 Triangulation of indicators Pennine Care has recently implemented a new integrated performance management framework.

The framework includes integrated performance reporting from team to Board level covering:-

• Quality; • Activity; • Finance; • Workforce; • Compliance.

The new performance reports contain key measures and indicators based on internal core standards, statutory and contractual requirements and a review of business plan objectives.

In additional to the integrated reports, a new assurance system has also been introduced. Performance and Quality review sessions are held quarterly where each Divisional Business Unit presents an integrated performance and quality report to a panel made up of Executive Directors, corporate heads of service and a Non-Executive Director. The sessions seek to provide assurance against internal core standards, statutory and contractual requirements and business plan objectives and provide strategic support to divisions where required.

Following the sessions, an overarching performance and quality report is produced for Executive Directors, prior to being presented at the formal Performance and Quality Governance Board Subcommittee. The new process enables and drives the use of information at all levels of the organisation, supporting the improvement of the quality of care and enhancing productivity.

4.0 Approach to workforce planning

The significant changes in care delivery expected in 2016/17 will provide a focus for both workforce planning and transformation. Key drivers for this work in Pennine Care will be:-

• Greater Manchester Devolution; • The procurement landscape; • Difficulty in recruiting to specific clinical posts, including district nursing and

the mental health workforce, and the impact of the ageing workforce in these key areas.

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2015/16 has seen the embedding of systems and processes to support workforce planning and transformation in Pennine Care as follows:-

• Implementation of the Adult Community Nursing group to review the existing roles and plans for the development of roles for the future;

• Implementation of training for staff to support the shift to new ways of working in self-management, using a self-management toolkit approach, motivational interviewing and shared decision-making. Alongside this, training for patients has been made available to support their confidence in caring for their condition;

• Implementation of phase 1 of our fundamental care certificate approach, enabling the development and trialling of a number of models, to determine best fit for service and new staff development;

• Agreement of integrated HR Policies across all staff groups, supporting alignment and integration ways of working;

• Implementation of an electronic ideas/crowd-sourcing platform “Spark” to support Pennine Care’s staff engagement agenda;

• Use of Pennine Care’s People Planning Toolkit alongside business planning processes;

• Review of Pennine Care’s performance management process and the provision of information to services has resulted in improvements in the system, enabling managers to triangulate and report on wellbeing indicators and information about service provision on a monthly basis. This has enabled local focus and targeted action. Quarterly divisional quality and performance assurance meetings use the information collated to highlight best practice, identify areas for local action, workforce risk areas and provide the opportunity to understand and address issues that are common across more than one service/division;

• Implementation of a Quality Review Panel and governance processes for any service change. This includes completion of Equality and Quality Impact assessments to highlight areas of concern or unequal impact on individual staff members, patients or groups.

During 2016/17 additional focus will be placed on the following:-

• Redesign work with services to support tender requirements • GM Devolution will result in significant changes in the care model. Although

the detail of this is not yet clear, different employment models, roles, ways of working and organisational forms are expected. Engagement with staff during this period will be essential to the effective delivery of services and design of the future model. An Organisational Development (OD) programme will be developed to support this work;

• As well as developing options for future delivery of care and staffing structures, existing pressures on capacity will need to be managed. Mental health and community services are both seeing a pattern of difficulty in recruiting qualified staff and the ageing workforce will only increase this pressure. New models both for recruitment, retention and role redesign will be a focus during the next year. This will include continuation of the work started in the Adult Community Nursing group and partnership working with academic

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institutions to look at future training models. This will inform and support the development of a clinical education strategic approach;

• Implementation of phase 2 of the fundamental care certificate and strategy to support staff development;

• Implementation of Pennine Care’s revised People Planning Toolkit focusing on different approaches for workforce planning versus workforce transformation and development of a people planning hub supported by HR, Information, and Learning and Development specialists. This will provide information, tools and support to clinical services undertaking business planning and review of services;

• Focus on our temporary workforce will continue following the implementation of a new computerised system for booking and management of shifts in 2015/16. We will be reviewing the quality and usage of temporary staff to realise the anticipated efficiencies enabled by the agency cap (see section below);

• Partnership work within the Stockport footprint will continue to develop appropriate staffing models in aligned services to support the Vanguard approach;

• Modelling of future workforce requirements and methods of recruiting will be supported through partnership work with Central Manchester Foundation Trust, Manchester University and Stockport Foundation Trust, with funding provided through Health Education North West to invest in a career and engagement hub. Additional funding provided by Health Education North West will also support our implementation of best practice from the Talent for Care and Widening participation strategies.

4.1 Reduction in Bank and Agency spend Pennine Care has developed a comprehensive action plan monitored by its Strategic and Tactical Operations Bank and Agency group, co-chaired by two senior managers. The key areas addressed in the plan, encompass a range of actions within each, with SMART objectives are:-

• Procurement; • Quality Review; • Reporting/Business Intelligence; • Skills Analysis; • Medical locums; • Recruitment and retention.

Each action has clear allocated timescales and will be RAG rated and updates documented. There is dedicated resource centrally in place to support this key project to support and engage with services, and ensure that tasks are completed, in line with the plan.

The Executive team and Board will be receiving regular reports of progress against the plan and reduction in spend against trajectory.

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4.2 Workforce Planning Governance

Workforce plans are developed at team, service, division and Trust-wide level depending on the needs identified. Support including the People Planning Toolkit and capacity and demand analysis tools are provided to services. Governance processes are in place to ensure that workforce plans are developed and agreed at the appropriate place. This includes:-

• Work with staff side colleagues through our formal consultation processes for any organisational change, identifying impact on staff, supported by the Equality Analysis process;

• Quality review panels for all Long Term Financial Model (LTFM) planning using Quality Impact Assessments to triangulate service and staff impact;

• Board level sign off and review of the annual workforce plan, developed for Health Education England, to support education commissioning;

• All plans are reviewed by appropriate service leads, Service Directors, Executive Directors/Board members as required. Pennine Care continues to work with Health Education North West using the Workforce Planning Tool and linking closely into the Clinical and Professional Education groups. This enables us to identify specific developments and needs and supports the commissioning of the education of our future staff.

Detailed plans for staffing transformation are included in the data pack for this plan. These projections will be developed further during the year to understand the transformation implications and work with and across GM to look at new roles and ways of working.

4.3 Staff wellbeing

In conjunction with plans for our workforce requirements for the future, we also focus on retention of our existing workforce. Continued focus in 2016/17 will be on the holistic approach to managing sickness absence including:-

• The agreement of standardised triggers and approaches across the organisation for management of absence;

• Support and training for managers to understand the wellbeing needs of staff; • Support for individual staff members to review their own wellbeing and

develop self-management skills.

Pennine Care commissions an innovative Staff Wellbeing Service led by psychologists which runs alongside the more traditional Occupational Health service provision to support mental wellbeing.

At a Trust-wide level, the annual staff survey provides valuable information that we use in conjunction with staff feedback through focus groups, our on line SPARK platform and staff suggestion scheme together with service quality metrics to highlight areas of best practice and areas for focus and support.

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Strategic objectives have been identified for 2016/17 that summarise the key priorities to achieve these areas of focus and the strategic goal of being a ‘Great Place to Work’. We will:-

• Develop and implement a comprehensive workforce plan that meets the aims and requirements of the organisation’s Strategic Plan and locality Sustainability and Transformation plans (STPs). This will include skills analysis, learning and development plans, permanent and temporary resourcing plans, talent management and succession planning;

• Pennine Care will also commence the development of a refreshed OD programme to improve the employee experience, which will include clinical and management supervision, IPDR, staff engagement, wellbeing and reward and recognition.

5.0 Approach to financial planning

5.1 Funding assumptions Pennine Care delivers both mental health and community services via contracts with CCGs, NHS England and Local Authorities primarily throughout Greater Manchester. As its contracted income is mainly derived through block contracts activity generated fluctuations are negligible. Pennine Care is anticipating, where contracts are continuing into 2016/17, that indicative activity plans will underpin each contract, but that there will be no risk to income based on any shifts in activity.

Across Greater Manchester all mental health trusts have agreed with all commissioners that a block contract arrangement will remain in place for 2016/17whilst work continues via the Greater Manchester Devolution project to develop alternative payment mechanisms for the future.

Pennine Care has agreed the vast majority of its finance schedules with most commissioners and the Trust is confident that all contracts will be signed before the end of April 2016.

The 2016/17 plan includes the final outturn figures for 2015/16, delivering an underlying surplus of £0.19m which is slightly in excess of the plan of £0.05m surplus.

Pennine Care has responded positively to local commissioning intentions and has worked to secure an additional £3.5m of funding for mental health services (£2.5m recurrent, £1.0m non-recurrent), most notably for Early Intervention in Psychosis, IAPT, CAMHS and Eating Disorders.

Addressing increased acuity on the mental health wards has created financial pressure, and staffing levels need to be redesigned to ensure Pennine Care can move towards compliance with what is expected to underpin the “Safer Staffing” guidance due out later this year. Pennine Care has identified internal investment of £1.0m to support this (£0.2m for each of its five localities), and following initial conversations with commissioners has secured match funding from four out of the five boroughs, giving an additional £0.8m to be invested in mental health services. This income, and matching expenditure, has been included within the plan.

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Following a large number of local procurement exercises across the majority of our community services, Pennine Care has been unsuccessful in re-securing existing contract income of approximately £17m. Whilst most of the direct staffing costs will be offset (via TUPE transfer), these exercises have created a significant cost pressure due to lost contribution to overheads of circa £3.2m for which Pennine Care will need to find recurrent solutions in 2016/17.

CQUIN has been assumed at 2.5% of block contract values for patient care income commissioned via health organisations (£4.2m in total). This is a reduction from previous years due to a reduction in income detailed above resulting in circa £0.4m loss, and also a further loss of circa £0.4m due to the transfer of a number of community contracts from NHS England to Local Authorities who have stipulated that CQUIN funding will not be paid on these contracts. An assumption that 100% of CQUIN payments will be received has been included.

At this stage, no income or costs have been included in the plan in relation to the proposed Manchester Mental Health transaction. Pennine Care is keeping Monitor fully briefed of the situation and any associated developments.

5.2 Efficiency savings

The efficiency requirement for 2016/17 is affected by a number of factors that, combined, increase the target for Pennine Care to a level above the national average.

Whilst the national “efficiency” target is on average approximately 2.0%, the Trust has a higher proportion of pay expenditure than most provider Trusts (77/23 split compared to national average of 66/35) and we therefore estimate that our baseline “efficiency” target is 2.3%. Added to the pressures of increased acuity in mental health, and the loss of contribution to overheads, the total cost pressures for 2016/17 are approximately 4.4%.

The following table shows the breakdown of Cost Improvement Programme (CIP) targets, both those derived from the national efficiency requirement and those driven by lost contribution to overheads

Target Identified

Front Line Services National Efficiency £4.9m £4.9m

Corporate National Efficiency £0.8m £0.8m

Corporate Efficiency re Lost Contribution £3.2m £3.2m

TOTAL £8.9m £8.9m

Where there is a requirement to deliver non-recurrently, due to either slippage in implementation of approved plans, or lack of identification of plans, Pennine Care is focussed on delivery of its plan and will ensure that services deliver the targets given. Close monitoring in the monthly Board report will ensure that any deviation from delivery will be addressed and rectified.

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5.3 Lord Carter

Although the recent productivity work plan developed by Lord Carter focussed mainly on acute organisations, Pennine Care has adopted a number of key practices that aim to deliver savings on agency and bank expenditure, estates utilisation, procurement of goods and service including pharmacy services.

Pennine Care is committed to delivering a reduction in the expenditure relating to agency staff in 2016/17 and, as described in section 4 above, there are a number of actions being developed to address this. It is anticipated that initially these changes will generate minimum savings of £1m and this has been reflected in the plan. These savings will be utilised to fund the investment in safer staffing initiatives. Pennine Care is heavily involved in the Greater Manchester Devolution project and it is hoped that opportunities for further efficiencies may emerge through system-wide transformation. Additionally, Pennine Care awaits further guidance from Lord Carter that specifically targets areas of efficiency in mental health and community settings.

5.4 Capital planning

The Capital Investment Plan has been developed in line with the Service Development Strategy and required investment to reduce risks and lifecycle maintenance. It covers the areas of:-

• Resilience - investment to ensure the Trust continues to perform at its current level, addressing investment into buildings, medical equipment and ICT lifecycle maintenance and essential works. This includes meeting priorities under fire, health and safety risk assessments;

• Sustainability - investment to facilitate growth, major refurbishments and new business.

The proposed Capital Investment Plan, considering requirements versus affordability and risk, is £6.7 million (including an element of carryover schemes from 2015/16). This investment is targeted and is addressing all essential resilience schemes including investment into new technology to enable patient facing staff to work more agile and respond to the change in service provision.

Investments include, but are not limited to:-

• Refurbishment of Parklands Ward, Royal Oldham Hospital; • Refurbishment and Estate Utilisation, Lee Street Clinic, Ashton; • Refurbishment of Outpatients Department, Royal Oldham Hospital; • Refurbishment of Outpatients and ECT Suite, Stepping Hill Hospital; • Reconfiguration and Refurbishment of Stockport Community Services; • Investment into increased fire compartmentation, detection and safety; • Medical equipment replacement, including ECT equipment; • Lift refurbishment; • ICT Lifecycle investment and software replacement; • Mobile and agile working investment into technology to support community

teams; • Estate rationalisation investment to contribute to changing working patterns.

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Pennine Care is conscious of the need to ensure that we maximise the use of existing estate while delivering services in environments which are fit for purpose. The estates strategy will form a core component of the developing Integrated Business Plan to ensure that any decisions made, both in terms of current estate and capital investment, are considered in line with the overarching strategy to allow resource to be invested in the schemes of most strategic and clinical value.

6.0 Link to the emerging Sustainability and Transformation Plan (STP)

6.1 The Greater Manchester Devolution Programme

Greater Manchester was the first ‘city-region’ to be given greater decision making and budgetary controls over its £6 billion health and social care services. In December 2015, the devolution programme published an ambitious five-year plan for health and social care across the region, focusing on four key areas:-

1. Fundamental changes in the way people and our communities take charge of, and have responsibility for their own health and wellbeing;

2. The development of local care organisations, which will see GPs, hospital doctors, nurses and other health professionals come together with social care teams, other public services, the voluntary sector and managers to plan and deliver care. This means that when people do need support from public services, it will be mainly in their community, with hospitals only needed for specialist care;

3. More collaboration between hospitals across Greater Manchester, to make sure that expertise, experience and efficiencies can be shared across the whole area in a consistent way;

4. Other changes to ensure that standards are consistent and high across Greater Manchester, as well as saving money, include exploring sharing some clinical and non-clinical support functions; investing in workforce development across Greater Manchester; sharing and consolidating public sector buildings; investing in new technology, research and development, innovation and ideas.

6.2 Pennine Care’s contribution

Table 1 (below) summarises Greater Manchester’s key areas for transformational change and the planned contribution from Pennine Care, as well as the desired future state.

A key part of the GM Devolution approach is a focus on people and places, not organisations. This philosophy has a strong alignment with the Pennine Care approach (section 1.0). As well as our place-based out of hospital commitment, as an organisation we aim to ensure that mental health services receive parity of esteem within the transformation discussions and approach.

In addition to the overarching Greater Manchester Strategy, each Locality of Greater Manchester has developed its own Locality Plan for transformation. Across Pennine

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Care, our local Divisional Business Unit plans will have a strong interface with each of the relevant locality plans.

To support the implementation of the GM Devolution plan, Pennine Care has identified the following there key enablers:-

• Leadership – the ambitious plan requires substantial change and strong leadership to keep the workforce informed, motivated and able to deliver the best care;

• Sustainability – services must be viable and increasingly efficient over time; • Flexibility – the plan prompts both opportunities and uncertainty. Pennine

Care must be sufficiently flexible to identify opportunity and drive change while monitoring risk, e.g. new payment systems, models of care, models of commissioning etc.

In addition, Pennine Care is currently liaising with the GM Devolution team and local partners to identify and develop evidence-based propositions with the intention of securing transformation fund investment.

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Table 1

Key Areas Pennine Care response Current examples Future state

1. Radical upgrade in population health prevention

• Patient activation, behaviour change and self-care

• Support healthy children and young people

• Promoting living and ageing well

• Use of technology, e.g. Flo tele-health

• Universal children’s services

• My Health, My community

All patients facing staff trained in patient activation and self-management skills. Universal access to a comprehensive My Health, My Community offer, to include the Recovery College programme.

2. Transforming care in localities

• Integrate health and social care • Models appropriate to the locality • Wrap teams around GPs • Urgent care in the community • Integrate physical and mental health

• Joint appointments with social care

• Integrated services (Trafford)

• Trafford Community Enhanced Care team

• RAID (liaison psychiatry)

Comprehensive locality model that offers transformed care pathways from community care co-ordination, through urgent and intermediate care in the community, through to bed based care with a focus on restoring independence and self-management.

3. Standardising acute hospital care

• Safe and sustainable • Deliver most services locally • Standardised treatment and pathways • Collaborate and work together

• Robust monitoring and evaluation

• Specialist mental health beds optimised

• Strong partnerships locally and across GM

Refreshed mental health strategy that provides standardised treatment and care pathways, optimises bed utilisation and repatriates out of GM placements.

4. Standardising clinical support and back office services

• Collaborate to offer back office efficiencies

• Co-ordinate access for all referrers • Collaborate to identify opportunities to

share clinical services

• Co-ordinated access arrangements

Redesigned and refocused back office function. Services to better support local care models and lean but effective central governance structure. Further work on care co-ordination linked to the electronic patient record programme.

5. Enabling better care • Embrace innovation and effective technology

• Business intelligence • Build and enhance staff skills,

capability and wellbeing – develop alternative career pathways

• Paris implementation • Mobile working • Online consultations • Estate planning • New roles and alternative

careers

Effectively support six Local Care Organisations, Greater Manchester provider collaboratives and core Trust business.

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7.0 Membership and Elections In April we will commence our well established election process to replace 12 governors whose terms of office are due to end on 30 June 2016. A programme of pre-election roadshows across all boroughs took place in February to publicise and provide information to any potential candidates. UK Engage has been appointed as the Independent Returning Officer. During 2016/17 we will consult with the Governors and members on the future composition of the Council of Governors to ensure it better reflects the structure of the organisation, which has changed significantly since the Trust was authorised in 2008. An ongoing Governor Development programme commenced with a welcome and induction for new Governors. Existing Governors are invited to participate to refresh their skills and knowledge and also share learning. Monthly development session include both ‘formal’ sessions linked to statutory duties and ‘informal’ sessions linked to Pennine Care services. Additionally, Governors are given the opportunity to attend a range of external events, such as the Governwell programme (NHS Providers), and the North West Governors’ Forum. Future joint sessions between the Board of Directors and the Council of Governors include the development of Pennine Care’s Strategic Plan and preparation for the forthcoming CQC inspection. Governors are invited to attend all Board and Sub-Committee meetings by rota to familiarise themselves with the Board as a whole and specifically to see the Non-Executives (which supports their decision-making on Non-Executives’ remuneration and/or re-appointment). Governors will continue to be invited to attend service visits with Non-Executive Directors. To keep the Governors informed of plans and developments within their respective communities, the Trust has organised monthly Local Constituency Meetings (LCM) to bring the Governors into regular contact with their local service areas and management teams. During 2016/17, a number of member recruitment opportunities will be used, including pre-election roadshows; media adverts; the Trust website; mailings (post and e-mail) to members; communication via third sector organisations (i.e. Healthwatch, Mind, RBUF etc.); communication via LCM’s; attendance at staff meetings, events, councils etc.; Pennine Post; Public notice boards; local events. Governors will be invited to participate in all events. The Trust’s publication (Pennine Post) is being reviewed, with a proposal to move from quarterly to bi-annual newsletters, supplemented by monthly, borough-specific briefings. A number of members events are being planned including a ’Pilot Bury Focus Group: Medicine for Members’ in April 2016 and a Stockport Mental Health Event in June. Pennine Care is running a range of educational health, wellbeing and recovery

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courses through its self-management college as part of its ‘My Health, My Community’ initiative, which are being publicised and offered to all members. Governors are also invited to participate in the implementation of the organisation’s Patient Experience Strategy, with representation at both the central Strategy Group and local experience forums. The recruitment of Membership and Engagement Officers will form part of a work programme to increase recruitment and engagement opportunities with both staff and public members. Two planned recruitment campaigns in the Stockport and Trafford constituencies will focus on working age males and increasing representation among the Asian communities. The membership team will continue to work with the Trust’s Equality and Diversity team and local services to identify appropriate events to ensure engagement with a diverse range of members such as LGBT, ADAB (Asian Development Association of Bury), third sector organisations (e.g. Voluntary Action, Oldham). Additionally through the ‘My Health, My Community’ initiative, bespoke training in diverse communities can be arranged on request.

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Implementation and development of Pennine Care NHSFT performance and assurance

systems Author Colin McKinless

Independent Management Consultant Executive Sponsor Michael McCourt

Chief Executive Date of Report March 2016 Action Required

The Board of Directors is asked to note the contents and conclusions of the report.


The report represents Mr McKinless’ final report on the Trust’s performance / assurance systems, and outlines the current position, progress and achievements, plus areas for further development (section four).


N/A


5 minutes


N/A

FOI Exemption (PI only) Full This paper relates to the following strategic goals/high level targets – select all that apply (see key overleaf): LPC (Put local people and communities first)

LPC1

LPC2

LPC3


SE1

SE2

SE3

SE4

SE5


UR1

UR2

UR3

UR4


PC1

PC2

PC3

PC4

PC5


GP2W1

GP2W2

GP2W3

GP2W4

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IMPLEMENTATION AND DEVELOPMENT OF PENNINE CARE FOUNDATION TRUST

PERFORMANCE AND ASSURANCE SYSTEMS

1 PURPOSE OF REPORT

1.1 Following consideration of my original diagnostic report (February 2015), and the

subsequent adoption of proposals to implement performance/assurance systems in the

Trust (April 2015), to provide an update on and appraisal of implementation arrangements

and associated benefits.

1.2 To also assess what further developments/investments are required to ensure full

implementation of the original proposals and to ensure sustainability and further

development of the system moving forward.

2. CURRENT POSITION

2.1 This report is not intended to document in detail the project implementation arrangements

over the past 12 months or so – these have been the subject of regular updates at the Executive

Team, Board, Board Development sessions and other forums ( including Commissioners).

2.2 The report is intended to reflect more upon the key changes (both from a systems and

cultural perspective) and the consequential benefits for the organisation and ultimately patients

and carers.

2.3 Essentially the implementation plan revolved around system and cultural change taking

place in tandem, the basic premise being that one has to lever the other.

2.4 As a result, we now have a performance/assurance system in place and operating, and the

nature of the discussion in the organisation has switched from “why are we doing this, is it

necessary?” to “how can we further improve and develop the system.”

2.5 However, despite this significant cultural shift, I think that when we reflect on the original

Implementation “Mind Map” diagram, it is fair to say that we have made relatively more

progress on the system design and structure elements of the project plan ( eg, core data set,

data pack, balanced scorecard, quarterly review panels and associated assurance and

governance arrangements), and that we have not made the same degree of progress on some of

the identified work streams that were intended to run in parallel and to lever cultural change

(eg, OD Strategy, Communications Strategy, Corporate Services Review).

2.6 However, bearing in mind the complex agenda the Trust has been dealing with over the past

12 months, I think some “slippage” is perhaps understandable. I also think the initial focus on

system design/ structure has been the essential initial lever to get personnel thinking about

performance in its holistic sense, accountability ,relationships with commissioners, patients and

the CQC, etc. – and hence how their approach to managing performance needs to develop and

evolve.

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2.7 We do need to make sure that we attend to the outstanding elements of the original

implementation plan, as these are essential to the ongoing sustainability and further

development/refinement of the overall system going forward. This is analysed in more detail in

Section 4 of the report.

3. PROGRESS, ACHIEVEMENTS AND BENEFITS

3.1 As stated in 2.4 above, perhaps the major achievement has been the degree of

acceptance/ownership of the performance system by EDs, Service Directors and their senior

managers, NEDs, etc, in a relatively short space of time. Having undertaken only two rounds of

the quarterly review panels, Exec. Team performance meetings and the Performance and

Quality Assurance Committee – the discussion is now clearly focused on further development

and improvement of the system. This takes us towards meeting the agreed “Performance

Aspirations of the Trust” (as per the diagnostic report – Feb 2015) much quicker than I originally

anticipated.

3.2 In the main, Service Directors and their senior management teams have bought into the

concept at a relatively early stage. They see accountability as a “two way street” with the

Executive also being held to account for issues identified for escalation, just as much as

themselves for operational issues. The majority of DBU management teams are also recognising

that they need to be reviewing performance information in an integrated way as a matter of day

to day business – analysing information in detail, and reaching conclusions, prior to submission

to quarterly review panels. There is an acceptance that investment in skills/capacity will be

needed to further develop expertise in relation to holistic data analysis (links here to corporate

services review/ OD strategy). A significant influence on this relatively positive situation has

been the leadership role of the Director of Operations, both as the Executive Team lead for the

Performance Project, and as direct line manager to the Service Directors and their DBUs.

3.3 Transparent communication of the performance project to commissioners has realised some

key benefits in relation to the conduct and focus of contract meetings and re-negotiation of KPIs.

Essentially, this has revolved around the development of trust and confidence in our

performance/assurance systems and a demonstration that we understand our business and are

able to effect improvement where necessary and required. This is a necessary platform for

moving towards an outcome based approach to contracting. This relationship will need constant

attention/nurturing.

3.4 There is now an understanding that the Executive Team has a pivotal role to play in the

performance/assurance system, and that it is being held to account for its role as part of that

system. The Executive Team planned cycle of meetings now includes dedicated

monthly/quarterly performance meetings, which should ensure an appropriate leadership focus

on the product of the performance/assurance system – leading to clarity in relation to collective

and individual roles and responsibility. Again the leadership role of the Chief Executive and the

Director of Operations has been critical in this regard.

3.5 There are now much clearer links between Business Planning Objectives and performance

measures/performance system – part of a single system. However, it is acknowledged this

requires some further refinement (see section 4.2(d) of the report).

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3.6 The redesign of governance/assurance systems has led to greater clarity of organisational

roles and responsibilities. There is still some fine tuning to do here, but we can now start to have

confidence that we have consistent internal performance management systems in place, with

clear escalation arrangements. Our ability to consistently describe these arrangements will be

crucial to the CQC visit, and our ability to demonstrate we are “well led.” We are now also

exploring the role of Governors as part of the system – possibly a nominated representative to

attend the quarterly review panels.

3.7 The system has provided us with the mechanism of identifying and resolving certain long

standing problems that have led to significant frustration in the organisation for a number of

years, eg CEST, IPDRs, workforce data. There is now an Executive Team lead for each of these

identified issues with an agreed resolution methodology in use, and with clear accountability

arrangements in place. Again this cements the role of the Executive Team in the system, and

provides the action and accountability process for all other similar strategic issues emerging

from the performance system.

4. AREAS FOR FURTHER DEVELOPMENT

4.1 As stated in 2.5 above, we have made relatively more progress on the system design and

structure elements of the original Implementation “Mind Map” diagram. As such, we need to

ensure that the softer, cultural change aspects of the project don’t get lost or overlooked – these

are essential to the sustainability of the project and the long term mind-set and culture of the

organisation,viz :-

(a) Corporate Services Review – including identification of operational support functions and

capacity as well as clearly defining the “residual” corporate function. NB the focus of any

Corporate Services Review will obviously extend beyond the aforementioned aspects and will

need to take account of the options/opportunities presented by Devolution Manchester.

(b) Communications Strategy

(c) O D Strategy – including best practice/learning transfer strategy; support to the continued

development of the system; management training strategy (the “Pennine Care Manager”); and

the targeting of improvement resources/techniques to accord with the product of the

performance system.

(d) Re-definition of Devolved Autonomy

4.2 The system design and structure elements of the project of course require further

refinement and development and this needs to continue to be an inclusive process. Ideas in this

regard are already emerging from various sources, which is a really positive reflection on the

degree of acceptance, engagement and ownership of the project at this stage in its

development. Key system design ideas are as follows:-

(a) Further development of the balanced scorecard with softer/qualitative data, eg patient

experience/views – leading to real service improvement. Testing staff morale in teams/services

53

(b) Building system structure/meetings into the Trust’s formal governance/assurance calendar

– with clarity about who needs to attend various meetings and their associated role. We must

not allow an opt out culture to develop because something else is considered to be more

important.

(c) Establish clear links with BAF/Risk Register/risk management systems

(d) Establish Business Planning, performance/assurance as a single system and integrated cycle

based on the NHS financial/business year. DBU Business Plans to be signed off as part of that

integrated cycle (possibly at appropriate quarterly performance panel meeting).

4.3 Consistent roll-out of objectives/performance measures and performance management

system throughout the organisational hierarchy. This is necessary to complete the assurance

system up and down the organisation, and for all concerned to be confident about the

information being provided as part of the overall assurance system. Some templates/guidelines

will need to be formulated to provide consistency, and it should be noted that some parts of the

organisation are already operating or starting to operate in this fashion. Essentially this will

provide the “golden thread” connection between the Trust’s Strategic Objectives and IPDRs, and

will provide the opportunity for greater patient focused objectives and measures for front line

teams/staff.

4.4 Development of a system for disseminating good practice and learning identified as a

consequence of the performance system – tangible demonstration of benefits to staff and

patients (this also needs to link to a planned Performance Communications Strategy).

4.5 Linked to 3.4 above, the Executive Team needs to maintain a real discipline in managing the

product of the performance system, which will demand allocation of time and focus, and clear

understanding of collective and individual roles, responsibility and accountability. This ongoing

discipline is crucial, as we have to recognise that this role and function has not previously been

undertaken by the Team as part of the Trust’s governance/assurance system. It is also a critical

aspect of the Team’s leadership role in the organisation.

4.6 Development of an organisational framework for “outcomes based approach to

contracting”. If we are to maximise current commissioner trust and confidence in our developing

performance/assurance systems, then it would be beneficial to have an organisational view of

what an outcomes based approach actually looks like – which informs ongoing discussions with

commissioners on a consistent basis. At present any conversations in this regard are being

pursued at local level and we need to ensure that we are able to minimise process based KPIs.

4.7 Resourcing the system – up to this point, developing and servicing the system has been

undertaken by a range of different personnel as part of their existing roles. However, the

ongoing maintenance and servicing of the system will require some dedicated capacity and skills

(strategic analytical skills and more general admin support). This will be essential to ensure

system sustainability and that the Executive Team is effectively supported as per 4.5 above.

NB – I would like to record my thanks to Rachel Clayton, Phil Cheetham and Louise Bishop, along

with numerous others, who have put so much effort into the development of the performance

54

and assurance systems we are now working with – their efforts have had a significant impact on

the positive position now reflected in this report.

4.8 There needs to be a clear and consistent articulation of the performance and assurance

system for the CQC visit. It is essential that everyone is “singing from the same hymn sheet”.

5. CONCLUSIONS

5.1 It is my view that the organisation has come a long way in a relatively short space of time.

The level of acceptance and ownership in the organisation has exceeded my original

expectations. However, the pace of change across the organisation is not consistent and this still

requires some attention.

5.2 There is still much to do, and there needs to be a continued focus on delivering the cultural

change aspects of the project to ensure sustainability. The project system and structure will

need to continue to develop, and the early signs of inclusive development are encouraging. The

maintenance and further development of the system will need to be appropriately resourced

going forward and the Corporate Services Review may well be the key to certain aspects of this

particular agenda.

5.3 Leadership is also a key element of successful sustainability, and the role and continued

focus and commitment of the Executive Team in this regard should not be under-estimated. It is

also essential that a member of the Executive Team (Director of Operations) continues to hold

the day to day lead for Project implementation and development and continues to support the

Performance Project Team. It is also important that the internal Performance Steering Group

meets on a regular basis as part of the governance structure for this project, in order to provide

an inclusive focus for project delivery and further development.

Colin McKinless ( Performance Project Advisor )

March 2016

55


Monthly performance highlight report: March 2016

Author Rachel Clayton

Head of Performance Executive Sponsor Keith Walker

Executive Director of Operations Date of Report April 2016 Action Required

The Board of Directors is asked to note the contents of the report.


The highlight report provides an update on Trust performance for the period 1 April 2015 to 31 March 2016. The report has been complied following submission of the monthly performance report to Executive Directors on 18 April 2016, and outlines the agreed key highlights and exceptions in month that require escalation to Board.


Any implications are outlined in the report.

Financial Implications Any implications are outlined in the report. Amount of time required on the Board agenda

10 minutes


Executive Directors


LPC1

LPC2

LPC3


SE1

SE2

SE3

SE4

SE5


UR1

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UR3

UR4


PC1

PC2

PC3

PC4

PC5


GP2W1

GP2W2

GP2W3

GP2W4

56

1

Monthly Performance Highlight report – March 2016

1. Introduction The following highlight report provides an update on Trust performance for the period 1 April 2015 to 31 March 2016. The report has been complied following submission of the monthly performance report to Executive Directors on 18 April 2016 and outlines the agreed key highlights and exceptions in month that require escalation to Board.

As agreed during the Board development session in December 2015 the new monthly performance report has been introduced to supplement the quarterly performance and quality assurance review process during which a full review of quality and performance is carried out for each Divisional Business Unit.

The Quarter 4 Performance and Quality Review process commences on 3 May 2016. The Assurance report will be presented at the Performance and Quality Assurance subcommittee on 24 May 2016.

The Board are asked to receive the information provided.

2. Key highlights and Exceptions from March reporting

2.1. Monitor Compliance

As at 15 April 2016 the Trust is under target on four out of the 18 Monitor targets due to be reported this quarter. As previously reported there have been challenges in meeting the new access targets for both IAPT and EIP with all three targets being missed. CPA reviews are also under trajectory at 94.5%, services are currently ensuring all records are up to date in time for the final submission and are confident that the 95% target will be achieved. A conversation with Monitor is planned prior to the formal quarterly meeting to advise them of the position and actions we have in place. Final figures are due to be signed off on 22 April 2016.

2.2. Agency Spend

Overall spend on Agency staff has increased in month from 6.93% to 8.46%. YTD spend on Nursing Agency has also increased from 4.09% to 4.25% following the second highest percentage spend all year in March 2016 at 6.23%. A review of the internal targets and reporting requirements is being carried out.

2.3. Contractual KPI review As at the 18 April 2016, 55% of KPI’s due to be reported in March 2016 have been achieved with overall compliance in 15/16 at 59%. Final figures are due to be signed off on 22 April 16 and a full update provided at the quarter four Performance and Quality review session. The opening position on KPIs for 2016/17 will be reported next month.

57

2

Contract Performance Notices remain open for Memory Assessments Services with performance in Tameside proving particularly challenging. The Trust is working closely with commissioners to understand the challenges and develop a business case.

We are still awaiting the final report from commissioners for the Joint Investigation regarding Oldham IHT; this has been raised as a concern at the contract meeting.

HMR Paediatric Salt has met the required targets and a formal closure of the notice has been received

A new Contract Performance Notice has been received for Looked After Children’s (LAC) assessments in HMR .The formal contract management meeting took place with commissioners on 20 April 16 the outcome of which was a remedial action plan (RAP) for review assessments of Rochdale children placed within the Rochdale borough and a Joint Investigation ( JI) for all other KPI’s. The commissioner’s position is that KPIs within the RAP should reach the required 95% performance by the end of quarter one with fortnightly reporting against an agreed trajectory. The JI will be completed by the 17 May 2016 and dependant on the outcomes it is expected that performance for these KPIs will improve to 80% within quarter one and 95% by the end of quarter two. If the required improvements are not met contractual penalties will be applied from quarter two. An improvement action plan has already been developed and the service, with support from the performance department, has begun to review and revise internal systems and processes. Updates will be provided to the Director of Operations on a fortnightly basis and will form part of the Monthly Performance report to Executive Directors.

2.4. Sickness Absence

Sickness Absence levels have improved in month from 4.82% to 4.40% with reduction across all Divisions and in both long and Short term sickness levels.

2.5. Core and Essential Skills Training ( CEST) Overall CEST compliance has improved to 88% in the month with all divisions showing improvement. Teams with the lowest levels of compliance are being contacted direct to ensure compliance level continue to improve.

2.6. IPDR compliance

IPDR compliance has reduced during the month to 76.60% with decreases being seen across a number of divisions. The Director of Operations will be contacting all services to ensure compliance levels improve.

2.7. Looked After Children Assessments

A report highlighting the internal and external performance issues across the Trust and providing assurance on the actions being taken to address these has been produced. This will be circulated to Board members prior to the April 2016 Board meeting.

2.8. Information Governance Training At the end of March 2016 the Trust had reached the 95% compliance for Information Governance training. This was required to ensure the compliance with the IG Toolkit.

58

3

2.9. Dental Contract

An issue has been raised by the Dental Service which is affecting the provision of general anaesthesia for paediatric patients requiring dental treatment in Greater Manchester.

Due to suspension of the four lists per week by Pennine Acute NHS Hospitals Trust at the Fairfield site, there is now an unsustainable and growing waiting list of children being unable to access treatment. Currently there are over 275 children waiting in the areas of Rochdale, Oldham and Bury and this is increasing daily.

Potential options to address the issues have been identified and shared with the Executive Team for review and strategic support.

2.10. Trafford District Nursing Capacity and Demand Trafford has for some time experienced demand difficulties with the district nursing service due to increased number of referrals and also their greater complexity. This has more recently been exacerbated by sickness and recruitment difficulties. In response to this, the DBU has worked with the CCG and recently submitted a proposal to change the way that the service operates. This was based on detailed analysis of six months of activity data. This has highlighted that considerable amount of work is taken up with delivering care that patients could carry out themselves if suitably prepared during pre-operative processes at hospital. If these changes are agreed then this should enable the service to reduce the work load the staff currently experience and also allow them time to deliver care which is more focused on prevention and self-management.

A further element of the proposal is to change the skill mix of the workforce to develop a health and social care practitioner role that will allow more qualified staff to carry out tasks better suited to their skill set and develop a more integrated approach to care. We are also introducing band seven roles to each of the teams who, whilst still carrying out clinical duties, will support the staff to develop their skills and become clearer about which patients they see and for how long. There will also be a stepped care model which allows easier movement of patients to the right step of the pathway. The final element of our approach is to introduce a daily ‘sitrep’ for the service which will allow the nursing and management team to have an immediate understanding of the demand and capacity of the service each day and follow up any difficulties in real time. Whilst this approach has always been in place, it will now become formalised and linked to business continuity and senior managers. This will start from 3 May 2016. The whole of this approach will be led and monitored by a monthly Community Nursing Strategy Group.

59

4

3. Update on Strategic Issues Action plan

3.1.1. CEST

As reported in section 2.5 CEST compliance continues to improve and at the end of March the overall performance across the Trust was 88.8%. A meeting is due to be held on 21 April 2016 to target any remaining areas of poor performance.

3.1.2. IPDR An Information collection has been exercise carried out with staff and managers to diagnose the underlying reasons for concerns about IPDR. Two concerns were identified, recording in ESR and ease of completing the paperwork. Actions have been taken to address these issues including tracking the number of records recorded on ESR in additional the previous system of informing HR assistants of IPDR’s will remain until after the CQC visit. Work is also continuing to integrate performance related pay into the IPDR process. This is currently in discussion with JNCC and when approved briefings will be developed to support launch and any change to paperwork required.

3.1.3. Workforce Data

An update on the mapping work stream is to be presented to ED /Service Director / Corporate Heads this month. This will agree local service actions, and identify any further work streams required with appropriate leadership and governance.

P&I are conducting a SPRINT on WC 18 April 2016, with the view to developing the architecture required to house ESR data in the trusts data warehouse. This will lead to the development of a core HR dataset for all trust reporting, delivering one source of data with robust assurance. Reporting and assurance for these work streams will take place via the Management Information Framework meetings, which in turn will feed in to the Performance Management Systems Steering Group.

3.1.4. Recruitment Retention Tactical and operational workforce groups in community nursing and Mental Health and for Bank and Temporary staff have been established to work through issues and monitor progress with services. A report was presented to Performance Quality Assurance subcommittee in February 2016 on immediate actions to address recruitment and retention. The draft People & OD Strategy has identified a key strategic aim of ‘Effective & Sustainable workforce’. Key strategic aims are outlined and an action plan has been developed which includes a range of wider longer term interventions including clinical education programme for staff for the future.

60

5

3.1.5. Activity levels and cluster data

A task and finish group met on 19 April 2016. A performance diagnosis has been completed and an action plan has been developed.

3.1.6. KPI reporting

Following the 2016/17 contract negotiations process new KPI schedules have now been agreed and the KPI risk stratification work is being finalised against the new KPI schedules.

3.1.7. Smoking Incidents

An initial meeting took place on the 23 February 2016. It was agreed that the performance diagnosis will take place at the Smoke Free group and a meeting date is being arranged.

61


Mental Health and Community Services Governance dashboards: March 2016

Author Zoe Molyneux, Associate Director of Quality Governance

Andrea Morris, Head of Integrated Governance Executive Sponsor Dr Henry Ticehurst, Medical Director

Ian Trodden, Director of Nursing & HCP Date of Report April 2016 Action Required Board of Directors to note the content of the dashboards. Key issues for Board discussion / approval

The Board of Directors will receive exception reports where there has been an increase in both month and year.


The dashboard provides an overview of Safety, Effectiveness and Experience for March 2016.

Financial Implications There are no financial implications.

Amount of time required on the Board agenda

10 minutes


None


LPC1

LPC2

LPC3


SE1

SE2 SE3

SE4

SE5


UR1 UR2 UR3 UR4


PC1 PC2 PC3 PC4 PC5



62

Mental Health Quality Governance Dashboard:

DescriptionNumber in

Month

M

Trend

Y

TrendDescription

Number

in MonthM Trend Y Trend Description

Number in

MonthM Trend Y Trend

STEIS CASES 7 t u PALS NORTH 13 t u AUDITS COMMENCED IN MONTH 8 t uNEVER EVENTS 0 w w PALS SOUTH 18 t u AUDITS COMPLETED IN MONTH 6 t u

REGULATION 28 0 u w PALS SSD 3 u u AUDITS CURRENTLY UNDERWAY 15 t uAUDITS COMPLETED YTD 27 t t


Month

M

Trend

Y

TrendDescription

Number

in MonthM Trend Y Trend AUDIT PROJECTS 42 u w

SELF HARM 128 t t COMPLIMENTS NORTH 8 t t

AWOLS 31 u u COMPLIMENTS SOUTH 10 t t DescriptionNumber in


SLIPS/TRIPS/FALLS 94 t t COMPLIMENTS SSD 6 u u MRSA BACTERAEMIA 0 w wMEDICATION ERROR 38 t t COMPLIMENTS CENTRAL 1 t w MSSA BACTERAEMIA 0 w w

ECOLI BACTERAEMIA 0 w w


Month

M

Trend

Y

TrendDescription

Number

in MonthM Trend Y Trend C DIFF TOXIN POSITIVE 0 w w

SUSPECTED SUICIDE 0 u u COMPLAINTS NORTH 2 u u ESBL 0 w w HOMICIDE 0 u u COMPLAINTS SOUTH 4 u u PERIODS INCREASED INCIDENTS 4 t t

GRADE 5 (excluding suicide) 30 t w COMPLAINTS SSD 5 w t CPE 0 w wCOMPLAINTS CENTRAL 1 t w

Description Ongoing NewPote

n-tialDescription

Number in


SAFEGUARDING ADULTS SCR 2 0 1 Description %Respond-

entsTrend NICE EVIDENCE RELEASED IN MONTH 3 u u

SAFEGUARDING CHILDREN SCR 3 0 0 Trust wide FFT % Overall 94% 2231 u NICE EVIDENCE DISTRIB. TO SERVICE 3 u uFFT % Mental Health Services 82% 436 u NICE EVIDENCE RELEASED YTD 43 t t


Month

M

Trend

Y

TrendFFT % Bury 82% 39 t

RISK VERY LOW 0 w w FFT % Oldham 77% 79 t

RISK LOW 2 w w FFT % Stockport 83% 54 u

RISK MODERATE 15 t w FFT % Tameside & Glossop 79% 167 uRISK HIGH 6 t t FFT % Rochdale 90% 97 u


Month

M

Trend

Y

TrendRCA COMPLETED 0 w uRCA < 60 DAYS 0 w uRCA > 60 DAYS 0 w w

Infe

ctio

n C

on

tro

lN

ICE

Ris

k R

eg

iste

rR

CA

'sS

afe

gu

ard

ing

Co

mp

lime

nts

Co

mp

lain

ts

Sa

fety

De

ath

s

Pa

tie

nt

Fe

ed

ba

ck

Mar-16

Patient Experience Clinical Effectiveness

Ex

tern

al

PA

LS

Patient Safety

Au

dit

s

Lesson Learned this Month: .

Lesson Learned this Month:

Following PCFT's response to The Mazar's Report, all of the cause codes for expected/unexpected deaths have been revised in line with recommendations. We have this month introduced 'Suspected suicide whilst on leave from the ward' to allow timely reporting.

63

Community Services Quality Governance Dashboard:


MonthM Trend

Y

TrendDescription

Number in

MonthM Trend

Y

TrendDescription

Number in


STEIS CASES 9 t u PALS OLDHAM 16 u u AUDITS COMMENCED IN MONTH 5 t tNEVER EVENTS 0 w w PALS HMR 12 w t AUDITS COMPLETED IN MONTH 4 u u

REGULATION 28 0 w w PALS BURY 7 t u AUDITS CURRENTLY UNDERWAY 22 t tPALS DENTAL 0 w w

PALS TRAFFORD 1 u u AUDITS COMPLETED YTD 33 t t


MonthM Trend Y Trend AUDIT PROJECTS 55 u t

Grade 1 128 t t DescriptionNumber in

MonthM Trend

Y

Trend

Grade 2 92 u u COMPLIMENTS OLDHAM 10 t u DescriptionNumber in


COMPLIMENTS DENTAL 2 t t

Grade 3 109 u t COMPLIMENTS HMR 8 t u MRSA BACTERAEMIA 0 w wGrade 4 17 t u COMPLIMENTS BURY 6 u t MSSA BACTERAEMIA 0 w wGrade 5 3 t w COMPLIMENTS TRAFFORD 22 u u ECOLI BACTERAEMIA 0 w w

Investigation Reports 9 u u C DIFF TOXIN POSITIVE 0 w w


MonthM Trend

Y

TrendESBL 0 w w

COMPLAINTS DENTAL 0 w w


MonthM Trend

Y

TrendCOMPLAINTS OLDHAM 3 u t

PERIODS INCREASED INCIDENTS0 u w

PRESSURE ULCERS 94 u t COMPLAINTS HMR 3 u t CPE 0 w wUNSAFE DISCHARGES 25 t t COMPLAINTS BURY 2 w u

SLIPS/TRIPS/FALLS 40 u u COMPLAINTS TRAFFORD 3 w t DescriptionNumber in


MEDICATION ERROR 16 t u NICE EVIDENCE RELEASED IN MONTH 3 u u

Description PercentageRespond-

ents Trend NICE EVIDENCE DISTRIB. TO SERVICE 3 u u

Description New OngoingPoten-

tialFFT % TRUST WIDE 94% 2231 u NICE EVIDENCE RELEASED YTD 43 t t

SAFEGUARDING ADULTS SCR 0 2 0 ***FFT % OVERALL COMMUNITY 97% 1443 uSAFEGUARDING CHILDREN SCR 0 8 0 FFT % OLDHAM 98% 227 u

FFT % TAMESIDE HIS 100% 33 t


MonthM Trend

Y

TrendFFT % BURY 98% 220 u

FFT % TRAFFORD 99% 117 w

RISK VERY LOW 1-3 1 t t FFT % HMR 96% 796 uRISK LOW 4-6 4 w t FFT % GRANGE VIEW 92% 26 u

RISK MODERATE 8-12 15 t u FFT % DENTAL 100% 325 tRISK HIGH 15+ 4 t u

* FFT data for Grange View is collected and reported quartlely

** FFT Data for Dental Services available from 1.5.2015


MonthM Trend

Y

Trend*** Excludes Grange View and Dental

RCA COMPLETED 0 w wRCA < 60 DAYS 0 w w

RCA > 60 DAYS 0 w wIn

fect

ion

Co

ntr

ol

NIC

E

RC

A's

PA

LS

Co

mp

lim

en

tsC

om

pla

ints

Inci

de

nts

Sa

fety

Sa

feg

ua

rdin

gR

isk

Re

gis

ter

Pa

tie

nt

Ex

pe

rie

nce

Mar-16

Patient Safety Patient Experience Clinical Effectiveness

Ex

tern

al

Au

dit

s

Key Message This Month: A review of the clinical audit process has led to a change of how the

clinical audit programme is structured and how the team will report the status of local priority clinical audits (Should do audits). from April 2016. Clinical audits pass through various stages to completion and it is now proposed that these stages will be tracked and reported on via the Quality Governance Dashboard as detailed in the information below. • Clinical Audits in planning • Clinical Audits in data collection • Clinical Audits in analysis • Clinical Audits in report writing • Clinical Audits handed over to the Clinical Lead/Service

64


Inpatient Quality Matrix (IQM) Heat Map

Author Carol Palk Modern Matron – Service Improvement

Executive Sponsor Ian Trodden Executive Director of Nursing and Healthcare Professionals

Date of Report 15 April 2016 Action Required The Board of Directors is asked to note the contents of the

report. Key issues for Board discussion / approval

Further to the IQM report presented to Board in February 2016, the report represents a high level ‘heat map’ of IQM scores and themes as at 15 April 2016. A full analysis of the IQM will be circulated outside Board in May 2016.


The report summarises key IQM findings for quality and patient care.


10 minutes


N/A

FOI Exemption (PI only)¹ None This paper relates to the following strategic goals/high level targets – select all that apply (see key overleaf): LPC (Put local people and communities first)

LPC1 LPC2 LPC3


SE1 SE2 SE3 SE4 SE5


UR1 UR2 UR3 UR4


PC1 PC2 PC3 PC4 PC5



65

Inpatient Quality Matrix Heat Map (15/04/16) Introduction

This report follows on from the briefing provided to Board in February 2016, which gave an update on the continued implementation of the Inpatient Quality Matrix (IQM). The information within the report is intended to summarise the current IQM scores in the form of a heat map, along with high level themes and actions. The full IQM report will be circulated outside Board in May 2016.

Scoring

The scoring system used in the IQM assessment and in matrices for the individual wards is slightly different to the RAG rating system for the ‘Heat Map’ below.

Red in the assessment means that there is no evidence at all for an indicator and a score of 1 has been allocated, whereas amber means that there was partial evidence (2) or nearly enough evidence (3) that the indicator had been met. All expected evidence has to be available for a green or a score of 4.

While this colour coding system works well in the ward matrices to indicate priorities to the teams, for the heat map it was thought that an average score of two would be more concerning than a RAG rating of amber would suggest, so anything below 3 is rated red. Also, very few of the rating categories would show a score of 4 when averages are used across a large number of indicators, so the parameter has been lowered slightly for a green.

Average score > 3.4 [ ]

Average score between 3 and 3.4 [ ]

Average score < 3 [ ]

It should be noted that the IQM matrix represents a point in time for each ward. There has been a delay in producing final reports due to the intensive roll-out over a short space of time to ensure that all areas had an assessment to help them prepare for the CQC. However, each area has had immediate post-visit access to the data base produced on the day of the visit, from which actions are already being implement.

The service line report for the Adult Acute areas is included after the heat map. The SSD and Older People’s Service Matrons will have completed their analysis soon and it will follow a similar format so that an overall view of the in-patient mental health wards can be seen. There are currently no scores available for Hope Unit as the need for a room

The following is a little more information for the reader to consider in relation to the red areas on the map:

Person Centred Care Scores for ‘Person Centred Care’ appear slightly differently under the IQM dimension and the CQC regulation. This is because the standards and indicators are slightly different in the different quality frameworks. However, there are clearly a number of red areas in both sections, particularly for the Adult Acute Wards, and these relate predominantly to the ‘Documentation’ evidence source for care planning indicators. Feedback at the IQM Quality

66

event has highlighted the difficulty the acute wards have in implementing care planning using the current Trust Approved Documentation. It has been agreed that a review of care planning process and tools needs to take place as a matter of urgency and this has been made a priority for the Quality Account.

Physical Health Physical Health is another dimension where low scores are common across the different service lines. Work is already underway to address this issue. Although training has been delivered in the past as part of the ‘Physical Health Matters’ programme, bringing about improvements in knowledge and some change in attitude according to evaluation, there appears to have been difficulties embedding the skills and knowledge gained into practice. This year’s training programme invests in the ward’s Physical Health Lead Nurses. The programme is being run in conjunction with Manchester Metropolitan University and focuses on skills to teach and assess competence as well as deepening knowledge in key areas to enable the leads to act as a resource within the services. Another essential component of the programme is on-going development sessions which will have educative, problems solving and clinical supervision elements, providing a comprehensive support network and a communication channel to influence the Physical health Steering Group.

North Ward There have been several managers over a two year period and the current manager had been in post only a few weeks at the time of the IQM visit. She has done a tremendous amount of work since the visit and the Matron is confident that scores will be greatly improved at the planned re-visit in May.

Stansfield Place There had been an incident at Stansfield Place the day before the IQM visit involving damage to visual displays and information, which adversely affected the observation scores. However, even taking this in to account there were clearly some difficulties. The Director Manger, Service Manager and Unit Manager held a meeting shortly after the visit and a detailed action plan was formulated. This has been implemented over the last few months and it is hoped that a significant improvement will be found at the re-visit planned for this month.

67

Average score > 3.4 [ ] Average score between 3 and 3.4 [ ] Average score < 3 [ ] A

rden

Nor

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Saxo

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Tayl

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Sout

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Nor

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Moo

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Hol

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Sout

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Dav

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Ros

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on

Hau

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Sum

mer

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Row

an

Ced

ars

Bee

ch

Ram

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tom

Hea

thfie

ld

Bev

an

Hur

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Bec

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Rho

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Stan

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ld

Tatto

n

Enga

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ent

Rec

over

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Incl

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Cob

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Hor

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Hop

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IQM Dimensions Overall 3.3 3.3 3.4 3.2 3.2 3.3 3.3 3.2 3.4 2.9 3.6 3.3 3.7 3.7 3.6 3.6 3.5 3.2 3.4 3.6 3.6 3.4 3.4 3.5 2.8 3.7 3.4 3.5 3.4 3.6 3.5

Nutrition 3.3 3.1 3.6 3.2 2.7 3.3 2.9 3.2 3.5 2.8 3.8 3.4 3.8 3.8 3.5 3.9 3.7 3.3 3.6 3.5 3.8 3.3 3.3 3.6 2.7 3.8 3.3 3.1 2.9 3.3 3.7

Med. Man. 3.5 3.9 3.8 3.3 3.9 3.8 3.8 3.8 3.7 3.9 3.5 3.6 3.6 3.7 3.9 3.9 3.9 3.6 3.9 4 3.8 3.9 3.8 3.8 3.1 4 3.7 3.6 3.4 3.9 3.9

Communication 3.4 3.6 3.6 3.4 3.6 3.5 3.2 3.2 3.8 3.2 3.6 3.3 3.7 3.7 3.7 3.6 3.8 3.1 3.3 3.8 3.5 3.4 3.5 3.5 2.9 3.6 3.5 3.5 3.7 3.6 3.5

Person Cent. 2.9 2.8 3.2 3 3.1 3.2 3.3 3.3 3.4 2.8 3.3 2.8 3.6 3.6 3.6 3.4 3.5 3.2 3 3.6 3.4 2.9 3 3.2 2.5 3.6 2.9 3.2 3.3 3 2.6

Therapeutic 3.3 3.2 3.4 3.3 3.3 3.4 3.4 3.6 3.6 2.8 3.7 3.1 3.7 3.9 3.5 3.7 3.3 3.3 3.5 3.9 3.7 3.5 3.4 3.4 3 3.5 3.2 3.4 3.8 3.2 3.6

Personal Care 3.8 3.4 3.7 3.4 3.3 3.4 2.9 2.9 3.5 3.1 3.8 3.1 3.7 3.8 3.9 3.6 3.1 3.5 3.5 3.5 3.6 3.4 3.9 3.8 3.3 4 3.7 3.9 3.6 3.8 3.5

Physical Health 3.1 2.9 2.9 3.3 2.5 2.9 3 2.8 3 2.4 3.4 3.2 3.5 3.4 3.2 3.6 3.3 2.7 3 3.3 3.2 3 3.1 3.2 2.8 3.4 3.1 3.3 2.9 2.8 3.2

Safety/Security 3.6 3.6 3.7 3.2 3.6 3.6 3.4 3.2 3.4 3 3.8 3.6 3.8 3.9 3.8 3.6 3.8 3.3 3.6 3.7 3.8 3.8 3.6 3.7 2.6 3.8 3.7 3.6 3.8 3.7 3.6

Protection 3.6 3.3 3.6 2.9 3.4 3.3 3.4 3 3.4 2.9 3.8 3.6 3.8 3.8 3.9 3.6 3.7 3.5 3.6 3.6 3.4 3.3 3.7 3.6 2.7 3.9 3.5 3.8 3.7 3.6 3.7

Infection Control 3.4 3.3 3.4 3.1 3.1 3.3 3.1 3 3.3 2.6 3.5 3 3.6 3.9 3.6 3.3 3.2 3.1 3.5 3.4 3.3 3.7 3.6 3.5 2.5 3.8 3.4 3.7 3.5 3.4 3.7

Evidence Sources Observation 3.5 3.5 3.8 3.6 3.5 3.6 3.2 3.6 3.7 3.6 3.8 3.6 3.7 3.8 3.8 3.8 3.5 3.3 3.8 3.6 3.6 3.6 3.6 3.8 2.8 3.9 3.4 3.8 3.8 3.6 3.8

Documentation 2.6 2.9 2.8 2.6 2.6 2.8 3.1 2.7 3.1 2.7 3.2 2.6 3.4 3.2 2.9 3.2 3.5 2.6 2.1 3.3 3.2 3.1 3.1 2.6 2.8 3.6 2.9 2.8 2.9 2.7 3.3

Process 3.6 3.3 3.7 2.8 3.5 3.5 3.4 2.8 3.5 2.9 3.8 3.7 4 4 4 3.7 3.8 3.3 3.7 3.7 3.6 3.7 3.7 3.6 2.8 3.9 3.8 3.7 3.8 3.7 3.7

Patient 3.5 2.6 3 3.6 3 3.6 3.5 3.8 3.9 2 3.9 X 4 3.9 3.8 3.9 X 3.8 3.9 3.9 X 3.7 3.4 3.5 X X X 3.5 3.6 3.5 X

CQC Regulations Person Centred 2.9 2.8 3 2.7 2.8 2.9 3 2.9 3.1 2.6 3.3 2.9 3.3 3.4 3.1 3.3 3.5 2.9 2.7 3 3.2 2.7 3 3 2.7 3.5 3.1 3.1 3 2.8 3.3

Dignity/Respect 3.2 3.3 3.6 3.2 3.3 3.2 3.3 3.3 3.4 3.2 3.6 3.1 3.7 3.8 3.5 3.6 3.4 3.2 3.3 3.6 3.5 3 3.2 3.5 3 3.5 3 3.5 3.4 3.2 3.5

Consent 2.8 2.9 3.2 2.9 3 3 3.1 3 3.2 2.7 3.5 2.8 3.3 3.6 3.1 3.4 3.3 3.1 3.2 3.4 3.2 2.7 3.2 3.5 3 3.4 2.9 3.3 3.1 3.1 3.4

Safe Care/Treat. 3.3 3.3 3.4 2.8 3.3 3.3 3.3 3.1 3.4 2.9 3.4 3.3 3.6 3.7 3.6 3.6 3.7 3.2 3.4 3.7 3.5 3.4 3.5 3.4 2.7 3.7 3.4 3.4 3.4 3.4 3.5

Safeguarding 3.4 3.2 3.5 2.7 3.1 3.2 3.3 3.1 3.3 2.8 3.6 3.3 3.6 3.8 3.6 3.5 3.5 3.3 3.5 3.7 3.4 3.2 3.6 3.5 2.7 3.6 3.2 3.5 3.5 3.4 3.4

Nutrition 3.2 3.1 3.5 3.1 3 3.3 3.1 3.1 3.3 2.9 3.7 3.3 3.8 3.8 3.5 3.8 3.6 3.4 3.6 3.5 3.6 3.2 3.2 3.5 2.6 3.7 3.2 3 2.9 3.2 3.6

Premises/Equip. 3.6 3.5 3.4 3.2 3.2 3.2 3.1 3.1 3.5 3.3 3.8 3.5 3.7 4 3.8 3.5 3 3.3 3.8 3.5 3.5 3.7 3.6 3.6 3 3.6 3.5 3.6 3.7 3.7 3.7

Complaints 3.4 3.3 3.9 3.6 3.4 3.4 3.6 3.2 3.9 2.8 3.6 3.4 3.9 3.8 4 3.7 4 3.6 3.5 3.8 2.9 3.6 3.6 3.8 2.8 3.9 3 3.4 3.9 3.7 3.5

Governance 3.5 3.7 3.6 3 3.7 3.5 3.5 3 3.7 3.2 3.7 3.4 3.9 3.7 3.7 3.4 3.8 3.3 3.5 3.8 3.7 3.6 3.7 3.5 2.7 3.8 3.7 3.7 3.7 3.7 3.6

Staffing 3.5 3.3 3.5 2.6 3.4 3.4 3.4 3.2 3.5 3 3.8 3.7 3.9 3.9 3.8 3.7 3.7 3.4 3.7 3.8 3.7 3.8 3.7 3.3 2.9 3.8 3.7 3.5 3.7 3.6 2.9

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Adult Acute Wards – Service Level Information

Areas of good Practice

Across the service line improvements, improvements have been evident in the following domains:

Medicines management – Improved audit results for the safe handling and storage of medications.

Communication – Improvements were evident in the quality of written entries in accordance with record keeping standards, carer information and engagement records, information available and accessible for patients and engagement with patients through community meetings.

Individual ward areas have also made improvements in relation to physical health with the introduction of the Physical health screening tool, although further work is required to embed this process and ensure analysis of the screen is undertaken.

Initiatives such as Safe Ward and the ReStrain project have enable the wards to consider changes to practice which has seen some individual improvements made in relation to therapeutic engagement and person centred care.

Service Line themes

Key areas that were identified as requiring improvement on all of the adult acute in-patient wards were:

Physical Health – whilst all of the wards have started using the new PH screen tool, it was identified that this was being completed to varying degrees and analysis of the screen was not always being undertaken, resulting in links and possible risk areas not always being identified.

Plan:

PH leads (some previously identified, and newly identified team members) have been invited to attend a 2 day training course developed and facilitated by the Modern Matrons in conjunction with subject expert presenters. The course has been designed to increase knowledge in the areas screened on the tool, increase understanding of how and why the tool should be completed, competency assessments in clinical skills and to develop resources which will be made available to the Leads to cascade training and assess competency of team members out in practice. The second cohort of training has recently commenced.

Care planning for PH needs was a further area for development of which there is a separate work stream to look at the care planning process. However it is anticipated that the training provided to the PH leads and further training that is planned will improve the recognition for the need for a nursing care plan and enhance the evidence base of interventions within the plan.

Care planning

This has caused most areas to score lower in all of the domains where care planning was assessed (PH, nutrition, personal care, etc). It was identified that on the whole care plans are taking a generic format, with little evidence of personalisation of goals or interventions, and collaboration with service users. As identified below, due to the nursing care plans currently being perceived as a separate component of care delivery there is tendency for them to be reviewed in

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isolation of the MDT and often do not reflect decisions or changes made in the wider MDT forum, evidencing a fragmented approach to care delivery.

Plan

A proposal has been submitted to undertake a review of in-patient documentation. The aim of this is to remove duplication where necessary and streamline processes for recording information. In doing so it is anticipated that staff will have time to be able to engage with service users in order to identify needs from which nursing care plans can be developed.

A project to introduce clinical supervision to all staff has commenced on the wards, through the provision of the model there is opportunity for staff to enhance their practice and learn from each other which may contribute to increased evidence based in assessment and care planning.

A Task & finish group has also been proposed to explore timeframes, care planning documentation and the existing process for identification of needs and care planning and evaluation, with a view to identifying where changes can be made.

In addition to this, consideration may need to be given as to how areas of need are identified and how best to equip the nursing team to do this. This may include additional guidance and training.

MDT working

The IQM has a strong nursing focus, however through the review of processes and all documentation relating to individual patients, it has been identified that the multi- disciplinary team continues to work in a fragmented format. This is particularly evident within documentation. There is evidence of different disciplines assessing needs and working with patients, however from a recording aspect this is completed in a very singular way with little connection being made across disciplines, which can result in duplication of care plans and a missed opportunity to link findings and interventions across the MDT.

In addition to this, processes for MDT reviews and on-going nursing planning of care are detached with very little links being made between MDT discussion and nursing care plans. There is very limited evidence of overarching care goals being set and can create a disconnect between care plans being devised and actual care delivery, often with the detriment being on the recording of rather than the delivery.

Clinical Supervision

From the IQM process it was identified that frameworks for clinical supervision are not in place. Provision differs between boroughs and is often provided by borough psychology teams, where feasible. Management supervision is more widely available and structures for this indicate some evidence of merging of the two forms of supervision.

Plan

A project has been commissioned and is underway involving the roll out of an alternative model for clinical supervision which has a nursing focus. The project is being coordinated by the Modern Matron for adult acute in-patient services and external Lecturer/practitioner who has been involved in the development of the model.

Findings from this are to be fed back to the Director of Nursing and if successful be incorporated into the clinical supervision policy.

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Divisional themes

North Division

Within the North Division the in-patient/community consultant model is in operation with one consultant allocated to each ward. In addition to the MDT reviews/ward rounds, the wards also operate a meeting which tracks service user progress referred to as a report out or business meeting which occurs between two-three times weekly. Whilst observed as an effective forum for communication and MDT discussion in relation to patient care, this isn’t currently captured or recorded and so there is little evidence of the discussions that have taken place. As this is the forum for sharing key information and reviews of risk, activity participation, leave and observation levels, it has created a deficit for the wards within the process and documentation areas of evidence.

Plan

Findings have been shared with the Service manager and solutions to this to be explored and agreed with the ward teams.

South Division

The multiple consultant model that is operated in the South division is resulting in multiple ward rounds occurring in a week and often simultaneously on the wards. This provides many challenges in regards to ensuring nursing representation is available, as it has been identified that this can also be on an ad-hoc basis making it difficult to plan for. Systems such as the PSAG board have less emphasis as there are no processes currently which require this to be up to date as it is not the focus of any MDT processes. Communication processes are in place to share information and to ensure key tasks are completed with service users, however these processes are often repetitive and reduce the time available for patient engagement even further. This has had a significant impact on standards of nursing documentation in relation to patient reviews and care planning.

Plan

Findings have been shared with In-patient service Manager to discuss with MDT members to consider alternative ways of working.

Where alternatives cannot be agreed, Modern Matron and In-patient Service Manager to work with individual ward teams to explore options for improving existing systems.

Individual Wards

Following the IQM, the wards have all received verbal feedback and more recently have received written reports providing guidance on areas for improvement. Given that there has been a time lapse between the IQM being undertaken and the reports being received, actions have already commenced by the wards to address some of these areas.

It is acknowledged that wider issues affecting all services have impacted on the results of the 2015 IQM, including staffing recruitment and retention. For some ward areas this has been particularly detrimental.

Other impact factors include the movement of staff to facilitate other projects and changes to senior roles on the ward.

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Where this has been identified the Modern matron has been working closely with the ward teams to provide support to those newly appointed to senior roles and to engage the teams in making changes and improvements to ward processes.

Summary

Overall the in-patient wards have maintained standards and in most cases further improvements have been made following on from the initial IQM that was undertaken in 2014. Given the challenges that have previously been identified in the report, and the increased demands that are being placed on in-patient teams, a decline in scores against the standards may have been anticipated, and this has not been the case.

It is difficult to make direct comparisons with the previous years’ results due the mapping in of the new CQC Fundamental standards. In addition to this the tool has this year been used as a preparatory tool for the pending CQC visit to the organisation and so is the main focus of feedback and reporting with less emphasis on other initiatives included in the tool. However it is acknowledged that improvements in the areas identified will also contribute to the other initiatives, and can still be accessed by the individual ward areas.

The in-patient teams continue to be innovative and there are good examples of new approaches to practice across the service line. Examples of these that have recently been presented at the Quality Forum are the mutual help meetings, a component of Safe Wards that have been roiled out at Bury and a carer questionnaire that has been devised by a Health care Support worker at Oldham to obtain direct feedback to influence changes to practice at ward level.

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National Guardian – Freedom to Speak Up

Author Sian Schofield Head of Nursing and Strategic Lead for Safeguarding

Executive Sponsor Ian Trodden Executive Director of Nursing and Healthcare Professionals

Date of Report 19 April 2016 Action Required

For information and consideration for implementation within Pennine Care NHSFT


Establishment of the role of Freedom to Speak Up Guardian within PCFT


Indirect impact on quality and patient care with the introduction of the role.

Financial Implications Financial implications for establishment of the role. Amount of time required on the Board agenda

10 minutes


N/A

FOI Exemption (PI only)¹ None This paper relates to the following strategic goals/high level targets – select all that apply (see key overleaf): LPC (Put local people and communities first)

LPC1

LPC2

LPC3


SE1

SE2 SE3

SE4

SE5


UR1 UR2 UR3 UR4


PC1 PC2 PC3 PC4 PC5



73

National Guardian – Freedom to Speak Up – Briefing Paper

Introduction The Department of Health responded to the Sir Robert Francis report on ‘Freedom to speak up’ and the investigation at Morecambe Bay University Hospitals NHS Foundation Trust in their report ‘Learning not Blaming’, published in July 2015. In the report, the department accepted a number of recommendations including the one that there should be a “Freedom to Speak Up Guardian” in every NHS trust and NHS foundation trust, appointed by the chief executive, to act in a genuinely independent capacity to provide the leadership and support to create a culture where staff understand and feel confident in raising concerns, however insignificant they may appear, so that it becomes part of normal, everyday practice. As well as ensuring staff know how to and where to raise concerns, they should feel entirely confident that their concerns will be listened to and acted upon as necessary and, most significantly, that they will not experience any detriment for having raised their concerns. These new local roles are being supported through a network by the newly established office of the National Guardian. Staff in this context includes all the workforce, including temporary and agency workers, students on placement and staff working for contractors. The success criteria for the Office of the National Guardian and the Freedom to Speak Up Guardians are to be determined with our stakeholders, but they will fall into three main areas:

• There are Freedom to Speak Up Guardians in place in every trust, supported by and engaged with the Office of the National Guardian

• Staff in NHS trusts feel more confident about speaking up and more confident that their concerns will be addressed, based on measures from the staff survey

• Those raising concerns will be feel more positive about the experience, based on measures to be determined by our Board of experts by experience

Since the publication of the report a number of NHS trusts and NHS foundation trusts have already taken forward the appointment of their guardian, and are reviewing their approaches to speaking up and are also in a position to share best practice. This is to be commended. However, other organisations are waiting for guidance from the National Guardian. The following document therefore sets out guidance for organisations on establishing the role of the Freedom to Speak Up Guardian. A detailed job description has not been created; it is for the discretion of each organisation how it wishes to take the requirement forward, as no one model will fit every situation. However, it is important that the Freedom to Speak Up Guardian role is consistent across the NHS. The

74

document does include advice on what has worked well and what hasn’t from those organisations which have already put these posts in place. This document also includes the initial proposals for how the National Guardian’s Office will support those appointed, but these will be developed with Freedom to Speak Up Guardians themselves. At present the remit of the National Guardian’s Office extends to NHS trusts and NHS foundation trusts. During the year from April 2016, the National Guardian’s Office will be working with NHS England to consider how this remit might be extended to cover primary care. However, this does not stop any primary care organisation or other body in establishing their own Freedom to Speak Up Guardian role and using this guidance. The appointment of a Freedom to Speak Up Guardian is part of a much bigger picture in relation to changing the culture of NHS organisations – to make raising concerns and speaking up a normal part of working life, and improving how those who raise concerns are treated. Therefore, the Freedom to Speak Up Guardian should sit as part of a wide range of activities. Establishing the Role of Freedom to Speak Up Guardian Every NHS trust and NHS foundation trust will be required to have appointed a Freedom to Speak Up Guardian during the coming financial year (2016/17). This is, however, not an appointment to be rushed. Trusts are expected to have plans in place by September 2016, based on local needs and how confident staff already are about raising concerns and speaking up. The title of these roles is to be the same across the NHS to ensure clarity and provide support for members of staff who move between organisations. How the role is configured and the specification for the post is attached within this briefing. The following points should be considered before finalising plans for making an appointment. Where an appointment has already been made, these provide a framework for a review of the current arrangements.

• Consult with a broad range of staff to seek their views on whether this should be an internal or external appointment

• Consider how members of staff who work across seven days and a variety of

shift patterns will have access to support and advice out of hours

• Consider how members of staff have access to independent external advice in addition to the Freedom to Speak Up Guardian

• Consider, depending on the size and complexity of your organisation, whether

you need to have a network of roles underneath the Freedom to Speak Up Guardian, such as advocates and ambassadors

75

• Build in a process for regular review of the role to ensure it is meeting your organisation’s needs.

The Freedom to Speak Up Guardian needs to be accessible and trusted by all staff and to have sensitivity, respect and credibility. Freedom to Speak Up Guardians also need to have an in-depth understanding about how difficult it is for someone to raise a concern and to be confident about supporting staff in using local policies and advising local managers to use those procedures appropriately, including the national NHS whistle blowing policy. Freedom to Speak Up Guardians should be appointed by and accountable to the Board and they should have open and frequent access to the members of the Board. They must also feel confident and have the necessary authority should they need to raise concerns externally and be able to act as ambassadors, liaising with key organisations, such as universities. What has worked well for those who have already established Freedom to Speak up Guardians? The following are examples of what has worked well based on engagement with existing Freedom to Speak Up Guardians:

• The freedom to establish the role in a way determined by local need and culture rather than a prescribed form

• Including a broad range of staff, including different professional and

backgrounds, from across the organisation in the appointment process

• Direct access to the chief executive and members of the Board, and giving authority to the Freedom to Speak Up Guardian, so that they can go anywhere and speak to everyone and anyone

• Access to an independent advisor such as a nominated non-executive

director and the establishment of an internal advisory board

• Proactive sharing of key information with the Freedom to Speak Up Guardian, which may not be widely published, such as staff survey results, GMC survey results, family and friends test reports and incident and complaint trends

• Providing external advice and support to the Freedom to Speak Up Guardian,

ensuring that there is a clause in the employment contract (if applicable) confirming the post’s independence and giving permission to support staff and to report issues freely

• An office away from the senior management team, located in an area which

will afford confidentiality

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• Establishing the role as part of the broader framework for developing an open transparent culture, not rushing it but being clear about expectations

• Setting very clear boundaries for the role

• Having clearly designated time for the role rather than the role being in

addition to a current post

• One clearly identified Freedom to Speak Up Guardian who is highly visible and accessible across the organisation, supported by the trust’s communication team

• Providing designated administrative support for the Freedom to Speak Up

Guardian and access to a confidential email address, a restricted area on the local IT system, and a dedicated telephone line

• Establishing regular events which are an open forum for staff to raise

concerns

• Regular reporting on the work of the Freedom to Speak Up Guardian across the organisation

• Including the role of the Freedom to Speak Up Guardian in induction

programmes, including those for students and the staff of contractors What hasn’t worked so well? The following are examples of what has not worked so well:

• No designated time, adding this onto someone’s already very busy day

• Establishing the role without it being part of an overarching framework to improve culture about raising concerns and transparency

• Adding the role to a non-executive director’s portfolio

• No regular access to the chief executive and a lack of open Board support

and sponsorship

• Having the Freedom to Speak Up Guardian working in the HR team. Support from the National Office From April 2016, the Freedom to Speak Up Guardians will be supported through a network established by the Office of the National Guardian. The National Guardian will be appointing national leads who will manage and support the network. Once

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the Office of the National Guardian has been launched, it will proactively support Freedom to Speak Up Guardians and trusts. Initial plans for how this will be achieved are being developed and will follow. There will be training and network days as part the support programme and support from trusts for Freedom to Speak Up Guardians in attending these will be welcomed. The training and events will be free, but the Office of the National Guardian will not be able to cover the cost of travel and accommodation. However, arrangements will be made to ensure these are kept to a minimum.

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A Guide for NHS Trusts & NHS Foundation Trusts in establishing the Freedom to Speak Up Guardian

Introduction The Department of Health responded to the Sir Robert Francis report on ‘Freedom to speak up’1 and the investigation at Morecambe Bay University Hospitals NHS Foundation Trust2 in their report ‘Learning not Blaming’3, published in July 2015. In this report, the department accepted a number of recommendations including the one that there should be a “Freedom to Speak Up Guardian” in every NHS trust and NHS foundation trust, appointed by the chief executive, to act in a genuinely independent capacity to provide the leadership and support to create a culture where staff understand and feel confident in raising concerns, however insignificant they may appear, so that it becomes part of normal, everyday practice. As well as ensuring staff know how to and where to raise concerns, they should feel entirely confident that their concerns will be listened to and acted upon as necessary and, most significantly, that they will not experience any detriment for having raised their concerns. These new local roles are being supported through a network by the newly established office of the National Guardian.

Staff in this context includes all the workforce, including temporary and agency workers, students on placement and staff working for contractors.

The success criteria for the Office of the National Guardian and the Freedom to Speak Up Guardians are to be determined with our stakeholders, but they will fall into three main areas:

• There are Freedom to Speak Up Guardians in place in every trust, supported by and engaged with the Office of the National Guardian

• Staff in NHS trusts feel more confident about speaking up and more confident that their concerns will be addressed, based on measures from the staff survey

• Those raising concerns will be feel more positive about the experience, based on measures to be determined by our Board of experts by experience

Since the publication of the report a number of NHS trusts and NHS foundation trusts have already taken forward the appointment of their guardian, and are reviewing their approaches to speaking up and are also in a position to share best practice. This is to be commended. However, other organisations are waiting for guidance from the National Guardian.

The following document therefore sets out guidance for organisations on establishing the role of the Freedom to Speak Up Guardian. A detailed job description has not been created; it is for the discretion of each organisation how it wishes to take the

1 https://www.gov.uk/government/publications/sir-robert-francis-freedom-to-speak-up-review 2 https://www.gov.uk/government/publications/morecambe-bay-investigation-report 3 https://www.gov.uk/government/publications/learning-not-blaming-response-to-3-reports-on-patient-safety

79

https://www.gov.uk/government/publications/sir-robert-francis-freedom-to-speak-up-review

https://www.gov.uk/government/publications/morecambe-bay-investigation-report

https://www.gov.uk/government/publications/learning-not-blaming-response-to-3-reports-on-patient-safety

https://www.gov.uk/government/publications/learning-not-blaming-response-to-3-reports-on-patient-safety

requirement forward, as no one model will fit every situation. However, it is important that the Freedom to Speak Up Guardian role is consistent across the NHS. The document does include advice on what has worked well and what hasn’t from those organisations which have already put these posts in place.

This document also includes the initial proposals for how the National Guardian’s Office will support those appointed, but these will be developed with Freedom to Speak Up Guardians themselves.

At present the remit of the National Guardian’s Office extends to NHS trusts and NHS foundation trusts. During the year from April 2016, the National Guardian’s Office will be working with NHS England to consider how this remit might be extended to cover primary care. However, this does not stop any primary care organisation or other body in establishing their own Freedom to Speak Up Guardian role and using this guidance.

The appointment of a Freedom to Speak Up Guardian is part of a much bigger picture in relation to changing the culture of NHS organisations – to make raising concerns and speaking up a normal part of working life, and improving how those who raise concerns are treated. Therefore, the Freedom to Speak Up Guardian should sit as part of a wide range of activities.

Establishing the Role of Freedom to Speak Up Guardian Every NHS trust and NHS foundation trust will be required to have appointed a Freedom to Speak Up Guardian during the coming financial year (2016/17). This is, however, not an appointment to be rushed. Trusts are expected to have plans in place by September 2016, based on local needs and how confident staff already are about raising concerns and speaking up.

The title of these roles is to be the same across the NHS to ensure clarity and provide support for members of staff who move between organisations. How the role is configured and the specification for the post is in the attachment.

The following points should be considered before finalising plans for making an appointment. Where an appointment has already been made, these provide a framework for a review of the current arrangements.

• Consult with a broad range of staff to seek their views on whether this should be an internal or external appointment

• Consider how members of staff who work across seven days and a variety of

shift patterns will have access to support and advice out of hours • Consider how members of staff have access to independent external advice in

addition to the Freedom to Speak Up Guardian

80

• Consider, depending on the size and complexity of your organisation, whether you need to have a network of roles underneath the Freedom to Speak Up Guardian, such as advocates and ambassadors

• Build in a process for regular review of the role to ensure it is meeting your

organisation’s needs. The Freedom to Speak Up Guardian needs to be accessible and trusted by all staff and to have sensitivity, respect and credibility. Freedom to Speak Up Guardians also need to have an in-depth understanding about how difficult it is for someone to raise a concern and to be confident about supporting staff in using local policies and advising local managers to use those procedures appropriately, including the national NHS whistle blowing policy. Freedom to Speak Up Guardians should be appointed by and accountable to the Board and they should have open and frequent access to the members of the Board. They must also feel confident and have the necessary authority should they need to raise concerns externally and be able to act as ambassadors, liaising with key organisations, such as universities. What has worked well for those who have already established Freedom to Speak up Guardians? The following are examples of what has worked well based on engagement with existing Freedom to Speak Up Guardians: • The freedom to establish the role in a way determined by local need and culture

rather than a prescribed form • Including a broad range of staff, including different professional and

backgrounds, from across the organisation in the appointment process

• Direct access to the chief executive and members of the Board, and giving authority to the Freedom to Speak Up Guardian, so that they can go anywhere and speak to everyone and anyone

• Access to an independent advisor such as a nominated non-executive director

and the establishment of an internal advisory board • Proactive sharing of key information with the Freedom to Speak Up Guardian,

which may not be widely published, such as staff survey results, GMC survey results, family and friends test reports and incident and complaint trends

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• Providing external advice and support to the Freedom to Speak Up Guardian, ensuring that there is a clause in the employment contract (if applicable) confirming the post’s independence and giving permission to support staff and to report issues freely

• An office away from the senior management team, located in an area which will

afford confidentiality • Establishing the role as part of the broader framework for developing an open

transparent culture, not rushing it but being clear about expectations • Setting very clear boundaries for the role • Having clearly designated time for the role rather than the role being in addition

to a current post • One clearly identified Freedom to Speak Up Guardian who is highly visible and

accessible across the organisation, supported by the trust’s communication team • Providing designated administrative support for the Freedom to Speak Up

Guardian and access to a confidential email address, a restricted area on the local IT system, and a dedicated telephone line

• Establishing regular events which are an open forum for staff to raise concerns • Regular reporting on the work of the Freedom to Speak Up Guardian across the

organisation • Including the role of the Freedom to Speak Up Guardian in induction

programmes, including those for students and the staff of contractors

What hasn’t worked so well? The following are examples of what has not worked so well:

• No designated time, adding this onto someone’s already very busy day • Establishing the role without it being part of an overarching framework to

improve culture about raising concerns and transparency • Adding the role to a non-executive director’s portfolio • No regular access to the chief executive and a lack of open Board support and

sponsorship • Having the Freedom to Speak Up Guardian working in the HR team

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Support from the National Office From April 2016 the Freedom to Speak Up Guardians will be supported through a network established by the Office of the National Guardian. The National Guardian will be appointing national leads who will manage and support the network

Once the Office of the National Guardian has been launched, it will proactively support Freedom to Speak Up Guardians and trusts. Initial plans for how this will be achieved are being developed and will follow. There will be training and network days as part the support programme and support from trusts for Freedom to Speak Up Guardians in attending these will be welcomed. The training and events will be free, but the Office of the National Guardian will not be able to cover the cost of travel and accommodation. However, arrangements will be made to ensure these are kept to a minimum.

Please email [email protected] with the name and contact details of your Freedom to Speak Up Guardian once an appointment has been made and the National Guardian’s Office will be in touch with them directly.

March 2016

83

mailto:[email protected]

Role specification for the Freedom to Speak Up Guardian Acting in a genuinely independent capacity, the Freedom to Speak Up Guardian will be appointed by the Board, working alongside them and members of the executive team to help support the organisation to become a more open, transparent place to work.

In particular the Freedom to Speak Up Guardian will:

• Work with the chief executive and Board to help create an open culture which is based on listening and learning and not blaming.

• Develop, alongside the Board, chief executive and executive team a range of

mechanisms, in addition to the formal processes, which empower and encourage staff to speak up safely.

• Ensure that staff with disabilities and those from black and other minority ethnic

backgrounds are encouraged to speak out and are not disadvantaged by doing so.

• Participate in the organisation’s educational programme for all staff so that they

understand how they can raise concerns and for managers about how they respond to concerns and supporting the member of staff appropriately.

• Be entirely independent of the executive team, so they are able to challenge

senior members of staff, reporting to the Board or externally as required. • Be a highly visible individual, who spends the majority of their time with ‘front

line’ staff, providing expertise in developing a safe culture which supports and encourages staff to speak up using the local procedures and if necessary advising them on how to raise concerns, including externally.

• Act in an independent and impartial capacity, listening to staff and supporting

them to raise concerns they may have by using the available structures and policies, both within the organisation and outside.

• Independently review any complaints from members of staff about the way they

have been treated as a result of raising a concern and report back to the individual and, with their agreement, to their manager, the chief executive and the director of human resources.

• Ensure members of staff who speak up are treated fairly through the

investigation, inquiry and or review and that there is effective and open communication during this time.

84

• Ensure that information about those who speak up is kept confidential at all times, subject to requirements around safeguarding and illegality.

• Meet quarterly with the chief executive to feedback themes from the concerns

raised and to share positive and negative experiences and outcomes. • Report at least every six months to the Board and the organisation as a whole. • Participate in the national network for the guardians, sharing and helping to

develop excellent practice in supporting members of staff who speak up. Those appointed as Freedom to Speak Up Guardian should have these characteristics: • Understand the trust, its values and key priorities and challenges.

• Have a track record of supporting and listening to staff and in demonstrating the

values of the trust and the NHS constitution in their daily working lives.

• Be able to facilitate a conversation between members of staff and their managers.

• Have a good understanding of how to raise concerns and the barriers that can

exist for those who speak up.

• Be an approachable, trusted, non-judgemental individual, who is comfortable with talking with ‘front line’ staff from all disciplines and all grades and can build a rapport which demonstrates compassion and understanding.

• Have the ability to set boundaries, be concise, synthesise and present

information and be able to write reports for the chief executive and the Board.

• Have an understanding of mediation and managing confidential matters; this includes an understanding of managing and keeping confidential records of cases.

• Be responsive and resilient.

• Have an ability to work with a range of stakeholders, especially those

responsible for patient safety and patient and staff experience, to ensure that lessons are learnt, themes identified and necessary changes are made.

• Confident in speaking at internal and external events.

March 2016

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Finance and Performance dashboard: March 2016

Author Simon Roper

Interim Assistant Director of Finance Finance

Executive Sponsor Martin Roe Executive Director of Finance/Deputy Chief Executive

Date of Report April 2016 Action Required

The Board of Directors is asked to note the content of the report and the financial position of the Trust. .


The Trust is reporting a small year-end surplus of £189k, excluding exceptional items.


There are no quality / patient care implications to the attached proposals.

Financial Implications As above Amount of time required on the Board agenda

5 minutes


N/A


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Finance Performance Dashboard Month 12 2015/16

Income and Expenditure Monitor Financial Sustainability Risk Ratings (FSRR) revised plan

Weight Q1 plan Q2 plan Q3 plan Q4 plan

25% 4 4 4 325% 4 3 3 225% 4 3 3 325% 4 4 4 4100% 4 4 4 3

Monitor Financial Sustainability Risk Ratings (FSRR) actual/forecast

Weight Q3 actual M12 actual

25% 4 325% 4 225% 4 325% 4 4

100% 4 3

4

3

Ratings

Ratings

LiquidityCapital Service Capacity

I&E Margin

LiquidityCapital Service Capacity

I&E MarginVariance in I&E Margin

Overall Score

Variance in I&E Margin

Overall Score

Rating Fcast

323

10,000

11,000

12,000

13,000

14,000

15,000

16,000

17,000

18,000

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

£'0

00

Cash flow forecast

Forecast

Actual

MonitorRevised Plan

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

£'0

00

Capital Expenditure

Actualcumulative

CumulativeRevisedPlan

Cumulativeforecast

85% target

115% limit

(500) -

500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500

I&E

su

rplu

s £

'000

ActualcumulativeNormalised

Cumulativeforecast

CumulativeRevised Plan

Total CIP CommunityServices

MentalHealth Medical Corporate

Target 7,604 3,729 2,425 450 1,000Achieved Recurrently and

released 2015/16 7,604 3,729 2,425 450 1,000

Non Rec plans identified 0 0 0 0 0Unidentified schemes 0 0 0 0 0

01,0002,0003,0004,0005,0006,0007,0008,000

£'0

00

Performance against the 2015/16 CIP Plan

87


Exception reporting - Trust overall performance as at month 12

Overall financial position The Trust is reporting a small year end surplus of £189k, excluding exceptional items. Following the previously agreed asset revaluation, the Trust incurred an impairment of £10.6m which resulted in a "technical" deficit of £10.9m. As the impairment is classified as an exceptional, it is excluded from the normalised reported position which is a surplus of £189k. Cost Improvement Plans In delivering a small surplus, savings for 2015/16 have been identified. The target for 2015/16 of £7,604k has been achieved recurrently. There is a revised target for 2016/17 of £9,031k. Plans for 2016/17 have been worked up with the Quality Impact Assessments (QIA’s) having been carried out in February, with the next round of QIA’s being reviewed at the end of April. Meetings with the service directors and finance and business partners have been carried out to determine deliverability of the schemes, with mitigating actions for recurrent and non-recurrent solutions. The shortfall of £1m in Corporate Loss of Contribution is being met by the corporate divisions as part of their revised efficiency targets. They have confirmed additional savings and therefore the target for 2016/17 has been met. Monitor risk rating At the end of the financial year the Trust is reporting an achieved level 3 on the 'Financial Sustainability Risk Rating' having achieved the planned level in all categories. Capital Expenditure At month 12 the capital programme is 44% of the plan submitted to Monitor and therefore below the 85% lower threshold set by Monitor. As previously reported the Trust has previously notified the revised the forecast outturn position based to the Monitor; this includes pausing a number of schemes until they receive full Board approval. The final expenditure incurred during 2015/16 on the Capital Programme is £2,407k against the original plan of £6,292k. The underspend of £3,719k has been brought forward into the capital programme for 2016/17 and is included in the new year capital programme. 2016/17 Control Total/Agency Ceiling The 2016/17 financial plan has been submitted on the basis of break even i.e. the Monitor control total of a surplus of £2.3m has not been agreed. The 2016/17 plan also anticipates a reduced level of agency expenditure of £1m to approximately £12m which is outside Monitor 's latest ceiling of £8.2m.

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Performance targets

Target RAG Mar In quarter position

99.2% 95% G 100.0% 99.9%97.2% 95% G 97.8% 98.0%95.1% 95% A 94.1% 94.3%2.6% <=7.5% G 2.9% 2.7%311 28 76

196.8% 186.7% 146.9%

99.3% 97% G 99.4% 99.4%99.1% G 95.1% 95.4%

97.0% G 94.6% 94.9%

79.3% G 65.7% 66.5%91.8% G 85.1% 85.6%

n/a 50% R tbc 0.0%n/a 75% A 60.8% 59.8%n/a 95% A 95.2% 94.5%

Achieved n/a G Achieved Achieved

99.8% 95% G 99.7% 99.8%57.8% 50% G 77.8% 63.0%

90.8% 50% G 91.1% 90.4%

76.6% 50% G 80.0% 75.7%

Accommodation Status

Having HoNOS assessment in last 12 months

Certification against compliance with requirements regarding to health care for people with learning disability

Me

nta

l H

ea

lth

G

Improving Access to Psychological Therapies - Patients referred within 6 weeks **Improving Access to Psychological Therapies - Patients referred within 18 weeks **

Employment Status

Community care - referral to treatment information

Meeting commitment to serve new cases of psychosis by Early Intervention Teams (Based

on VSMR Target Line 5378 )

Mental Health data completeness: identifiers (MH MDS)

Mental Health data completeness: outcomes for patients on CPA

Data Completeness: Community Services

Community care - referral information

50%

A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge

Co

mm

un

it

y

2015/16

2014/15

95% (qtly target

of 51.75 -

100%)

Overall - combined results of aboveMeeting commitment to serve new psychosis cases by early intervention teams*

Monitor Compliance Framework

Key Indicators

Admissions to inpatient services had access to CRHT (Gatekeeping)Care Programme Approach (CPA) Adults

receiving follow up contact within 7 dayshaving a formal review witihin 12 months

Minimising mental health delayed transfers of care

Community care - treatment activity information

Notes Monitor :The figures reported on this dashboard for Qtr. 4 are provisional . Final figures are due to be signed off on 22nd April 2016 . As at 15/04/16 the trust is under target on 4 out of the 18 Monitor targets due to be reported this quarter. As previously reported there have been challenges in meeting the new access targets for both IAPT and EIP with all three targets being missed. CPA reviews are also under trajectory at 94.5% , services are currently ensuring all records are up to date in time for the final submission and are confident that the 95% target will be achieved. A conversation will Monitor is planned prior to the formal meeting to advise them of the position and actions we have in place.

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Accounts preparation: Going Concern basis

Author Sharon Hassall

Chief Financial Accountant Executive Sponsor Martin Roe

Executive Director of Finance / Deputy Chief Executive Date of Report April 2016 Action Required

The Board is asked to assess and confirm that the Trust is a going concern for purposes of preparing financial statements for the year ended 31 March 2016.


The purpose of this paper is to provide the Board with the necessary information to make the assessment regarding going concern to coincide with the preparation of the Trust’s financial statements for 2015/16.


N/A

Financial Implications See report for financial details Amount of time required on the Board agenda

5 minutes


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Accounts Preparation: Going Concern Basis

Report for year ended 31 March 2016

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Contents

Contents ................................................................................................................. 1

Accounts Preparation: Going Concern Basis ............................................................. 1

Reporting Requirements ......................................................................................... 1

Role of management and external audit ................................................................. 1

Factors to consider ................................................................................................. 1

Liquidity ............................................................................................................... 2

Solvency ............................................................................................................. 3

Business model and customers .......................................................................... 6

Political factors .................................................................................................... 7

Conclusion on going concern ................................................................................. 7

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Accounts Preparation: Going Concern Basis Reporting Requirements The Trust is required to prepare annual financial statements in accordance with the Foundation Trust Annual Reporting Manual (ARM) published by Monitor. The ARM follows International Financial Reporting Standards (IFRS) as adapted by the HM Treasury Financial Reporting Manual (FReM). There have been no changes to these requirements from last financial year end. Section 3.20 of the ARM requires that: ‘financial statements should be prepared on a going concern basis unless management either intends to apply to the Secretary of State for the dissolution of the NHS foundation trust without the transfer of the services to another entity, or has no realistic alternative but to do so’. This follows the requirements of IAS 1 and the Framework within IFRS. Going concern is defined as being the assumption that the entity will continue in operation for the foreseeable future. For 2015/16 the ARM has included an extract from the FReM that states: The anticipated continuation of the provision of a service in the future, as evidenced by inclusion of financial provision for that service in published documents, is normally sufficient evidence of going concern’. Under IFRS the minimum period is defined as being at least 12 months from the end of the reported financial period, i.e. until 31 March 2017. In the UK the definition has often been extended to be 12 months from the date at which financial statements are approved, i.e. May 2017. The normal assumption for all entities is that they are a going concern; specific disclosures and accounting treatments may be required if there is significant doubt regarding the going concern assumption or if it does not apply.

Role of management and external audit Section 3.20 of the ARM states that IAS 1 requires management to assess, as part of the accounts preparation process, the NHS foundation trust’s ability to continue as a going concern. The Trust’s external auditors are required to review this assessment and, if necessary, challenge it. The purpose of this paper is to provide the Board with the necessary information to make the assessment regarding going concern to coincide with the preparation of the Trust’s financial statements for 2015/16.

Factors to consider There are a number of factors to be considered in making an assessment of going concern:

• Liquidity, being the ability to pay liabilities as they fall due • Solvency, being the long term financial viability of the operation • Business model and customers • Political factors within the NHS regionally and nationally

Each of these areas is reviewed below.

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Liquidity Monitor’s liquidity measure is defined as net current assets (excluding inventories) divided by annual operating expenses, multiplied by 360. This ratio indicates how many days a trust can operate for without receiving further income or financing. Pennine Care has traditionally had a strong track record on liquidity, and has consistently held in excess of £20m in cash balances however the purchase of the Trust Headquarters in 2014/15 had an impact on the cash balance and also the Monitor liquidity ratio. In 2015/16 the Trust had an average daily cash balance of £15.3m. It should be noted that to score a level 4 on Liquidity, the highest score available, the ratio just needs to be positive. As at the 31st March 2016, the Trust report liquidity day of (0.83) day, which resulted in the achievement of level 3. The Trust had planned to (2.8) days ratio which was a level 3. At the end of the financial year the Trust has achieved the planned ratio achieving level 3 liquidity rating.

Looking to 2016/17 although the liquidity position is reducing the Trust is forecasting a level 2 on liquidity which is acceptable to Monitor. As outlined in the reviews of solvency and business model below, the Trust has agreed income contracts with its major customers. The payment model for these contracts is monthly instalments on a block contract; in 2016/17 and beyond the Trust can reasonably expect to receive around £20m per month from block contract payments alone, which is sufficient to cover the normal monthly expenses. It is assessed that the Trust has sufficient liquidity to withstand moderate disruptions to its working cash flows, such as a single CCG withholding block contract payment for a period of months due to a dispute. A major cash event, for example all CCGs and NHS England being unable to pay block contracts in a given month due to a technical fault with SBS would cause the Trust significant cash flow problems. However such an event is considered extremely unlikely and should it arise it would affect the wider NHS economy such that the Department of Health would almost certainly be compelled to act. In such emergency circumstances the Trust could apply to drawdown additional Public Dividend Capital to aid cash flow.

Conclusion: The likelihood of a liquidity or cash flow failure preventing the Trust from continuing as a going concern is considered remote.

2012/13 2013/14 2014/15 2015/16£'000 £'000 £'000 £'000

Current Assets 32,491 33,419 26,922 29,116Inventories (88) (87) (88) (88)Current Liabilities (23,814) (23,444) (25,999) (29,655)Working capital balance 8,589 9,888 835 (627)Operating expenditure 246,058 279,859 271,377 270,482Liquidity Ratio days 12.57 12.72 1.11 (0.83)Liquidity Rating 4.00 4.00 4.00 3.00(working capital x 360 / operating expenditure

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Solvency Short term ability to meet liabilities as they fall due is of limited use if the long term financial prospects of the Trust are poor. The pressures on funding across the NHS and the on-going requirement for all trusts to identify and deliver savings set a difficult context. Three elements can be considered in assessing solvency:

1) The historic financial performance of the Trust as an indicator of financial management, including the risk ratings assessed by Monitor in previous years

2) The current strength of the balance sheet 3) The Annual Plan for 2016/17 and financial model for subsequent years

Historic performance The Trust’s financial performance is summarised in the following table:

Although the Risk Assessment Framework introduced during 2013/14 replaced the previous Financial Risk Ratings (FRR) that Monitor used to assess foundation trust financial performance, it is considered that these ratings still give a helpful insight to the strength of historic financial performance. In 2013/14 the FRR were replaced by the Continuity of Service Risk Ratings (CoSRR). During 2015/16 Monitor introduced the Financial Sustainability Risk Ratings (FSRR) which replaced the CoSRR. Detail below are the ratings for the period 2012/13 to 2015/16 using the various rating models:- The Monitor FRR performance under the old rating was:

2012/13

EBITDA margin rating 2 EBITDA % achieved 4 Financial Efficiency 4 Liquidity 4 Combined score 3

2012/13 2013/14 2014/15 2015/16£'000 £'000 £'000 £'000

Operating income 243,961 283,615 282,289 280,015Operating expenditure (including depreciation) (246,058) (279,859) (273,579) (272,767)

Operating surplus/(deficit) (2,097) 3,756 8,710 7,248Non operating income/costs (2,761) (2,998) (5,303) (18,204)Retained surplus/(deficit) (4,858) 758 3,407 (10,956)Impairments 5,123 3,859 (2,202) 11,034Restructure 2,854 1,057 2,038 110Normalised surplus for year 3,119 5,674 3,243 188

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The performance under the CoSRR ratings is as follows:

2013/14 2014/15

Liquidity 4 4 CSR 4 3 CoSRR 4 4

The performance under the new FSRR ratings as follows:-

This shows the Trust has achieved strong operating surpluses in previous years, which is reflected in the FRR scores achieved. Although a bottom line deficit was recorded in 2012/13 and also in this financial year 2015/16 due the restructuring provision and the asset impairment which were charged during that financial year. These items are excluded from calculation of Monitor’s FRRs as they do not reflect underlying performance of the Trust. Impairments of land and buildings would only be considered to reflect a solvency issue if it was assessed that the diminution of asset values arose from excessive physical deterioration or under-utilisation. In such circumstances there may be a concern that the asset base would not be fit for purpose in supporting the on-going activity of the Trust, and thereby adversely impact operational viability. The primary factor creating the impairments to land and buildings in 2012/13 was due to external market factors. The Trust conducted a full revaluation exercise to be effective 31 March 2014 and a desk top exercise in 2014/15, this was completed by the District Valuer. In 2015/16 the Trust has appointed Cushman and Wakefield (previously known as DTZ) to complete a full valuation as at the 1st April 2015 and a desktop valuation as at 31st March 2016. This has reflected an impairment charge in the year, resulting from the assets having a downward valuation. Cushman and Wakefield have physically reviewed and assessed all the land and buildings owned by the Trust, taking into consideration the different usages of the properties. They have also reviewed the asset lives of all the properties, which has resulted in a reduced depreciation charge for the Trust in 2015/16 and future years.

Ratings 2015/16Liquidity 3Capital Service Capacity 2I&E Margin 3Variance in I&E Margin 4Overall Score 3

96

Balance sheet The above section on liquidity clearly demonstrates the strength regarding the Trust’s net current assets/liabilities and ability to meet short term liabilities. In the longer term consideration also has to be given to how leveraged the Trust is and whether meeting the requirements to repay borrowings and interest will represent a financial risk. The Trust has two long term loans as at 31 March 2016. The Independent Trust Financing Facility (ITFF) loan from the Department of Health has a carrying value of £3.75m, repayable in instalments of £1.25m per annum, plus interest of approximately £120k per annum, reducing as the principal is repaid. Repayment of the loan is due to complete in financial year 2019/20. The Trust also has an on-balance sheet PFI scheme, for which the carrying value of the liability at year end is £16m with £236k repayable in 2015/16. Interest on the PFI borrowing is currently over £1m per annum. The completion of the PFI contract and repayment of the borrowing is due in 2042/43. At 31 March 2016 ability to meet the short term repayment requirements is demonstrated in the Trust’s liquidity assessment and its forecast performance on the Capital Servicing Capacity ratio. The Risk Assessment Framework requires foundation trusts to report on two ratios, jointly referred to as the Continuity of Service Risk Ratings. The following extract from the Framework outlines the calculation and scoring of these ratios.

97

Annual Plan and financial forecasts On the 8th February 2016 the Trust submitted its draft plan for 2016/17 to Monitor. The final annual plan has also been submitted to Monitor on the 18h April 2016. The financial forecast included in the submission to Monitor is as follows:

Delivery of this performance on income and expenditure is expected to give the following results under the Financial Sustainability Risk Ratings:

The above is detailing the Trust will have an overall score of 3 this is the second highest available result for a foundation trust, and demonstrates the long term ability to maintain a solvent position. Conclusion: the evidence shows that the Trust is solvent and has the capability to deliver sound financial performance in the future.

Business model and customers Pennine Care has a clearly established market providing a range of mental health services across a large footprint around the eastern periphery of Greater Manchester and delivering community health services in Bury, Oldham, Rochdale, and Trafford. The Trust has contracts in place for the on-going delivery of these services. The Trust’s key customers are the Clinical Commissioning Groups (CCGs) across the region, NHS England, and the North West Specialist Commissioning group for certain mental health services. As in 2015/16 the Trust will have to continue to bid for new contracts and to retain existing contracts.

2016/17£'000

Income 257,694Expenditure 257,564Net surplus 130

Ratings 2016/17Liquidity 2Capital Service Capacity 2I&E Margin 3Variance in I&E Margin 4Overall Score 3

98

Conclusion: the Trust has a clear business model and established customer base that gives solid grounds for assuming the business is a going concern

Political factors Following the major restructure of the NHS in recent years, including Transforming Community Services and the abolition of the Primary Care Trusts, it is not expected that further major restructuring will take place. The Five year Forward View and Devolution Manchester means the political landscape is forever shifting, although this should not have a direct substantive impact on the Trust in the next 18 months. The Trust is not considered to be at particular risk of being taken over by another provider in the region. The Trust has a good track record of financial performance and quality. The Trust is sufficiently large for a non-acute provider that it is not an obvious target for takeover by another provider. Conclusion: there are no current indications within the local or national political considerations that suggest Pennine Care is liable to be terminated or significantly impacted by outside intervention.

Conclusion on going concern From the evidence considered it is recommended to the Board of Pennine Care that they assess the Trust to be a going concern for purposes of preparing financial statements for the year ended 31 March 2016.

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Monitor Governance submission: Q4 2015/16

Author Karen M Byrne

Head of Corporate Governance Corporate Governance

Executive Sponsor Michael McCourt Chief Executive

Date of Report April 2016 Action Required

The Board of Directors is asked to note the content of the report and approve the report.


To provide the Board with information in support of signing off the Q4 2015/16 Governance Monitor submission.


There are no quality / patient care implications to the attached proposals.

Financial Implications There is no financial implication to the attached proposals.

Amount of time required on the Board agenda

< 5 minutes


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GOVERNANCE QUARTERLY MONITORING

COMMENTARY TO IN YEAR GOVERNANCE DECLARATION

REPORT FOR THE QUARTER ENDED: 31st March 2016 This document has been created to supplement the Governance Quarter 4 declaration and provide additional commentary. The Trust is achieving all elements of the mental health compliance framework. Hospital Acquired infections MRSA Cases C Diff Cases Q1 0 0 Q2 0 0 Q3 0 0 Q4 0 0 Board Skills The Trust has continued to deliver the Board Skills programme at Board Development sessions, covering the following topics.

• Strategic framework and strategic objectives • Integrated Business Plan • Operational plan / LTFM • New IAPT and EI targets • My Health My Community Self-management College • Preparation for CQC inspection • Trafford S75 agreement • Manchester Mental Health and Social Care NHS Trust bid

Membership Update Membership Figures as at 31 March 2016 Public members: 16,224 Staff members: 6,150 Total Membership: 22,374 Communication with Council of Governors of the Trust A full meeting of the Council of Governors took place on 2 February 2016; topics discussed at this meeting included the following:

• Council of Governors Activity Report • Chairman’s and Non-Executive Directors’ Communications

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• Chief Executive Report o Chief Executive Update o Governors’ Questions

• Appointment and Remuneration Committee o Minutes from the Appointment & Remuneration Committee held on

20 January 2016 o Chairman’s Appraisal Process o NED Terms and Conditions

• Performance and Assurance Committee o Briefing note from the Performance & Assurance Committee held on

2 December 2015 • Council of Governors

o Feedback from Local Constituency Meetings o Governance Reporting: Q3 o Attendance Dashboard Report

o Other Reports o Governor and Lead Governor Role Descriptions o Process for the termination of a Governor position o Election roadshow timetable

• Any Other Business

Development sessions delivered to the Council of Governors Educational

• Experience of Sierra Leone Facilitated by the Trafford Infection Control Lead/Modern Matron

• Devolution Manchester

Facilitated by Executive Director (seconded from PCNHSFT) to the Greater Manchester Health and Social Care Devolution

• Dementia Friends

Facilitated by the Regional Support Officer to the Alzheimer’s Society Mandatory

• Audit Committee Annual Report 2015 & Fraud Awareness Facilitated by the External Auditor (KPMG)

• Quality Accounts

Facilitated by the Internal Auditor (Grant Thonrton) and Associate Director of Quality Governance and Head of Integrated Governance

• Operational Plan 2016/17

Facilitated by the Deputy Director of Business Development

• Care Quality Commission Inspection Facilitated by the Associate Director of Quality Governance

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Sub Groups of the Council of Governors The following working groups have taken place: Appointment and Remuneration The committee met on 20 January 2016 and received feedback following observation of Board of Directors and its formal sub-committees. The Committee also approved the process for the Chairman’s Appraisal and the updated NEDs Terms and Conditions. Performance and Assurance Committee The function of the committee is to seek assurance on behalf of the Council of Governors that the Trust is meeting appropriate standards of healthcare. The committee meets quarterly and met on 15 March 2016. The committee was currently in a period of change in order to reflect the improved processes of the Board meeting structure. The result being that the Board and Governors received much slimmer reports at fewer meetings, because challenge and assurance had been built up through the new reporting process. The committee received the new Performance and Quality Governance Committee assurance update. Council of Governors (CoG) Strategy Group This group is responsible for overseeing the Governors’ agenda and work programme, including training and development, events, oversight of various working groups. The group meets quarterly and recent agenda items have included:

• Council of Governors Meeting: agenda for 4 May 2016 • Council of Governors Terms of Reference • Development Sessions

o Schedule of Development Sessions 2016 o Actions from the Information Session re: Manchester Mental Health

and Social Care Trust • Sub Groups / Task & Finish Groups

o Paper Free o Constitutional Review o Chairman/NED and Governor Meeting

• Membership and Engagement o Membership Budget o Membership Analysis Report o Feedback from the Patient Experience Steering Group

• Feedback from Governor Conferences and Forums • Any other business

o Operational Plan 2016/17 Strategy and Development Committee & Membership Strategy Group In December 2015 the Board agreed that the new Board Performance and Quality Assurance Committee (PQAC) would replace SDTC and QGAC. The Governor meeting structure mirrors the Board structure and the improved processes would be

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reflected within the Governor structure. The Strategy and Development Committee and Membership Strategy Group had since been disbanded. Functions from the committees would be addressed in the Performance and Assurance Committee and CoG Strategy Group. Other Involvement Governors have been involved in a range of events/working groups across the Trust such as: Bury DBU Bury Focus Group Bury: Neighbourhood Integrated Working Chairman and SID Meetings Charitable Funds Committee Clinical Business Meeting: Stockport Constitutional Review Consultant Interview Training CSR Steering Group Dementia Partnership Meeting: Oldham Divisional Business Unit Meeting: Bury Environmental Management Group Governor Pre-Election Roadshows Healthwatch Committee Meetings HMR Community Tender: Adult Services Local Constituency Meetings My Health My Community Steering Group Patient Experience Steering Group Patient Participation Group: Oldham Pennine Care Choir Pennine Post Planning Meeting Self Management College Steering Group Service User and Carer Forum Stockport CBU Tender: Manchester Mental Health & Social Care Trust Steering Group Tender: Trafford MSK Triangle of Care Steering Group Attendance at Board of Directors and formal sub committees Finance Strategy Group: 26 January 2016 Performance and Quality Assurance Committee: 23 February 2016 Audit Committee: 16 March 2016 Board of Directors: 27 January, 24 February and 30 March 2016 Events Health Fair: Stockport Spotlight on Quality Event Health and Wellbeing Event: Trafford Community Podiatry & Lymphoedema Presentation My Health My Community Visioning Day Your Health Your Voice

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Service Visits Ramsbottom Ward: Bury Parklands House: Northside & Southside Wards, Oldham Speech and Language Therapy Team: Bury Irwell Unit: North and South Ward HM Coroner During this reporting period the Trust has received 1 Regulation 28 letter from H.M Coroner (North Manchester), in relation to discharge processes, record keeping, nursing communication and access to psychological therapies. HMC North also referred 2 nurses to the NMC in relation to evidence heard. The Trust is currently re-reviewing the actions of both nurses and will provide a response in the stipulated timeframe.

Karen Byrne Head of Corporate Governance

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Reports of statutory registers for the period 1 April 2015 to 31 March 2016

Author Pamela Upton, Senior PA to the Chairman; on behalf of

Louise Bishop, Trust Secretary Executive Sponsor Michael McCourt, Chief Executive Date of Report April 2016 Action Required

The Board of Directors is asked to note the content of the reports.


The following report comprises of the following registers: • Declaration of interests • Gifts and hospitality register • Report on the use of the corporate seal • Register of monies collected by staff on behalf of

charities The reporting period is 1 April 2015 to 31 March 2016.


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PENNINE CARE NHS FOUNDATION TRUST DECLARATIONS OF INTEREST 1ST APRIL 2015 – 31ST MARCH 2016 ________________________________________________________________________________________________________ Interest Declared on Tony Berry Non-Executive Director John Schofield Chairman Lisa Jowitt Health and Wellbeing Manager Clare Nelson Counsellor

Daughter Katriona Berry is moving from her role at Deloitte’s to a new job with PWC, albeit on their tax team. PWC are one of the tendering companies on the framework (Declared at Audit Committee on 10.12.2014). Trustee of Grace’s Place Children’s Hospice Teaches fitness in her spare time in the Glossop area and sells ‘Juice Plus’ privately which is a whole food nutrition product. Works in private practice under the name ‘Mynd’ Integrative Counselling. Has a clinic at home address where she holds appointments. In special circumstances will consider home visits within the local area and wishes to advertise and develop her practice. Additionally she works for Pulse on Tuesday’s and Wednesday’s, currently at Ballenden house, Rawtenstall, Rossendale (subject to location change/dependant on contract).

20.4.15. 24.6.15. July 2015 11.6.2015.

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Alison Matthews Team Manager, Speech and Language Therapy Rebecca Lee Physiotherapist Mary O’Reilly Dental Officer Louise Jenner Lead Dental Nurse Debra Burgess Dental Nurse/Oral Health Promotion Officer Justine English Dental Nurse Team Manager Gaynor Kershaw Health Visitor

Is practising part-time as a Speech and Language Therapist outside of the NHS. Is registered with the Private Practice Register ASLTIP. Is in the process of developing a policy statement to ensure they avoid any potential conflict of interest with Pennine Care NHS FT. Declared that the service she is involved with is not for profit. Is registered as a sole trader and will be providing a private physiotherapy service under both her name and the name of Ricphysio in addition to her substantive post with Pennine Care NHS FT. Is employed by Central Manchester NHS FT to work 3 hours every Wednesday 6.00p.m.- 9.00p.m., once a month Friday 6.00p.m. - 9.00p.m., once a month Saturday 10.00a.m. - 4.00p.m., once a month Sunday 10.00a.m. - 4.00p.m. at the Emergency Dental Service, Ancoats Primary Care Centre. Has been working for Go-to-Doc since 2004 on the out-of-hours Emergency Dental Service on telephone triage. She is currently contracted to work 20 hours per month. The shifts are at weekends and bank holidays. Works for Bardoc on Saturdays and occasionally on a Sunday doing dental triaging and that the total amount of hours worked is 11 per week. Is in secondary employment with Bardoc and this post allows her to work a maximum of 16 hours per month (4 hours extra per week). Is a Director of “Transport for Sick Children’s Charity”.

3.7.2015. 21.7.2015. 26.8.2015. 6.8.2015. 7.8.2015. 12.8.2015. 26.8.2015.

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Christine Battison Senior Dental Officer Sian Wimbury Service Development and Contracts Manager Dr Henry Ticehurst Medical Director Richard Spearing Actg. Director of Service Development and Partnerships Petra Bryan Actg. Director of Workforce and Organisational Development Martin Roe Executive Director of Finance/Deputy Chief Executive Michael Livingstone Non-Executive Director Mike Livingstone Non-Executive Director Mike Livingstone Non-Executive Director

Is employed by Health Education North West as a Training Programme Director for Foundation Dentistry working 3 sessions per week. She is also employed by the Parliamentary and Health Service Ombudsman as a Clinical Advisor working one day per week. Has been a voluntary Trustee for Homestart, Oldham, Stockport and Tameside (Host) since August 2015. Is married to a Consultant Anaesthetist at Central Manchester Foundation Trust. Trustee of 42nd Street (Young People’s Mental Health Charity). Additional paid employment with the Open University which ceased in March 2015. No further interests to declare. No interests to declare. Self employment – Director of Mike Livingstone Associates Limited. Main customers are Stockport MBC, Together Trust, Mutual Ventures, Frontline PB Coaching, Solace, LGA. Membership of professional bodies – ADCS,LGA, ILM, Solace, BASW, ADCS Virtual College, Academy of Leadership and Management, Frontline, PB Coaching. Wife, Linda Livingstone, is an employee of Fostering Solutions – Independent Provider.

4.9.2015. 14.9.2015. 17.9.2015. 18.9.2015. 21.9.2015. 22.9.2015. 25.9.2015. 25.9.2015. 25.9.2015.

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Rt. Hon. Lord Keith Bradley Non-Executive Director Rt. Hon. Lord Keith Bradley Non-Executive Director Rt. Hon. Lord Keith Bradley Non-Executive Director Lesley Stott Dental Therapist/Hygienist Amy Jones Highly Specialist Speech and Language Therapist Katy Calvin-Thomas Executive Director of Planning, Performance and Information

Member of House of Lords Council Member – Medical Protection Society Hon. Special Advisor, University of Manchester Non-Executive Chair, Manchester, Salford and Trafford Lift Company Non-Executive Chair, Bury Tameside and Glossop Lift Company Trustee – Centre for Mental Health Trustee – Prison Reform Trust Member – Government’s Advisory Group for Female Offenders Spouse (Lady Rhona Bradley) Non-Executive Director, Central Manchester University Hospitals NHS Foundation Trust Chief Executive – Addiction Dependency Solutions Son (Jonathan Bradley) Employee, Addiction Dependency Solutions Works part-time for Bamford Dental Practice, Norden Road, Rochdale, as a Dental Hygienist/Therapist Works privately as a Speech and Language therapist infrequently outside of contracted hours with Pennine Care and does not impact on weekly working hours or professional duties. Does not compete directly for work which otherwise would have come to Pennine Care. Some children I work with live within areas covered by Pennine Care (never HMR) but clients have made the choice not to access NHS therapy and to employ a private Speech and Language Therapist instead. Currently on secondment to the Devolution Management Team which may cause potential conflicts of interest to be declared.

30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 18.9.2015. 8.10.2015. 2.11.2015.

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Judith Crosby Director of Service Development and Sustainability Sandra Jowett Non-Executive Director John W Schofield Chairman Alison Matthews Team Leader, Speech and Language Therapy Nicola Butterworth Specialist Podiatrist Ian Marshall Podiatrist Carly Telford Podiatrist

No interests to declare. Resigned from full time post at the University of Cumbria, leaving on the 31st December 2015 but will retain links with them as an Emeritus Professor. Fellow of Chartered Certified Accountants (FCCA) Trustee of Mellor Trust Fund Auditor of St. Hilda School Fund Treasurer for Old Park Residents Association Committee Member and Auditor of Bury Town Twinning Association Trustee of Grace’s Place Children’s Hospice Has been appointed as a Trustee for a charity in Bury called Bury ILD which provides supported living for adults with learning disabilities (I live in Bury but work in Oldham). Undertakes private podiatry work – mobile only. Is a Younique presenter on-line and home based. Carries out a small amount of private routine podiatry work within the Oldham area, which he confirms has no impact or conflict of interest with his employment with PCFT. Works for Oldham Community Leisure as a part-time Swimming Teacher which does not interfere or overlap any aspects of her NHS employment. Also works 6½ hours for OCL.

9.11.2015. 19.10.2015. 18.11.2015. 18.11.2015. 18.11.2015. 18.11.2015. 18.11.2015. 18.11.2015. 11.11.2015. 24.11.2015. 23.11.2015. 20.11.2015.

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Philip Jackman Podiatrist Jacqueline Smithson Podiatrist James Stanton Senior Physiotherapist Dr Dawn Edge Non-Executive Director Professor Sandra Jowett Non-Executive Director Joan Beresford Non-Executive Director Paula Ormandy Non-Executive Director Paula Ormandy Non-Executive Director Paula Ormandy Non-Executive Director

I undertake private Podiatry work (outside of work for Pennine Care NHS FT). (Stated initial declaration completed approx. 2 years ago). I undertake private podiatry work outside the Oldham area. I work privately as a Physiotherapist. This can involve working in clinics and sports clubs around the North West. It is classed as a second job where I am self-employed. This has been done for the last 6 years and I intend to continue this in the foreseeable future. This will not have any impact on my ability to work within the NHS. No interests to declare. Employment at University of Cumbria Vice-Chair NOCN Son employed at KPMG Paid as an External Advisor by Personal Social Services Research Unit (PSSRU) at Manchester University as a member of an observational study sub-group. This is part of their research programme ‘Effective Home Support in Dementia Care’ Components, Impacts and Costs of Tertiary Prevention’. Paid employment - University of Salford – full time Professor of Research. Non-paid – Vice-President for Research British Renal Society and Trustee. Member, Royal College of Nursing UK Kidney Research Consortia Chair – co-ordinate 12 clinical research groups.

19.11.2015. 20.11.2015. 25.11.2015. 30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 30.9.2015. 1.10.2015. 1.10.2015. 1.10.2015. 1.10.2015.

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Paula Ormandy Non-Executive Director Michael McCourt Chief Executive Antony E Berry Non-Executive Director Antony E Berry Non-Executive Director Antony E Berry Non-Executive Director Ian Trodden Director of Nursing and Healthcare Professionals Robert Ainsworth Non-Executive Director/Deputy Chairman Keith Walker Executive Director of Operations Richard Valle-Jones Clinical Director for Dentistry

KRUK Research Board Member. Renal Association Research Board Member. Hope Kidney Patients Association Member. Trustee on Charity Rugby League Cares. Is (self); Chief Executive and Company Secretary of Ashton Pioneer Homes Ltd. Pioneer Homes Services Ltd. APH Developments Ltd. Is a Trustee of Charities; Groundwork UK. Groundwork Manchester, Salford, Stockport, Trafford and Tameside St. Peter’s Community Partnership (Partner) C Berry Consultancy Limited. Director of community interest company Oasis Café representing Pennine Care NHS Foundation Trust which has a third ownership of this company Fellow of the Institute of Chartered Accountants in England and Wales No interests to declare. Director of a company called Open Odonto Community Interest Company.

1.10.2015. 1.10.2015. 1.10.2015. 2.10.2015. 4.10.2015. 4.10.2015. 4.10.2015. 4.10.2015 4.10.2015. 4.10.2015. 4.10.2015. 6.10.2015. 6.10.2015. 13.10.2015. 9.9.2015.

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Kate Frodsham Dental Nurse Davina Bennett Dental Nurse Julie Taylor Director of Business Development Robert Ainsworth Non-Executive Director

I have worked for Go to Doc on the out-of-hours Emergency Service (Dental) on the telephone triage. I am currently contracted to work 8 hours per month. The shifts are evenings, weekends and some bank holidays. Working as a Dental Nurse Assessor at Bury College and Hopwood Hall College, Rochdale. No interests to declare. On the 7th March 2016, I was appointed a Non-Executive Director of the Christie NHS Foundation Trust for a period of three years.

27.11.2015. 8.12.2015. 1.3.2016. 9.3.2016.

LB/PU/310316

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Report to the Board of Directors – April 2016

Annual Gifts and Hospitality Report for the period 1st April 2015 – 31st March 2016

The Trust’s policy on the Receipt of Hospitality, Gifts, Payment and Commercial Sponsorship” was developed in 2007 in line with good practice guidance around probity and business conduct in the NHS1. It reflects the requirements of the Trust’s Standing Orders (in particular, Section 9 relating to Standards of Business Conduct) and sets out the principles of business conduct for staff in relation to gifts, hospitality and entertainment. The policy states that it is the responsibility of all staff to ensure that they are not placed in a position which risks or appears to risk conflict between their private interests and NHS duties. Gifts, hospitality or entertainment other than articles of low intrinsic value or modest hospitality should be declined and those accepted may need to be formally registered. Declarations of the acceptance or refusal of gifts or hospitality are entered into a corporate Register of Hospitality and signed off by the Chief Executive (or in his absence, the Deputy Chief Executive). The policy further requires that, in line with good governance, this information is submitted to the Trust Board on an annual basis and the following report covers the period from 1st April 2015 to 31st March 2016. The Trust Board is asked to note the content of the report. Michael McCourt Chief Executive

1 “Standards of Business Conduct for NHS Staff” – HSG (93)5 and “Commercial Sponsorship – Ethical Standards for the NHS” – Department of Health, November 2000

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Report from the Hospitality Register For the period 1st April 2015 to 31st March 2016 Date Gift or Hospitality Accepted Gift or Hospitality

Declined/Accepted

9.4.2015. An invitation to an awards dinner in London on the 14.5.2015. sponsored by Consort Healthcare as the PFT scheme has been shortlisted for an international award.

Accepted

22.4.2015. An invitation to an awards ceremony at the Savoy Hotel in London on the 1.5.2015. The event is run by the Nursing Standard and my attendance is to join the Trust’s Diabetes Nurses as they have been selected by the Nursing Standards as finalists for their work on ‘Sugar Cube’ an innovative platform for children who suffer from Diabetes to engage on line in treatment and education.

Accepted

29.6.2015. An invitation from KPMG to attend an Integration of Health and Social Housing drinks reception and presentation at KPMG in Manchester on 24.6.2015.

Accepted

6.5.2015. An invitation from KPMG to a Healthcare private drinks reception, due to be held in Liverpool on the 4.6.2015.

Declined

11.6.2015. Gift vouchers to the value of £30 from a patient.

Declined

16.7.2015. An invitation to a summer social event, held in Manchester on the 18.6.2015. The event was sponsored by KPMG.

Accepted

29.7.2015. A travel set ‘Elimis – Travel with Elimis Collection’ received with a thank you card from a patient.

Accepted

3.8.2015. A gift of a silver coloured pendant necklace with an estimated value of £9.99.

Accepted

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23.7.2015. An invitation to lunch with 2 members of the KPMG Personal Assistant Team on 31.7.2015.

Accepted

4.8.2015. A gift of a card and a bottle of perfume from a patient and relative.

Accepted

18.8.2015. A gift of games, CD and songbooks and conversation cards with a value of £107.12. These have been purchased for and will be used by her team.

Accepted

28.8.2015. An invitation from Michael Page Financial Consultants to a ladies evening on the 1.9.2015. at James Martin’s restaurant.

Accepted

17.9.2015. £10.00 received in a card from a patient.

Declined

5.10.2015. 9.10.2015.

Sponsorship towards refreshments for a General Practice and Practice Nurse study day at the Toby Hotel, Rochdale on 18.11.2015. £130 each from Eli Lilley & Co, Spirit Healthcare, Sanofi Avensis, Roche Diabetes Care Ltd., Abbott Laboratories Ltd., MSD Ltd., Astra Zenica Ltd., Janssen (A Johnson and Johnson Co. Ltd) Total cost £1040.00.

Refused

24.9.2015. Declaration made by Team Manager for herself and 4 members of her team of sponsorship to attend an event for prescribing practice ‘North West Bladder the Cholinergic Burden Issue’. Sponsored by Astellas Pharma Ltd., £45.00 per person Total cost £225.00.

Accepted

21.10.2015. Registration to the British Academy of Audiology Conference to be held from 26.11.2015. until 27.11.2015. at the International Harrogate Centre. Registration provided by Phonak with an estimated value of £209.00.

Accepted

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8.3.2016. (3 separate declarations from staff- same declaration)

Invitation to attend a Bard Continence Care Event, from Bard Ltd., to be held in Warrington from 18th May to 19th May 2016. Estimated value £75.00.

Accepted

2.3.2016. Gift of a £5.00 note Declined 3.3.2016. (2 separate declarations from staff – same declaration)

A place from Dansac to attend a study day on Intestinal Failure with an estimated value of £85.00

Accepted

24.3.16. An invitation from Hill Dickinson, Solicitors, to myself and a colleague to attend a Manchester United v Everton football match on 3.4.16.

Accepted

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Report from the Drugs and Therapeutics Committee Register For the period 1st April 2015 to 31st March 2016 25.5.2015. Support of printing costs to

produce the Pennine Care NHS Wound Formulary Resources with an estimated value of £4,000 from Crawford Healthcare, Aspen Medical, Activa, Advantis Healthcare, Coloplast and Richardson Healthcare.

Accepted

21.5.2015. Attended a Joint Northern Chief Pharmacists meeting on the 14th and 15th May 2015 at the Castle Hotel in Kendal. The Pharmaceutical Companies Gilead, Mylan, Novartis, Pfizer and Sanofi-Aventis, supported the educational aspects and funding of the accommodation and catering.

Accepted

12.10.2015. Sponsorship from Smith and Nephew to attend a Wounds UK Conference in Harrogate from 9.11.2015. until 11.11.2015. Sponsorship includes 2 nights accommodation, conference fees and expenses.

Accepted

27.11.2015. Attending a 1 day course ‘Physical Illness in Mental Health’ with an estimated value of £50.00 sponsored by Janseen.

Accepted

Please note: For the purposes of this report, staff and client details have been omitted. However these details are contained in full within the corporate Register of Hospitality, which is scrutinised periodically by the auditors and is available for public inspection in line with the Freedom of Information publication scheme.

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USE OF THE CORPORATE SEAL FROM 1ST APRIL 2015 – 31ST MARCH 2016

Date of Sealing Description of Document Sealed by 16.4.2015. Measured term contract between Warden Construction Ltd, Kirkham Preston and Pennine Care

NHS Foundation Trust for maintenance and minor works to be carried out in hospital, health, administration and service buildings and other places owned, occupied and/or managed by the employer at Stepping Hill Hospital

Michael McCourt Ian Trodden

7.5.2015. Counterpart lease of Unit 1, Oriel Court, Ashfield Road, Sale, M33 7DF for a term of 5 years from 1.11.2014. until 31.10.2019. between Nicolas Bookbinder, Martin Bookbinder and Debra Ryan (Landlord) and Pennine Care NHS Foundation Trust

Ian Trodden Dr Ticehurst

1.6.2015. Deed of variation between NHS Trafford Clinical Commissioning Group and Pennine Care NHS Foundation Trust relating to a business transfer agreement dated 28.2.2013. for referral booking management system (RBMS)

Martin Roe Dr Henry Ticehurst

1.6.2015. Deed of novation and variation between NHS Trafford Clinical Commissioning Group and Pennine Care NHS Foundation Trust and Trafford Council, dated 28.3.2013. for smoking cessation service


23.6.15. Lease of second and third floor premises at Brook House, Oldham Road, Middleton, Manchester, M24 1HF between Park Road Developments Ltd. And Pennine Care NHS Foundation Trust.


1.3.2016. Minor works building contract for internal alterations, Memory Clinic, Watergrove Reception, Birch Hill Hospital, Littleborough, Rochdale, with Projects Limited.

Dr Henry Ticehurst Martin Roe

LB/PU/31.3.16.

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PENNINE CARE NHS FOUNDATION TRUST CHARITY REGISTER Money collected by Trust staff, on behalf of Charities, between the dates; 1ST APRIL 2015 – 31ST MARCH 2016 ________________________________________________________________________________________________________ Date of Location of collection Collection on behalf of (Charity) Amount collection collected 8.5.2015. 28.9.2015. 5.5.2015. 13.5.2015. 3.3.16.-17.3.16.

Ellen House, Waddington Street, Oldham, OL9 6EE Pennine Care NHS FT Headquarters, 225 Old Street, Ashton-under-Lyne, OL6 7SR Pennine Care NHS FT Headquarters, 225 Old Street, Ashton-under-Lyne, OL6 7SR Buckton Building, Tameside General Hospital, Fountain Street, Ashton-under-Lyne, OL6 9RW Pennine Care NHS FT Headquarters, 225 Old Street, Ashton-under-Lyne, OL6 7SR

Grace’s Place Children’s Hospice, Bury MacMillan Cancer Support Grace’s Place, Children’s Hospice, Bury Grace’s Place, Children’s Hospice, Bury Muscular Dystrophy UK

£72.00 £322.56 £24.00 £24.00 £165.00

LB/PU/31.3.16.

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The Naming of the Trust’s Charity

Author Louise Bishop

Trust Secretary Executive Sponsor Director of Operations Date of Report 20 April 2016 Action Required

The Board of Directors is asked to approve the recommendation from the Charitable Fund Committee.


Ahead of launching the Trust’s charity, a consultation exercise was undertaken with staff and stakeholders to vote on a number of proposed options for the Charity’s name. The results were considered by the Charitable Funds Committee, along with a number of alternative suggestions and the outcome of that discussion is submitted to the Board of Directors for approval.


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Report to the Board of Directors on the Naming of the Trust’s Charity Background In July 2015, the Trust made a decision to re-establish its Charitable Fund and began preparations to launch the new charity during 2016/17. At a meeting of the Charitable Funds Committee in April 2016, members reviewed a shortlist of potential names for the newly formed charity, which had been consulted on with staff and stakeholders, in order to make a recommendation to the Board of Directors, as Trustees, to name the charity.

Consultation An online survey was created and promoted through the Trust’s internal channels to staff, which included a news item and featured as a top story on the Connected Bulletin for two weeks in March 2016. The survey was also promoted to the Trust’s Governors and through social media to capture external stakeholders. Respondents were given four proposed names and asked to rate the options according to first, second, third or fourth preference. The proposals were:

• The Pennine Care Charity • Pennine Care’s Charity • Friends of Pennine Care • The Pennine Care Foundation

The survey also requested alternative suggestions.

Number of responses and reach A total of 119 responses were received.

Results As can be seen on the below table, the most popular first choice is The Pennine Care Foundation followed by the most popular second choice of The Pennine Care Charity.

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A total number of 19 alternatives were suggested: • Charity Fund for Pennine Care • The Pennine Care Charitable Foundation • Pennine Care Foundation Trust Fund • Community voices PCFT charity • Pennine Care Charitable Fund • Something less boring. Pennine Cares • The Pennine Fund • Pennies from health • Pennine Care Fund • Pennine Charity (Need Help Sometimes)NHS • Pennine making a difference • The Pennine Care Charitable Fund • Pennine's cared for charity • Pennine Care Charity Fund • Pennine Pennies • Not friends of - as this suggests people rather than money. • Pennine Care Charitable Fund • The helping hands of Pennine Care • Caring for Pennine

Considerations At its meeting on 13 April 2016, the Charitable Funds Committee considered the results of the consultation. The Committee discussed the fact that the preferred option - Pennine Care Foundation – sounded very similar to the Trust’s name, however did not want to stray too far from the choice of those who had voted. Also considering the alternative suggestions, the Committee proposed that a hybrid be

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recommended to the Board for approval – namely Pennine Care Charitable Foundation.

Next steps Once the Charity’s name is approved by the Board of Directors, the Charitable Fund Committee will progress the plans to launch the charity, having agreed that an identity for the Charity be developed in keeping within the Trust brand. A full Communications Plan has been developed, with the aim of launching the charity along with clear guidance and explanation of the processes in place (as per the policy approved by Board in February 2016) in early summer 2016.

Recommendation The Board of Directors, as Trustees of the charity, is asked to approve the recommendation from the Charitable Funds Committee to name the Trust’s charity Pennine Care Charitable Foundation.

JS/LB/KB: 20 April 2016

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Minutes and highlight report from a meeting of the Audit Committee

held on 16 March 2016 Author Tony Berry

Non-Executive Director Chair of Audit Committee

Executive Sponsor Executive Director of Finance / Deputy Chief Executive Date of Report April 2016 Action Required

The Board of Directors is asked to note the contents of the Audit Committee minutes and highlight report.


Key items of discussion and actions from Audit Committee are set out in the highlight report. The full minutes are made available for Board’s information.


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FOI Exemption (PI only) Part This paper relates to the following strategic goals/high level targets – select all that apply (see key overleaf): LPC (Put local people and communities first)

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Audit Committee: 16 March 2016 Highlight summary Item Highlight Comment / action Audit Committee feedback survey

• Overview provided regarding the post-meeting feedback survey conducted following the December 2015 meeting

• Audit Committee noted the report. • This exercise would be repeated in September 2016.

Presentation: Safeguarding

• Presentation delivered by Head of Nursing and Strategic Lead for Safeguarding regarding the systems in place for safeguarding in terms of assurance structures, statutory requirements, audit scrutiny, and independent reviews.

• Assurance provided that the Trust has strong safeguarding systems and processes in place.

• Audit Committee acknowledged the work to develop a new safeguarding strategy, and to further enhance learning across the organisation.

Presentation: contracts controls review

• Presentation delivered by Executive Director of Operations, Interim Director of HR, and Workforce and OD Governance Manager regarding the controls processes for the issuing of contracts.

• Audit Committee examined the gaps in assurance and asked that the recommendations arising from this review were made clearer.

• This area would be added to the IA calendar once the recommendations had been actioned and embedded.

External audit progress report: March 2016

• Grant Thornton presented a progress report regarding the 2015/16 audit, including an update on an interim accounts audit and preparations for the full account audit.

• The Committee discussed the value for money audit in the context of the organisation and wider NHS.

• External audit confirmed the indicators required for testing as part of the Quality Report audit; along with local indicator selected by the Council of Governors.

Year-end accounts timetable

• Summary of the 2015/16 year-end accounts timetable. • Audit Committee noted the timeframes set out in the report.

• The final accounts will be submitted to the Audit Committee on Friday 20 May 2016.

IA progress report: March 2016

• Quarterly update on progress against the internal audit plan provided by KPMG.

• Five reviews completed in the reporting period. • Remaining audits expected to be completed in line with

the 2016/17 plan.

• The Committee noted the report.

Compliance against PSIA standards and Internal Audit charter

• Report presented regarding KPMG’s compliance with Public Sector Internal Audit standards; along with an Internal Audit charter, which set out activities, purpose, authority and responsibilities of internal audit at Pennine Care NHSFT.

• Audit Committee noted internal audit’s compliance with PSIA standards, and approved the Internal Audit charter.

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Counter Fraud (CF) progress report: March 2016

• Quarterly update on CF work, including a summary of work undertaken since the last meeting.

• An update was provided on one case previously reported to the Committee along with an overview of new referrals.

• Audit Committee noted the report.

Counter Fraud Strategic and Operational Plan 2016/17

• Detailed work plan for 2016/17, consistent with the approach taken in 2015/16 and areas of focus from NHS Protect.

• Audit Committee approved the CF Strategic and Operational Plan 2016/17.

Waivers to competitive tendering requirements

• Audit Committee reviewed the waivers approved since the last meeting.

• The Committee noted the report. • Several queries raised, answers to which would be

circulated to members outside the meeting. Closed session • External and internal audit were asked if they wished to

raise any issues in the absence of management. • The auditors confirmed there were no issues to raise.

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Council of Governors Terms of Reference

Author Louise Bishop

Trust Secretary Executive Sponsor Michael McCourt

Chief Executive Date of Report April 2016 Action Required

The Board of Directors is asked to approved the Council of Governors Terms of Reference.


The Terms of Reference for the Council of Governors have been developed pursuant to a best practice recommendation from an internal audit of the Code of Governance. Once agreed by Board, they will be submitted to the full Council of Governors on 4 May 2016.


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COUNCIL OF GOVERNORS TERMS OF REFERENCE 1 CONSTITUTION 1.1 The role of the Council of Governors is derived from Schedule 7 and other

sections of the NHS act 2006 as amended by the Health and Social Care Act 2012.

2 MEMBERSHIP 2.1 The Council of Governors consists of: Elected Governors (Public) Constituency Number of Seats Bury 4 Oldham 4 Heywood, Middleton & Rochdale 4 Stockport 4 Tameside & Glossop 4 Trafford 4 Rest of England 1 Elected Governors (Staff) Constituency Number of Seats Allied Health Professionals 2 Corporate & Support 2 Medical & Dental 1 Nursing 2 Social Care 1 Appointed Governors Organisation Number of Seats Bury Council 1 Bury CCG 1 Oldham MBC 1 Oldham CCG 1 Rochdale MBC 1 HMR CCG 1 Stockport MBC 1 Stockport CCG 1 Tameside MBC 1 Tameside & Glossop CCG 1 Trafford BC 1 Trafford CCG 1 Derbyshire CC 1

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2.2 The Chairman of the Trust or, in his absence, the Deputy Chair/Senior

Independent Director, shall chair meetings of the Council of Governors. 2.3 In accordance with Monitor’s Code of Governance it is expected that the

Council of Governors will invite the Chief Executive to attend all meetings, and that other executive and non-executive directors will be invited to attend where appropriate.

2.4 The Trust Secretary or, in her absence, the Assistant Trust Secretary, shall

attend each meeting and provide appropriate advice and support to the Chair and Council members.

3 MEETINGS OF THE COUNCIL OF GOVERNORS 3.1 Meetings shall be held quarterly. 3.2 Meetings of the Council of Governors are held in public. Members of the

public may be excluded from a meeting for special reasons. 3.3 To ensure accountability and that the views of their constituents are heard,

Governors have a responsibility and are expected to attend meetings of the Council of Governors and its committees. When this is not possible they should submit an apology to the Trust Secretary in advance of the meeting.

3.4 Governors are expected to attend for the duration of all meetings. When this

is not possible, they should notify the Trust Secretary in advance of the meeting.

3.5 Failure to attend three consecutive meetings of the full Council of Governors

or three consecutive meetings of any of its formal sub-committees without reasonable explanation approved by the Chair will render the Governor liable for disqualification. (Examples of a ‘reasonable explanation’ would be due to long-term sickness absence, or if constituency governors have agreed to attend and share feedback on a rota basis and advised the Chair of this agreement).

3.6 Attendance at the full Council of Governors and formal sub-committees will

be monitored and reported in the Annual Report. 3.7 The Chairman may call a meeting of the Council of Governors at any time. 3.8 In the case where a vote or closed ballot is required, not less than three-

quarters of governors in attendance must be in agreement.

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4 QUORUM 4.1 In line with the Trust’s Constitution a quorum shall consist of 11 Governors,

including not less than six public Governors and not less than five staff and appointed Governors.

5 SECRETARY 5.1 The Trust Secretary or their nominee shall act as secretary to the Council. 5.2 Meeting papers are circulated at least five days in advance of the meeting. 6 MINUTES 6.1 The Trust Secretary shall ensure that all proceedings and resolutions of

meetings of the Council are minuted, including the names of those present and in attendance.

6.2 The Trust Secretary shall ensure a separate record is kept of all points of

action arising from the meetings and all issues carried forward, and that these are progressed as necessary.

6.3 The Trust Secretary shall ascertain at the beginning of each meeting, the existence of any conflicts of interest and ensure these are minuted accordingly.

6.4 The agenda and minutes of each meeting of the full Council of Governors will be displayed on the Trust website.

7 ROLE AND FUNCTION

7.1 The Council of Governors represent the interests of the local community and

shares information about key decisions with Foundation Trust members. 7.2 It is the responsibility of the Council of Governors to represent the interests of

their Trust members and of the public, particularly in relation to the strategic directions of the Trust.

7.3 The statutory duties of the Council of Governors are to:

• Appoint and, if appropriate, remove the Chair and Non-Executive Directors • Agree the remuneration and allowances and other terms and conditions of

the Chair and other Non-Executive Directors • Approve the appointment of the Chief Executive • Appoint and, if appropriate, remove the Trust’s external auditor • Receive the NHS Foundation Trust’s annual accounts, any report of the

auditor on them, and the annual report • Hold the Non-Executive Directors, individually and collectively, to account for

the performance of the Board of Directors

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• Represent the interests of Trust members and the interests of the public • Approve significant transactions, mergers and acquisitions • Decide whether the Trust’s non-NHS work would significantly interfere with its

principal purpose • Approve amendments to the Trust’s constitution

7.4 General duties of the Council of Governors are to:

• Approve the appointment and role of the Lead Governor • Promote and support the organisation’s strategy • Feedback information about the Trust, its vision and its performance to

members or stakeholder organisation • Attend meetings of the Council of Governors • Abide by the Code of Conduct and uphold the Trust’s values • Act in the best interests of the Trust • Comply with policies and procedures of the Trust, including its Constitution • Maintain an appropriate level of confidentiality in respect of information

provided to the Council of Governors and its committees • Attend development sessions as necessary in order to fulfil the role • Represent the interests of the community, including service users and carers,

by ensuring effective communication with members, feeding back information to the Trust as necessary

8 RELATIONSHIPS WITH OTHER COMMITTEES 8.1 The Council of Governors, on occasion, may delegate some of its powers to

formally constituted committees, such as:

• Appointment and Remuneration Committee • Performance and Assurance Committee • External Audit Review Group

8.2 Minutes/briefing note from the above committees will be presented to the next

scheduled meeting of the Council of Governors following the committee meeting.

9 COLLECTIVE EVALUATION OF PERFORMANCE 9.1 The Council of Governors will commission a periodic review of its

effectiveness and efficiency in the discharge of its responsibilities and achievement of objectives.

REVIEW 10.1 These terms of reference will be subject to review in xx/xx/xxxx

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Information circulated to Board members outside of Board meetings March 2016 – April 2016

Date Item Sender

29.03.16 Feedback on draft Operational Plan 2016/17 M Roe

29.03.16 Letter from Jim Mackey (Chief Executive, NHS Improvement) M McCourt

31.03.16 Manchester bid update G Graham

01.04.16 Correspondence with Sir David Dalton (Chief Executive, Salford Royal NHS FT) M McCourt

08.04.16 Centre for Mental Health: priorities for mental health publication M McCourt

08.04.16 Draft Quality Account 2015/16 A Morris

12.04.16 Report on staff survey results 2015/16 P Bryan

13.04.16 Supporting documentation for Board development on 13 April 2016

J King / G Graham

14.04.16 Update regarding HR Director post K Walker

18.04.16 Supporting documentation for Board development on 20 April 2016

J Taylor / G Graham

19.04.16 Children and Young People Now: article regarding Trafford S75 agreement M McCourt

20.04.16 Information relating to draft submission for MMHSCT bid G Graham

21.04.16 Update on CPA 12-month review target K Walker

21.04.16 MMHSCT AP update G Graham

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21.04.16 Final Strategic Objectives 2016/17 J Taylor

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Documents

AGENDA - Pennine Care NHS Foundation Trust BOARD OF DIRECTORS PART I Wednesday 27 April 2016 To be held in the Boardroom, Ground Floor, Pennine Care Trust HQ, 225 Old Street, Ashton-under-Lyne,